Morning Report
rd
september 3 2015
Case Resume
NORMAL
LABOR
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
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
14.30
UC : FHB : 11-12-12
15.00
UC : FHB : 12-12-12
15.30
UC : 1x10~15
FHB : 12-11-12
15.30
UC : 1x10~15
FHB : 12-12-13
16.00
UC : 1x10~15
FHB : 12-12-11
16.30
UC : 2x10~15
FHB : 12-12-12
17.00
UC : 2x10~15
FHB : 12-12-11
17.30
UC : 2x10~20
FHB : 11-11-12
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
19.00
UC : 2x10~20
FHB : 11-12-12
19.30
UC : 2x10~20
FHB : 11-11-12
20.00
UC : 3x10~20
FHB : 11-12-11
20.30
UC : 3x10~20
FHB : 12-12-11
21.00
UC : 3x10~20
FHB : 12-12-12
21.30
UC : 2x10~25
FHB : 12-12-11
22.00
UC : 2x10~25
FHB : 12-12-11
22.30
UC : 2x10~25
FHB : 12-12-11
TIME
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLANNING
23.00
UC : 2x10~20
FHB : 12-12-12
23.30
UC : 2x10~20
FHB : 11-12-12
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
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
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
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 ..