MORNING REPORT

April 26th 2012

Supervisor : dr. Edi Prasetyo W, SpOG
Medical Students:
Nana, Ira, Nisia, Fahmi, Heri, Hasaniah, Rani, Zihni, Fadhil

Cases resume :
Normal Labor

Phatologic Labor

G3P2A0L2 37-38 weeks/S/L/IU breech presentation with active phase

first stage of labor
G5P4A0L3 A/S/L/IU with active phase 1st stage of labor
G3P2A0L1 38-39 weeks/S/L/IU with impending eclamsia

Name

: Mrs. H

Age

: 30 years old

Address

: Narmada

CTH

: April 25h 2011

At 13.00 wita

Time

Subject

Object

Assesment

Planning

25/04/
2012
13.00

Patient referred from Sumbawa GH

with G3P2A0L2
A/S/L/IU active
phase first stage of labor with
severe
preeklampsia.
History
rupture of membrane (+) since
06.30
(25/04/2012).
Patient
confessed abdominal pain since
06.00 (25/04/2012), bloody slim
(+). FM (+). History of DM (-), HT (), asthma (-).

General Condition : well

Consciousness : CM
BP : 160/100 mmHg PR : 88 x/minute
RR: 26 x/minute
T : 37,4C

G3P2A0L2 A/S/L/IU
active phase first stage
of labor with severe
preeklampsia

Observe mother &

fetal well being
DL,
UL,
HbSAg
checked
Observe progress of
labor

LMP : Forgot
EDD : History of ANC : >4x, at PHC
Last ANC : 13/04/12
History of USG : never

Obstetrical history :
I. Aterm,
male,
3300
g,
spontant, midwife, PHC, 12 yo
II. Aterm, female, 3000 g,
spontant, midwife, PHC, 7 yo
III. This

Status Generalis:
Eye :anemis(-), icteric (-)
Thorax :
Cor : S1S2 single reguler (murmur -),
(gallop -)
Pulmo : vesikuler (+/+), wheezing (-/-),
Ronkhi (-/-).
Abdomen : scar (-), striae (+),linea
nigra(+)
Extremity : edema (-), warm acral (+)
Obstetrical status :
L1 : breech UFH: 32 cms
L2 : fetal back on right side
L3 : head
L4 : 4/5
EFW : 3255 gram
UC: (+), 2 x 10 30
FHR : (+), 11-11-12 (136bpm)
VT : 9 cms, eff 90%, amnion (-) clear ,
head palpable HI, denominator
unclear, Unpalpable small part /
umbilical cord.

Time

14.00

Chronologist :

Lab :
DL:HGB : 10,2
RBC : 3,07
HCT : 34,5
WBC : 16,0
PLT : 478
HbSAg : Urineprotein : +2

Mother confessed abdominal pain

more often

General Condition : well

Consciousness : CM
BP : 140/90 mmHg PR : 84 x/minute
RR: 24 x/minute
T : 36,6C
UC : (+) 2 x 10 ~30
FHR : (+) 11-12-12 ( 140x )
VT :

Arrested active phase

first stage of labor +
PEB

Obs. Mother and fetal

well being
DM co to GP, GP co to
SPV, SPV adv:
- Improve UC
- Give Nifedipine oral 1
tab/8hours (15.10)
- Inj. Ampicillin 1g/IV
(15.35)

Subject

16.05

Abdominal pain (++)

Object

Assesment

Planning

General Condition : well

Consciousness : CM
BP : 160/100 mmHg PR : 88 x/minute
RR: 26 x/minute
T : 37,4C

Arrested active phase

1st stage of Labor with
severe preeklampsia

- Obs Mother and fetal

well being
- Obs progress of Labor
- Co to SPV pro CS, SPV
adv: acc CS, CIE
patient and family,
rehidration, call SPV
again at 19.30

Arrested active phase

1st stage of Labor with
severe preeklampsia

Co to SPV, SPV adv:

Pro CS cito now

Obstetrical status :
L1 : breech UFH: 36 cms
L2 : fetal back on right side
L3 : head
L4 : 4/5
EFW : 3875 gram
UC: (+), 4 x 10 40
FHR : (+), 12-13-12 (148bpm)
VT : 9 cms, eff 90%, amnion (-) clear ,
head palpable HI, denominator sutura
sagitalis transversal, moulage Gr. I,
unpalpable small part / umbilical cord.

19.30

General Condition : well

Consciousness : CM
BP : 150/90 mmHg PR : 92 x/minute
RR: 24 x/minute
T : 37,5C
Obstetrical status :
UC: (+), 4 x 10 40
FHR : (+), 13-13-12 (152bpm)
VT : 9 cms, eff 90%, amnion (-) clear ,
head palpable HI, denominator sutura
sagitalis transversal, moulage Gr. III,
caput (+), unpalpable small part /
umbilical cord.

Subject

Object

Assesment

Planning

20.00

CS began
Lower segment of uteri thin
Baby was born female, AS 7-9, 3500g, Anus
(+), Anomali congenital (-)
Placenta was born manually, complete,
bleeding 250cc
Intraoperative finding: Ovarian Cist dextra
12x7cm oophorectomy dextra

20.50

CS finished

20.5022.50

Operation
wound pain

GC: well
BP: 110/60 mmHg
PR: 84x/mnt
RR: 20x/mnt
T: 36.5C
UFH: 1 finger below umbillicus
UC: (+) good
AB: (-)
UO: 70cc/hour

2 hours post CS

Obs. Mother well being

CIE patient to take a rest
Drip oxytocin 10IU+ketorolac 1amp in RL
500cc 20tpm

Subject

26/05/
12
07.00

Operation
wound pain

Object

GC: well
BP: 110/70 mmHg
PR: 80x/mnt
RR: 20x/mnt
T: 36.8C
UFH: 1 finger below umbillicus
UC: (+) good
AB: (-)
UO: 70cc/hour
Baby in NICU
PR: 144x/mnt
RR: 40x/mnt
T: 5,6C

Assesment

1 day post CS

Planning

Obs. Mother well being

CIE patient to take a rest
Mefenamat Acid 500mg/8 hours
Amoxicillin 500mg/8hours
SF 1 tab/12 hours