GOOD

MORNING
MORNING REPORT
DUTY ON : SATURDAY, NOVEMBER 7th 2015

Visi program studi Obstetri dan Ginekologi

Menjadi lembaga pendidikan spesialis obstetri dan ginekologi
yang unggul, mandiri, dan berbudaya serta mampu bersaing di
tingkat Nasional, Regional dan Global.
Misi program studi Obstetri dan Ginekologi
Melaksanakan dan mengembangkan Good Clinical
Governance
Meningkatkan penyelenggaraan pendidikan dokter spesialis
obstetrik dan ginekologi yang profesional, unggul, mandiri dan
berbudaya.
Meningkatkan penelitian dasar dan terapan baik di Program
Studi maupun bekerja sama dengan lembaga nasional maupun
internasional.
Meningkatkan pengabdian masyarakat dengan melibatkan
sivitas akademika, alumni, dan stakeholder.

MORNING REPORT
DUTY ON : SATURDAY, NOVEMBER 7th 2015
RESIDENTS : WST-GIR-ADP/SYT-TAP/AYT-SKW-WAP-RAI/GAP/WID/SDW-BMN
CHIEF
: ALB
SUPERVISOR : Prof. SW
RESUME OF OPERATIVE PROCEDURE
I. OBSTETRIC
Vaginal delivery
:Spontan delivery
:2
Bracht
:VaE
:FE
:1
Induction/Augment
:CS
:1
Others
:RESUME OF INWARD PATIENT
III. INLABOR
HCU
:ICCU
:ICU
:-

II. GYNECOLOGIC
Curettage
Laparatomy
Others

:1
::1

MS/RATNA
Cempaka OBS
Cempaka GYN
Others

::::-

MORNING REPORT
DUTY ON : SATURDAY, NOVEMBER 7th 2015
OPERATING ROOM SCHEDULE : MONDAY, NOVEMBER 9th 2015
N0

1.

Name

YEN

Age

Parity

23 yo

P0married

Ward

Diagnosis

Procedure

Operator

OR

MHT

Ovarian Cyst + Primary

Infertility
(ICD X : N83.2, N97)
(ICD IX : 54.1)

Laparotomi FZ
Fallopian Tubes
Patency Test

dr. ART,
O&G (C)

IX

OBSTETRIC EMERGENCY ROOM REPORT

DUTY ON : SATURDAY, NOVEMBER 7th 2015
1. ARI, 29 yo

WAP

N0

DATA BASED

1.

Anamnesis (ICD IX : 89.03) :

Referred from midwife with G1P0000
A/S/L hypertension (170/100 mmHg),
in labor.
Labor pain (+) since 01.00 pm
(07/11/15), watery vaginal discharge(+)
since 03.00pm (07/11/15), FM (+).
Subjective complain (-). Known
hipertension since admitted to
midwife (7/11/15).
LMP : 30/01/2015
EDD : 06/11/2015
PNC : midwife, O&G
Obstetric history :
1.Current pregnancy
Married 1x ~ 5 month
Contraception: -

ASSESS
MENT

PROBLEM
LIST

ICD X

PLAN OF CARE

OBSTETRIC EMERGENCY ROOM REPORT

DUTY ON : SATURDAY, NOVEMBER 7th 2015
1. ARI, 29 yo
N0
2.

WAP
DATA BASED

Physical Examination (ICD IX 89.03)

W/H : 58/148
Present state :
BP : 170/110
RR : 20
P : 88
Tax : 36.7
General st :
Eyes : anemic (-)
Thorax : Cor :S1S2 sgl, reg, m (-)
Po : Ves +/+, rh -/-, wh -/Abd
: ~ Obstetric state
Ext
: warm +/+
+/+
Obstetric state :
Abd
: FH 3 fgrs bpx (32cm), O 4/5
UC (+) 2-3x/10~30-35
FHB (+) 144 bpm
VT (GAP) 09.00 pm :
CD 2 cm, eff 25%, AM (-)
Head palp, SS transverse, HI
Unpalp small part/ umb cord

ASSESS
MENT

PROBLEM
LIST

ICD X

PLAN OF CARE

OBSTETRIC EMERGENCY ROOM REPORT

DUTY ON : SATURDAY, NOVEMBER 7th 2015
1. ARI, 29 yo

WAP

N0

DATA BASED

3.

USG (ICD IX : 88.78) :

Fetus (+), S/L, FHB(+),FM(+),head pres
Biometry :
BPD : 9.24 ~ 38W1D
AVE : 37W2D
HC : 34.8 ~ 38W0D
EFW : 2873 g
AC : 31.2 ~ 36W3D
EDD : 26/11/15
FL : 7.49 ~ 38W2D
Placenta fundus corpus posterior II
AFI : 6.2 cm
CTG ~ Normal

4.

Lab (ICD IX 99.07) :

WBC : 14.3
HCT : 38.2
HGB : 13.0
PLT : 183
SGOT/SGPT : 24,2/12,5
Alb : 3,95
BUN/SC : 11/0,17
LDH : 502
Urine:
Protein uria : +3

ASSESS
MENT

PROBLEM
LIST

G1P0000, 40 weeks
1 days, S/L,
Severe PE, 1st stage
of labor (ROM)

1. Risk of
seizure
2. Hypertensi
on
3. In Labor
4. Risk of
infection

EFW :2873g

ICD X

PLAN OF CARE

O.14.1
O42.1

Intervention :
1.Anti Seizure
2.Anti Hypertension
3.Exp. vaginal delivery
accelarated 2nd stage of
labor
4.antibiotic
Target :
1.No Seizure
2.MAP 125 mmHg
3.Born baby vigorously
and mother in agood
condition
4.Reduce infection
Instruction:
Tx:
1.MgSo4~ Guidelines
2.Nifedipine 3 x 10 mg
(IO)
3.Exp. vaginal delivery
accelarated 2nd stage of
labor with FE
4.Amoxicilin 3x500mg (io)
Mx : C, VS, FHB, UC,
impending eclampsia &
intoxication MgSO4
CIE

OBSTETRIC EMERGENCY ROOM REPORT

DUTY ON : SATURDAY, NOVEMBER 7th 2015
1. ARI, 29 yo
N0

DATA BASED

WAP
ASSESSMENT

PROBLEM

ICD X

PLAN OF CARE

At 00.15 am
CD : 4 cm
Progress of labor:
At 04.15 am
Patient urge to bear down

2nd stage of labor

ICD IX
72.53
71.79

Evaluation:
Abdomen :
UC (+) 4-5x/10 ~ 40-45
FHB (+) 152 bpm
VT (WAP) At 04.15 am:
CD complete, AM (-)
Head palp, OA, HIII+

Instruction :
Pdx : Tx :
Accelerated 2nd stage of
labor with FE
At 04.23 am, born baby ,
2650 g, AS 6-7, episiotomy
(+)

3rd stage of labor

Tx :
Management active 3rd
stage of labor
At 04.30 am, born placenta
complete, done perineal
hecting

ARI, 29 yo

ARI, 29 yo

ARI, 29 yo

ARI, 29 yo

OBSTETRIC EMERGENCY ROOM REPORT

DUTY ON : SATURDAY, NOVEMBER 7th 2015
2. YUL, 34 yo

Hospitalized : 07/11/2015

S
Treated with G2P1001
40 weeks 6 days, S/L,
Secondary Primi, 1st
stage of labor (ROM)
EFW: 3349 g
EDD: 01/11/2015

Progress Of Labor:
At 03.40 pm
Patient urge to bear
down

O
Present st :
BP : 120/80
RR : 20

ADP
A

ICD X

P : 80
Tax : 36.9

General state :
Eye
: anemic (-)
Thorax :
Cor : S1S2 sgl, reg, m (-)
Po : Ves +/+, rh -/-, wh -/Abd : ~ Obstetric state
Ext : warm +/+
+/+
Evaluation:
Abdomen :
UC (+) 4-5x/10 ~ 40-45
FHB (+) 152 bpm
VT (ADP) At 03.40 pm:
CD complete, AM (-)
Head palp, OA, HIII+
Unpalp small part/umb cord

2nd stage of
labor

73.59

Tx:
lead to bear down

At 03.48 pm
Spontaneously born
baby , 3050g,
vigorously

OBSTETRIC EMERGENCY ROOM REPORT

DUTY ON : SATURDAY, NOVEMBER 7th 2015
2. YUL, 34 yo
S

ADP
O

A
3rd stage of
labor

ICD X

ICD IX

Tx :
active management
3rd stage of labor

Z97.5
97.71

At 03.53 pm
Born placenta
complete
IUD insertion

OBSTETRIC EMERGENCY ROOM REPORT

DUTY ON : SATURDAY, NOVEMBER 7th 2015
3. SAD, 31 yo
N0

1.

TAP
DATA BASED

Anamnesis (ICD IX : 89.03) :

Referred from Balimed hospital with
G1P0000, 38-39 weeks, 4 years
infertile,PROM, CTG
patologic/suspicious
Watery vaginal discharge (+) since
07.00 pm (7/11/15). Labor pain (+)
since 08.00 pm (07/11/15), FM (+).
LMP : 07/02/2015
EDD : 14/11/2015
PNC : O&G
Obstetric history :
1.Current pregnancy
Married 1x ~ 5 years
Contraception: -

ASSESS
MENT

PROBLEM
LIST

ICD X

PLAN OF CARE

OBSTETRIC EMERGENCY ROOM REPORT

DUTY ON : SATURDAY, NOVEMBER 7th 2015
3. SAD, 31 yo
N0
2.

TAP
DATA BASED

Physical Examination (ICD IX 89.03)

W/H : 70/161
Present state :
BP : 120/80
RR : 20
P : 84
Tax : 36.7
General st :
Eyes : anemic (-)
Thorax : Cor :S1S2 sgl, reg, m (-)
Po : Ves +/+, rh -/-, wh -/Abd
: ~ Obstetric state
Ext
: warm +/+
+/+
Obstetric state :
Abd
: FH 3 fgrs bpx (31cm), O 4/5
UC (+) 2-3x/10~30-35
FHB (+) 148 bpm
VT (GAP) 11.00 pm :
CD 4 cm, eff 50%, AM (-)
Head palp, LO transverse, HI
Unpalp small part/ umb cord

ASSESS
MENT

PROBLEM
LIST

ICD X

PLAN OF CARE

OBSTETRIC EMERGENCY ROOM REPORT

DUTY ON : SATURDAY, NOVEMBER 7th 2015
3. SAD, 31 yo
N0
3.

TAP
DATA BASED

USG (ICD IX : 88.78) :

Fetus (+), S/L, FHB(+),FM(+),head pres
Biometry :
BPD : 8,9~ 36W3D
AVE : 37W0D
HC : 33.73 ~37W3D
EFW : 3107 g
AC : 32,7 ~37W5D
EDD : 22/11/15
FL : 7.41 ~ 38W0D
Placenta fundus corpus posterior III
AFI : 8.2 cm
CTG ~ Normal

4.

Lab (ICD IX 99.07) :

WBC : 11.0
HCT : 34.7
HGB : 11.2
PLT : 164
BT/CT : 2/9

ASSESS
MENT

PROBLEM
LIST

G1P0000, 39
weeks, S/L,
primary
infertile 4
years,
1st stage of
labor (ROM)

1. In Labor
2. ROM

EFW :3107 g

ICD X

PLAN OF CARE

O80.0
O42.1
N97.9

Intervention :
1. Exp. vaginal
delivery
2 Risk of infection

ICD IX
73.59
71.79
99.21

Target :
1.Born baby
vigorously and
mother in agood
condition
2.Reduce risk of
infection
Instruction:
Tx:
1.Exp. vaginal
delivery
2.Amoxycillin 3x
500 mg (IO)
Mx: manage ~
P.WHO

OBSTETRIC EMERGENCY ROOM REPORT

DUTY ON : SATURDAY, NOVEMBER 7th 2015
3. SAD, 31 yo
N0

DATA BASED

Progress of labor:
At 03.30 am
Evalution 4 hours
Evaluation:
Abdomen :
UC (+) 3-4x/10 ~ 35-40
FHB (+) 132 bpm
VT (TAP) At 03.00 am:
CD 8 cm, eff 75%, AM (-)
Head palp, LOA, HII
Unpalp small part/ umb
cord

TAP
ASSESSMENT

G1P0000, 39
weeks, S/L,
primary infertile 4
years,
1st of labor (ROM)
EFW :3346g

PROBLEM

ICD X

PLAN OF CARE

Instruction:
Tx:
1.Exp. vaginal delivery
2.Amoxicillin 3x 500 mg
(IO)
Mx : manage ~ P WHO

OBSTETRIC EMERGENCY ROOM REPORT

DUTY ON : SATURDAY, NOVEMBER 7th 2015
3. SAD, 31 yo
S

Progress of labor
At 03.30 am patient
urge to bear down,

TAP
O

Evaluation:
Abd
:
UC (+) 4-5x/10~40-45
FHB (+) 140 bpm

2nd stage of
labor

VT (TAP)
CD complete, AM (-)
Head palp, OA, HIII+
Unpalp small part/ umb
cord

ICD X

Instruction :
Pdx : Tx :
Lead to bear down
At 03.40 am, born baby
, 2950 g, vigorous,
episiotomy (+)
Tx :
Management active 3rd
stage of labor

3rd stage of
labor
At 03.45 pm, born
placenta complete,
done perineal hecting

SAD, 31 yo

SAD, 31 yo

OBSTETRIC EMERGENCY ROOM REPORT

DUTY ON : SATURDAY, NOVEMBER 7th 2015
4. KAT, 18 yo
N0

1.

GAP
DATA BASED

Anamnesis (ICD IX : 89.03) :

Referred from PHC I Denpasar Timur
with G1P0000, 37 weeks 4 days,
breech pres, S/L, PROM.
Watery vaginal discharge (+) since
01.00 am (8/11/15). Labor pain (-), FM
(+). Known breech pres since she
came to PHC (7/11/15)
LMP : 04/02/2015
EDD : 11/11/2015
PNC : midwife, O&G
Obstetric history :
1.Current pregnancy
Unmarried
Contraception: -

ASSESS
MENT

PROBLEM
LIST

ICD X

PLAN OF CARE

OBSTETRIC EMERGENCY ROOM REPORT

DUTY ON : SATURDAY, NOVEMBER 7th 2015

4. KAT, 18 yo
N0

DATA BASED

2.

Physical Examination (ICD IX 89.03)

W/H : 60/161
Present state :
BP : 120/80
RR : 20
P : 84
Tax : 36.5
General st :
Eyes : anemic (-)
Thorax : Cor :S1S2 sgl, reg, m (-)
Po : Ves +/+, rh -/-, wh -/Abd
: ~ Obstetric state
Ext
: warm +/+
+/+
Obstetric State:
Abdomen : FH 3 finger bpx (37 cm), w
4/5
LA 98 cm, UC (-)
FHB 144 bpm
Vagina : Insp v/v :
amniotic fluid (+) from OUE
Lacmus test (+)
VT (GAP) 06.10 am:
CD 1cm, eff 25%, AM (-)
buttock palp, unclear denom,HI
unpalp umb cord

ASSESS
MENT

PROBLEM
LIST

ICD X

GAP

PLAN OF CARE

OBSTETRIC EMERGENCY ROOM REPORT

DUTY ON : SATURDAY, NOVEMBER 7th 2015
4. KAT, 18 yo

GAP

N0

DATA BASED

3.

USG (ICD IX : 88.78) :

Fetus (+), S/L, FHB(+),FM(+), breech
pres
Biometry :
BPD : 9.57~ 39W5D
AVE : 39W0D
HC : 33,62 ~38W2D
EFW : 3672 g
AC : 35.09 ~39W5D
EDD :
15/11/15
FL : 7.39 ~ 37W5D
Placenta fundus corpus posterior III
AFI : 9,1 cm
CTG ~ Normal

4.
Lab (ICD IX 99.07) :
WBC : 20,8
HCT : 37,3
HGB : 11.4
PLT : 223
BT/CT : 130/930

ASSESS
MENT
G1P0000,
39 weeks 4
days, S/L,
breech
pres, PROM
EFW :3672g

PROBLEM
LIST
1. Breech
pres
2. PROM

ICD X

PLAN OF CARE

O32.1
O42.1

Intervention :
1. CS
2 Risk of infection

ICD IX
74.0
99.21

Target :
1.Born baby
vigorously and
mother in agood
condition
2.Reduce risk of
infection
Instruction:
Tx:
1.Pre op
2.CS Cito
At 08.25 am born
baby , 3980 g,
vigorously

Thank
you