Morning Report

Aug, 26th 2010

NAME/AGE : Mrs. Ni Nyoman Sri/30 years old

ADDRESS : Lembuak, Narmada
H
24/07
/2010
at
10.15

S
Patient referred from Narmada PHC with
hypovolemic shock et causa suspect Abortus
infectious.
Chronologist :
Patient came to Narmada PHC at 8 p.m
(24/07/2010) confess vaginal bleeding since
three days ago with volume 10 15 cc with
descend conciousness.
Examination at Narmada PHC:
General condition : well
Conciousness
: somnolen
Vital sign
: BP 60 mmHg palpation
PR 120 x / minutes, weak
pulse
RR 28 x / minutes
Tax 37,5 0C
Head & neck : eye anemi -/- , icterus -/Thorax : *Cor : S1S2 Single/ reguler/mur-mur
- , gallop *Pulmo: ves +/+, whz -/-, rh-/Abdomen :
Extremity : cold
VT : CD 1 cm, unpalpable tissue, bad smell,
active bleeding, yellowish secret.
PP test : +
Therapy from Narmada PHC
- RL flash 1, fast drops
- Amoxicillin 3 x 500 mg
-Paracetamol 3 x 500 mg

Admitted: 24/07/2009, 10.15 p.m

O

Examination at emergency room :

General status : well
Conciousness : E4 V5 M6
BP : 110/70 mmHg
PR : 100x /
RR : 24 x/
Tax : 36,0 oC
Head : an -/-, ict -/-, sianosis -/Pulmo : ves +/+, Rh -/-, Wh -/Cor : S1S2 tung, reg, mur (-), Gal (-)
Abd : peritonitis sign (+)
Ext : warm
Gynecology status :
-Inspeksi : cervix dilatation (-), vaginal
bleeding (-)
- Inspeculo : fluksus (+), fluor (-), livide
(+), tissue (-)
- VT : slinger pain (+), Douglas cavity
prominent
Lab. Examination :
Hb : 9,7 gr%
Lekosit : 30.900/mm3
Trombosit : 390.000/ mm3
Hematokrit : 27,2 %
HBsAg : (-)

A
Disturbed Ectopic
Pregnancy with
Compensated shock

P
-

time

Subjective

objective

assesment

planning

G1P0A0H0 38-39 weeeks

S/L/IU head presentation
with prolonged active
phase of 1st stage of labor
and fetal tachicardi

Amniotomy
Found amnion fluid
clearly

Obstetric history :
1.This
Contraception history : not yet
LMP : 15-11-08
EDD : 22-08-09
ANC : 5 x
22.10

Abdominal pain ++

Referred to VK

22.30

Abdominal pain ++++

BP : 110/80 mmHg
PR : 80 x/
UFH : 31 cm
RR : 20 x/
EFW : 3100 gr
Tax : 37,0
UC : 3-4x/10~ 45
FHR : 140 x/
VT : CD 8 cm, eff 80%, AM (-),
head palpable, HIII, denominator
fontanella minor left anterior, small
part and umbilical cord wasnt
palpable

G1P0A0H0 38-39 weeks

S/L/IU, head presentation
with prolonged active
phase of 1st stage of labor

Obs. Mother and fetal

wellbeing
Motivated mother to sweet
drink and eat
Left lateral position

23.00

Abdominal pain +++++

Mother want to bearing down

UC : 4x/10~50
FHR : 142 x/
Doran teknus perjol vulka

2nd stage of labor

Motivated mother to
bearing down
Baby was born at 23.05,
male, 3250 gr, A-S : 7-9

3rd stage of labor

Placenta was born

spontan, complete
Bleeding 100 cc

time

Subjective

objective

assesment

planning

01.15

Abdominal pain << ----

BP : 110/70 mmHg
PR : 79 x/
RR : 18 x/
Tax : 36,8
UFH : 2 finger umbilical below
AC : good
Bleeding : 40 cc

4th stage of labor

-Observation vital sign, and active

bleeding
-Motivated mother to breast
feeding
-Motivated mother to eat and
drink

07.00

Abdominal pain (-)

BP : 100/50 mmHg
PR : 100x/
RR : 24 x/
Tax : 37,0
UFH : 2 finger umbilical below
AC : good
Stolcel : 100 cc

1st day of puerperalis

-Observation vital sign, and active

bleeding
-Motivated mother to breast
feeding
-Motivated mother to eat and
drink
- Baby and mother was still in VK
room

NAME/AGE : Mrs. Sunarti/30 yo

ADDRESS : Selong, Lotim
H

02.15

Patient referred from Selong GH with

G1P0A0 35-36 weeka S/L/IU head
presentation with failure drip and fetal
distress.
Chronologist :
12.30 (07/08/09) : came to Selong GH with
confess watery vaginal discharge since 00.00,
abdominal pain, bloody show (+), pregnancy 9
months, fetal movement (+).
examining :
LMP : forget
BP : 120/80 mmHg
RR : 17 tpm
PR : 84 tpm
t : 37 C
FUH : 28 cm
EFW : 2635 gr
FHR : 150x
UC (+) : 2 x/10~20
VT : CD 2 cm, AM (-), head presentation, H1
16.30 : drip oxytocin 1st flacon
00.30 : drip oxytocin 2nd flacon
01.00 :
BP : 130/80 mmHg
RR : 19 tpm
PR : 92 tpm
t : 38C
FHR : 165x
UC (+) : 2 x/10~20
VT : CD 2 cm, AM (-), head presentation, H1
Therapy :
02
Xylodella
Cefotaxime 1 gr iv .infus not insert
Co SpOG : Reffered to Mataram GH

Admitted: 08/08/2009, 02.15 Wita

O
Examination at emergency room :
General status : well
BP : 90/60 mmHg
PR : 98 /
RR : 22 x/
Tax : 36,8
Head : an -/-, ict -/-, sianosis -/Pulmo : ves +/+, Rh -/-, Wh -/Cor : S1S2 tung, reg, mur (-), Gal (-)
Abd : dbn
Ext : warm
Obstetric status :
L1 : breech
L2 : right back
L3 : head
L4 : was pelvic inlet 4/5
UFH : 30 cm
FHR : 168 /
EFW :2945 gr
UC (+):2x/10~25
VT : CD 2 cm, eff 25%, AM (-), clear,
head palpable Caput, HI, small part and
umbilical cord wasnt palpable.
lab. Examination :
Hb : 11,3 gr%
Lekosit : 9.700/mm3
Trombosit : 94.000
Hematokrit : 34,7
HBsAg : -

A
G1P0A0H0 A/S/L/IU,
head presentation with
neglected labor

P
- Obs fetal and mother
Wellbeing
- Check DL,HBsAg
- Report to supervisor.
Advice :
Cefotaxime 1 gr iv
Antipiretic
Resucitation IU
Left lateral position
O2
RL : D5- 2:1

time

Subjective

objective

Obstetric history :
1.This

assesment

planning

G1P0A0H0 A/S/L/IU,
head presentation with
neglected labor

Contraception history : not yet

03.15

Abdominal pain ++, weakness

BP : 90/60 mmHg
PR : 92 x/
RR : 22 x/
Tax : 37,0
UC : 2x/10~ 20
FHR : 164 x/

G1P0A0H0 A/S/L/IU,
head presentation with
neglected labor

Resusitasi intrauterine
continued
Motivated mother to drink
and eat sweet drinks

04.15

Abdominal pain ++, weakness

BP : 90/60 mmHg
PR : 96 x/
RR : 22 x/
Tax : 37,2
UC : 2-3x/10~ 25
FHR : 162 x/

G1P0A0H0 A/S/L/IU,
head presentation with
neglected labor

Obs. Mother and fetal

wellbeing
Motivated mother to drink
and eat sweet drnks
Left lateral position

05.15

Abdominal pain ++, weakness

BP : 90/60 mmHg
PR : 100 x/
RR : 26x/
Tax : 37,4
UC : 2-3x/10~ 30
FHR : 158 x/

G1P0A0H0 A/S/L/IU,
head presentation with
neglected labor

Obs. Mother and fetal

wellbeing
Motivated mother to drink
and eat sweet drinks
Left lateral position

time

Subjective

objective

assesment

planning

07.00

Abdominal pain ++, weakness

BP : 90/60 mmHg
PR : 96 x/
RR : 24x/
Tax : 37,5
UC : 3x/10~ 35
FHR : 154x/
VT : CD 5cm, eff 50 %, AM (-),
green, H1 caput

G1P0A0H0 A/S/L/IU,
head presentation with
neglected labor

Obs. Mother and fetal

wellbeing
Motivated mother to drink
and eat sweety
Left lateral position
Report to supervisor
Advice : continue
observation

Name

: Mrs. Zaenab

age

: 22 years

Address

: Keruak-Lotim

Admitted

: 07-08-2009
: 22.10

Time

Subject

Object

Assesment

Planning

22.10

Patient referred from Selong

GH with G3P0A2H0 3940 W/S/L/IU
head
presentation laten phase
of labor with severe
preeclampsia

In VK IRD to VK room at
22.20, from examination
found :
General status :
General condition: well,
Conciousness: CM
BP: 150/110 mmHg
RR: 20 x/mnt
PR: 88 x/mnt
T: 37 C
Eyes : an(-), ikt (-)
Cor -Pulmo : in normal range

G3P0A2H0 39-40
W/S/L/IU
head
presentation laten
phase of labor with
severe preeclampsi
+ mild anemia

Observation mother
and fetal well being.
Advice patient to take
left lateral position,
and take drink and eat
Laboratory
examination : DL,UL
HBsAg
Report to supervisor
propossed to drip
oxytocin
Advice : proposed
agreed

Chronologis :
Patient came to keruak polindes
at 09.30 wita (07/08/09)
for routine examination,
there is diagnosis with
severe preeclampsia and
then patient refere to
Selong GH at 10.00
wita.
Subjective
complain (-), abdominal
pain (-), watery vaginal
discharge (-).
From examination found :
(14.00)
General condition: well
BP : 160/100 mmHg
Pulse : 88x/
RR : 20x/
UFH : 33 cm
T : 36,8 C
EFW : 3410 gr
UC : (-)

Obstetric status :
L1 : breech
L2 : left back
L3 : head
L4 : was in pelvic inlet 4/5
UFH 31 cm
EFW : 3100 g
UC : (-)
FHR : 148x/mnt
VT : CD 1 cm, eff 25%,
AM(+), head descencus H1,
unpalpable small part of fetus
or umbilical Cord
Pelvics score: 5
Opening: 1
station : 0

Time

Subject
(14.30)
Drip MgSO4 40% 6 gr 28 dpm
Bolus MgSO4 40% 4 gr IV
Insert DC
Report to supervisor,
Advis Induction
(18.30)
FHR : 160x/mnt
VT : CD 1 cm, AM (+),
head descencus H1,
unpalpable small part of fetus
or umbilical cord
Induction Delayed
LMP : 10/11/08
EDD : 17/08/09
Obstetrical history :
1. Abortus, 8 month
2. Abortus, 3 month
3.This
History of family Planning: (-)
Family planning: (-)

Object

Assesment

Planning

Time

Subject

Object

Assesment

Planning

22.30

Subjective complain (-)

BP : 150/110 mmHg
PR : 88x/mnt
FHR : 143x/mnt
UC : (-)
DC : 500 cc since 22.00 pm

G3P0A2H0 39-40
W/S/L/IU
head
presentation laten
phase of labor with
severe preeclampsi
+ mild anemia

Drip MgSO4 Fl 2
Start to induction, oxy
5 iu in D5% => 8 dpm
Observation mother
and fetal well being.
Advice patient to take
left lateral position
Advice patient to take
drink and eat

23.00

Subjective complain (-)

FHR : 148x/mnt
UC : (-)

G3P0A2H0 39-40
W/S/L/IU
head
presentation laten
phase of labor with
severe preeclampsi
+ mild anemia

Elevated drip to 12 dpm

Observation mother and
fetal well being.

23.30

Subjective complain (-)

BP : 150/110 mmHg
PR : 88x/mnt
FHR : 143x/mnt
UC : (-)
DC : 50 cc

G3P0A2H0 39-40
W/S/L/IU
head
presentation laten
phase of labor with
severe preeclampsi
+ mild anemia

Elevated drip to 16 dpm

Observation mother and
fetal well being.

24.00

Subjective complain (-)

FHR : 144x/mnt
UC : (-)

G3P0A2H0 39-40
W/S/L/IU
head
presentation laten
phase of labor with
severe preeclampsi

Elevated drip to 20 dpm

Time

Subject

Object

Assesment

Planning

01.30

Subjective complain (-)

FHR :
UC :1x/10~10
DC : 170 cc

G3P0A2H0 39-40
W/S/L/IU
head
presentation laten
phase of labor with
severe preeclampsi
+ mild anemia

Elevated drip to 32dpm

02.00

Subjective complain (-)

FHR : 148x/mnt
UC : (-)

G3P0A2H0 39-40
W/S/L/IU
head
presentation laten
phase of labor with
severe preeclampsi
+ mild anemia

Elevated drip to 36dpm

02.30

Subjective complain (-)

FHR : 148x/mnt
UC : (-)
DC : 40 cc

G3P0A2H0 39-40
W/S/L/IU
head
presentation laten
phase of labor with
severe preeclampsi
+ mild anemia

Elevated drip to 40dpm

03.00

Subjective complain (-)

FHR : 148x/mnt
UC : (-)

G3P0A2H0 39-40
W/S/L/IU
head
presentation laten
phase of labor with
severe preeclampsi
+ mild anemia

Maintenance
dpm

drip

40

Time

Subject

Object

Assesment

Planning

04.30

Subjective complain (-)

FHR : 144x/mnt
UC : (-)
DC : 40 cc

G3P0A2H0 39-40
W/S/L/IU
head
presentation laten
phase of labor with
severe preeclampsi
+ mild anemia

Drip MgSO4 Fl 3
Drip oxytocin flash 2

05.00

Subjective complain (-)

FHR : 148x/mnt
UC : (-)
DC : 40 cc

G3P0A2H0 39-40
W/S/L/IU
head
presentation laten
phase of labor with
severe preeclampsi
+ mild anemia

Maintenance
dpm

drip

40

05.30

Subjective complain (-)

BP : 150/110 mmHg
PR : 88x/mnt
FHR : 143x/mnt
UC : 1x/10~35
DC : 100 cc

G3P0A2H0 39-40
W/S/L/IU
head
presentation laten
phase of labor with
severe preeclampsi
+ mild anemia

Maintenance
dpm

drip

40

06.00

Subjective complain (-)

FHR : 155x/mnt
UC : 2x/10~30

G3P0A2H0 39-40
W/S/L/IU
head
presentation laten
phase of labor with
severe preeclampsi
+ mild anemia

Maintenance
dpm

drip

40

age

: 22 years

Address

: Banjar kemuning-Selong

Time

Subject

03.00

Patient reffered from Selong GH with

G1P0A0 30-31 W/S/L /IU breech
presentation with partus prematurus
immatur + APB susp. Plasenta Previa
Totalis
Chronology:
(07/08/09 22.15)
Patient came from Wanasaba PHC with
confess bleeding from genitalia that
begun at 18.00, dark red with colic
abdomen.
Examination In Selong:
(22.15)
General status: well
GCS: E4V5M6
BP: 110/70 mmHg
PR: 84 tpm
T: 37C
RR: 18 tpm
VT: CD 2 cm, AM(+) palpable small
part of high
FHR: 150x/mnt
UC ; +
TFU : 19 cm
(22.45)
VT: CD 2 cm, AM (-), foot and placenta
palpable.
Patient vomiting
Active bleeding (+)
BP : 90/70 mmHg
Therapy:
O2 4 lpm
2 flash RL (double line, 1 flash
max.drops)
2 Kaltrofen supp
Consult SpOG advice sent to Mataram

: 02.45 wita

Object
General status :
General condition : well
GCS: E4V5M6
Vital sign
BP : 100/70 mmHg
Pulse: 88 x/
RR: 20 x/
Temp: 37,3c
Cor/Pulmo: normal
Eye: an-/-, ict-/Akral: warm, edema -/Obstetric status
L1: Head
L2: left back
L3: Breech
L4: wasnt pelvic inlet
UFH : 19 cm
EFW : 1085 g
FHR: 156x/mnt
HIS: 1x/10~20
VT : not be done
Lab Result:
Hb: 11.2
WBC: 10.400
PLT: 240.000
HCT: 34.0
HbSAg : (+)

Assesment

Planning

G1P0A0H0
27-28
W/S/L/IU
breech
presentation with APB
susp.Placenta previa

Observation mother and

fetal well being
Lab.check (DL, HbsAg)
Report to supervisor
Advice : Konservatif and
give kaltrofen if his >>

Time

Subject

Object

Assesment

Planning

G1P0A0H0
27-28
W/S/L/IU
breech
presentation with APB
susp.Placenta previa

Advice patient to take drink

and eat

LMP : 15/02/09
EDD : 22/11/09

04.00

Abdominal pain (-)

BP: 100/60 mmHg

PR: 84 tpm