MORNING REPORT

th
July 14 2014

Supervisor : dr. Made Putra Juliawan, Sp.OG

DM :
Sakti, Ita, Nurul, Santi
 CASE RESUME
Case Resume :
No. Case Total
Pathology Delivery 1
1. G1P0A0L0 38-39 week/S/L/IU head
presentation with prolonged 2nd stage
 Case Report
Name : Mrs. S A
Age : 25 yo
Address : Meninting
Admitted : 13th July 2014
RM : 54 24 01

G1P0A0L0 39-40 week/S/L/IU head

presentation with prolonged 2nd stage of
labor
Time Subject Object Assessment Planning
13/07/ Patient referred from General status G1P0A0L0 38- Obs. Mother and
2014 Meninting PHC with GC : well 39 week/S/L/IU fetal well being.
21.14 G1P0A0L0 38-39 GCS: CM (E4V5M6) with prolonged DM co to GP pro
WITA week/S/L/IU head BP : 130/80 mmHg 2nd stage continue
presentation with prolonged PR: 88 bpm rehydration,
2nd stage. RR: 20 bpm injection antibiotic
Patient confessed T: 36,6C and pro VE
abdominal pain since 05.00 GP co to SPV pro
WITA (12/07/2014). Bloody Local status VE, advice: VE
slim (+) since 20.30 WITA Eye : an (-/-), ict (-/-) Check CBC,
(13-07-2014) Water leaked Pulmo: ves (+/+), rh (-/-), wh Urinalysis and
out from her womb (-), FM (-/-) HBsAg
(+). Cor : S1S2 single regular, Continue
History of DM (-), HT (-), M(-), G(-) Rehydration RL
asthma (-). Abd : striae gravidarum (+), : D5 = 2 : 1 from
linea nigra (+), scar (-) Injection Cefotaxim
LMP : 15 10 - 2013 Ext : edema (-/-), warm acral 1 gr
EDD : 22 7 -2014 (-/-) CIE patient and
family (for planning
History ANC : 11x at Obstetric status VE)
Posyandu L1 : breech
Last ANC at 13/02/2014, L2 : back on the left side
Result : Vital sign normal, L3 : head
UFH 32 cm, head L4 : 1/5
presentation, 5/5, FHB (+).
37-38 weeks UFH: 31 cm
EFW : 3100 gram
History USG : (-) UC : 4 x 10 ~ 40
FHB : 11.11.11 (132x/min)
Time Subject Object Assessment Planning
23/02/ History of family planning: - VT : complete, amnion (-)
2014 Next family planning: meconeal , head palpable,
Injection 3 month HIII, caput (+), denom LOA,
unpalpable small part of
Obstetric History: fetus/ umbilikal cord
1. This

Lab:
HGB = 10.8 g/dl
RBC = 4.10 K/ul
HCT = 33,2 K/ul
WBC = 20,84 M/ul
PLT = 291 M/ul
HBsAg = (-)
Chronologist at PHC:
13/07/14 (9.30 WITA)
S: patient come to Meninting PHC
confessed abdominal pain since
05.00 WITA (12/07/2014). Water
leaked out from her womb (-)
bloody slim (+) FM (+).
O: GC : well
BP : 100/70 mmHg
PR: 82 bpm
RR: 20 bpm
T: 36,9C
UC: 3x10 40

Obstetrical Status
FHB: 10-11-10 (124 bpm)
UFH: 31 cm
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
VT 3 cm, eff 25%, amnion (+), head
palpable denom unclear, HI,
unpalpable small part of fetus/umbilical
cord
A: G1P0A0L0 38-39 week/S/L/IU with
laten phase
P:
-Obs progress of labor 4 hours again
-Suggest mother to eat and drink
-Obs mother and fetal well being
Time Subject Object Assessment Planning
13.30 WITA
S/ abdominal pain
O/
GC : well
BP : 110/70 mmHg
PR: 80 bpm
RR: 20 bpm
UC: 5x10 45
FHB: 12-11-12 (136 bpm)
UFH: 31 cm

VT 5 cm, eff 50%, amnion (+), head palpable

denom unclear, HII, unpalpable small part of
fetus/umbilical cord

A: G1P0A0L0 38-39 week/S/L/IU with active phase

P:
- Obs mother and fetal well being
- Obs progress of labor with partograf
-Suggest mother to eat and drink
Time Subject Object Assessment Planning
17.30 WITA

S/ abdominal pain , water leakage

from her vagina (+), FM (+)
O/
GC : well
BP : 110/70 mmHg
PR: 84 bpm
RR: 22 bpm

VT 9 cm, eff 75%, amnion (+),

head palpable denom LOA, HII,
unpalpable small part of
fetus/umbilical cord

A: G1P0A0L0 38-39 week/S/L/IU

with active phase

P:
-Suggest mother to eat and drink
-obs mother and fetal well being
Time Subject Object Assessment Planning
18.30 WITA

S/ : abdominal pain

VT 10 cm, eff 100%, amnion (+),

head palpable denom LOA, HIII,
unpalpable small part of
fetus/umbilical cord

A: G1P0A0L0 38-39 week/S/L/IU

with 2nd stage

P:-obs mother and fetal well being

- Suggest mother to bearing down if
contraction
-Conduct of labor

19.30
Midwife Co to GP, GO
Advice :
resucitation RL : D5
evaluation 1 hours, if no progress
of labor referred to NTB GH.
Time Subject Object Assessment Planning
20.25 WITA

S/ : -

VT 10 cm, eff 100%, amnion (+),

head palpable denom (UUK), HIII,
unpalpable small part of
fetus/umbilical cord

A: G1P0A0L0 38-39 week/S/L/IU

head presentation with Prolonged
2nd stage of labor

P:-obs mother and fetal well being

- Referred to GH NTB
Time Subject Object Assessment Planning
13-07- VE began
14
22.00 22.10 WITA
WITA Baby was born , male, BW :
3300 g, BL : 52 cm, AS :7-9,
anus (+), anomali congenital
labiopalatoschisis

22.14
Placenta was born, complete,
weight : 500 g
Bleeding : + 150 cc
Ruptur Perineum gr. 1
heacting

14-07- GC: well cons:E4V5M6 2 hours post VE Observation mother and

2014 BP: 120/90 mmHg baby well being
00.10 PR: 88x/minute, Suggest mother to eat and
RR: 20x/minute, drink
T: 36,6 0C Suggest mother to
UC: (+) well mobilitation
UFH: 2 fingers below
umbilicus
Active bleeding: (-)
Time Subject Object Assessment Planning
14-07- - GC: well cons:E4V5M6 1 day post VE Observation mother and baby
2014 BP: 120/90 mmHg well being
07.00 PR: 88x/minute,
RR: 20x/minute,
T: 36,6 0C
UC: (+) well
UFH: 2 fingers below
umbilicus
Active bleeding: (-)

Baby in NICU:
PR: 140 bpm
RR: 46 tpm
Temp : 37 o C
PHOTO