MORNING REPORT

07 Oktober, 2014
Supervisor :
dr. I Made Putra Juliawan , Sp.OG
Medical Students :
Lala, Rila, Nana, Aang
CASE RESUME
NORMAL LABOR

PATHOLOGIC LABOR

7
1.G1P0A0H0 38 39 weeks S/L/IU with PROM > 12 hours

Case Report
Mrs. D, 22 yo, from Gerung,
Hospitalization on 06 oktober 2014, 12.30

G1P0A0H0 38 39 weeks S/L/IU with PROM

> 12 hours

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

13.30

UC: FHB: 12.12.12 (144x/minute)

Flash I
Dryp oxy began 8
tpm

14.00

UC: FHB: 12.12.13 (148x/minute)

Dryp oxy 12 tpm

14.30

UC: FHB: 12.11.12 (140x/minute)

Dryp oxy 16 tpm

15.00

UC: FHB: 12.13.13 (152x/minute)

Dryp oxy 20 tpm

15.30

Abdominal pain came and relieved

UC: 2x/10 ~ 20
FHB: 12.12.12 (144x/minute)
VT : 5cm, eff. 50%,
Amnion (-) clear, head
palpable HII, denominator
unclear, impalpable small part
of fetal & umbilical cord.

Dryp oxy 24 tpm

Obs in partograf

16.00

Abdominal pain came and relieved

UC: 2x/10 ~ 20
FHB: 12.12.11 (140x/minute)

Dryp oxy 28 tpm

16.30

Abdominal pain came and relieved

UC: 3x/10 ~ 20
FHB: 12.12.1.(142x/minute)

Dryp oxy 32 tpm

17..00

Abdominal pain came and relieved

UC: 3x/10 ~ 25
FHB: 12.13.13 (152x/minute)

Dryp oxy 36 tpm

17.30

Abdominal pain came and relieved

UC: 3x/10 ~ 35
FHB: 12.13.12.(148x/minute)

Dryp oxy 40 tpm

Time

Subject
Abdominal pain more often

16.30

Object
GC : well
BP : 110/80 mmHg
PR : 88 bpm
RR : 20 bpm
Temp : 36,5oC
UC : 4x10 ~ 40
FHB : 12-12-13 (148 bpm)

Assessment

Planning

G1P0A0H0 38
39 weeks S/L/IU
active phase first
stage of labor
with PROM > 12
hours

-Observation progress
of labor
-suggest mother to eat
and drink
Suggest mother tilted o
left
Observation with
partograf

VT : 7 cm, effacement
75%, amnion (-), head
palpable HII, denom ,
impalpable small
part/umbilical cord.
18.00

Mother want to bearing down

GC : well
BP : 110/70 mmHg
PR : 87 bpm
RR : 20 bpm
Temp : 36,7oC
UC : 4x10 ~ 45
FHB : 12-13-13 (152 bpm)

Second stage of
labor

Conduct of labor
Observation mother
and baby well being

VT : 10 cm, effacement
100%, amnion (-), head
palpable HIII, denom ,
impalpable small
part/umbilical cord.
18.20

Baby was born,

female, AS 7-9,
2500 gram, 49 cm,
Anus (+), congenital
anomaly (-)
Placenta was born

Time
20.20

Subject
Delivery wound pain

Object
GC: well
Cons: CM
BP: 120/80
HR : 80
bpm
RR : 20 tpm
T : 36,4 C
UFH : 2 fingers below
umbilicus
UC : (+) good

Assessment
2 hour post partum

Planning
Observation mother
and baby well being
Suggest mother to
eat, drink, mobilitation
CIE mother to
exclusive ASI

Baby rooming in:

PR:144
RR: 46
T: 36,4

07/10/20
14
07.00

-Delivery wound pain

GC: well
Cons:
CM
BP: 120/70
HR : 87
bpm
RR : 20 tpm
T : 36,8
C
UFH : 2 fingers below
umbilicus
UC : (+) good
Baby rooming in:
PR:144
RR: 46
T: 36,4

One day post

partum

Observation mother
and baby well being
Suggest mother to
eat, drink,
mobilitation
CIE mother to
exclusive ASI