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Morning Report

November 26th 2014


Supervisor : dr. H. Agus
Thoriq, Sp.OG
Medical Students :
Diana, Ida, Dimas
CASE RESUME
NORMAL
LABOR

PATHOLOGIC
AL LABOR

1. G1P0A0L0 42-43 wks /S/L/IU head


presentation latent phase 1st stage of labor
with severe anemia and susp. Macrosomia
2. G1P0A0L0 39-40 wks /S/L/IU head
presentation with prolonged latent phase of
labor

Case Report
Name : Mrs. S
RM

: 11-59-670

Age : 25 years old


Address

: Batu Layar, Lombok Barat

Admitted : November, 25th 2014 (12:30 am)


Diagnosis : G2P1A0L0 39-40 weeks/S/L/IU
head presentation latent phase 1 st stage of
labor with severe anemia and susp.
macrosomia

TIME

SUBJECTIVE

25/11/20
14
12.00
wita

Patient from
obstetric
department with G2P1A0L0
39-40 weeks /S/L/IU head
presentation latent phase
1st stage of labor with
severe anemia.
Patient
confess
lower
abdominal pain that spread
to
flank
region
since
25/11/2014 (05.00 wita),
history
of
membrane
ruptured (-), bloody slim
(-), fetal movement (+).
Dizzy (-), nausea (-)
history of DM (-), HT(-),
asthma (-) allergy (-).
LMP : 23-02-2014
EDD : 30- 11-2014
History of ANC : 10 times
at polindes
Last result: 25/11/2014 BP
110/70 mmHg, 39-40
weeks, UFH 38 cm, head
presentation, FHB +
History of USG : 1 time at
SpOG
Last result: 20/10/2014
S/L/IU, 35-36 wks, head
presentation, 2721 g,
male, sufficient amnion,
clear, placenta at fundus
grade III.
History of family planning :

OBJECTIVE
General Status :
GC : moderate GCS : E4V5M6
BP : 110/70 mmHg
PR : 80 bpm
RR : 20 bpm
T : 36,2oC
Eye : anemis (+), icteric (-)
Cor : S1S2 single regular,
murmur (-), gallop (-).
Pulmo : vesicular (+/+),
wheezing (-/-), rhonchi (-/-).
Abdomen : scar (+), stria
gravidarum (+), linea nigra
(+).
Extremity : edema (-/-), warm
acral (+/+).
Obstetrical Status :
L1 : breech
L2 : back on the left side
L3 : head
L4 : 5/5
UFH : 38 cm
EFW : 4030 gram
UC : (+) 2x/10~25
FHB : 12-12-12 (144 bpm)
VT : 1 cm, eff. 10 %, Amnion
(+),
head
palpable,
HI,
denom unclear,
impalpable
small part of fetus or umbilical
cord

ASSESSMENT

PLANNING

G2P1A0L0 3940 weeks with


head
presentation
/S/L/IU latent
phase 1st stage
of labor with
severe
anemia+susp.
Macrosomia+
history of Csection

Observation
mother & fetal well
being.
Lab exam
DM co to GP pro
CTG and
transfusion, GP
agreed and co. SPV
advice: pro
transfusion 3 kolf
and CTG

TIME
25/11/14
12.30
wita

SUBJECTIVE

OBJECTIVE
PE :
Spina ischiadica not prominent,
Os coccygeus mobile
Arcus pubis <90
Lab Examination :
HB : 6.2 g/dl
RBC : 3.98 x 106/L
HCT : 22.5%
WBC: 11.32x 103/L
PLT : 269 x 103/L
HbSAg : (-)
Proteinuria : (-)

ASSESSMENT

PLANNING

TIME

SUBJECTIVE

25/11/201
4
15.00 wita

16.00 wita

17.30 wita

OBJECTIVE
GC : well
GCS : E4V5M6
BP : 110/80 mmHg
PR : 88 bpm
RR : 20 bpm
T : 36,4oC
UC : (+) 2x/10~25
FHB : 13-13-13 (156 bpm)

Mother
confessed
abdominal pain (+)

ASSESSMENT
G2P1A0L0 3940 weeks with
head
presentation
/S/L/IU with
severe
anemia+susp.
macrosomia

PLANNING
Observation mother &
fetal well being.
Transfusion PRC 1 kolf

UC: (+) 2x/10~25


FHB: 13-13-14 (160 bpm)
VT : 2 cm, eff. 25 %,
Amnion (+), head palpable,
HI, denom unclear,
impalpable small part of
fetus or umbilical cord

Observation Mother and


baby well being
DM co. to GP pro CTG, GP
co to SPV about result of
CTG, SPV pro SC.
CIE family
preparing CS

General condition: Good


BP : 120/80 mmHg
HR : 84 bpm
RR : 22 tpm
T : 36,7oC

CS began
Baby was born, male, BW
3900 gr, BL 50 cm, AS 89 , anus (+), congenital
anomaly (-)
Placenta delivered
completed, bleeding 150
cc
Intraoperatif finding: CPD
Baby was in NICU

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

19.30 wita

General condition: Good


BP : 120/80 mmHg
HR : 84 bpm
RR : 22 tpm
T : 36,7oC
UFH : 1 finger below umbilical
UC : (+) well
Lochia rubra +
UO : 600 cc
Active bleeding (-)
Baby was in NICU
GC: well, HR: 154 bpm, RR: 53
bpm, T: 36,5 0C

2 hours Post CS

Observation Mother
and
baby
well
being
Suggest mother to
mobilization
Suggest mother to
eat and drink

26/11/2014
07.00 am

General condition: Good


BP : 110/80 mmHg
HR : 84 bpm
RR : 20 tpm
T : 36oC
UFH : 1 finger below umbilicus
UC : + well
Active bleeding: (-)
Lochia rubra +
UO : 100cc
Baby was in NICU
GC: well, HR: 154 bpm, RR: 53
bpm,
T: 36,5 0C

1 day post CS

Observation Mother
and
baby
well
being
Suggest mother to
mobilization
Suggest mother to
eat and drink

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Case Report
Name : Mrs. Y
RM

: 55 05 19

Age : 29 years old


Address

: Pagutan, Mataram

Admitted : November, 25th 2014 (09.30


wita)
Diagnosis: G1P0A0L0 39-40 wks /S/L/IU
head presentation with prolonged latent
phase of labor

TIME

SUBJECTIVE

25/11/20
14
09.30
wita

Patient came to VK IRD


NTB GH confess lower
abdominal pain that spread
to flank region since 05.30
wita (25/11/2014), history
of Water broke from her
womb (-), bloody slim (-).
Fetal movement (+).
History of DM (-), HT(-),
asthma (-) allergy (-).
LMP : 16/02/2014
EDD : 23/11/2014
History of ANC : 8 times at
posyandu
Last Result : 04/11/14: BP :
90/60 mmHg, 38
week,
BW 54 kg, FHB (+).
History of USG : 1 time at
SpOG
Last result: 17/11/2014
History of family planning :
Next family planning : IUD
Obstetrical History :
I. This

OBJECTIVE
General Status :
GC : well GCS : E4V5M6
BP : 100/60 mmHg
PR : 98 bpm
RR : 22 bpm
T : 36,9oC
Eye : anemis (-), icteric (-)
Cor : S1S2 single regular,
murmur (-), gallop (-).
Pulmo : vesicular (+/+),
wheezing (-/-), rhonchi (-/-).
Abdomen : distention (-), scar
(-), stria gravidarum (+), linea
nigra (+).
Extremity : edema (-/-), warm
acral (+/+).
Obstetrical Status :
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH: 32 cm
EFW : 3255 gram
UC : 2x/10~ 30
FHB : 12-12-12 (144bpm)
VT : 2 cm, eff 25%, amnion
(+), head palpable, denom
unclear, HI, impalpable small
part of fetal/umbilical cord

ASSESSMENT
G1P0A0L0 3940 wks /S/L/IU
head
presentation
with latent
phase first
stage of labor

PLANNING
Lab exam
CIE and explain
result of
examination
Obs. Mother and
fetal well being.
Obs. Progress of
labor
DM co. to GP pro
CTG, GP agreed and
pro observation.

TIME

SUBJECTIVE

OBJECTIVE
Pelvic Evaluation :
Spina ischiadica not prominent
Sacrum concave
Os coccygeous mobile
Arcus pubis > 900
PS: 6
Dilatation: 1
Length:1
Consistency: 2
Position: 1
Station: 1
Lab Examination :
HB : 12.9 g/dl
RBC : 4.33 x 106/L
HCT : 38.5 %
WBC: 12.71 x 103/L
PLT : 315 x 103/L
HbSAg : (-)
BT: 215
CT: 610

ASSESSMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

13.30
wita

General Status
GC : well
GCS : E4V5M6
BP : 110/80 mmHg
PR : 82 bpm
RR : 21 bpm
T : 37,0 C
UC : 2 X 10~20
FHB : 12 -12-12 (144 bpm)
VT : 2 cm, eff 25%, amnion (+),
head palpable, denom unclear,
HI, impalpable small part of
fetal/umbilical cord

latent phase
first stage of
labor

- Obs. Mother and fetal well


being.
- Obs. Progress of labor
- DM co. to GP pro CTG, GP co
result of CTG, SPV advice
observation progress of labor.

17.30
wita

General Status
GC : well
GCS : E4V5M6
BP : 115/70 mmHg
PR : 88 bpm
RR : 21 bpm
T : 36,6 C
UC : 2 X 10~30
FHB : 12 -11-11 (136 bpm)
VT : 2 cm, eff 25%, amnion (+),
head palpable, denom unclear,
HI, impalpable small part of
fetal/umbilical cord

prolonged latent
phase first
stage of labor

DM co to GP pro rehydration, GP
agreed and co to SPV. SPV
advice:
-Pro acceleration
CIE patient and family

18.00
wita

UC : 2 X 10~35
FHB : 12 -11-12 (140 bpm)

- Rehydration began
RL: D5% = 2:1

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

20.30
wita

GC : well
GCS : E4V5M6
BP : 115/70 mmHg
PR : 88 bpm
RR : 21 bpm
T : 36,6 C
UC : 2 X 10~30
FHB : 12 -11-11 (136 bpm)
UC : 2 X 10~35
FHB : 12 -11-12 (140 bpm)

- Acceleration began
drip Oxytocin 8 dpm

21.00
wita

UC : 2 X 10~35
FHB : 12 -12-12 (144bpm)

Drip oxytocin 12 dpm

21.30
wita

UC : 2 X 10~35
FHB : 12 -12-12 (144bpm)

Drip oxytocin 16 dpm

22.00
wita

Mother confessed water


leaked out from her
womb

GC : well
GCS : E4V5M6
BP : 115/70 mmHg
PR : 88 bpm
RR : 21 bpm
T : 36,6 C
UC : 2 X 10~30
FHB : 12 -11-11 (136 bpm)
UC : 2 X 10~35
FHB : 12 -13-13 (152bpm)
VT : 2 cm, eff 25%, amnion (-)
meconeal, head palpable, denom
unclear, HI, impalpable small
part of fetal/umbilical cord

Neglected
latent phase of
labor

- Drip oxytocin 20 dpm


- CIE patient and family
- DM co to GP pro CS, GP co. to
SPV advice CS at 23.30

22.30

GC : well
GCS : E4V5M6
BP : 110/70 mmHg
PR : 88 bpm
RR : 21 bpm
T : 36,6 C
UC : 2 X 10~30
FHB : 12 -11-11 (136 bpm)

Preparing CS
CIE family

23.30

01.30

CS began
Baby was born, male, BW 3800
gr, BL cm, AS 8-9 , anus (+),
congenital anomaly (-)
Placenta delivered completed,
bleeding 150 cc
General condition: Good
BP : 100/80 mmHg
HR : 80 bpm
RR : 22 tpm
T : 36,7oC
UFH : 1 finger below umbilical
UC : (+) well
Lochia rubra +
UO : 500cc
Active bleeding (-)
baby was in NICU
HR: 140 bpm RR : 54x/m, T: 36,7
C

2 hours Post CS

Observation Mother and baby


well being
Suggest mother to mobilization
Suggest mother to eat and
drink

TIME
26/11
/14
06.00

SUBJECTIV
E

OBJECTIVE

ASSESSMENT

PLANNING

General condition: Good


BP : 110/80 mmHg
HR : 88 bpm
RR : 20 bpm
T : 36,0oC
UFH : 1 finger below umbilicus
UC : + well
Active bleeding: (-)
Lochia rubra +
UO : 100cc/jam
baby was in NICU
HR: 146 bpm RR : 58x/m, T: 36,7
C

1 day post CS

Observation Mother and baby


well being
Suggest mother to mobilization
Suggest mother to eat and
drink

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