MORNING REPORT

Jan 2th, 2013

Supervisor: dr. Rusdy Hamid.

Sp.OG
Medical Students:
Ren, Estry, Fai, Adit, Yogi, Ela, Ditha
CASE RESUME
NORMAL LABOR

PATHOLOGIC CASE

1. G4P3A0L3 A/S/L/IU head

presentation with neglected 2nd
stage of labour

Name : Mrs. N
Age : 32 yo
Address :Gn. Sari
CTH : 2nd January 2013

Time

Subject

2/1/
2013
20.4
5

Patien come to GH reffered

from Gn. Sari PHC with
G4P3A0L3
A/S/IU
38-39
weeks head presentation
mother and baby in a good
condition with prolonged 2nd
stage of labor. FM (+), patiet
confessed waist pain spread
to lower abdominal with
rupture of membrane (+),
Blood slim (+). History of
HT(-), DM (-), asthma (-)
LMP : forgot
EDD : History of ANC : 4x PHC
Last ANC : USG : History of family planning :Next family
planning :
injection 3 months
Obstetrical history :
1. Aterm,
Male,
spontan,
MW, live, 12 years old.
2. Aterm, Female, spontan,
TBA, live, 6 years old.
3. Aterm, Male,
Spontan,
MW, Live, 4 years
4. this

Object
GC : well
GCS : E4V5M6
BP : 120/80 mmHg
bpm
T : 37,7 C
20 bpm

HR: 105
RR :

General Status :
Eye : an (-/-) , ict (-/-)
Thorax :
C : S1S2 single reguler, murmur
(-), gallop (-).
P : ves +/+ , wh (-/-). Rh (-/-)
Abdomen : scar (-) , striae (+)
Extremity : edema
-/-, warm
acral +/+
Obstetrical status :
L1 : breech
UFH : 36 cm
L2 : back on the right side
L3 : head
L4 : 3/5
EFW : 3875 g
UC : 4x/10 ~ 40
FHR : 156 bpm (13.13.13)
VT : complete , amnion (-)
meconeal, caput (+)H III,
impalpable small part of fetal
and umbilical cord.
Lab Examination :
Hb : 12,1
RBC : 4,46
WBC : 21,190x103
3

Assesment

Planning

G4P3A0L3
A/S/L/IU head
presentation with
neglected 2nd
stage of labor

Check
CBC
and
HBsAG
Observe
mother
and
fetal
wellbeing
Recusitation
intrauterine
DM co to GP to pro
vacuum
extraction, GP co
to
SPV,
SPV
advices : VE

Time

Subject
Chronologist:
(02/01/2013)
S:
Patient come to Gn Sari PHC
at 14.00 wita confessed waist
pain
spread
to
lower
abdominal .
O:
Mother was in a good
condition,
GC : well
Cons : CM
Emotion : stable
BP : 120/80 mmHg
HR : 90 bpm
T : 37,8C
RR : 22 rpm
UFH : 33 cm
headpresentation
4/5
UC : 3x/10-40
FHR : 140 bpm
VT: complete, eff 100%,
amnion (-), head palpable,
head HII, not palpable small
part (18.30 wita)
A:
G4P3A0H3, uk 38-39 weeks
S/L/IU
head
presentation
mother and baby well with
prolonged 2nd stage of labour.
P:
Inj. Ampicilin and Rehidration
with RL iv

Object

Assesment

Planning

Time

Subject

Object

Assesment

22.0
0
22.1
0

01.1
0

Planning
VE begin

GC: well
BP : 120/80 mmHg
bpm
T : 37,5 C
20 tpm

HR: 92
RR :

GC : well
BP : 110/80
HR : 80 bpm
T : 37,4 C
RR: 18tpm
UC : +
UFH : 3 fingers below umbilicus
AB : Baby in NICU
HR : 142
RR : 38
T : 36,2 0C

Baby was born with

VE
,
three
traction,
3800
g/52cm, female,
live, AS 7-9, anus
(+). Caput (+) at
ROA
d=3
cm,
thickness= 1 cm.
Plasenta was born
spontaneously,
complete,
Bleeding 50 cc.
2 hours post VE

Observe mother
and baby well being
Suggest mother to
eat and drink

Time
03/0
1/13

Subject

Object
GC : well
BP : 110/80
HR : 80 bpm
T : 37,4 C
RR: 18tpm
UC : +
UFH : 3 fingers below umbilicus
AB : UO : Baby in NICU
HR : 140
RR : 38
T : 36 0C

Assesment
1 day post VE

Planning
Observe mother
and baby well being
Suggest mother to
eat and drink
mobilization