MORNING REPORT

August 4th, 2012

Supervisor : dr. I Made P.
Juliawan, Sp.OG
Medical Students :
Ira, Lanira, Yan, Rona, Tari, Dini H.

CASES RESUME
NORMAL LABOR 3
PATHOLOGY 1. G1P0A0H0 37-38 weeks S/L/IU with
LABOR arrested active phase 1st stage of
labor (dystocia 5 cm) et causa
secondary inersia uteri.
Name : Mrs. J
Age : 28 yo
Adress : Duwung, Batu Layar, Lombok
Barat
Admitted: August, 4th 2012 at 18.15
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

4/08/2 Patient referred from Meninting General Status G1P0A0H0 37-38 Observe pervaginam
012 PHC with G1P0A0H0 37-38 weeks S/L/IU with delivery using
GC : well
weeks S/L/IU head presentation arrested active partograf
18.15 Consciusness : CM
with prolonged inpartu active phase 1st stage of Rehydration
BP : 120/70 mmHg
phase 1st stage of labor. labor (distocia 5 CTG reactive
PR : 96 bpm
Patient confessed abdominal cm) et causa DM co to SPV pro
RR : 24 bpm
pain that spread to frank since secondary inersia acceleration, advice :
T : 37oC
16.00 (03/08/2012) and water uteri Acc acceleration.
leaked from her womb since Eye : anemis (-/-), icteric (-/-)
20.00 (03/08/2012). Bloody slim Cor : S1S2 single reguler, M (-), G (-)
(+), FM (+).
No history of DM, HT, asthma. Pulmo : vesikuler (+/+), wheezing
(-/-), ronkhi (-/-).
LMP : 12/11/2011 Abdomen : scar (-), striae (+), linea
EDD : 19/08/2012 nigra (+).
Extremity : edema (-/-), warm acral
History of ANC : >4x at Posyandu (+/+)
Last ANC : 31/07/2012
History of USG : never Obstetrical Status
L1 : breech
History of family planning : (-) L2 : back on the left side
Next family planning : Injection 3 L3 : head
months. L4 : 4/5
UFH : 30 cm
Obstetrical History : EFW : 2945 g
I.Ini UC :1x/10 ~ 20
FHB : 11-11-11 (132 bpm)
VT : 5 cm, eff 50%, amnion (+),
head palpable H I +, denominator
unclear, impalpable small part /
umbilical cord.
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
Chronologist at Meninting PHC : Pelvic Evaluation :
Spina ischiadica not prominent
00.00 (04/08/2012)
Os coccigeous mobile
S : Abdominal pain spread to frank since Pubic arch > 900
16.00 (3/08/2012). History rupture of
membrane (+), bloody slim (+),FM (+). Lab Evaluation
O : GC : well HB : 11,4 g/dl
BP : 120/80 mmHg RBC : 3,67 M/dl
PR : 84 bpm HCT : 34,5 %
RR : 24 bpm WBC : 21,93 K/dl
T : 36,5oC PLT : 261 K/dl
L1 : breech HbSAg : (-)
L2 : back on the left side
L3 : head
L4 : 4/5
UFH : 28 cm
FHB : 11-11-12 (136 bpm)
VT : 1 cm, eff 25%, amnion (+), head
palpable HI , denom unclear,
unpalpable small part / umbilical cord.
A : G1P0A0 37-38 weeks S/L/IU head
presentation with inpartu latent phase
1st stage of labor.
P:
Suggest mother lay to the sideways,
eat, and drink.
Observe mother and fetal well being
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
04.00
S : Mother confessed abdominal pain +++
O : GC well
BP : 110/70 mmHg
PR : 80 bpm
RR : 20 bpm
T : 36oC
UC : 2x/10~35
FHB : 11-12-11 (136 bpm)
VT : 3 cm, eff 50%, amnion (+), head
palpable HI , denom unclear,
unpalpable small part / umbilical cord.
A : G1P0A0 37-38 weeks S/L/IU head
presentation with inpartu latent phase
1st stage of labor.
P:
Suggest mother lay to the sideways,
eat, and drink.
Observe mother and fetal well being
Observe progress of labor

08.00
S : Mother confessed abdominal pain +++
O: GC : well
BP : 110/70 mmHg
PR : 78 bpm
RR : 20 bpm
T : 36,7oC
UC : 2x/10~35
FHB : 11-12-11 (136 bpm)
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
VT : 3 cm, eff 25%, amnion (+),
head palpable HI, denominator LOA,
unpalpable small part / umbilical cord.
A : G1P0A0 37-38 weeks S/L/IU head
presentation with inpartu latent phase
1st stage of labor.
P:
Suggest mother lay to the sideways,
eat, and drink.
Obs. mother and fetal well being
Obs. progress of labor

12.00
S : Mother confessed abdominal pain
+++
O : GC well
BP : 110/70 mmHg
PR : 82 bpm
RR : 20 bpm
T : 37oC
UC : 3x/10~40
FHB : 11-11-11 (132 x/min)
VT : 5 cm, eff 50%, amnion (+),
head palpable H-II , denom LOA,
unpalpable small part / umbilical cord.
A : G1P0A0 37-38 weeks S/L/IU head
presentation with inpartu active phase
1st stage of labor
P:
Suggest mother lay to the sideways,
eat, and drink
Obs. mother and fetal well being
Obs. progress of labor using
partograf
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
16.00
S : Mother confessed abdominal pain +++
O : GC well
BP : 130/80 mmHg
PR : 80 bpm
RR : 20 bpm
T : 37oC
UC : 3x/10~45
FHB : 11-11-12 (136 bpm)
VT : 6 cm, eff 50%, amnion (+), head
palpable H-II, denominator LOA,
unpalpable small part / umbilical cord.
A : G1P0A0 37-38 weeks S/L/IU head
presentation with prolonged inpartu
active phase 1st stage of labor.
P : Co to GP, advice :
Rehydration RLII flash + DS 5% 40 tpm
at 16.30 Wita
Injection Ampicillin 1 g/IV at 17.00
CIE patient refered to RSUP-NTB

19.30 Abdominal pain (+) UC : 2x/10~20 Dryp oxy began 8 tpm

FHB : 11-11-11(132 bpm)

20.00 Abdominal pain came and relieved UC : 2x/10~25 Dryp oxy 12 tpm
FHB : 12-11-11 (136 bpm)
20.30 Abdominal pain came and relieved UC : 3x/10 ~ 25 Dryp oxy 16 tpm
FHB : 12-11-12 (140 bpm)
21.00 Abdominal pain came and relieved UC : 3x/10 ~ 30 Dryp oxy 20 tpm
FHB : 12-12-12 (144 bpm)
21.30 Abdominal pain came and relieved UC : 4x/10 ~ 30 Dryp oxy 20 tpm
FHB : 11-12-12 (140 bpm) Maintenance
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
21.35 Mother confessed water came GC : well 2nd stage of labor
out from her womb UC : 4x/10 ~ 30
Mother wants to bearing down FHB : 12-12-12 (144 bpm)
VT : complete, amnion (-) clear,
head palpable H III+, denom
LOA, impalpable small part/
umbilical cord.

21.40 Teknus Perjol Vulka Conduct mother to bearing

down.
Baby was born, male, AS
7-9, 2900 gram, 50 cm,
Anus (+), congenital
anomaly (-)
Placenta was born
spontaneous, completed,
bleeding 150cc

23.4 Delivery wound pain GC : well 2 hours post Observed mother and
0 BP : 100/60 mmHg partum baby well being.
PR : 88 bpm Suggest mother to
RR : 20 bpm mobilisation.
T : 36,5 C
UC : (+) well
UFH : 2 finger belowumbilicus
Active bleeding : (-)
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
05/08/ Delivery wound pain GC : well One day post Observed mother and
2012 BP : 110/80 mmHg partum baby well being
PR : 88 bpm Suggest mother to
07.00
RR : 20 bpm mobilisation, eat, and
T : 36,40C drink, medication.
UFH : 3 finger below umbilicus
UC : (+) well
Lochea rubra : (+)

Baby rooming in :
PR :144 bpm
RR : 46 bpm
T : 36,40C