Morning Report

Oct, 16th 2009

Supervised by : dr. Punarbawa SpOG

Medical Student:
Syarif
Winda
Cases resume :
1

G1P0A0L0 A/S/L/IU head presentation with PRoM

>12 hours

Normal labor

Admitted
to
Hospital

Name/adress

: Mrs. Erniwati / kekait

Age

22 years old

Address
Time

Narmada
Subject

Object

Patient came to Mataram GH

referred by Gunung sari PHC with
G1P0A0L0
A/S/L/IU
head
presentation with PRoM
Chronologist :
Patient came to Gunung sari PHC at
06.00 (15/10/09) confess watery
vaginal discharge since 02.00
(14/10/09), clear, volume about 50
cc, bloody show (-), abdominal pain
(-) fetal movement (+).
LMP : forgot
ANC : 4x at PHC
Examination at PHC :
06.00
BP: 110/70 mmHg
PR: 83 tpm
RR:19 tpm
T: 36,5C
UFH : 30 cm
FHR : 12-12-11
UC : 1x10/10
VT : CD 1 cm, eff 10%, AM (-), head
palpable, descend H1, unclear
denominator, small part of fetal and
umbilical cord unpalpable
Therapy : amoxicilin 1 tab 500 mg
Referred to Mataram GH at 10.00

Examinaton at VK :
BP :120/70 mmHg
PR : 80 x/
RR : 20x/
Temp : 36,7C
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 :29 cm
EFW : 2945 gr
FHR :140
UC :VT : CD 1 cm, eff 10%, AM (-),
clear, head palpable, descend
H1, unpalpable small part of fetal
and umbilical cord
Lab. Examination :
Hb : 10.3 gr%
Leko : 7.800 mm3
Trombo : 251.000 mm3
Hct : 37,1 gr%
HBsAg : -

10.00

15 okt 2009

10.00 wita
Assesment

Planning

G1P0A0L0
A/S/L/IU head
presentation with
PRoM >12 hours

Obs. Mother and fetal

wellbeing
Ampicilin 1gr/iv
Report
to
supervisor
(10.30)
Advice : oxy drip

Time

Subject
Obstetric status:
1. now

Object
Pelvic evaluation:
Os coccygeus mobile
Archus pubis >90
Spina
ischiadica
prominent
Pelvic score: 5

Assesment

Planning

0%

not

11.00

Abdominal pain(-)

CTG baseline : 140x/mnt

UC: -

Oxytocin 5 IU in D5% 500

cc start at 8 dpm

11.30

Abdominal pain (-)

UC: FHR:11-12-12

Observed UC and FHR

30 minutes again

12.00

Abdominal pain (-)

UC: FHR:12-12-12

Observed UC and FHR

30 minutes again

12.30

Abdominal pain>

UC: 1x10/20
FHR:11-12-11

Observed UC and FHR

30 minutes again

13.00

Abdominal pain>

UC: 2x10/30
FHR:13-12-12

Observed UC and FHR

30 minutes again

13.30

Abdominal pain>>

UC: 3x10/20
FHR:12-12-12

Observed UC and FHR

30 minutes again

14.00

Abdominal pain>>>

UC: 3x10/40
FHR:12-12-13

Observed UC and FHR

30 minutes again
Vaginal examination 2
hours again
32 dpm

14.30

Abdominal pain>>>

BP :110/70 mmHg
UC: 3x10/45
FHR:12-12-11

Observed UC and FHR

30 minutes again

Time

Subject

Object

Assesment

Planning

15.00

Abdominal pain>>>

UC: 3x10/40
FHR:13-12-12

Observed UC and FHR

30 minutes again

15.30

Abdominal pain>>>

UC: 3x10/40
FHR:12-12-13

Observed UC and FHR

30 minutes again

16.00

Abdominal pain>>>

UC: 3x10/40
FHR:12-12-13
L4:3/5
VT: CD 6 cm, eff 50%, AM
(-), clear, head palpable,
descend HII, denominator
fontanella
minor
right
anterior, unpalpable small
part of fetal and umbilical
cord

16.30

Abdominal pain>>>>

UC: 3x10/40
FHR:13-12-13

Observed UC and FHR

30 minutes again

17.00

Abdominal pain>>>>

UC: 3x10/40
FHR:12-12-13

Observed UC and FHR

30 minutes again

17.30

Abdominal pain>>>>

UC: 4x10/40
FHR:12-13-13

Observed UC and FHR

30 minutes again

18.00

Abdominal pain>>>>

UC: 4x10/40
FHR:12-13-13

-Observed UC and FHR

30 minutes again

18.30

Abdominal pain>>>

UC: 3x10/40
FHR:12-12-13

Observed UC and FHR

30 minutes again

0%
G1P0A0L0
A/S/L/IU
head presentation active
phase of first stgage of
labor with history of
watery vaginal discharge

Vaginal examination 4
hours again
Observed on partograph

Time

Subject

Object

Assesment

19.00

Abdominal pain>>>>, mother want to

bear down

UC: 4x10/45
FHR:12-13-13
L4: was in pelvic inlet 1/5
VT: CD complete, AM (-),
clear,
head
palpable,
descend HIII, denominator
fontanella
minor
right
anterior, unpalpable small
part of fetal and umbilical
cord

G1P0A0L0 A/S/L/IU head

presentation 2nd stage of
labor

Abdominal pain>>>>, mother want to

bear down

FHR: 13-12-12
Doran teknus perjol vulka

19.15

0%

19.40

Stage 2 of labor

06.30

Active vaginal bleeding (-)

BP :100/60 mmHg
PR : 76 x/
RR : 16x/
Temp : 36,8C
UC : good
UFH : 2 finger
umbilicus
BP :110/80 mmHg
PR : 76 x/
RR : 16x/
Temp : 36,5
UC: good
FUH:
2
finger
umbilicus
Baby:
T:36,6 C
RR: 36 tpm
HR : 120 bpm

2 hours post partum

below

below

Educate to prepare for

delivery of baby

Conduct mother to bear

down

Stage 3 of labor
21.40

Planning

Baby male was born, 2600

gr, A-S 7-9
Amniotic fluid clear
Placenta was born 10
minutes later
Referred mother and baby to
melati room

Time

Subject

Object

Assesment

Planning

18.30

Abdominal pain>>>

UC: 3x10/40
FHR:12-12-13

19.00

Abdominal pain>>>>, mother want

to bear down

UC: 4x10/45
FHR:12-13-13
L4: was in pelvic inlet 1/5
VT: CD complete, AM (-),
clear,
head
palpable,
descend HIII, denominator
fontanella
minor
right
anterior, unpalpable small
part of fetal and umbilical
cord

G1P0A0L0
A/S/L/IU
head presentation 2nd
stage of labor

Educate to prepare for

delivery of baby

21.00

Active vaginal bleeding (-)

BP :100/60 mmHg
PR : 76 x/
RR : 16x/
Temp : 36,8C
UC : good
UFH : 2 finger below
umbilicus

2 hours post partum

Referred mother and baby

to melati room

06.30

0%

BP :110/80 mmHg
PR : 76 x/
RR : 16x/
Temp : 36,5
UC: good
FUH: 2 finger
umbilicus
Baby:
T:36,6 C
RR: 36 tpm
HR : 120 bpm

below

Observed UC and FHR

30 minutes again

Name/adress

: Mrs.Juhaeriah/ teloke

Age

20 years old

Address
Time

Narmada
Subject

21.30

Admitted
to
Hospital

Object

Patient came to Mataram GH

referred by Meninting PHC with
G1P0A0L0 A/S/L/IU with prolonged
2th stage labor.
Chronologist :
Patient came to meninting PHC at
19.30 (5/10/09) confess abdominal
pain (+) since 4/10/09. at 12.00
(6/10/09) bloody show (+), watery
vaginal discharge at 18.15

Examinaton at VK :
GCS : E4V5M6
BP :130/90 mmHg
PR : 86x/
RR : 22x/
Temp : 36,8C
An -/-, ict -/Cor & pulmo : in normal range
Abd : normal range
Ext : oedema -/

LMP : 25/12/2008
EDD : 2/10/2009
ANC : > 4x
Examination in PHC:
BP: 120/80 mmHg
UFH : 28 cm
FHR: 132 bpm
UC: 2x10-30
VT : CD 3 cm, eff 25%, AM (+), head
palpable, descend H1, small part of
fetal and umbilical cord unpalpable
A: G1P0A0L0 A/S/L/IU laten fase 1th
of labor
23.30
CD 3 cm, eff 25%, AM (+), head
palpable, descend H1,unpapable
small organ or, small part of fetal and
umbilical cord unpalpable and
amniotic cord.

Obstetric status :
L1 : breech
L2 : fetal back on the right side
L3 : head
L4 : was in pelvic inlet 1/5
UFH :28 cm
EFW : 2635 gr
FHR : 143bpm
UC : 3x10/35
VT : CD complete, AM (-), clear,
head
palpable,
caput
(+)
descend HIII, small part and
umbilical cord wasnt palpable.
Lab. Examination :
Hb : 11,3 gr%
Leko : 15.700 mm3
Trombo : 190.000 mm3
Hct : 33,5 gr%
HBsAg : -

07 Oktober 2009

21.30 wita
Assesment
G1P0A0L0
A/S/L/IU with
prolonged 2th
stage labor.

Planning
Obs. Mother and fetal
wellbeing
Resucitation
Ampicillin 1 gr iv
Report
to
supervisor
(22.00): advise Vacum
Ekstraction

Time

Subject
03.30 (06/10/09)
CD 3 cm, eff 30%, AM (+), head
palpable, descend H1,unpapable
small organ or, small part of fetal and
umbilical cord unpalpable and
amniotic cord.
07.30
CD 3 cm, eff 40%, AM (+), head
palpable, descend HII
11.30
CD 4 cm, eff 45%, AM (+), head
palpable, descend HII+,unpapable
small organ or, small part of fetal and
umbilical cord unpalpable and
amniotic cord.
BP: 120/80 mmHg; PR: 84; FHR: 132
bpm; UC: 3x10-40
15.30
CD 7 cm, eff 75%, AM (+), head
palpable, descend HII+
18.30
CD 10 cm, eff 100%, AM (-), head
palpable, descend HIII.
BP: 110/70 mmHg; PR: 80 bpm;
FHR: 136 bpm; UC: 3x10-45
Conduct mother to bearing down.
20.30
Mother can not
be continue to
bearing down
BP: 110/70 mmHg; PR: 80 bpm;
FHR: 136 bpm; UC: 3x10-45

Object
Pelvic evaluation:
Spina ischiadica not prominent
Os coccygeus mobile
Archus pubis >90

Assesment

Planning

Time
22.30

Subject

Object

Vacum Exrtaction begun

Assesment
Stage 2 of labor

Stage 3 of labor

00.30
07/10/
09

Active vaginal bleeding (-)

BP :110/60 mmHg
PR : 76 x/
RR : 16x/
Temp : 36,8
UC: good
FUH: 2 finger below umbilicus

2 hours post
Vacum
Ekstraction

06.30

Active vaginal bleeding (-)

BP :100/80 mmHg
PR : 76 x/
RR : 18x/
Temp : 36,8
UC: good
FUH: 2 finger below umbilicus
Baby:
T:36,5 C
RR: 40 tpm
HR : 120 bpm

1 st day of puer
post
Vacum
Ekstraction

Planning
Baby was born with
Vacum Ekstraction in 2th
extraction, female, 2500
gr, A-S 5-7, green amniotic
fluid with episiotomy
Placenta born complete

Admitted
to
Hospital

Name/adress

: Mrs. Sumiatun / karang Jangkong

Age

30 years old

Address
Time

Narmada
Subject

Object

Patient came to Mataram GH at

17.30 (06/10/09) confess watery
vaginal discharge since 14.00 clear,
bloody show (-), abdominal pain (-)
fetal movement (+), history of
hipertension (-), and history of DM (-).
LMP : 26/12/08
EDD: 02/10/09
ANC : 4x at PHC , last about 2 weeks
ago,
Contraception history
Planning of contraception : injection 3
months

Examinaton at VK :
BP :110/70 mmHg
PR : 88 x/
RR : 16x/
Temp : 36,9C
An -/-, ict -/Cor & pulmo : in normal range
Abd : normal range
Ext : oedema -/Obstetric status :
L1 : breech
L2 : fetal back on the left side
L3 : head
L4 : was in pelvic inlet 4/5
UFH :32 cm
EFW : 3300 gr
FHR : 12-12-11
UC : 3x10/45
VT : CD 6 cm, eff 50%, AM (-),
clear, head palpable, descend
H1,
denominator
unclear,
unpalpable small part of fetal and
umbilical cord
Lab. Examination :
Hb : 12,6 gr%
Leko : 19.400 mm3
Trombo : 252.000 mm3
Hct : 38,4 gr%
HBsAg : -

17.30

6 okt 2009

17.30 wita
Assesment

Planning

G1P0A0L0 40
-41 weeks/S/L/IU
head
presentation with
history of watery
vaginal
discharge

Obs. Mother and fetal

wellbeing
Ampicillin 1 gr iv
Observed 4 hours again
with partograph

Time

Subject

Object
Pelvic evaluation:
Promontorium
prominent
Spina
ischiadica
prominent
Os coccygeus mobile
Archus pubis >90

Assesment

Planning

not

0%

not

18.00

Abdominal pain >>>

FHR : 12-12-11
UC : 3x10/45

18.30

Abdominal pain >>>

FHR : 144 tpm

UC : 3x10/45

19.00

Abdominal pain >>>

FHR : 140 tpm

UC : 3x10/45

19.30

Abdominal pain >>>

FHR : 136 tpm

UC : 3x10/45

20.00

Abdominal pain >>>

FHR : 148 tpm

UC : 3x10/45

20.30

Abdominal pain >>>

FHR : 148 tpm

UC : 3x10/45

21.00

Abdominal pain >>>

FHR : 144 tpm

UC : 3x10/45

21.30

Abdominal pain >>>

BP :110/70 mmHg
PR : 88 x/
RR : 16x/
Temp : 36,9C
FHR : 12-12-11
UC : 4x10/45
L4: was in pelvic inlet 3/5
VT: CD complete, AM (-),
clear,
head
palpable,
descend H2 with caput,
denomiator
fontanella

Stage 2 o labor

Educate to eat and drink

Time

Subject

Object

22.00

FHR : 12-12-11
UC : 3x10/45

22.30

FHR : 12-12-11
UC : 3x10/45

23.00

FHR : 12-12-11
UC : 3x10/45

Assesment

Planning

0%

23.30

Abdominal pain>>

FHR : 12-12-11
UC : 1-2x/10~20
VT: CD complete, AM
(-),
clear,
head
palpable, descend H2
with caput, denomiator
fontanella minor left
anterior,
unpalpable
small part of fetal and
umbilical cord

G1P0A0L0 40 -41
weeks/S/L/IU
head
presentation
with
prolonged stage 2 of
labor

Report to supervisor :
Proposed : SC
Advice : rehidration
oxytocin

00.00

Abdominal pain >>

FHR : 12-12-12
UC : 2x/10~20

Continued rehidration

00.30

Abdominal pain >>

FHR : 12-12-12
UC : 2x/10~20

Oxytocin 5 IU in D5% 500 cc

start at 8 dpm

01.00

Abdominal pain >>

FHR : 12-12-12
UC : 2x/10~20

12 dpm oxytocin

01.30

Abdominal pain >>>

FHR : 12-12-12
UC : 3x/10~40

16 dpm oxytocin

Time

Subject

Object

01.45

Abdominal pain >>>, mother want

to bearing down

FHR : 12-12-12
UC : 3x/10~40
VT: CD complete, AM (-),
green, head palpable,
descend H3 with caput,
denomiator
fontanella
minor
left
anterior,
unpalpable small part of
fetal and umbilical cord

Stage 2 of labor

Abdominal pain >>>, mother want

to bearing down

FHR : 12-12-12
UC : 3x/10~40
Doran teknus perjol vulka

Stage 2 of labor

Baby male was born,3300

gr A-S 5-7, amniotic fluid
green
Placenta was born
complete with rupture
perineum stage 2

Active vaginal bleeding (-),

BP :110/70 mmHg
PR : 88 x/
RR : 16x/
Temp : 36,9C
UC : good
FUH: 2 finger
umbilicus

2 hours post partum

Referred mother and

baby to melati room

02.00

04.00

07.00

Active vaginal bleeding (-),

Assesment

Planning

0%

BP :110/60 mmHg
PR : 76 x/
RR : 16x/
Temp : 36,5C
UC : good
FUH: 2 finger
umbilicus
Baby :
RR : 36 tpm
HR: 120 bpm
T:36,5C

below
Puer 1st day

below

Admitted
to
Hospital

Name/adress

: Mrs. Nurhayati / Tanjung

Age

26 years old

Address
Time

Narmada
Subject

Object

Patient came to Mataram GH

referred by Tanjung PHC with
G1P0A0L0 40 weeks/S/L/IU head
presentation with PRoM
Chronologist :
Patient came to Tanjung PHC at
07.30 (06/10/09) confess watery
vaginal discharge since 21.00
(05/10/09), clear, bloody show (-),
abdominal pain (-) fetal movement
(+), history of hipertension (-), and
history of DM (-).
LMP : forgot
ANC : 4x at Posyandu , last about 2
weeks ago,
Examination at PHC :
07.30
Mother height: 139 cm
BP: 120/90 mmHg
PR: 88 tpm
L4: wasnt in pelvic inlet
T: 37,8C
RR:18 tpm
UFH : 34 cm
EFW: 3565 gr
FHR : +
UC : 2x10/20
VT : CD 1 cm, eff 25%, AM (-), head
palpable, descend H1, unclear
denominator, small part of fetal and
umbilical cord unpalpable

Examinaton at VK :
BP :120/70 mmHg
PR : 88 x/
RR : 16x/
Temp : 36,9C
An -/-, ict -/Cor & pulmo : in normal range
Abd : normal range
Ext : oedema -/Obstetric status :
L1 : breech
L2 : fetal back on the left side
L3 : head
L4 : was in pelvic inlet 4/5
UFH :35 cm
EFW : 3720 gr
FHR : 12-12-12
UC : 1x10/20
VT : CD 2 cm, eff 10%, AM (-),
clear, head palpable, descend
H1,
denominator
unclear,
unpalpable small part of fetal and
umbilical cord
Lab. Examination :
Hb : 10,4 gr%
Leko : 17.100 mm3
Trombo : 329.000 mm3
Hct : 31,9 gr%
HBsAg : -

11.45

6 okt 2009

11.45 wita
Assesment
G1P0A0L0 40
weeks/S/L/IU
head
presentation with
PRoM>12 hours

Planning
Obs. Mother
wellbeing

and

fetal

Time

Subject
Therapy : paracetamol tab
PP 1,2 million unit

Object
Pelvic evaluation:
Promontorium
prominent
Spina
ischiadica
prominent
Archus pubis >90
Os coccygeus mobile

Assesment

Planning

not

0%

not

15.00

Abdominal pain (-)

CTG baseline : 140x/mnt,

UC: -

Report to supervisor :
proposed induction with
oxytocin 5 IU in D5% 500
cc
Proposed agree

15.30

Abdominal pain (-)

BP:110/70 mmHg
PR:88 tpm
RR:16 tpm
T:36,8C
UC:FHR:11-12-12

Induction start at 8 dpm

16.00

Abdominal pain (-)

UC:FHR:11-12-12

Continued induction

16.30

Abdominal pain (-)

UC:FHR:11-12-12

Continued induction

17.00

Abdominal pain (-)

UC:FHR:11-12-12

Continued induction

17.30

Abdominal pain (-)

UC:FHR:11-12-12

Continued induction

18.00

Abdominal pain (-)

UC:FHR:11-12-12

Continued induction

Time

Subject

Object

Assesment

Planning

18.30

Abdominal pain (-)

UC:FHR:11-12-11

Continued induction

19.00

Abdominal pain (-)

UC:FHR:11-12-12

Continued induction

19.30

Abdominal pain (-)

UC:FHR:11-11-12

Continued induction

20.00

Abdominal pain (-)

UC:FHR:11-12-12

Continued induction

20.30

Abdominal pain (-)

UC:FHR:11-12-12

Continued induction

21.00

Abdominal pain (-)

UC:FHR:11-12-11

Continued induction

21.30

Abdominal pain (-)

UC:FHR:11-12-12

Continued induction

22.00

Abdominal pain (-)

UC:FHR:11-12-11

Continued induction 2nd flacon

22.30

Abdominal pain (-)

UC:FHR:11-12-11

Continued induction

23.00

Abdominal pain (-)

UC:FHR:12-12-12

Continued induction

23.30

Abdominal pain (-)

UC:FHR:11-12-12

Continued induction

00.00

Abdominal pain (-)

UC:FHR:11-11-12

Report to supervisor:
Advice: observed
Continued induction
Prepare for SC tomorrow
morning if nothing progres

00.30

Abdominal pain (-)

UC:FHR:11-11-12

Continued induction

0%

Time

Subject

01.00

Abdominal pain (-)

01.30

Abdominal pain (-)

06.30

Object

0%

BP:110/70 mmHg
PR:88 tpm
RR:16 tpm
T:36,8C
UC:FHR:11-11-12

Assesment

Failure induction

Planning

Stop induction and

observed