Morning Report

July 3rd 2012

Supervisor : dr. Made

Mahayasa, Sp.OG
Medical Students :
Yan, Wiwid, Novi, Sapto, Ika, Ira,
Lani
CASE RESUME
NORMAL LABOR

PATHOLOGY
LABOR

1.G1P0A0L0 40-41 weeks S/L/IU with prolonged

2nd stage of labor.
2.G4P1A2L1 42-43 weeks S/L/IU with severe
pre-eclampsia
3.G1P0A0H0 A/S/L/IU with neglected active
phase 1st stage of labor & eclampsia.

Case Report
Name

: Mrs. I

RM

: 044809

Age

: 23 years old

Address : Selagalas, Mataram

Admitted

: July 2nd 2012

TIME

SUBJECTIVE

OBJECTIVE

ASSESSME
NT

PLANNING

02/0
7/20
12

Patient came to VK IRD

confessed water came
out from her womb since
00.30 (02/07/2012), clear,
odorless. Abdominal pain
(+)
since
22.00
(30/06/2012). Bloody slim
(+), FM (+).
No history of DM, HT,
asthma.

General Status :
GC : well
BP : 120/80 mmHg
PR : 84 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 (+/+).

G1P0A0L0
40-41 weeks
S/L/IU latent
phase 1st
stage of
labor with
history of
rupture
membrane +
mild anemia

Observation
mother & fetal
well being.
Observation
progress of labor

01.3
0

LMP : 18/09/2011
EDD : 25/06/2012
History of ANC : > 4x at
Polindes
Last ANC : 26/06/2012
History of USG : 1x, result
normal
History of family planning
: (-)
Next family planning :
injection 3 months.
Obstetrical History :
I.This

Obstetrical Status :
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH : 34 cm
EFW : 3565 gram
UC : 2x/10 ~35
FHB : 11-12-12 (140 bpm)
VT : 2 cm, effacement
50%, amnion (-) clear,
head palpable HI+,

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

PE :
Spina
ischiadica
not
prominent
Os coccygeus mobile
Arcus pubis > 90o
Lab Examination :
Hb : 8,9 g/dl
RBC : 4,12 x 106/L
HCT : 30,1 %
WBC : 12,59 x 103/L
PLT : 288 x 103/L
HbSAg: (-)
05.3
0

Patient
confessed
abdominal pain

UC : 3x/10 ~35
FHB : 12-12-12 (144
bpm)
VT : 4 cm, effacement
50%, amnion (-), head
palpable

HI+,
denominator
unclear,
impalpable small part
and umbilical cord.

G1P0A0L0 4041 weeks

S/L/IU active
phase 1st
stage of labor
with history of
rupture
membrane +
mild anemia

Observation
mother & fetal well
being.
Observation
progress of labor
with partograph

09.3
0

Patient
abdominal
frequently

UC : 4x/10 ~30
FHB : 12-11-12 (140
bpm)
VT : 8 cm, effacement
75%, amnion (-), head
palpable

HII,
denominator
LOA,
impalpable small part

G1P0A0L0 4041 weeks

S/L/IU active
phase 1st
stage of labor
with history of
rupture
membrane +

Observation
mother & fetal well
being.
Observation
progress of labor
with partograph

confessed
pain more

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMEN
T

PLANNING

11.3
0

Patient
confessed
abdominal pain

UC : 2x/10 ~25
FHB : 12-12-12 (144
bpm)
VT : 9 cm, effacement
90%, amnion (-), head
palpable HII+, caput
(+), impalpable small
part and umbilical cord.

G1P0A0L0 4041 weeks

S/L/IU with
prolonged
active phase
1st stage of
labor with
history of
rupture
membrane +
mild anemia

Observation
mother & fetal
well being.
CTG reactive
DM co to GP, GP
advice
:
acceleration with
drip oxytocin.

12.3
0

Mother wants to bearing

down

UC : 4x/10 ~30
FHB : 12-11-11 (136
bpm)
VT : complete, amnion
(-), head palpable HII+,
caput (+), impalpable
small part and umbilical
cord.

2nd stage of
labor

Drip
oxytocin
began 8 tpm
Suggest mother to
eat and drink.
Suggest mother to
squatting down.

13.0
0

Patient
confessed
abdominal pain

UC : 4x/10 ~30
FHB : 12-11-12
bpm)

13.3
0

Patient
confessed
abdominal pain

UC : 4x/10 ~30
FHB : 12-12-12
bpm)

14.0
0

Patient
confessed
abdominal pain

UC : 4x/10 ~30
FHB : 12-11-11

(140

Drip oxytocin 12
tpm

(144

Drip oxytocin 16
tpm

(136

Drip oxytocin 20
tpm

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMEN
T

15.0
0

17.0
0

PLANNING
VE began
VE succeed in 2 times
traction.
Perineum
episiotomy
(+)
Baby was born, male,
3500 gram, 50 cm, A-S
6-8, caput (+) on
occiput,
anus
(+),
anomaly congenital (-).
Placenta
was
born
spontaneous,
complete.
Bleeding 150 cc
Rupture
perineum
grade II

Patient confessed
delivery wound

GC : well
BP : 120/90 mmHg
PR: 80 bpm
RR : 20 bpm
T : 36.7C
UFH : 2 fingers below
the umbilicus

2 hours post
VE

Observe mother and

baby well being.
Suggest mother to
take a rest, eat, and
drink.

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

03/0
7/20
12

Patient confessed
delivery wound

GC : well
BP : 110/70 mmHg
PR : 72 bpm
RR : 20 bpm
T : 36.2C
UFH : 2 fingers
below the umbilicus
Lochea rubra : (+)

1st day post partum

Observe
mother
and
baby
well
being.
Suggest mother to
take a rest, eat, and
drink.

07.0
0

Baby in NICU :
GC : well
PR : 120 bpm
RR : 52 bpm
T : 36,4oC