MORNING REPORT

Anamnesis
Hospital date : September 19
th
, 2014

Name : Mrs. H Name : Mr. Q
Age : 24 years old Age : 25
years old
Religion : Moslem Religion : Moslem
Last Education : S1 Last Education :
Senior High School
Occupation : Housewife Occupation :
Tribe : Bugis Tribe : Bugis
Address : Sidodamai Address : Sidodamai

Anamnesis
Chief Complaint:
Abdominal contraction came and releaved, and bloodslym
came out from her womb.
Present Illness:
Patient reffered by Midwife from PT. Khaleda with chief
complain are abdominal contraction came and releaved since
14 hours before. Mother confessed bloodslym came out from
her womb. Patient was diagnosed as G
1
P
0
A
0
gravid
38-39 weeks, latent phase
1
st
stage of labor + susp.
Gemelli / Makrosomia ?


Anamnesis
History of Past Illness: -

Antenatal Care:
- Patient routinely come to the Midwife for the check up every month.
Last check up is on last week.
- Patient never do examination by USG.
- There is no complain during this pregnancy.

History of Menstruation :
Menarche since 13 years old, cycle of menstruation is 7 days
LMP : 20 12 2013
EDD : 27 9 - 2014

Anamnesis
Marriage History : -
Patients was married since 1 years ago and
once

Contraceptional History: -
Obstretic History
1. 2014 Now pregnancy
Physical Examination
Height/Weight : 149 cm / 80 kg

Consciusness : Composmentis

Vital Sign:
BP : 130/90 mmHg
PR : 80 bpm
T : 36C
RR : 20 bpm
Physical Examination
Head : Normochepaly
Eye : Anemis (-/-), icteric (-/-)
Thorax
Cor : S1 S2 single reguler
Pulmo : vesiculer, rhonki (-/-), wheezing (-/-)
Abdomen : scar (-), striae (+), linea nigra (+)
Ekstremity : edema (-/-), warm acral (+/+)
Obstetric State
Linea nigra (+), striae
albicans (+)
Palpation
Leopold I : UFH : 35 cm, breech
Leopold II : back on the right side
Leopold III : head
Leopold IV : 4/5
VT
3 cm, amnion (+), head
palpable H1
FHB I: 129 bpm, FHB II: 134 bpm; UC 2 x 10 duration 25-30
Inspection
Laboratory Finding
Hb : 10,2 g/dl
WBC : 10.000/mm
3

HCT : 32,6 %
PLT : 277.000/mm
3

BT : 3
CT : 9
GDS : 88 mg/dl
Ur : 20,3 mg/dl
Cr : 0,5 mg/dl
HBsAg : Non Reaktif
112 : Non Reaktif
Diagnosis
G
1
P
0
A
0
gravid 38-39 weeks, Single/Life/Intra
Uterine, head presentation, latent phase 1
st

stage of labor
TIME OBSERVATION
20.38 Receive a new patients from ER, anamnesis and physical examination :
- BP : 180/120 mmHg
- PR : 88 bpm
- RR : 20 bpm
- T : 36,5 C (per axiller)
Leopold I : UFH : 35 cm, breech
Leopold II : back on the right side
Leopold III : head
Leopold IV : 4/5
VT : 3 cm, amnion (+), head palpable H1
FHB I: 129 bpm, FHB II: 134x/m; UC 2 x 10 duration 25-30
G
1
P
0
A
0
gravid 38-39 weeks, S/L/IU, head presentation, latent phase 1
st

stage of labor
21.00 Consult to dr. Sp.OG:
Observation the FHB and UC
03.00 FHB I: 140 bpm; FHB II: 146 bpm
UC : 3 x 10 duration 30-45
06.00
VT 10 cm, amnion (+), head palpable H1
Consult to dr Sp.OG:
- Amniotomy
TIME OBSERVATION
08.10 Amniotomy: green amnion
08.35 VT 10 cm, amnion (-), head palpable H
II
+
bloodslym (+)
FHB I: 130 bpm, FHB II: 135 bpm; UC 3 x 10 x 40
08.40 Consult to dr. Sp.OG:
- Drip oxytocin 5 IU in RL 20 increase 4 dpm/15 minutes, maximum
until 40 dpm
- Evaluation and reconsul in 1 hours
08.45 Drip oxytocin 5 IU in RL 20 dpm
FHB I: 130 bpm, FHB: 135 bpm; UC 3 x 10 x 20-25
09.00 Drip oxytocin 5 IU in RL 24 dpm
FHB I: 136 bpm, FHB: 146 bpm; UC 3 x 10 x 20-30
09.15 Drip oxytocin 5 IU in RL 28 dpm
FHB I: 138 bpm, FHB: 144 bpm; UC 3 x 10 x 30-35
09.30 Drip oxytocin 5 IU in RL 32 dpm
FHB I: 112 bpm, FHB II: 102 bpm; UC 4 x 10 x 30-35
09.45 Drip oxytocin 5 IU in RL 36 dpm
FHB I: 120 bpm, FHB II: 112 bpm; UC 4 x 10 x 30-45
10.00 Drip oxytocin 5 IU in RL 40 dpm
FHB: 121 bpm; UC 4 x 10 x 35-45
TIME OBSERVATION
10.10 Consult to dr. Sp.OG:
- Tappering on oxytocin 40 dpm and reconsul
10.46 The baby born spontaneusly, Male, A/S 7/8 Anus (+), Congenital
Defect (-), Weight 3200 gr, Height 51 cm, green amnion, placenta
born completely, episiotomy on perineum, hecting (+)
Time
Blood
Preassure
PR UFH
Uterus
Contraction
Vesica
Urinaria
Bleeding
11.00 110 / 70 88 At the navel
level
Good Empty 30 cc
11.15 110 / 70 82 At the navel
level
Good Empty 20 cc
11.30 110 / 80 88 At the navel
level
Good Empty 10 cc
11.45 110 / 70 80 At the navel
level
Good Empty 5 cc
12.15 120 / 70 80 At the navel
level
Good Empty 5 cc
12.45 120 / 80 80 At the navel
level
Good Empty 3 cc
Post Partum Observation
THANK YOU