Morning Report

20 May 2016
DM : Yoga, Ida, Brian, Fauzan, Ardian,
Abrista, Ulfa
CASES RESUME
Pathology

1. G1P0A0H0, 39-40 weeks S/L/IU head

presentation with prolonged latent phase of
labor

Remain
Patient

2. G1P0A0L0 aterm S/L/IU head presentation

with PROM >12 hours

Case 1
Name
: Mrs. D
Age
: 25 yo
Adress : Bantek, Sedau
Admitted : 19 April 2016

Time

Subject

20/5/16
05.00

Patient came to NTB GH with

abdominal pain referred to
flank since 12.00 am
(19/5/2016), water leaked from
her womb (-), bloody slime (-)
FM (+).
History of DM (-), HT (-),
asthma (-).
Family history DM (-), HT (-),
asthma (-).
History of allergy: (-)
LMP :15/8/2015
EDD :22/5/2016
GW : 39-40 weeks
History of ANC: 12x at PHC
last ANC: 19-5-2016
Result BP: 130/90, BW: 60 kg,
GW: 39-40 week,
UFH: 30cm, head presentation,
back on the right side
FHB (+)
Edema (-)
History of USG: 1x at SPOG
Last result (22-02-2016):
female, head presentation,
amnion enough, EFW:1070,
GW:27-28weeks, EDD: 16-52016

Object
General status
GC : well
GCS: CM (E4V5M6)
BP : 120/80mmHg
PR: 84 tpm
RR: 20 tpm
T: 36,5C
Local status
Eye : an (-/-), ict (-/-)
Pulmo: ves (+/+), rh (-/-), wh
(-/-)
Cor : S1S2 single regular
M(-), G(-)
Abd : striae gravidarum (+),
linea nigra (+), scar (-), BU
(+)
Ext : edema (-/-), warm (+/+)
Obstetric status
L1 : breech UFH: 31 cm
EFW : 3100 gr
L2 : back on the left side
L3 : head
L4 : 4/5
UC : 1x10~15
FHB : 11.11.12 (136x/min)
VT : 1cm, eff. 25%,
Amnion (+), head palpable,
denominator unclear, HI,
impalpable of small part of
fetal or umbilical cord.

Assessment
G1P0A0H0, 39-40
weeks S/L/IU head
presentation

Planning
DM Planning:
Diagnostic:
CBC, CTG, HbsAg,
PTT, APTT.
Therapy:
Obs. Mother and
fetal well being.
Obs. Sign of inpartu

Time

Subject
Obstetrical History:
1.This
History of family planning: Next family planning: inj. 3
month

Object
PS: 5
dilatation servic: 1cm (1)
Servic length: 1 cm (1)
station : H I (1)
Concystency : average (1)
Position : mid (1)
PE:
Promontorium non palpable
Spina ischiadica non
prominent
os coccygeus mobile
Pubis arch > 90 degree.
Lab:
HB 13.5
RBC 4,61
HCT 41,1
WBC 14,91
PLT 224
HbSAg non reactive

Assessment

Planning

Time
09.00

Subject
Abdominal pain (+)
Bloody slime +

Object
General status
GC : well
GCS: CM (E4V5M6)
BP : 120/80mmHg
PR: 84 tpm
RR: 20 tpm
T: 36,5C

Assessment

Planning

G1P0A0H0, 39-40
weeks S/L/IU head
presentation
with latent phase of
labor

Obs. Mother and fetal

well being.
Obs. progress of labor

latent phase of labor

Obs. Mother and fetal

well being.
Obs. progress of labor

DM co GP, GP co SPV,
advice:
Obs. progress of labor

UC : 2x10~25
FHB : 11.12.12 (140x/min)
VT : 2cm, eff. 25%, Amnion
(+), head palpable,
denominator unclear, HI,
impalpable of small part or
umbilical cord.
13.00

Abdominal pain (+)

General status
GC : well
GCS: CM (E4V5M6)
BP : 130/80mmHg
PR: 84 tpm
RR: 20 tpm
T: 36,5C
UC : 2x10~25
FHB : 12.13.13 (152x/min)
VT : 2cm, eff. 25%, Amnion
(+), head palpable,
denominator unclear, HI,
impalpable of small part or
umbilical cord.

Time
17.00

Subject
Abdominal pain (+), nausea (+)

Object
General status
GC : well
GCS: CM (E4V5M6)
BP : 130/80mmHg
PR: 88 tpm
RR: 20 tpm
T: 36,5C

Assessment
Prolonged latent
phase of labor

Abdominal pain (+), nausea (-)

General status
GC : well
GCS: CM (E4V5M6)
BP : 130/80mmHg
PR: 92 tpm
RR: 20 tpm
T: 36,7C
UC : 3x10~30
FHB : 10.11.11 (128x/min)
VT : 4cm, eff. 50%, Amnion
(+), head palpable,
denominator ROA, HI,
impalpable of small part or
umbilical cord.

Obs. Mother and fetal

well being.
Obs progress of labor
DM co to GP,about
mother and fetal
condition ,GP co
SpOG, advice:
- obs. for 6 hours, FHB,
- Consult at 23.00
- Ranitidin inj (k/p)

UC : 2x10~25
FHB : 10.11.11 (128x/min)
VT : 2cm, eff. 25%, Amnion
(+), head palpable,
denominator ROA, HI,
impalpable of small part or
umbilical cord.

21.00

Planning

Active phase of labor

Obs. Mother and fetal

well being.
Obs progress of labor
with WHO patograph

Time
23.00

Subject
Abdominal pain (+), nausea (-)

Object
General status
GC : well
GCS: CM (E4V5M6)
BP : 130/70mmHg
PR: 88 tpm
RR: 20 tpm
T: 36,6C

Assessment

Planning

Active phase of labor

Obs. Mother and fetal

well being.
Obs. progress of labor
DM co to GP,about
mother and fetal
condition
GP co to SPV, advice:
-Lay to the left side
-O2 3 lpm
-Rehidration 1 flash RL

UC : 4x10~45
FHB : 13.13.13 (156x/min)
VT : 7cm, eff. 75%, Amnion
(+), head palpable,
denominator ROA, HI,
impalpable of small part or
umbilical cord.
00.10

Mother wanted to bearing down

FHB: 13-13-12
UC: 3X10-45

2nd stage of labor

-Conduct the labor

Bulging of perineum
Pressure of anus
Opening of the vulva
Crowning (+)

00.15

Baby was born,

spontan, female, BW:
2600g, BL: 49cm, HC:
33cm, anus (+) anomali
congenital (-) AS 7-9
-Plasenta was born
spontaneously
complete

Time
02.15

Subject
Abdominal pain (-), nausea (-),
vomitting (-) flatus (-) headache (-)

Object
General status
GC : well
GCS: CM (E4V5M6)
BP : 110/70mmHg
PR: 88 tpm
RR: 18 tpm
T: 36,8C

Assessment

Planning

2 hours post partum

DM planning:
-Obs. Bleeding
-Obs. Mother and baby
well being

1 day post partum

DM planning:
-Obs. Bleeding
-Obs. Mother and baby
well being

UFH: 2 fingers below umbilicus

UC: well
Lochia + rubra

06.00

Abdominal pain (-), nausea (-),

vomitting (-) flatus (-)
headache (-)

General status
GC : well
GCS: CM (E4V5M6)
BP : 110/70 mmHg
PR: 88 tpm
RR: 18 tpm
T: 36,8C

Case 2

Name : Mrs. M
Age : 21 years old
Address : Meninting
Admitted : 21th May 2016

Time
21th May
2016
04.15

Subject
Patient referred from Meninting
PHC with G1P0A0L0 40-41
weeks S/L/IU head presentation
with PROM. Patient confessed
water leaked from her womb (+)
since 13.00 (20/05/2016),
abdominal pain (-), bloody slime
(-), FM (+).
History of DM (-), HT (-), asthma
(-),.
Family history of DM (-), HT (-),
asthma (-),
History of allergy (-).
LMP : Forgot
EDD : GW : History ANC : 2x at PHC
Last ANC: 12-03-2016,
Result GW 21-22 weeks, BP :
110/60 mmHg, BW: 55 kg, head
presentation, UFH: 18cm, FHB
(+), edema (-), Lab: Proteinuria
+1.
History of USG : 1x at Sp.OG
Last USG 07/04/2016
Result: F/S/L/IU head
presentation 34-35 weeks,
placenta at fundus, amnion
enough, EFW 2200, EDD
15/05/2016.

Object
General status
GC : well
Consciousness: CM
BP : 110/60 mmHg
PR: 82 tpm
RR: 22 tpm
T: 36,6C
Local status
Eye : anemic -/-, icteric -/Cor : S1S2 single regular,
murmur (-), gallop (-).
Pulmo : vesicular (+/+),
wheezing (-/-),
rhonchi (-/-).
Abdomen : scar (-), striae (+),
linea nigra (+).
Extremity : edema (-/-), warm
acral (+/+).
Obstetric status
L1 : breech
L2 : back on left side
L3 : head
L4 : 4/5
UFH : 29 cm
EFW : 2790 gr
FHB: 12-12-12
UC : 2x10~15
Inspeculo: fluid at fornix
posterior, clear.

Assessment
G1P0A0L0 aterm
S/L/IU head
presentation with
PROM >12 hours.

Planning

Diagnostic:
CBC
Urinalysis
Lakmus test

Monitoring:
Obs. Temperature
every 4 hours
Obs. Mother and
fetal well being.
Therapy:
Ampicillin inj. 2 gr,
continued with
ampicillin oral
3x500gr for 7 days.
Pro-termination with
Oxytocin drip.
DM co to GP, GP co
to SPV, SPV advice:
Drip Oxytocin
Obs. Mother and
fetal well being

Time

Subject
History of family planning: Next family planning: IUD
Obstetric history:
1. This

Object
VT : 1 cm, eff 25%, amnion
(-), head presentation, HI,
denominator unclear, small
part or umbilical cord
unpalpable.
Pelvic score = 5
Dilatation of cervix : 1
Length of cervix : 1
Station : 1
Consistency : 1
Position : 1
Pelvic examination:
Promotorium not palpable
Spina ischiadica not
prominent,
os coccygeus mobile,
pubis arc > 90o
Lab:
HB: 10,6
RBC: 3,95
HCT: 32,9
WBC: 9,47
PLT: 262
HbsAg: (-)
CTG: reactive

Assessment

Planning

Time

Subject

20/05/2
016

Chronology at Meninting PHC

:
S:
Patient pregnant 9 month
confessed abdominal pain (+)
since 08.00 (20/05/2016), water
leaked from her womb (+), bloody
slime (-), FM (+)

15.30

O:
General status
GC : well
Consciousness: CM
BP : 120/70 mmHg,
PR : 80 ppm,
RR : 20 rpm,
T : 36,6 C.
UC: 2x10~25
FHB: (+) 12-12-12 tpm
VT: 1cm eff 25%, amnion (-)
clear, head presentation, HI,
small part or umbilical cord
unpalpable.
A:
G1P0A0L0 40-41 weeks S/L/IU
head presentation with PROM.
P:
- IVFD: RL 28 dpm.
- Inj. Ampicillin 1gr/IV (22.00)

Object

Assessment

Planning

Time
21/05/
2016
06.00

Subject
Confessed abdominal pain (+)

Object
General status
GC : well
Consciousness: CM
BP : 120/80 mmHg
PR: 86 tpm
RR: 18 tpm
T: 36,5C

Assessment
G1P0A0L0 aterm
S/L/IU head
presentation with
PROM

Planning

CTG