MORNING REPORT

July 23th 2014

Supervisor : dr. Agus Thoriq, Sp.OG
DM :
Sakti, Ita,Nurul, Era, Jatna

CASE RESUME
Case Resume :
No.

Case
Pathology Delivery

1.

G2P1A0L1 A/S/L/IU head

presentation with prolonged 2nd stage
of labor

Total
1

Case Report
Name
Age
Address
Admitted
RM

: Mrs. H
: 23 yo
: Gn. Sari
: 22th July 2014
: 54 29 06

G2P1A0L1 A/S/L/IU head presentation

with prolonged 2nd stage of labor

Time
23/07/
2014

Subject
History of family planning:
injection 3 month
Next family planning:
injection 3 month
Obstetric History:
1.Aterm, Female, 2200
g,doctor, NTB GH, 5 yo, life
2.This

Object
VT : 8 cm, effacement
75%, amnion (+), head
palpable, denom unclear, H
II, unpalpable small part of
fetus/ umbilikal cord
Lab:
HGB = 9,2 g/dl
RBC = 4.23 K/ul
HCT = 29,2 K/ul
WBC = 19,06 M/ul
PLT = 311 M/ul
HBsAg = (-)

Assessment

Planning

Chronologist at PHC:
22/07/14 (10.00 WITA)
S: patient come to Gunung sari PHC
confessed abdominal pain and
bloody slim (+) since 04.00 WITA
(22/07/2014). Water leaked out
from her womb (-) bloody slim (+)
FM (+).
O:
GC : well
BP : 120/80 mmHg
PR: 80 bpm
RR: 20 bpm
T: 36,5C
VT : Complete, eff 100%, amnion
(+), head palpable denom LOA, HI
+, unpalpable small part of
fetus/umbilical cord
A: G2P1A0L1 A/S/L/IU head
presentation with 2nd stage of labor
P:
- Observation of labor
- Suggest mother to eat and drink
- Obs mother and fetal well being

Time

Subject
11.00 WITA
S/ abdominal pain
O/
GC : well
BP : 120/80 mmHg
HR: 80 bpm
RR: 20 bpm
T : 36,50C
VT : complete, eff 100%, amnion (+), head palpable
denom LOA, HI +, unpalpable small part of
fetus/umbilical cord
A: G2P1A0L1 A/S/L/IU head presentation with prolonged
2nd stage of labor.
P:
- Obs mother and fetal well being
- Suggest mother to eat and drink
- Co to GP, Advice Reffered to NTB GH and rehydrasi

Object

Assessment

Planning

Time
22-0714
13.10
WITA

Subject
Abdominal pain ,
Water leaked out
from her womb (+)

Object
General status
GC : well
GCS: CM (E4V5M6)
BP : 110/70 mmHg
PR: 84 bpm
RR: 20 bpm
T: 36,6C
UC : 3x10 40
FHB : 12-12-12 (144 bpm)

Assessment

Planning

Prolonged
active phase

Observation mother and

fetal well being
Suggest mother to eat and
drink

Arrested active
phase

DM Co to GP,GP advice
rehydration
Observation mother and
fetal well being

VT : 9 cm, eff 100%,

amnion (-) clear, head
palpable denom unclear,
HI +, unpalpable small part
of fetus/umbilical cord
13.30
WITA

UC : 3x10 45
FHB : 12-13-12 (148 bpm)

14.00
Wita

UC : 3x10 45
FHB : 12-11-12 (140 bpm)
VT : 9 cm, eff 100%,
amnion (-) clear, head
palpable denom unclear,
HI +, unpalpable small part
of fetus/umbilical cord

Time

Subject

Object

14.30

UC : 4x10 40
FHB : 12-11-12 (140 bpm)

15.00

UC : 4x10 40
FHB : 12-11-12 (140 bpm)

Assessment

15.30
WITA

Planning

GP co to SPV, SPV cant

reach

16.00
WITA

UC : 4x10 40
FHB : 12-11-12 (140 bpm)
VT : complete, eff
100%, amnion (-) clear,
head palpable denom
unclear, HI +, unpalpable
small part of
fetus/umbilical cord

2nd stage

Observation mother and

fetal well being
Suggest mother to eatand
drink
Observation progress of
labor

17.00
Wita

UC : 4x10 40
FHB : 12-11-12 (140 bpm)

Prolonged 2nd
stage of labor

DM co to GP pro CS, GP co
to SPV, SPV advice : acc
VE
CIE family about planning
VE

VT : complete, eff
100%, amnion (-) clear,
head palpable denom
unclear, HI +, unpalpable
small part of
fetus/umbilical cord

Time

Subject

Object

Assessment

18.40
WITA

Planning
VE began
20.05 wita
- Baby was born , female, BW
: 3250 g, BL : 52 cm, AS :79, anus (+), congenital
anomaly (-)
- Placenta was born,
completetly, weight : 500 g
Bleeding : + 150 cc
Ruptur Perineum gr. II
heacting

20.40
WITA

GC : well
BP : 110/80 mmHg
PR: 88 bpm
RR: 20 bpm
T : 36,50C
UC: (+) well
UFH : 2 finger bellow
umbilical
Active bleeding: (-)
Baby in NICU
General condition : well
FHR : 146 bpm
RR : 42x/minute
T
: 36,2 0C

2 hours post VE

Observation mother and

baby well being
Suggest mother to eat and
drink
Suggest mother to
mobilitation
CIE ASI Eksclusif

Time
23-072014
07.00

Subject
-

Object
GC: well cons:E4V5M6
BP: 110/90 mmHg
PR: 88x/minute,
RR: 20x/minute,
T: 36,6 0C
UC: (+) well
UFH: 2 fingers below
umbilicus
Active bleeding: (-)
Baby in Melati rooms
General condition : well

Assessment
1 day post VE

Planning
Observation mother and baby
well being