Morning Report

4
th
December 2013
Supervisor : dr. Agus Thoriq, Sp.OG
Medical Students :
Erna, Alpi, Rangga, Rara, Putri
RESUME
PATOLOGY LABOR:
1. G4P3A0H2 A/S/L/IU breech presentation
with active phase of labor + history of ROM

Name : Mrs. R
RM : 528046
Age : 37 years old
Address : gunung Sari
Admitted : December 4
th
2013
Case Report
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
04/12
/2013

17.10
Patient referred from Gunung
Sari PHC with G4P3A0L2 A/S/L/IU
with active phase of labor &
breech presentation. Patient
confessed abdominal pain that
spread to frank since 09.00
(04/12/13). Bloody slim (-).
History rupture of membrane (+)
09.00 (04/12/13), FM (+).
No history of DM, HT, asthma.

LMP : forgot
EDD : (-)

History of ANC : 5x at Posyandu
Last ANC : 16/11/2013
History of USG : (-)

History of family planning : oral
KB
Next family planning : -

Obstetrical History :
1. Female, 9 month, spontan,
TBA, 15 years old, life.
2. Male, 9 month, spontan, TBA,
1,5 years old, death.
3. Male, 9 month, spontan, TBA,
11 years old, life.
4. This
General Status :
GC : well
BP : 120/80 mmHg
PR : 90 bpm
RR : 22 bpm
Temp : 36,5
o
C

Eye : palor (-/-), icteric (-/-)
Cor : S
1
S
2
single regular,
murmur (-), gallop (-).
Pulmo : vesicular (+/+),
wheezing (-/-), ronkhi (-/-).
Abdomen : scar (-), striae (+),
linea nigra (+).
Extremity : edema (-/-), warm
acral (+/+).

Obstetrical Status :
L1 : head
L2 : back on the right side
L3 : breech
L4 : W
UFH : 30 cm
AC ; 96 CM
EFW : 2880 gram
UC : 2x10 ~ 35
FHB : 12-12-13 (148 bpm)
G4P3A0H2 A/S/L/IU
breech presentation
with active phase of
labor + history of
ROM
Observation
mother & fetal well
being.
Observation
progress of labor
with partograph

- Inj. Ampicilin 1gr/ 6
hour
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
Chronologist at PHC Gn Sari
15:30
S : Patient confessed
abdominal pain that spread to
frank since 13.00 (4/12/13).
Meconium (+). FM (+).
O :
GC : well
BP : 120/80 mmHg
PR : 84 bpm
RR : 24 bpm
T : 36,7
o
C
UFH : 30
AC : 96
L1 : head
L2 : back on the Right side
L3 : breech
L4 : (-)
EFW : 2880 gr
FHB : 11-11-11 (132 bpm)
UC : 2x/10~30
VT : 4 cm, amnion (-), breech
palpable, H1, impalpable
fetal and umbilical cord.
A : G4P3A0L2 A/S/L/IU with
inpartu active phase breech
presentation
P : - explain examination result
- Co to GP adv Refer to NTB GH
VT : 5 cm, effacement 50 %, amnion (-
), breech palpable HI, impalpable
umbilical cord and small part

ZA score : 7
Multigravida (1)
Gestation age : < 37 weeks (2)
History of breech presentation : 1x(1)
EFW : 3100 g (1)
5 cm (2)
Station : <- 3 (0)

Lab Examination :
HB : 11,2 g/dl
RBC : 3,87 x 10
6
/L
WBC : 16,2 x 10
3
/L
PLT : 428 x 10
3
/L
HCT : 32,5 %
HbSAg : (-)


TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
18.00 Abdominal pain (+)

GC : well
BP : 120/80 mmHg
PR : 88 bpm
RR : 20 bpm
T : 36,7
o
C
UC : 3x/10 ~ 35
FHB : 11-11-12 (136 bpm)

G4P3A0H2 A/S/L/IU
breech presentation
with active phase of
labor + history of
ROM

- Obs. mother and fetal well
being.
- Obs. progress of labor
19.50 Patient want to bearing
down
Breech seen in vulva

2
nd
stage of labor Conduct labor with spontan
bracht
19.55 2
nd
stage of labor

Manual aid louvset &
mauriceau

Baby was born (20.05) :
Male, 3300 gram, BL 50 cm,
AS 3-5
Amnion fluid: clear
Anus (+). Congenital anomaly
(-)
Placenta was born spontan,
complete, 300 gram.

Ny. R
4/ 12 / 2013
23 yo 4 3
0
09.00 (04 / 12/ 2013)
0
U U
0
09.00 (04 / 12/ 2013)
X
17.10
18.10
19.10
36,5 36,7
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
22.00 GC : well
BP : 110/70 mmHg
PR : 96 bpm
RR : 20 bpm
T : 36,5
o
C
UFH : 2 finger below umbilicus
UC : (+) well
Lochea rubra : (+)
2 hours post partum





Observe mother well being
Suggest mother to take a rest,
eat, and drink.



07.00 - GC : well
BP : 110/80 mmHg
PR : 84 bpm
RR : 20 bpm
T : 36,4
o
C
UFH : 2 finger below umbilicus
UC : (+) well

Baby in NICU :
O
2
2 lpm
PR : 108 bpm
RR : 66 bpm
T : 34,3 C

One day post partum Observed mother & baby well
being.
Suggest mother to eat & drink,
mobilisation, medication.