Morning Report

September, 3rd 2015

Supervisor:
Dr. H. AGUS THORIQ, SpOG
DM VK:
tia

Morning Report
rd
september 3 2015
Case Resume
NORMAL
LABOR

PATHOLOGIES 1. G2P1A0L1 39-40 weeks S/L/IU head

presentation with oligohidramnion + failure of
LABOR
drip oxytocin

Case 1
Name : Mrs. NSS
Age : 22 years old
Address : Batu Layar
Admitted : 01-09-2015
No. RM : 12-25-21
G2P1A0L1 39-40 weeks S/L/IU head
presentation with oligohidramnion +
failure of drip oxytocin

TIME

SUBJECTIVE

01/09/201
5
12.00 wita

Patient reffered from obstetric

poly with G2P1A0H1 40-41
weeks S/L/IU head
presentation. Patient not
confessed about abdominal
pain, history of water leaked out
(+) since yesterday, history of
bloody slim (-), FM (+).
History of DM (-), HT in
pregnancy (-), asthma (-) and
allergy (-).
LMP : 1/12/2014
EDD : 8/9/2014
History of ANC : 8x at Posyandu
Last result: (28/08/2015)
BP 100/70 mmHg, BW 74 kg,
GW 39-40 wk, UFH 32 cm,
head presentation, FHB (+)
History of USG : 3x, at NTB GH
Last : 01/09/2015
S/L/IU head presentation, male,
GW 39-40 weeks, placenta at
fundus, AFI clear, minimal,
EFW 3003 g
History of family planning:
injection 3 month
Next family planning : injection
3 month

OBJECTIVE
General status
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 88 bpm
RR: 22 bpm
T: 36.6C
Local status
Eye : an (-/-), ict (-/-)
Pulmo : ves (+/+), rh (-/-), wh
(-/-)
Cor : S1S2 single regular, m
(-), g (-)
Abd : striae gravidarum (+),
linea nigra (+), scar (-)
Ext : edema of lower
extremity(-/-), warm acral (+/
+).
Obstetric status
L1 : breech
L2 : back on the right side
L3 : head
L4 : 4/5
UFH: 33 cm
EFW : 3410 gr
UC : FHB : 11-12-12
VT : 1 cm, eff 10%, amnion
(+), head presentation, H1,
denominator unclear, not
palpable small part &
umbilical cord

ASSESSMENT
G2P1A0L1 39-40
weeks S/L/IU head
presentation with
oligohidramnion

PLANNING
DM planning:
Diagnostic : CBC,
HbsAg,, BT, CT, CTG
Therapy :
Pro induction with
oxytocin drip
Monitoring : VS mother,
UC, FHB, observation
progress of labor
CIE : CIE mother and
family about
diagnostic planning
and therapeutic
planning
13.50
DM co to GP co to SPV
advice :
CTG normal, drip
oxytocin

TIME

SUBJECTIVE
Obstetric History:
I. Aterm/Polindes/midwife/27
00 g/18 years/female/live
II. This

OBJECTIVE
Pelvic score = 5
Dilatation of cervix : 1
Length of cervix : 1
Station : 1
Consistency : 1
Position : 1
Laboratory (01/09/2015
12.56):
HB: 10.3 g/dl
RBC: 3.90
HCT: 32.3 %
WBC: 8.37
PLT: 229
HbsAg: non reactive
BT : 150
CT : 630

ASSESSMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

14.00

UC : FHB : 12-12-11

Drip oxytocin 8 dpm

14.30

UC : FHB : 11-12-12

Drip oxytocin 12 dpm

15.00

UC : FHB : 12-12-12

Drip oxytocin 16 dpm

15.30

UC : 1x10~15
FHB : 12-11-12

Drip oxytocin 20 dpm

15.30

UC : 1x10~15
FHB : 12-12-13

Drip oxytocin 24 dpm

16.00

UC : 1x10~15
FHB : 12-12-11

Drip oxytocin 28 dpm

16.30

UC : 2x10~15
FHB : 12-12-12

Drip oxytocin 32 dpm

17.00

UC : 2x10~15
FHB : 12-12-11

Drip oxytocin 36 dpm

17.30

UC : 2x10~20
FHB : 11-11-12

Drip oxytocin 40 dpm

TIME
18.00

SUBJECTIVE
Patient confess about
abdominal pain

OBJECTIVE
UC : FHB : 11-12-11
VT : 1 cm, eff 10%, amnion
(+), head presentation, H1,
denominator unclear, not
palpable small part & umbilical
cord

ASSESSMENT

PLANNING
DM planning:
Diagnostic :
Therapy :
Drip oxytocin 40 dpm
Monitoring : VS mother,
UC, FHB, observation
progress of labor
CIE : CIE mother and
family about
diagnostic planning
and therapeutic
planning

18.30

UC : 2x10~20
FHB : 12-12-12

Drip oxytocin 40 dpm

19.00

UC : 2x10~20
FHB : 11-12-12

Drip oxytocin 40 dpm

19.30

UC : 2x10~20
FHB : 11-11-12

Drip oxytocin 40 dpm

20.00

UC : 3x10~20
FHB : 11-12-11

Drip oxytocin 40 dpm

20.30

UC : 3x10~20
FHB : 12-12-11

Drip oxytocin 40 dpm

21.00

UC : 3x10~20
FHB : 12-12-12

Drip oxytocin 40 dpm

21.30

UC : 2x10~25
FHB : 12-12-11

Drip oxytocin 40 dpm

22.00

UC : 2x10~25
FHB : 12-12-11

Drip oxytocin 40 dpm

22.30

UC : 2x10~25
FHB : 12-12-11

Drip oxytocin 40 dpm

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

23.00

UC : 2x10~20
FHB : 12-12-12

Drip oxytocin 40 dpm

23.30

UC : 2x10~20
FHB : 11-12-12

Drip oxytocin 40 dpm

02/09/201
5
00.00

GC : well
consciousness: CM
BP : 100/70 mmHg
PR: 82 bpm
RR: 20 bpm
T: 36.6C
UC : 2x10~20
FHB : 11-11-12
VT : 1 cm, eff 10%, amnion
(+), head presentation, H1,
denominator unclear, not
palpable small part & umbilical
cord

G2P1A0L1 39-40
weeks S/L/IU head
presentation with
oligohidramnion +
failure of drip
oxytocin

DM planning:
Diagnostic : Therapy :
Pro CS
Monitoring : VS mother,
UC, FHB, observation
progress of labor
CIE : CIE mother and
family about
diagnostic planning
and therapeutic
planning
DM co to GP co to SPV
Advice : CS tomorrow
at 10.00

TIME
06.00

SUBJECTIVE
Mother confessed about
abdominal pain

OBJECTIVE
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 88 bpm
RR: 20 bpm
T: 36.6C

ASSESSMENT

PLANNING

G2P1A0L1 39-40
weeks S/L/IU head
presentation with
oligohidramnion +
failure of drip
oxytocin

DM planning:
Diagnostic : Therapy :
Pro CS
Injection ampicillin 2
gr/IV
Monitoring : VS mother,
UC, FHB, observation
progress of labor
CIE : CIE mother and
family about
diagnostic planning
and therapeutic
planning
Suggest mother to
laydown at the left
side

G2P1A0L1 39-40
weeks S/L/IU head
presentation with
oligohidramnion +
failure of drip
oxytocin

DM planning:
Diagnostic : Therapy :
CIE :
Monitoring :
C Section begin at
10.00

UC : FHB : 12-11-12
VT : 1 cm, eff 10%, amnion
(+), head presentation, H1,
denominator unclear, not
palpable small part & umbilical
cord

10.00

Patient transffered to OK

GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 88 bpm
RR: 20 bpm
T: 36.6C
UC : FHB : 12-11-12
VT : 1 cm, eff 10%, amnion
(+), head presentation, H1,
denominator unclear, not
palpable small part & umbilical
cord

At 10.05 Baby was

born,male, BW 3450 g,
BL 50 cm, A-S 7-9
Placenta was born
completely at 14.10
Do the management of
4th stage of labor

TIME
12.30

SUBJECTIVE
Patient confessed about
abdominal wound pain

OBJECTIVE
GC : well
consciousness: CM
BP : 100/70 mmHg
PR: 88 bpm
RR: 20 bpm
T: 36.4C
UC : well
UFH : 2 fingers below umbilical
UO : 200 cc/2 hours
Active bleeding (-)

ASSESSMENT

PLANNING

2 hours post
partum

DM planning:
Diagnostic :
Therapy :
Injection ampicillin 1
gr/6 hours
Injection ketorolac 30
mg/8 hours
Monitoring : VS mother,
UC, UFH, UO
CIE : suggest mother
to eat and drink

1 day post partum

DM planning:
Diagnostic :
Therapy :
Injection ampicillin 1
gr/6 hours
Injection ketorolac 30
mg/8 hours
Monitoring : VS mother,
UC, UFH, UO
CIE : suggest mother
to eat and drink

Baby in NICU :
HR : 152x/minute
RR : 54x/minute
T : 36,3oC
03/09/201
5
07.00

Patient confessed about

abdominal wound pain

GC : well
consciousness: CM
BP : 100/70 mmHg
PR: 88 bpm
RR: 20 bpm
T: 36.7C
UC : well
UFH : 2 fingers below umbilical
UO : 300 cc/4 hours
Active bleeding (-)
Lochea rubra (+)
Baby in NICU :
HR : 148x/minute
RR : 50x/minute
T : 36,5oC

.. Thank
You ..