Morning Report

Mrs.S, 22 yo, from Suranadi, Narmada,

Hospitalization on 25th December 2012, 11.10
G2P0A1H0, 39 40 wk S/A/IU with PROM > 12 hours

Time

Subject
Chronology (24/12/2012,
21.20,in Narmada PHC):
S: Patient gestation 9 month
came to Narmada PHC
confessed Rupture of
membrane(+) since 09.30
(24/12/2012). (+). Abdominal
pain ( -). Blood slim (+). FM
(+).
LMP : 23/08/2012
O: General status : GC well,
con. CM, BP 120/70mmHg,
PR 80 x/minute, RR 22
x/minute, T 36,5 C.
Obstetric status:
L1: breech TFU: 35 cm
EFW: 3756 gram
L2 : back on the left
L3 : head
L4 : 4/5
UC : 1x/10-20
FHR : 11-11-12 (136x/mnt)
VT : 1 cm, eff. 10 %, Amnion
(-) clear, head palpable,
denom: unclear, HI.
A: G3P2A0H1 A/S/L/IU head
presentation latent phase 1st
stage of labor
- P: - Obs. Mother and fetal
well being.
- Obs. Progress of labor.
- Give parecetamol 3 x 500 mg
+ amoxicillin 3 x 500 mg

Object
Lab
result
25/12/2012:
Hb = 10,4 g/dl
Rbc = 3,98
Leu = 10,04
Plt = 334
Hct = 32,1%
HbSAg = (-)

at

Assessment
11.33

Planning

Time
25-122012
01.02
pm

05.20
pm

Subject
O: General status : GC well,
con. CM, BP 120/70mmHg,
PR 80 x/minute, RR 22
x/minute, T 36,5 C.
UC : 1x/10-20
FHR : 11-12-12 (140x/mnt)
VT : 1 cm, eff. 10 %, Amnion
(-) clear, head palpable,
denom: unclear, HI.
A: G3P2A0H1 A/S/L/IU head
presentation latent phase 1st
stage of labor
P: - Obs. Mother and fetal well
being.
- Obs. Progress of labor.
General status : GC well, con.
CM, BP 120/70mmHg, PR
80 x/minute, RR 22 x/minute,
T 36,5 C.
UC : 1x/10-20
FHR : 11-11-12 (136x/mnt)
VT : 1 cm, eff. 10 %, Amnion
(-) clear, head palpable,
denom: unclear, HI.
A: G3P2A0H1 A/S/L/IU head
presentation latent phase 1st
stage of labor
P: - Obs. Mother and fetal well
being.
- Obs. Progress of labor.

Object
Lab
result
08/06/2012:
Hb = 11,9 g/dl
Rbc = 4,19
Leu = 12,6
Plt = 350
Hct = 39,3%
HbSAg = (-)

at

Assessment
12.00,

Planning

Time
09.20
pm

Subject
O: General status : GC well,
con. CM, BP 110/60mmHg,
PR 80 x/minute, RR 22
x/minute, T 36,5 C.
UC : 1x/10-10
FHR : 11-11-12 (136x/mnt)
VT : 1 cm, eff. 10 %, Amnion
(-) clear, head palpable,
denom: unclear, HI.
A: G3P2A0H1 A/S/L/IU head
presentation white rupture of
membrane > 12 h
P: - Obs. Mother and fetal well
being.
Obs. Progress of labor.
- IV RL 1 flas
- Injection ampicillin 1 gram /
IV
- Referred to GH NTB.

Object
Lab
result
08/06/2012:
Hb = 11,9 g/dl
Rbc = 4,19
Leu = 12,6
Plt = 350
Hct = 39,3%
HbSAg = (-)

at

Assessment
12.00,

Planning

Time

Subject

Object

Assessment

12.00

Planning
DM pro termination
with oxytosin drip and
SPV no answer.

13.00

General status : GC well, con.

CM, BP 120/80mmHg, PR 86
x/minute, RR 20 x/minute, T
37,3 C.
UC : FHR : 13-12-12 (148x/mnt)

G2P0A1H0 39 40
wk S/L/IU with
PROM > 12 hours.

- Observation began
- DM co SPV result
CTG and SPV require
result CTG via MMS.

14.00

General status : GC well, con.

CM, BP 120/80mmHg, PR 80
x/minute, RR 20 x/minute, T
36,7 C.
UC : FHR : 12-12-12 (144x/mnt)

G2P0A1H0 39 40
wk S/L/IU with
PROM > 12 hours.

- IV D5 set
- co repeatedly to SPV
result CTG via MMS.

16.40

DM pro termination
with oxytosin drip SPV
advice to acc drip
Oxytocin.

Time

Subject

Object

16.45
(at DR
Teratai)

UC : FHB : 12.12.12 (144 x/minute)

17.15

UC: 2 x 10 20
FHB: 13.14.14 (164x/minute)

17.45

UC: 2 x 10 25
FHB: 13.14.14 (164x/minute)

Assessment
PROM > 12 hours.

Planning
-CTG, result reactive,
Oxytocin Drip.
Drip Oxytocin (1st
flash):
-8 dpm
-12 dpm

-16 dpm

18.15

UC: 4x/10 ~ 30
FHB: 13.13.12 (152x/minute)

- 20 dpm

18.45

UC: 4x/10 ~ 35
FHB: 13.13.13 (156x/minute)

-24 dpm
-28 dpm

19.15

UC: 4x/10 ~ 45
FHB: 13.13.13 (156x/minute)

-28 dpm

19.45

UC: 4x/10 ~ 45
FHB: 13.12.13 (152x/minute)

20.15

Patien complien to delivary

UC: 4x/10 ~ 45
FHB: 12.12.12.(144x/minute)
VT : 4 cm, eff. 50 %,
Amnion (-) clear, head
palpable, denom: clear, HI.

G2P0A1H0, 39 40
wk S/A/IU with active
phase 1st stage of
labor

-28 dpm

Time
20.45

Subject
-

Object

Assessment

UC: 4x/10 ~ 45
FHB: 13.13.13 (156x/minute)

Planning
-28 dpm
-28 dpm

21.15

UC: 4x/10 ~ 45
FHB: 13.13.13 (156x/minute)

-28 dpm

21.45

UC: 4x/10 ~ 45
FHB: 13.13.13 (156x/minute)

-28 dpm

22.15

UC: 4x/10 ~ 45
FHB: 13.12.13 (152x/minute)

-28 dpm

22.45

UC: 4x/10 ~ 45
FHB: 13.12.13 (152x/minute)

-28 dpm

23.15

UC: 4x/10 ~ 45
FHB: 12.12.12.(144x/minute)

-28 dpm

23.45

UC: 4x/10 ~ 45
FHB: 12.12.12.(144x/minute)

- 28 dpm

00.15

UC: 4x/10 ~ 45
FHB: 12.12.12.(144x/minute)
VT : 10 cm, eff. 100 %,
Amnion (-) clear, head
palpable, denom: clear, HI.

2nd stage of labor.

- 28 dpm

Time
00.30

Subject
Patient want to bearing down.

Object
Seen heads fetus out from
vulva.

Assessment

Planning

2nd stage of labor.

-Lead mother to
bearing down
Amnion fluid: clear
Baby was born (16.42).
Male. 3500 gram. 50
cm, AS 7-9. Anus (+).
Congenital anomaly (-).
Placenta was born
spontan. Complete.
300gram.
Leukia 400cc
Perineum laseration ( +
)

13.30

GC : well
BP : 130/80 mmHg
PR : 96 bpm
RR : 20 dpm
Temp : 36,6C
UC : +
UFH : 2 finger below
umbilicus.
Lochea: +
Baby rooming in:
PR: 144 x/mnt
RR: 44 x/mnt
T: 36,3 C

2 hours post partum

-Obs. Mother and baby
well being.
-CIE mother to eat and
drink.
-Suggest mother to
breast feeding.

Time
08/06/12
07.00

Subject
-

Object
GC : well
BP : mmHg
PR : bpm
RR : dpm
Temp : C
UC : +
UFH : 2 finger below
umbilicus.
Lochea: +
Baby rooming in:
PR: 130 x/mnt
RR: 36 x/mnt
T: 34,4 C

Assessment
1st day post partum

Planning
-Obs. Mother and baby
well being.
- CIE mother to
mobilization, eat and
drink.
-Suggest mother to
breast feeding.