Morning Report

22 OCTOBER 2009

Supervisor : dr. Edi Prasetyo Wibowo

SpOG
Medical Student:
Syarif
Cases resume :
1

G2P1A0L1 40W /S/L/IU with breech

presentation

Name

: Mrs. Muslihatun/Marong Karang Baru

Age

: 21 years old

Wakt
u

Subject

23.3
0
(28/
10/0
9)

Patient refered by Nurmalasari

midwife with G2P1A0 40W/S/L/IU
with breech presentation.
Cronologis :
Patient came to bidan Nurmalasari
at 18.30 (28/10/09) confess
abdominal pain (+) since 16.00,
watery vaginal discharge (-)
bloody show (-).
LMP : 22/1/2009
EDD: 29/10/2009
ANC : 4x
Examination in midwife:
BP: 120/80 mmHg
PR; 88 bpm
RR: 24 tmp
UFH : 34 cm
AC:100cm
EFW:3400 gram
FHR: 144 bpm
UC: 1x1020
VT : CD 1 cm, eff 10%, AM (+),
breech
palpable,
descend
H1,unpapable small organ or,
small part of fetal
Refered to Mataram GH at 23.00.

admite
d

: Oct, 28 th 2009
: 18.00pm

Object

General status :
General condition: good
Conciousness: CM
BP: 110/70
RR: 16x/mnt
Pulse :88 x/mnt
T: 36,2C
Eyes : an(-) ikt (-)
Cor -Pulmo : within normal limit
Obstetric status :
L1 : head
L2 : L3 : breech
L4 : desend 4/5
UFH: 33 cm
AC:98 cm
EFW : 3234 g
UC : 1-x10-20
Fetal Heart Rate : 136 bpm
VT : 1 cm, eff 25 %, AM (+),

breech palpable descend

unpalpable small organ
umbilical cord

HI,
and

Assesment

Planning

G2P1A0 40W/S/L/IU
with breech
presentation

Obs. Mother and baby

wellbeing
Cek lab
Obs. Inpartu sign

Wakt
u

Subject

Object

Assesment

Planning

Lab. result:
HBsAg (-)
HB = 13,8
WB =20.200
TRB = 371.000
Hct = 28.0
07.0
0

Abdominal pain -

FHR:148 bpm
UC:-

Obs.inpartu sign

12.0
0

Abdominal pain -

FHR:144 bpm
UC:-

Move to melati room

Obs.inpartu sign

08.0
0(29
/10/
09)

Abdominal pain -

FHR:150 bpm
UC: -

Obs.inpartu sign

08.0
0(30
/10/
09)

Abdominal pain -

FHR:140 bpm
UC: -

Obs.inpartu sign

14.0
0

Abdominal pain -

FHR:140 bpm
UC: -

Obs.inpartu sign

20.1
5

Abdominal pain >

FHR:152 bpm
UC: 3x10-35
VT : 5 cm, eff 40 %, AM (+), palpable
breech descend HI, unpalpable small organ and
umbilical cord

G2P1A0 H1
40W/S/L/IU
active phase
first stage of
labor

Obs.inpartu sign
Move to VK

20.3
0

Abdominal pain >

FHR:152 bpm
UC: 3x10-35
VT : 4 cm, eff 40 %, AM (+), breech
palpable descend HI, unpalpable small organ
and umbilical cord
ZA score:5

G2P1A0 H1
40W/S/L/IU
active phase
first stage of
labor

Report
to
supervisoradvice:obser
vation

Wakt
u

Subject

Object

Assesment

Planning

00.2
0

Watery vaginal discharge

FHR:144 bpm
UC: 3x10 40
VT : 4 cm, eff 25 %, AM (+), breech
palpable descend HI, unpalpable small
organ and umbilical cord

00.5
0

abdominal pain >>>

FHR:144 bpm
UC: 3x10 40

Observation

01.2
0

abdominal pain >>>

FHR:144 bpm
UC: 3x10 45

Observation

01.5
0

abdominal pain >>>

FHR:144 bpm
UC: 3x10 40

Observation

02.2
0

abdominal pain >>>

FHR:144 bpm
UC: 3x10 40

Observation

02.3
0

abdominal pain >>>

Mother want to bearing down

FHR:144 bpm
UC: 3x10 40

Observation

02.4
0

abdominal pain >>>>

Doranteknus perjol vulka

Prepare for delivery baby

02.5
5

Conduct mother to bearing

down

G2P1A0 H1
40W/S/L/IU
prolong active
phase first stage
of labor

Report to supervisor: SC
tomorrow
Observation mother and
baby wellbeing

Satge 2 of labor

Baby was born female,

3750 gram, AS 6-8,
amnion fluid green.

Satge 3 of labor

Placenta was
minuts letter

born

04.5
5

Active vaginal bleeding -

General condition: well, Consciousness:

CM,BP : 120/80,
PR: 88 x/mt, RR : 16 x/mt
Uterine Contraction: good
FH: 2 fingers under umbilicus

2 hour post
partum

- observation mother
well being
- Observation for
hemorrhage sign

Active vaginal bleeding -

General condition: well, Consciousness:

CM,BP : 110/80,
PR: 80 x/mt, RR : 24 x/mt
Uterine Contraction: good
FH: 2 fingers under umbilicus

1 day post
partum

motivied mother to
breast feeding.

Wakt
u

Subject

Object

Assesment

Planning

Inspection: HIII
22.0
0

22.1
5

Report to supervisor:
prorpose
Vacum
ekstraction:agree

Vacum ekstraction Begun

Stage 2 of labor

Baby was born female,

3400 at first traction, AS
6-8

Stage 3 of labor

Placenta was
minuts letter

born

00.1
5

Active vaginal bleeding -

General condition: well,

Consciousness: CM,BP : 110/80,
PR: 88 x/mt, RR : 24 x/mt
Uterine Contraction: good
FH: 2 fingers under umbilicus

2 hour post
partum

- observation mother
well being
- Observation for
hemorrhage sign

06.0
0

Active vaginal bleeding -

General condition: well,

Consciousness: CM,BP : 110/80,
PR: 88 x/mt, RR : 24 x/mt
Uterine Contraction: good
FH: 2 fingers under umbilicus

1 day post
partum

MOTHER AND
BABY WELL BEING

Name/adress

Age
Address
Time
23.30

Admitted
to
Hospital

: Mrs.linda/Kayangan

19 years old
Narmada
Subject

Patient came to Mataram GH referred by

tanjung PHC with G1P0A0L0 A/S/L/IU with
neglected 2th stage of labor
Chronologist :
Patient came to kayangan PHC at 10.30
(21/10/09) confess abdominal pain (+)
Examination in PHC:
BP: 110/70 mmHg
PR; 84 bpm
RR:18 tpm
T:36 C
UFH : 35 cm
FHR: 132 bpm
UC: 2x10-30
VT : CD 4 cm, eff 40%, AM (+), head
palpable, descend HI,unpapable small organ
or, small part of fetal and umbilical cord
unpalpable and amniotic cord.
Vulva Edema
Pasien refered to tanjung PHC
Patient came to tanjung PHC refered by
kayangan PHC at 12.00 (21/10/09) with
G1P0A0L0 A/S/L/IU actif phase of labor and
vulva edema
LMP : forgot
Examination in PHC
BP: 120/80 mmHg
PR; 80 bpm
UFH : 34 cm
FHR: 140 bpm
UC: 3x10-30

11 Oktober 2009

23.30 wita
Object
Examinaton at VK :
GCS : E4V5M6
BP :110/70 mmHg
PR : 96x/
RR : 18x/
Temp : 38 C
An -/-, ict -/Cor & pulmo : in normal range
Abd : normal range
Ext : oedema -/
Obstetric status :
L1 : breech
L2 : fetal back on the right side
L3 : head
L4 : was in pelvic inlet 4/5
UFH :34cm
EFW : 3410 gr
FHR : 148 bpm
UC :3x10-35
VT :vulva edema, CD complete, AM (-),
green,
head palpable, caput (+)
descend HIII, small part and umbilical
cord wasnt palpable.
Lab. Examination :
Hb : 11,9 gr%
Leko : 19.600 mm3
Trombo : 224.000 mm3
Hct : 36,2 gr%
HBsAg : -

Assesment

Planning

G1P0A0L0 A/S/L/IU
with neglected 2th
stage of labor.

Obs. Mother and fetal wellbeing

Inject cefo 1 g IV
Report to supervisor:
Proposed:
Vacum
Ekstractionagree

Time

Subject

Object

Assesment

Planning

VT : CD 5 cm, eff 50%, AM (+), head

palpable, descend HII, unpapable small
organ or, small part of fetal and umbilical cord
unpalpable and amniotic cord.
18.30
Watery vaginal discharge+,
19.00
VT:CD complate, ket (-), descend HIII,
unpapable small organ or, small part of fetal
and umbilical cord unpalpable and amniotic
cord.
Conduct mother to bearing down about 1
hour but not progres
20.30
refered to mataram GH
Therapy: RL 28 dpm
Obstetric history
1.this
00.15

Vacum Ekstraction begun

Satge 2 of labor

Satge 3 of labor

Baby was born female, 2800

at second traction, AS 5-7
Placenta was born 2 minuts
letter

02.15

Active vaginal bleeding -

General condition: well,

Consciousness: CM,BP : 120/80,
PR: 88 x/mt, RR : 16 x/mt
Uterine Contraction: good
FH: 2 fingers under umbilicus

2 hour post partum

- observation mother well

being
- Observation for
hemorrhage sign

06.00

Active vaginal bleeding -

General condition: well,

Consciousness: CM,BP : 110/80,
PR: 80 x/mt, RR : 24 x/mt
Uterine Contraction: good
FH: 2 fingers under umbilicus

1 day post partum

MOTHER AND BABY

WELL BEING