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Morning Report

July 16th 2014


Supervisor : dr. I Made Putra
Juliawan, Sp.OG
Medical Students :
Yid, Ayu, Zia, Santi
CASE RESUME
NORMAL LABOR

PATHOLOGY
LABOR

1
2

G5P4A0L4 with head presentation 41 wks S/L/IU with


neglected active phase of labor
G1P0A0L0 A/S/L/IU head presentation latent phase with
history of ROM

Case Report
Name: Mrs. N
RM
Age

: 542525
: 37 years old

Address : Narmada
Admitted : July, 15th 2014 (22.45)
Diagnose

: G5P4A0L4 with head presentation


41 wks S/L/IU with neglected active phase of
labor

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

15/07/
2014
22.45
wita

Patient was reffer from Narmada


PHC with G5P4A0L4 head
presentation 41 wks S/L/IU with
neglected Active Phase of Labor.
Patient came to VK IRD NTB GH
confess lower abdominal pain that
spread to flank region since 19.00
wita (15/07/2014), history of
membrane ruptured at 16.00 wita
(15/07/2014), bloody slim (+).
Fetal movement (+).
No history of DM, HT, asthma or
allergy.

General Status :
GC : moderate GCS : E4V5M6
BP : 120/80 mmHg
PR : 84 bpm
RR : 22 bpm
T : 36,8oC
Eye : anemis (-), icteric (-)
Cor : S1S2 single regular, murmur
(-), gallop (-).
Pulmo : vesiculer (+/+), wheezing
(-/-), ronkhi (-/-).
Abdomen : scar (-), stria
gravidarum (+), linea nigra (+).
Extremity : edema (-/-), warm acral
(+/+).

G5P4A0L4 with
head presentation
41 wks S/L/IU
with neglected
active phase of
labor

Observation mother &


fetal well being.
Lab exam

LMP : 01/10/2013
EDD : 08/07/2014
History of ANC : never
History of USG : never
History of family planning : pil
Next family planning : IUD
Obstetrical History :
I. Aterm/female/2500g/normal/
14yo
II. Aterm/female/3000g/normal/
13yo
III. Aterm/female/3100g/normal/
10yo
IV. Aterm/female/3600g/normal/
4,5yo
V. This

Obstetrical Status :
L1 : breech
L2 : back on the right side
L3 : head
L4 : 3/5
UFH : 33 cm
EFW : 3410 gram
UC : 3x10~35
FHB : 13-13-14 (160 bpm)
VT : 8 cm, eff. 75%, Amnion (-),
head palpable, caput (+), HII,
impalpable small part of fetus or
umbilical cord .

DM co to GP pro
resucitation and CS,
GP advice:
resucitation
GP co to SPV pro CS
and SPV advice :
If his no adequate,
Accelaration till 20
dpm
Observe. Progres of
labor

TIME

SUBJECTIVE
Chronologist at poskesdes:
20.25 wita (15/07/2014)
S/ Patient come to Poskesdes
with lower abdominal pain refer to
flank region and history of bloody
slim, mother wants to bearing
down.
O/
BP : 120 / 80 mmHg
HR: 84 bpm
RR: 21 tpm
T: 36,5
UFH: 31 cm
FHB : 11-12-11 (136 x/minute)
UC: (+) 4x10~40
VT : 9 cm, eff. 90%, amnion
(-), head palpable, HIII, denom
LOA, portio oedema (+),
impalpable small part / umbilical
cord.
A/ G5P4A0L4 40 wks S/L/IU with
head presentation, mother and
fetal well being with neglected
labor
P/
KIE family
Infus RL
Reffer to PHC narmada

OBJECTIVE
PE :
Spina ischiadica not prominent,
Os coccygeus mobile,
Arcus pubis > 900
Lab Examination :
HB : 9,6 g/dl
RBC : 3,46 x 106/L
HCT : 28,7 %
WBC : 16,16 x 103/L
PLT : 327 x 103/L
HbSAg : (-)

ASSESSMENT

PLANNING

TIME

SUBJECTIVE
Chronologist at |Narmada PHC:
21.30 wita (15/07/2014)
S/ Patient came from poskesdes
dasan tereng with neglected labor,
patient confess abdominal pain
since 19.00 wita. FM (+), water
leaked out from her vagina since
20.25 at poskesdes
LMP : 01/10/2013
O/
BP : 120 / 80 mmHg
HR: 88 bpm
RR: 20 tpm
T: 37,9
UFH : 34 cm
FHB : 14-14-13 (168 x/minute)
UC: (+) 3x10~35
VT : 8 cm, eff. 75%, amnion
(-), head palpable, portio oedema
(+), head HII, denom. LOA,
impalpable small part / umbilical
cord.
A/ G5P4A0L4 41 wks S/L/IU with
head presentation, mother and
fetal well being with neglected
labor
P/
KIE family
Inj. Ampisilin 1 gr /IV
Paracetamol 500 mg
Reffer to GH NTB with O2 4 lpm

OBJECTIVE

ASSESSMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

23.30 wita

UC : 3x10~30
FHB : 13-13-14 (160 bpm)

Drip oxy 8 dpm

16/07/2014
00.00 wita

UC : 3x10~30
FHB : 12-13-12 (148 bpm)

Drip oxy 12 dpm

00.30 wita

UC : 3x10~30
FHB : 13-13-12 (152 bpm)

Drip oxy 16 dpm

01.00 wita

GC : well
GCS : E4V5M6
BP : 110/80 mmHg
PR : 88 bpm
RR : 20 bpm
T : 36,4oC
UC : 3x10~30
FHB : 14-14-15 (172 bpm)
VT : 8 cm, eff. 75%, Amnion (-),
head palpable, caput (+), HII,
oedema portio (+), molase
(+)impalpable small part of fetus or
umbilical cord

DM co to GP pro CS, co
to SPV , advice:
Prepare for CS

01.30 wita

KIE family about CS


Inj. Cefotaxime 2 gr I.V
(skin test before injection)
DC

Send patient to operation


room

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

02.30
wita

PLANNING
CS began
(02.36) Baby was
born, male, BW 3900
gr, BL 54 cm, AS 7-9 ,
anus (+), kongenital
anomaly (-)
Placenta delivered
completed, bleeding
150 cc.

04.30
wita

General condition: Good


BP : 120/80 mmHg
HR : 84 bpm
RR : 22 tpm
T : 36,7oC
UFH : at umbilical
UC : (+) well
Lochea rubra +
UO : 70 cc/ho

07.00
wita

General condition: Good


BP : 110/80 mmHg
HR : 84 bpm
RR : 20 tpm
T : 36oC
UFH : 2 finger bellow umbilikus
UC : + well
Active bleeding: (-)
Lochea rubra +
UO : 60 cc/ho

2 hours Post CS

Observation Mother
and baby well being
Suggest mother to
mobilazation
Suggest mother to eat
and drink

1 day post CS

Observation Mother
and baby well being
Suggest mother to
mobilazation
Suggest mother to eat
and drink

TIME
17/07/
2014
07.00
wita

SUBJECTIVE

OBJECTIVE
General condition: Good
BP : 120/80 mmHg
HR : 88 bpm
RR : 20 tpm
T : 36,4oC
UFH : 3 finger bellow umbilikus
UC : + well
Active bleeding: (-)
Lochea rubra +
UO : 60 cc/ho
Baby in NICU
Pulse : 144 bpm
RR : 58x/m
T : 36,4 C

ASSESSMENT

PLANNING

2 day post CS

Observation Mother
and baby well being
Suggest mother to
mobilazation
Suggest mother to eat
and drink

CASE 2
Name : Mrs.H
Age
: 35 years old
Address : Sesela, Gn. Sari
Admitted : 15-07-2014
No. RM
: 54-25-12
G1P0A0L0 A/S/L/IU head presentation
latent phase with history of ROM

Time
15-072014
17.40

Subject
Patient come to NTB GH
referred from Gn. Sari PHC
with G1P0A0L0 A/S/L/IU
head presentation with
latent phase + history of
ROM.
Patient 9 months pregnancy
confessed abdominal pain
since 14-07-2014 (20.00),
bloody slim (+), water come
out from her vagina (+) 1507-2014 (08.00), and FM
(+).
History of DM (-), HT (-),
asthma (-).
LMP : forget
EDD : History ANC : 3x at
posyandu
Last ANC : 28-02-2014
result: BP : 120/80, BW 55
kg, 20 weeks

Object
General status
GC : well
GCS: CM (E4V5M6)
BP : 120/80 mmHg
HR: 88 x/m
RR: 22 x/m
T: 36,5 C
Local status
Eye : an (-/-), ict (-/-)
Pulmo: ves (+/+), rh (-/-), wh
(-/-)
Cor : S1S2 single regular, M(-),
G(-)
Abd : striae gravidarum (+),
linea nigra (+), scar (-)
Ext : edema (-/-), warm (+/+)
Obstetric status
L1 : breech
L2 : back on the right side
L3 : head
L4 : 4/5
UFH: 31 cm
EFW : 3100 gram
UC : 3 x 10 ~ 30
FHB : 11-10-11 (148x/min)

Assessment
G1P0A0L0
A/S/L/IU head
presentation
with latent
phase +
history of ROM

Planning
Obs. Mother and
fetal well being
Observation
progress of labor

Time

Subject
History of USG : History of family
planning : Next family planning :
IUD
History of obstetric :
I.
This

Object
VT : 3 cm, eff. 50 % amnion (-)
clear, head palpable, HI, denom
unclear, unpalpable small part of
fetus/ umbilikal cord
Pelvic examination:
Promontorium unpalpable
Spina ischiadica not prominent
Os coccygeus mobile
Arcus pubic > 90 degree
Lab:
HGB = 10.4 g/dl
RBC = 4.00 K/ul
WBC = 17.96 M/ul
HCT : 31.9 %
PLT = 288 M/ul
HBsAg = (-)
BT 250
CT 500

Assessment

Planning

Time

Subject
Chronologist : at Gn. Sari PHC (15-072014 08.15)
S : Patient 9 months pregnancy, confessed
lower abdominal pain and flank pain
since 14-07-2014 (20.00) . Bloody slim
(+) Water come out from her vagina (+)
since 15-07-2014 (08.00), FM (+).
O : GC : well
Cons : CM
BP : 120/70mmHg
HR : 82x/m
RR : 20x/m
T : 36,6
UFH : 31 cm
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
FHR : +
UC : 2x10-35
VT : 1 cm, eff 50%, amnion (-), head
palpable, HI+, unpalpable small part of
fetus/ umbilical cord
A : G1P0A0L0 40 weeks /S/L/IU head
presentation latent phase 1st stage
P : left lateral decubitus position, inj.
Ampicillin, observation mother and fetal
well being

Object

Assessment

Planning

Time

Subject
12.15
S : abdominal pain and flank pain
O : GC : well
Cons : CM
BP : 120/80mmHg
HR : 80x/m
RR : 20x/m
T : 36,5
VT : 2cm, eff 50%, amnion (-) , head palpable, H1,
unpalpable small part of fetus/ umbilcal cord
A : G1P0A0L0 40 weeks /S/L/IU head presentation
latent phase 1st stage with history of ROM
P : suggest mother to eat and drink,
15.00
inj.ampicillin (2nd)
16.15
S : abdominal pain more frequently
O : GC : well
Cons : CM
BP : 120/80mmHg
HR : 84x/m
RR : 22x/m
T : 37,
FHB: 136 ~ 11-11-12
VT : 2cm, eff 25%, amnion (-) clear, head palpable,
H1, unpalpable small part of fetus/ umbilcal cord
A : G1P0A0L0 40 weeks /S/L/IU head presentation
latent phase 1st stage with history of ROM
P : referred to NTB GH, IV line

Object

Assessment

Planning

Time

Subject

Object

Assessment

Planning

21.35

GC: well
BP: 120/70 mmHg
HR: 80 bpm
RR:20 bpm
T: 37 0C
HIS: 3x/10 ~ 30
DJJ: 12-12-13
VT : 4 cm, eff. 50 %,
Amnion (-) clear , head
palpable HI denominator
unclear, impalpable small
part of fetal & umbilical
cord.

Active phase

Obs. Mother and fetal


well being
Observation progress of
labor with partograf
WHO

16-072014
01.45

GC: well
BP: 120/70 mmHg
HR: 80 bpm
RR:20 bpm
T: 37,1 0C
HIS: 4x/10 ~ 40
DJJ: 12-11-12
VT : 4 cm, eff. 50 %,
Amnion (-), head palpable
HI, denominator unclear,
impalpable small part of
fetal & umbilical cord.

Arrested active
phase

DM co to GP pro CS, GP
co to SPV, adv: CS
Preop: dower catheter,
inj.cefotaxim (skintest)

Time
04.15

Subject

Object

Assessment

Planning
CS began
Baby was born (04.24),
female, AS 7-9, 3350
gram, 51 cm, Anus (+),
congenital anomaly (-),
meconeal (-),
Placenta was born
complete, bleeding 400
cc

07.00

Abdominal wound
pain

GC: well
GCS:E4V5M6
BP: 120/70 mmHg
PR: 88x/m
RR: 20x/m
T: 36 0C
UC: (+) well
UFH: 2 fingers below
umbilicus
Active bleeding: (-)
UO: 200cc/2 hour
Lokea rubra (+)

2 hours post CS

Observation mother and


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

Time

Subject

17-072014
07.00

Abdominal wound
pain

Object
GC: well
cons:E4V5M6
BP: 120/80 mmHg
PR: 88x/m
RR: 20x/m
T: 36,4 0C
UC: (+) well
UFH: 2 fingers below
umbilicus
Active bleeding: (-)
UO: 60cc/hour
Lokea rubra (+)
Baby in NICU
Pulse : 140 bpm
RR : 56x/m
T : 36,5 C

Assessment
1 day post CS

Planning
Observed mother and baby
well being
Suggest mother to
mobilisation.

THANKYOU