Morning Report

September, 10th 2015

Supervisor:
Dr. Agus Thoriq, SpOG
DM Jaga:
Rian

Morning Report
th
september 10 2015
Case Resume
NORMAL
LABOR

PATHOLOGIES
LABOR

1.
2.

G5P2A2L2 39-40 weeks S/L/IU head presentation with arrest

active phase 1st stage of labor
G1P0A0L0 39-40 weeks S/L/IU head presentation with arrested
active phase 1st stage of labor

Case 1
Name : Mrs. I
Age : 32 years old
Address : Narmada
Admitted : 09-09-2015
No. RM : 56-65-82
G5P2A2L2 39-40 weeks S/L/IU head
presentation with arrest active phase 1 stst
stage of labor

TIME

SUBJECTIVE

09/09/201
5
21.44 wita

Patient reffered from Narmada

PHC with G5P2A2L2 39-40
weeks S/L/IU head presentation
mother and fetal well being with
inpartu arrest 1st stage active
phase of labor. Patient
confessed about abdominal
pain since 20.00 (08/09/2015)
history of water leaked out from
her womb (-). History of blood
slim (+), FM (+).
History of DM (-), HT in
pregnancy (-), asthma (-) and
allergy (-).
LMP : 08/12/2014
EDD : 15/09/2015
History of ANC : 7x at PHC
Last result: (13/08/2015)
BP 120/90 mmHg, BW 78 kg,
GW 36 w UFH 30 cm, head
presentation, FHB (+)
History of USG : 1x, at SpOG
Last : 25/07/2015
S/L/IU
head
presentation,
female, GW 32-34 weeks,
placenta at fundus gr II-III,
amnion enough, clear, EFW
3200 g
History of family planning:
Injection 3 month
Next family planning : Injection
3 month

OBJECTIVE
General status
GC : well
consciousness: CM
BP : 120/80 mmHg
PR: 82 bpm
RR: 20 bpm
T: 37.5C
Local status
Eye : an (-/-), ict (-/-)
Pulmo : ves (+/+), rh (-/-), wh
(-/-)
Cor : S1S2 single regular, m
(-), g (-)
Abd : striae gravidarum (+),
linea nigra (+), scar (-)
Ext : edema of lower
extremity(-/-), warm acral (+/
+).
Obstetric status
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH: 35 cm
EFW : 3720 g
UC : 3x10~30
FHB : 13-12-12
VT : 4 cm, eff 50%, amnion
(+), head presentation, H1,
denominator unclear, not
palpable small part &
umbilical cord

ASSESSMENT

PLANNING

G5P2A2L2
39-40
weeks S/L/IU head
presentation
with
arrest active phase
1st stage of labor

DM planning:
Diagnostic : CTG
Therapy :
Pro amniotomy
Observation progress
of labor
Monitoring : VS mother,
UC, FHB
CIE : CIE mother and
family about
diagnostic planning
and therapeutic
planning
DM co to GP co to SPV
Advice : amniotomy
Acceleration if UC
inadequate
Amniotomy was done
at 22.30
VT : 5 cm, eff 50%,
amnion (-), clear,
head presentation,
H1, denominator
unclear, not palpable
small part & umbilical
cord
UC : 3x10~30
Oxytocin Drip starting
from 8 dpm (23.30)

TIME

SUBJECTIVE
Obstetric History:
I. Aterm/normal/polindes/390
0 g/female/7 yo
II. Aterm/normal/polindes/350
0 g/male/3 yo
III. Abortus
IV. Abortus
V. This

OBJECTIVE
Pelvic score = 6
Dilatation of cervix : 2
Length of cervix : 1
Station : 1
Consistency : 1
Position : 1
Laboratory (09/09/2015
21.57):
HB: 12.8 g/dl
RBC: 4.15
HCT: 37.5 %
WBC: 15.78
PLT: 235
HbsAg: non reactive
BT : 215
CT : 630

ASSESSMENT

PLANNING

TIME

SUBJECTIVE
Chronology at Narmada PHC
(09/09/2015)
05.00
S:
Patient 9 months of pregnancy
come to PHC confessed
abdominal pain since 20.00
(08/09/2015) bloody slim (+)
amnion (-) FM (+)
O:
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 80 bpm
RR: 20 bpm
T: 36.4C
Obstetric status
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH: 37 cm
UC : 3x10~25
FHB : 12-11-12
VT : 3 cm, eff 25%, amnion
(+), head presentation, HI,
denominator unclear, not
palpable small part & umbilical
cord

OBJECTIVE

ASSESSMENT

PLANNING

TIME

SUBJECTIVE
14.00
S:
Patient confessed abdominal
pain
O:
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 80 bpm
RR: 20 bpm
T: 36.6C
UC : 3x10~30
FHB : 12-11-12
VT : 4 cm, eff 50%, amnion
(+), head presentation, HI,
denominator unclear, not
palpable small part & umbilical
cord

OBJECTIVE

ASSESSMENT

PLANNING

TIME

SUBJECTIVE
18.00
S:
Patient confessed abdominal
pain
O:
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 80 bpm
RR: 20 bpm
T: 36.5C
UC : 3x10~35
FHB : 12-12-12
VT : 4 cm, eff 50%, amnion
(+), head presentation, HI,
denominator unclear, not
palpable small part & umbilical
cord
A:
G5P2A2L2 39-40 weeks S/L/IU
head presentation with mother
and fetal well being + arrest
active phase 1st stage of labor
P:
CIE mother about examination
result
RL : D5 infusion 2:1
Observation for mother and
fetal well being, progress of
labor

OBJECTIVE

ASSESSMENT

PLANNING

TIME

SUBJECTIVE
21.00
S:
Patient confessed abdominal
pain
O:
GC : well
consciousness: CM
UC : 3x10~35
FHB : 11-12-12
VT : 4 cm, eff 50%, amnion
(+), head presentation, HI,
denominator unclear, not
palpable small part & umbilical
cord
A:
G5P2A2L2 39-40 weeks S/L/IU
head presentation with mother
and fetal well being + arrest
active phase 1st stage of labor
P:
CIE mother about examination
result
Co to GP advice
Refer to NTB GH

OBJECTIVE

ASSESSMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

23.30

UC : 3x10~30
FHB : 12-11-12

Drip Oxytocin 8 dpm

10/09/201
5
00.00

UC : 3x10~30
FHB : 12-12-13

Drip Oxytocin 12 dpm

00.30

UC : 4x10~40
FHB : 12-12-13
VT : 9 cm, eff 80%, amnion
(-), not clear, head
presentation, HII,
denominator transverse
sagitalis suture, not palpable
small part & umbilical cord

2
hours
amniotomy

post

Drip Oxytocin 12 dpm

TIME
00.55

SUBJECTIVE
Mother want to bearing down

OBJECTIVE
General status
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 92 bpm
RR: 20 bpm
T: 36,7C

ASSESSMENT

PLANNING

G5P2A2L2 39-40
weeks S/L/IU head
presentation with
2nd stage of labor

DM planning:
Diagnostic : Therapy : Monitoring : VS mother,
UC, FHB
CIE : suggest mother
to bearing down

UC : 4x10 ~40
FHB : 12-12-13

Conduct mother to
bearing down

Sign of 2nd stage of labor (+) :

crowning, anus pressure,
opening of vulva, bulging of
perineum

At 01.00 Baby was

born, male, A-S 3-5,
3900 g, BL 52 cm, HC
34 cm, anus (+)
congenital anomaly (-)
Baby rooming in NICU

VT : not perform

Placenta was born

uncompletely at 01.10
pro USG
Do the management of
4th stage of labor

TIME

SUBJECTIVE

03.00

OBJECTIVE
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 88 bpm
RR: 20 bpm
T: 36.4C

ASSESSMENT

PLANNING

2 hours post
partum + rest
placenta

DM planning:
Diagnostic : USG
Therapy :
Amoxicillin 3x500 mg
Mefenamic Acid 3 x
500 mg
Monitoring : VS mother,
UC, UFH
CIE : suggest mother
to eat and drink

1 day post partum

+ rest placenta

DM planning:
Diagnostic : USG
Therapy : Monitoring : VS mother,
UC, UFH, UO
CIE : suggest mother
to eat and drink

UC : well
UFH : 1 fingers below umbilical
UO : not measured
Active bleeding (-)
Baby in NICU :
HR : 142x/minute
RR : 44x/minute
T : 35,8oC
07.00

Patient confessed about

abdominal wound pain

GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 80 bpm
RR: 20 bpm
T: 36.4C
UC : well
UFH : 1 fingers below umbilical
UO : not measured
Active bleeding (-)
Baby in NICU :
HR : 144x/minute
RR : 46x/minute
T : 36,1oC

Case 2
Name : Mrs. S
Age : 34 years old
Address : Gunung Sari
Admitted : 09-09-2015
No. RM : 12-27-02
G1P0A0L0 39-40 weeks S/L/IU head
presentation with arrested 1stst stage of
labor active phase

TIME

SUBJECTIVE

09/09/201
5
16.21 wita

Patient reffered from Gunung

Sari PHC with G1P0AL0 41-42
weeks S/L/IU head presentation
mother and fetal well being with
post term. Patient confessed
about abdominal pain since
09.00 (08/09/2015) history of
water leaked out from her
womb (+) since 10.00
(09/09/2015) History of bloody
slim (+), FM (+).
History of DM (-), HT in
pregnancy (-), asthma (-) and
allergy (-).
LMP : 08/12/2014
EDD : 15/09/2015
History of ANC : 7x at SpOG
Last result: (08/09/2015)
BP 100/80 mmHg, BW 45 kg,
GW 39 w UFH 29 cm, head
presentation, FHB (+)
History of USG : 7x, at SpOG
Last : 09/09/2015
S/L/IU head presentation, male,
GW 39-40 weeks, placenta at
corpus
posterior,
amnion
enough, not clear, EFW 3200 g
History of family planning: Next family planning : -

OBJECTIVE
General status
GC : well
consciousness: CM
BP : 100/70 mmHg
PR: 84 bpm
RR: 20 bpm
T: 36.7C
Local status
Eye : an (-/-), ict (-/-)
Pulmo : ves (+/+), rh (-/-), wh
(-/-)
Cor : S1S2 single regular, m
(-), g (-)
Abd : striae gravidarum (+),
linea nigra (+), scar (-)
Ext : edema of lower
extremity(-/-), warm acral (+/
+).
Obstetric status
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH: 31 cm
EFW : 3100 g
UC : 2x10~25
FHB : 12-11-12
VT : 3 cm, eff 25%, amnion
(+), head presentation, H1,
denominator unclear, not
palpable small part &
umbilical cord

ASSESSMENT

PLANNING

G1P0A0L0
39-40
weeks S/L/IU head
presentation latent
phase 1st stage of
labor

DM planning:
Diagnostic : CTG
Therapy :
Observation progress
of labor
Monitoring : VS mother,
UC, FHB
CIE : CIE mother and
family about
diagnostic planning
and therapeutic
planning
DM co to GP advice :
Observation progress
of labor

TIME

SUBJECTIVE
Obstetric History:
I. This

OBJECTIVE
Pelvic Examination
Promontorium unpalpable
Spina ishiadica non prominem
Arcus pubis >90o
Os coccygeus mobile
Laboratory (09/09/2015
16.34):
HB: 10.4 g/dl
RBC: 3.92
HCT: 32.2 %
WBC: 10.31
PLT: 252
HbsAg: non reactive
BT : 200
CT : 510

ASSESSMENT

PLANNING

TIME

SUBJECTIVE
Chronology at Gunung Sari
PHC (09/09/2015)
10.00
S:
Patient 9 months of pregnancy
come to PHC confessed
abdominal pain since 09.00
(09/09/2015) bloody slim (+)
O:
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 84 bpm
RR: 20 bpm
T: 36.7C
Obstetric status
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH: 30 cm
EFW : 2945 g
UC : 1x10~20
VT : 1 cm, eff 25%, amnion
(+), head presentation, HI,
denominator unclear, not
palpable small part & umbilical
cord

OBJECTIVE

ASSESSMENT

PLANNING

TIME

SUBJECTIVE
A:
G1P0A0L0 39-40 weeks /S/L/IU
head presentation mother and
fetal well being with postterm
P:
CIE mother about examination
result
RL infusion 20 dpm
Refer to NTB GH

OBJECTIVE

ASSESSMENT

PLANNING

TIME
19.30

SUBJECTIVE
Patient confess about
abdominal pain

OBJECTIVE
General status
GC : well
consciousness: CM
BP : 120/80 mmHg
PR: 86 bpm
RR: 22 bpm
T: 36.5C

ASSESSMENT

PLANNING

G1P0A0L0
39-40
weeks S/L/IU head
presentation active
phase 1st stage of
labor

DM planning:
Diagnostic :
Therapy :
Observation progress
of labor with
partograph
Monitoring : VS mother,
UC, FHB
CIE : CIE mother and
family about
diagnostic planning
and therapeutic
planning

G1P0A0L0
39-40
weeks S/L/IU head
presentation
with
arrested 1st stage of
labor active phase

DM planning:
Diagnostic :
Therapy :
Observation progress
of labor with
partograph
Pro amniotomy
Monitoring : VS mother,
UC, FHB
CIE : CIE mother and
family about
diagnostic planning
and therapeutic
planning

UC : 3x10~40
FHB : 11-11-12
VT : 4 cm, eff 50%, amnion
(+), head presentation, H1,
denominator transverse
sagitalis suture, not palpable
small part & umbilical cord

23.30

Patient confess about

abdominal pain

General status
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 84 bpm
RR: 20 bpm
T: 36.7C
UC : 3x10~40
FHB : 12-11-12
VT : 4 cm, eff 50%, amnion
(+), head presentation, H1,
denominator unclear, not
palpable small part &
umbilical cord

DM co to GP co to SPV
: not answered

TIME
01.30

SUBJECTIVE
Patient confess about
abdominal pain

OBJECTIVE
General status
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 84 bpm
RR: 20 bpm
T: 36.7C
UC : 3x10~45
FHB : 13-12-13
VT : not perform

ASSESSMENT

PLANNING

G1P0A0L0
39-40
weeks S/L/IU head
presentation
with
arrested 1st stage of
labor active phase

DM planning:
Diagnostic :
Therapy :
Observation progress
of labor with
partograph
Pro amniotomy
Monitoring : VS mother,
UC, FHB
CIE : CIE mother and
family about
diagnostic planning
and therapeutic
planning
DM co to GP co to SPV
advice (02.00) :
amniotomy
Acceleration
Amniotomy was done
at 02.15
VT : 4 cm, eff 50%,
amnion (-), not clear,
head presentation,
H1, denominator
transverse sagitalis
suture, not palpable
small part & umbilical
cord
Oxytocin Drip starting
from 8 dpm (02.45)

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

02.45

UC : 3x10~30
FHB : 13-12-13

Drip Oxytocin 8 dpm

03.15

UC : 3x10~30
FHB : 13-12-12

Drip Oxytocin 12 dpm

03.45

UC : 3x10~30
FHB : 12-11-12

Drip Oxytocin 16 dpm

04.15

UC : 3x10~35
FHB : 12-11-12
VT : 4 cm, eff 50%, amnion
(-), not clear, head
presentation, H1,
denominator transverse
sagitalis suture, not palpable
small part & umbilical cord

04.45

UC : 3x10~35
FHB : 12-13-13

Drip Oxytocin 24 dpm

05.15

UC : 3x10~35
FHB : 12-12-12

Drip Oxytocin 28 dpm

05.45

UC : 4x10~40
FHB : 12-12-12

Drip Oxytocin 32 dpm

2
hours
amniotomy

post

Drip Oxytocin 20 dpm

TIME
06.15

SUBJECTIVE
Mother
confessed
abdominal pain

OBJECTIVE
about

General status
GC : well
consciousness: CM
BP : 110/60 mmHg
PR: 86 bpm
RR: 20 bpm
T: 36.8C
UC : 4x10~40
FHB : 13-12-12
VT : 4 cm, eff 50%, amnion
(+), head presentation, H1,
denominator transverse
sagitalis suture, not palpable
small part & umbilical cord

ASSESSMENT

PLANNING

G1P0A0L0
39-40
weeks S/L/IU head
presentation
with
arrested 1st stage of
labor active phase
suspect CPD

DM planning:
Diagnostic :
Therapy :
Pro CS
Monitoring : VS mother,
UC, FHB
CIE : CIE mother and
family about
diagnostic planning
and therapeutic
planning
DM co to GP co to SPV
Advice : observation
progress of labor for 2
hours if there is no
progression CSection

.. Thank
You ..