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Morning Report VK

December 01st 2014


Supervisor : dr. Edi Prasetyo W., Sp.OG
DM:
Anshoril, Diana

Name
Age
Address
Admitted
RM
Diagnose

: Mrs. M
: 28 yo
: Taman Sari, Gunung
Sari,
Lombok Barat
:December, 01st 2014
: 550835
: G2P1A0L1 A/S/L/IU
head
presentation
with history of CSection 13 years ago
and CPD.

Time

December
01st 2014
03.30 wita

Subjective

Objective

Patient referred from Gunung Sari


PHC came to VK IRD of NTB GH,
confessed 9 month of pregnancy
with abdominal pain spread to flank
region (+) since 20.00 wita
30/11/2014, water leaked out from
her womb (-) , bloody slim (+) since
02.00 wita (1/12/2014), FM (+)
History : DM (-), HT (-), Asthma (-)
Family history : DM (-), HT (-)
LMP : ?-03-2014
EDD : ?- 12-2014
ANC history : 9x at PHC
Last ANC : 26/11/2014
BP : 120/90 mmHg, BW : 60
UK : 36 weeks, UFH : 32 cm,
Presentation : head, FHB (+)

kg,

USG History : 1 x at Sp.OG


Result : (13/10/2014)
Fetal S/L/IU head presentation, EFW
2412 gr, AFI : suficient, clear.
Placenta in fundus grade III, UK : 3435 weeks, EDD: 26/11/2014
Familiy planning history : Injection 3
months/2 years
Next family planning : IUD
Obstetrical history :
I. aterm/4000 grams/female/SC/
RSUP NTB/15 yo

General status
GC : well
GCS : E4V5M6
BP : 120/90 mmHg
PR : 84 bpm
RR : 22 tpm
T : 36,9 0C
Eye : anemis (-/-), ikteric (-/-)
Cor : S1S2 single, M (-), G (-)
Pulmo : BVes (+/+), Whz (-/-),
Rh (-/-)
Abdomen : striae gravidarum
(+), linea nigra (+), scar (+)
Extremity :
Upper : oedem (-/-), warm

(+/+)
Lower :oedem (-/-),warm

(+/+)
Obstetrical Status
L1 : breech L2 : back at left
side
L3 : head
L4 : 4/5
UFH : 31 cm EFW : 3100 gr
UC : + His: 3x/10~30
FHB : 12-12-11 (140 bpm)
VT : 3 cm, eff : 25%, amnion
(+), head presentation, denom
unclear, HI, impapable small
part of fetus/ umbillical cord

Assessme
nt

Planning

G2P1A0L1
A/S/L/IU
head
presentatio
n latent
phase 1st
stage of
labor with
history of
C-Section
15 years
ago

Diagnostic:
Laboratoriu
m test
Obs.
Mother and
fetal well
being
Obs.
Progress of
labor
CIE family

Time

Subjective

Objective

PS : 6
Cervix Dilatation : 2
Cervix length : 1
Cervix position : 1
Station : 1
Cervix Consistency : 1
PE :
Spina ischiadica: not prominent
Os coxygeus : mobile
Arcus pubis : >90o
Lab result :
HB : 11,7 g/dL
HCT : 35,6 %
WBC : 15,78x 103/uL
PLT : 283 x 103/uL
BT : 210
CT : 620
HbsAg : (-)
Proteinuria : -

Assessm
ent

Planning

Time

Subjective

Chronologist at Gunung Sari PHC


(01/12/2014) 02.55 wita:
Patient with 9 month of pregnancy
with abdominal pain spread to flank
region (+) since 20.00 wita
30/11/2014, water leaked out from
her womb (-) , bloody slim (+) since
02.00 wita (01/12/2014), FM (+).
LMP : forgot
EDD :O/
BP : 130/80 mmHg
HR: 80 bpm
RR: 22 tpm
T: 36,7 0C
L1
L2
L3
L4

:
:
:
:

breech
back on the right side
head
4/5

UFH: 35 cm
FHB : 11-11-12 (136 bpm)
UC : 3x/10-35
VT : 3 cm, eff 50%, amnion (+),
head palpable, HI, impalpable
small part of fetus or umbilical cord.
A/ G2P1A0L1 40-41 wks L/IU head
presentation postterm with history
of C-Section 15 years ago
P/-

Objective

Assessme
nt

Planning

Time

Subjective

Objective

Assessment

Planning

December, 01st
2014

GC : Well
BP : 130/80 mmHg
PR : 80 bpm
RR : 22 tpm
T : 36,0 0C
UC : +
His:
3x/10~35
FHB : 12-11-11 (136 bpm)
VT : 5 cm, eff : 50%,
amnion (-) clear, head
presentation, denom
unclear, HI, impapable
small part of fetus/
umbillical cord,

active phase
labor

04.30

08.30 wita

GC : Well
BP : 120/80 mmHg
PR : 84 bpm
RR : 22 tpm
T : 36,0 0C

Obs. Mother and fetal well


being.
Suggest mother to eat
Skin test and injection
ampicillin 1 gr/IV

DM co. GP, GP co. SPV pro


C-Section
CIE Familiy
Preparing SC

UC : +
His:
4x/10~40
FHB : 12-12-13 (148 bpm)
VT : 10 cm, eff : 100%,
amnion (-) clear, head
presentation, denom
unclear, HII impalpable
small part of fetus/
umbillical cord

09.00 wita

CS began
Baby was born, female,
BW 3300 gr, BL 49 cm,

Time

Subjective

11.00 wita

02/12/2014
07.00 wita

Mobilization (+), eat


and
drink
(+)
breastfeeding (+),
BAK (+), BAB (-)

Objective

Assessmen
t

Planning

General condition: Good


BP : 130/80 mmHg
HR : 84 bpm
RR : 22 tpm
T : 36,7oC
UFH : 1 finger below
umbilical
UC : (+) well
Lochia rubra +
UO : 600 cc
Active bleeding (-)
Baby was in NICU. HR
144 bpm
RR : 58x/m, T: 36,6 C

2 hours Post
CS

Observation Mother and


baby well being
mother
to
Suggest
mobilization
Suggest mother to eat
and drink

General condition: Good


BP : 130/80 mmHg
HR : 84 bpm
RR : 22 tpm
T : 36,7oC
UFH : 1 finger below
umbilical
UC : (+) well
Lochia rubra +
UO : 100 cc/hour
Active bleeding (-)
Baby was in NICU. HR
148bpm
RR : 58x/m, T: 36,6 C

1 day post
partum

Observation Mother and


baby well being
Suggest
mother
to
mobilization
Suggest mother to eat
and drink

THANK YOU