Morning Report

July 29th 2012

Supervisor : dr. I Made W. Mahayasa, Sp.OG
Medical Students :
Lanira, Ira, Yan, Tari, Rona
CASES RESUME

NORMAL LABOR 2

PATHOLOGY LABOR 1. G1P0A0L0 39-40 weeks S/L/IU with severe pre-eclampsia

and PROM .
2. G1P0A0L0 P/S/L/IU breech presentation with eclampsia
3. G1P0A0L0 39-40 weeks S/L/IU with prolonged 2nd stage of
labor.
 Case Report
Name : Mrs. N
RM : 049213
Age : 24 years old
Address : Sigerongan, Lingsar
Admitted : July 28th 2012 at 23.45
 TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

28/07/ Patient referred from Sigerongan General Status : G1P0A0L0 39-40 Observation mother &
2012 PHC with G1P0A0L0 37 weeks GC : well weeks S/L/IU with fetal well being.
S/L/IU head presentation, mother BP : 150/100 mmHg severe preeclampsia Observation progress
23.45
and fetal condition well with PROM PR : 96 bpm & PROM < 12 hours of labor.
and severe preeclampsia. RR : 20 bpm Continue drip MgSO4
Patient confessed abdominal pain T : 37,0OC 40% 6 gram 28 tpm
and water came out from her from PHC.
Eye : anemis (-), icteric (-)
womb since 13.30 (28-07-2012), DM co to SPV, advice :
Cor : S1S2 single regular, murmur (-),
bloody slim (-), FM (+). continue therapy of
gallop (-).
No history of blurred vision, severe preeclampsia
Pulmo : vesicular (+/+), wheezing (-/-),
epigastric pain, nausea and vomit. & therapy for PROM.
ronkhi (-/-).
No history of DM, HT, asthma. Do CTG, if reactive
Abdomen : scar (-), striae gravidarum
drip oxytocin.
(+), linea nigra (+).
LMP : 02/11/2011 Extremity : edema (-/-), warm acral
EDD : 09/08/2012 (+/+).
History of ANC : > 4x at PHC Obstetrical Status :
Last ANC : 23/07/2012 L1 : breech
History of USG : never L2 : back on the left side
L3 : head
History of family planning : (-) L4 : 4/5
Next family planning : Injection 3 UFH : 29 cm
months EFW : 2790 gram
UC : 3x/10~15
Obstetrical History :
FHB : 12-12-11 (140 bpm)
I. This
VT : 1 cm, effacement 10%, amnion
(-), head palpable HI, denominator
unclear, impalpable small part and
umbilical cord.
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
Chronologist (28/07/2012) Pelvic Evaluation :
Spina ischiadica not prominent
22.00
Os coccygeus mobile
S : Patient confessed abdominal pain that
Arcus pubis > 90o
spread to frank, History rupture of
membrane (+) since 13.30 (28-07-12).
Pelvic Score : 5
O : GC : well
Cervix dilatation 1 cm : 1
BP : 180/100 mmHg
Cervix length 2 cm : 1
PR : 88 bpm
Station H1 : 1
RR : 20 bpm
Cervix consistency moderate : 1
T : 36,8OC
Cervix position mid : 1
Head presentation
UFH : 27 cm
Lab Examination :
UC : 2x10~35
HGB : 10,9 g/dl
FHB : (+) 11-11-11 (132 x/min)
HCT : 35,0 %
VT : 1 cm, eff 25%, amnion (+), head
RBC : 3,92 M/uL
palpable, HI, impalpable small part /
umbilical cord. WBC : 10,61 K/uL
PLT : 257 K/uL
Lab : protein urine (+) 1
HbSAg : (-)
A:
Protein urine : +3
G1P0A0L0 37 weeks S/L/IU head
presentation, mother and fetal condition
well with PROM and severe preeclampsia
P:
Ampicilin 1 g/IV (22.10)
Bolus MgSO4 4 g/IV (23.15)
Drip MgS04 6 g/IV (23.15)
Nifedipin 10 mg (23.00)
Refer to NTB GH
 TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

29/07/12 Abdominal pain UC : 2 x 10 ~ 20 Flash I

06.30 FHB : 12-12-12 (144 bpm) Drip oxytocin began 8 tpm

07.00 Abdominal pain came and UC : 3 x 10 ~ 20 Drip oxytocin 12 tpm

relieved FHB : 12-11-12 (140 bpm) Nifedipin 10 mg

07.30 Abdominal pain came and UC : 3 x 10 ~ 25 Drip oxytocin 16 tpm

relieved FHB : 12-12-12 (144 bpm)

08.00 Abdominal pain came and UC : 3x 10 ~ 25 Drip oxytocin 20 tpm

relieved FHB : 12-12-12 (144 bpm)

08.30 Abdominal pain came and UC : 3 x 10 ~ 30 Drip oxytocin 24 tpm

relieved FHB : 12-12-11 (140 bpm)

09.00 Abdominal pain came and UC : 3 x 10 ~ 35 G1P0A0L0 39-40 weeks Drip oxytocin 28 tpm
relieved FHB : 11-11-11 (132 bpm) S/L/IU latent phase 1st Maintenance
VT : 3 cm, effacement stage of labor with severe
25%, amnion (-), head preeclampsia & history
palpable HI+, denominator rupture of membrane
unclear, impalpable small
part and umbilical cord.

09.30 Abdominal pain came and UC : 4 x 10 ~ 35 Drip oxytocin 28 tpm

relieved FHB : 11-11-11 (132 bpm)

10.00 Abdominal pain came and UC : 4 x 10 ~ 35 Drip oxytocin 28 tpm

relieved FHB : 11-11-11 (132 bpm)

10.30 Abdominal pain came and UC : 4 x 10 ~ 40 Drip oxytocin 28 tpm

relieved FHB : 11-11-11 (132 bpm)
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

11.00 Abdominal pain came and UC : 4 x 10 ~ 40 Drip oxytocin 28 tpm

relieved FHB : 12-11-11 (136 bpm)
11.30 Abdominal pain came and UC : 4 x 10 ~ 40 Drip oxytocin 28 tpm
relieved FHB : 11-11-11 (132 bpm)
12.00 Abdominal pain came and UC : 4 x 10 ~ 45 Drip oxytocin 28 tpm
relieved FHB : 11-11-11 (132 bpm)
12.30 Abdominal pain came and UC : 4 x 10 ~ 45 Drip oxytocin 28 tpm
relieved FHB : 11-11-11 (132 bpm)
13.00 Abdominal pain came and UC : 4 x 10 ~ 45 G1P0A0L0 39-40 weeks Drip oxytocin 28 tpm
relieved FHB : 11-11-11 (132 bpm) S/L/IU active phase 1st
VT : 9 cm, effacement 75%, stage of labor with
amnion (-), caput (+), head severe preeclampsia
palpable HII+, denominator
unclear, impalpable small
part and umbilical cord.

13.45 Abdominal pain came more
frequently
Mother wants to bearing down
UC : 4 x 10 ~ 45
FHB : 12-12-13 (148 bpm)
Teknus perjol vulka
2nd stage of labor with Drip oxytocin 28 tpm
severe preeclampsia Continue drip MgSO4 40% 6
gram 28 tpm.
Pull off DC
Conduct mother to bearing
down.
Baby was born (14.00) :
Male, 2500 gram, 48 cm, AS
5-7 caput (+) on occiput,
anus (+), anomaly congenital
(-).
Placenta was born spontan,
complete. Bleeding 150 cc.
 TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
16.00 Patient confessed delivery GC : well 2 hours post Observed mother well being
wound pain BP : 140/90 mmHg partum Observed bleeding & VS mother
PR : 96 bpm Suggest mother to mobilisation, eat
RR : 24 bpm and drink.
T : 36,7OC Continue drip MgSO4 40% 6 gram
UC : (+) well 28 tpm.
UFH : 2 fingers below umbilicus
Lochea rubra : (+)
UO : 80 cc/hours

30/07/ Delivery wound pain GC : well One day post Observed mother well being
2012 BP : 140/90 mmHg partum Suggest mother to mobilisation, eat
PR : 80 bpm and drink, medication.
07.00
RR : 20 bpm Continue drip MgSO4 40% 6 gram
T : 36,5OC 28 tpm.
UC : (+) well Breast feeding
UFH : 2 fingers below umbilicus
Lochea rubra : (+)
UO : 100 cc/hours

Baby in NICU :
GC : well
PR : 120 bpm
RR : 36 bpm
T : 36,2OC