MORNING REPORT

October 26th, 2012

Supervisor : dr. Made Widya

Mahayasa, Sp.OG
Medical Students :
Diah, Rani, Dini, Rifka, Era, Vera, Farid,
Wawan
CASES RESUME

NORMAL LABOR

PATHOLOGY LABOR

1. G3P2A0L2 40-41 weeks S/L/IU head presentation with

postdate and failed drip 2nd serial
2. G1P0A0L0 A/S/L/IU with eclampsia + Susp. Macrosomia +
2nd Stage of Labor neglected.

Case report
Name

: Mrs.SI (062488)

Age

: 35 years old

Address : Sesela, Gunung Sari, LOBAR

Admitted : October 23th 2012, 10.30 WITA

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

23/10/
2012

Patient from Pregnancy Policlinic

NTB GH with G3P2A0L2 40-41
weeks S/L/IU head presentation
with post date. Patient confessed
her
pregnancy
postdates.
Abdominal pain (-) history rupture
of membrane (-), bloody slim (-),
FM (+).
No history of DM, HT, asthma.

General Status :
GC : well
BP : 110/70 mmHg
PR : 72 bpm
RR : 20 bpm
T : 36,5oC
Eye : anemis (-/-), icteric (-/-)
Cor : S1S2 single regular, murmur
(-), gallop (-).
Pulmo : vesicular (+/+), wheezing
(-/-), ronkhi (-/-).
Abdomen : scar (-), stria
gravidarum (+), linea nigra (+).
Extremity : edema (-/-), warm acral
(+/+).

G3P2A0L2 40-41
weeks S/L/IU
head presentation
with postdate

Observation mother &

fetal well being.
DM co SPV : pro
termination
induction oxytocin if
PS 5 and CTG
reactive.

12.30

LMP : 15-01-2012
EDD : 22-10-2012
History of ANC : > 4x at Posyandu
and SpOG
Last ANC : 22-10-2012
History of USG : 1x
Last USG : 22-10-2012
Result : normal
History of family planning
injection 3 months
Next family planning : IUD

Obstetrical History :
I.Male, 9 month, 4000 gr, spontan,
midwife, 12 y.o
II.Female, 9 month, 4000 gr,
spontan, midwife, 8 y.o
III.This

Obstetrical Status :
L1 : breech
L2 : back on the left side
L3 : head
L4 : 5/5
UFH : 36 cm
EFW : 3875 gram
UC : (-)
FHB : 12-12-11 (140 bpm)
VT : -

Result:
PS 5 and CTG
reactive .

TIME

SUBJECTIVE

OBJECTIVE
PS : 5
Cervix dilatation : 1
Cervix length : 1
Cervix consistency : 1
Cervix position : 1
Station H I : 1
CTG reactive
Lab Examination :
Hb : 12.0 g/dl
HCT : 37.3 %
WBC : 9.89 x 103/L
PLT : 178 x 103/L
HbSAg : non reactive

ASSESSMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

15.00

UC : FHR : 12-12-12 (144 bpm)

Infusion oxy drip D5% 8

dpm

15.30

UC : FHR : 12-12-12 (144 bpm)

Infusion oxy drip D5% 12

dpm

16.00

UC : FHR : 12-12-11 (140 bpm)

Infusion oxy drip D5% 16

dpm

16.30

UC : 1x10~10
FHR : 11-12-12 (136 bpm)

Infusion oxy drip D5% 20

dpm

17.00

UC : 1x10~15
FHR : 13-12-12 (148 bpm)

Infusion oxy drip D5% 24

dpm

17.30

UC : 1x10~15
FHR : 12-12-12 (144 bpm)

Infusion oxy drip D5% 28

dpm

18.00

UC : 1x10~15
FHR : 12-12-12 (144 bpm)

Infusion oxy drip D5% 32

dpm

18.30

UC : 1x10~15
FHR : 11-12-12 (136 bpm)

Infusion oxy drip D5% 36

dpm

19.00

UC : FHR : 12-12-12 (144 bpm)

Infusion oxy drip D5% 40

dpm

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

19.30

UC : FHR : 12-12-12 (144 bpm)

Maintenance Infusion oxy

drip D5% 40 dpm

20.00

UC : FHR : 12-12-12 (144 bpm)

Maintenance Infusion oxy

drip D5% 40 dpm

20.30

UC : FHR : 12-12-13 (148 bpm)

Maintenance Infusion oxy

drip D5% 40 dpm

21.00

UC : FHR : 11-12-12 (136 bpm)

Maintenance Infusion oxy

drip D5% 40 dpm (flash
II)

21.30

UC : FHR : 13-12-13 (152 bpm)

Maintenance Infusion oxy

drip D5% 40 dpm

22.00

UC : FHR : 12-12-12 (144 bpm)

Maintenance Infusion oxy

drip D5% 40 dpm

22.30

UC : FHR : 12-12-12 (144 bpm)

Maintenance Infusion oxy

drip D5% 40 dpm

23.00

UC: FHR : 11-12-12 (140 bpm)

Maintenance Infusion oxy

drip D5% 40 dpm

23.30

UC: FHR : 11-11-12 (136 bpm)

Maintenance Infusion oxy

drip D5% 40 dpm

24.00

UC: FHR : 12-12-12 (144 bpm)

Maintenance Infusion oxy

drip D5% 40 dpm

00.30

UC: FHR : 11-12-12 (140 bpm)

Maintenance Infusion oxy

drip D5% 40 dpm

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT
G3P2A0L2 40-41
weeks S/L/IU head
presentation with
postdate and failed
drip 1st serial

PLANNING

24/10/
2012
01.00

UC : FHR : 12-12-12 (144 bpm)

Drip Oxy Fls II finished

changed with RL
Pro co.tomorrow

07.00

GC : well
BP : 110/70 mmHg
PR : 72 bpm
RR : 20 bpm
T : 36,5oC
UC : FHR : 11-12-12 (140 bpm)

Co.SPV advice: rest for

24 hours
Move to Melati

11.00

GC : well
UC : FHR : 12-12-12 (144 bpm)

Observation mother & fetal

well being.

15.00

GC : well
UC : FHR : 11-12-12 (140 bpm)

Observation mother &

fetal well being.

25/10/
2012
08.00

GC : well
UC : FHR : 13-12-12 (148 bpm)

Observation mother &

fetal well being.
Pro drip 2nd serial
Move to VK Teratai

10.30

GC : well
UC : FHR : 13-12-12 (148 bpm)

11.00

CTG reactive

Co. GP advice CTG and

drip 2nd serial

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

11.00

UC : FHR : 12-12-12 (144 bpm)

Infusion oxy drip D5% 8

dpm

11.30

UC : FHR : 12-12-12 (144 bpm)

Infusion oxy drip D5% 12

dpm

12.00

UC : FHR : 12-12-11 (140 bpm)

Infusion oxy drip D5% 16

dpm

12.30

UC : 1x10~10
FHR : 11-12-12 (136 bpm)

Infusion oxy drip D5% 20

dpm

13.00

UC : 1x10~15
FHR : 13-12-12 (148 bpm)

Infusion oxy drip D5% 24

dpm

13.30

UC : 1x10~15
FHR : 12-12-12 (144 bpm)

Infusion oxy drip D5% 28

dpm

14.00

UC : 1x10~15
FHR : 12-12-12 (144 bpm)

Infusion oxy drip D5% 32

dpm

14.30

UC : 1x10~15
FHR : 11-12-12 (136 bpm)

Infusion oxy drip D5% 36

dpm

15.00

UC : FHR : 12-12-12 (144 bpm)

Infusion oxy drip D5% 40

dpm

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

15.30

UC : FHR : 12-12-12 (144 bpm)

Maintenance Infusion oxy

drip D5% 40 dpm

16.00

UC : FHR : 12-12-12 (144 bpm)

Maintenance Infusion oxy

drip D5% 40 dpm

16.30

UC : FHR : 12-12-13 (148 bpm)

Maintenance Infusion oxy

drip D5% 40 dpm

17.00

UC : FHR : 11-12-12 (136 bpm)

Maintenance Infusion oxy

drip D5% 40 dpm (flash
II)

17.30

UC : FHR : 13-12-13 (152 bpm)

Maintenance Infusion oxy

drip D5% 40 dpm

18.00

UC : FHR : 12-12-12 (144 bpm)

Maintenance Infusion oxy

drip D5% 40 dpm

18.30

UC : FHR : 12-12-12 (144 bpm)

Maintenance Infusion oxy

drip D5% 40 dpm

19.00

UC: FHR : 11-12-12 (140 bpm)

Maintenance Infusion oxy

drip D5% 40 dpm

19.30

UC: FHR : 11-11-12 (136 bpm)

Maintenance Infusion oxy

drip D5% 40 dpm

20.00

UC: FHR : 12-12-12 (144 bpm)

Maintenance Infusion oxy

drip D5% 40 dpm

20.30

UC: FHR : 11-12-12 (140 bpm)

Maintenance Infusion oxy

drip D5% 40 dpm

TIME
21.00

SUBJECTIVE

OBJECTIVE
UC : FHR : 12-12-12 (144 bpm)

22.00

PLANNING

G3P2A0L2 40-41
weeks S/L/IU head
presentation with
postdate and failed
drip 2nd serial

Drip Oxy Fls II finished

changed with RL
Co.SPV advice:
observation until tomorrow
Co.SPV advice:
observation until tomorrow

26/10/
2012
08.00

GC : well
TD: 140/90 mmHg
N: 82 x/menit
RR: 22 x/menit
T: 37o C
UC : FHR : 11-12-12 (140 bpm)

12.00

TD: 120/80 mmHg

N: 80 x/menit
RR: 22 x/menit
T: 36,5o C
UC : FHR : 12-11-12 (140 bpm)

14.00

GC : well
UC : FHR : 11-12-12 (140 bpm)

17.15

ASSESSMENT

Co.SPV advice: pro CS if

there is CS cyto today

Call from VK IGD advice

SPV CS at 18.00 WITA
Prepare pre op
Tell patient and family

18.30

CS began
Baby was born :
Male, AS 7-9, 3300 gram,
51 cm. Anus (+),
congenital anomaly (-).
Placenta was born
spontaneous, complete,
bleeding 150 cc

20.30

Wound pain (+)

GC : well
BP : 120/70 mmHg
HR : 72 bpm
RR : 24 tpm
Temp : 35,2C
UC : + , well
UFH : 2 finger below umbilicus
Lochea rubra : +
UO: 200 cc

2 hours post CS

Observation mother and

baby well being
Suggest mother to
mobilisation, eat and
drink, medication

1 day post CS

Observation mother and

baby well being
Suggest mother to
mobilisation, eat and
drink, medication
Suggest mother to give
breast feeding

Baby in NICU:
PR: 120 x/mnt
RR: 64 x/mnt
T: 36,9 C
27/10/
2012
07.30

GC : well
BP : 120/70 mmHg
HR : 72 bpm
RR : 24 tpm
Temp : 35,2C
UC : + , well
UFH : 2 finger below umbilicus
Lochea rubra : +
UO: 200 cc
Baby in NICU:
PR: 120 x/mnt
RR: 64 x/mnt
T: 36,9 C