Morning Report

CASE RESUME
NORMAL LABOR

PATHOLOGY
LABOR

1. G1P0A0L0 A/S/L/IU head presentation, stage I

latent phase with drip failure at second serial

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

30/10
/2012
14.00

Patient
reffered
from
policlinic
NTB GH with
G1P0A0L0
40-41
weeks
S/L/IU head presentation with
mother & fetal well being.
Patient confessed abdominal
pain that spread to waist
since 10.00 (30/10/2012).
History rupture of membrane
(-), bloody slim (+) since
10.00 (30/10/2012), FM (+).
No history of DM, HT,
asthma.

General Status :
GC : well
BP : 120/80 mmHg
PR : 88bpm
RR : 20 bpm
T : 36,5OC
Eye : anemis (-), icteric (-)
Cor : S1S2 single regular,
murmur (-), gallop (-).
Pulmo
:
vesicular
(+/+),
wheezing (-/-),
ronkhi (-/-).
Abdomen : scar (-), striae
gravidarum (+), linea nigra (+).
Extremity : edema (-/-), warm
acral (+/+).

G1P0A0L0 40-41
weeks S/L/IU
head
presentation with
mother & fetal
well being

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

LMP : EDD : History of ANC : > 4x at

Posyandu
Last ANC : 01/07/2012
History of USG : 1 x
History of family planning :
(-)
Next family planning : IUD
Obstetrical History :
I. This

Obstetrical Status :
L1 : breech
L2 : back on the right side
L3 : head
L4 : 4/5
UFH : 32 cm
EFW : 3255 gram
UC : FHB : 12-11-12 (140 bpm)
VT : 1 cm, effacement 10%,
amnion (+), head palpable HI,
denominator
unclear,
impalpable small part and
umbilical cord.

TIME

SUBJECTIVE
Chronologist : (-)

OBJECTIVE

ASSESSME
NT

PLANNING

G1P0A0L0 4041 weeks

S/L/IU head
presentation
with mother &

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

Pelvic Evaluation :
Spina
ischiadica
not
prominent
Os coccygeus mobile
Arcus pubis > 90o
PS : 5
Cervix dilatation 1 cm : 1
Cervix length 1 cm : 2
Cervix consistency
moderate : 1
Cervix position posterior :
0
Station H I : 1
Lab Examination
(30/10/2012) :
HB : 10,8 g/dl
RBC : 3,61 x 106/L
HCT : 32,2 %
WBC : 16,06 x 103/L
PLT : 316 x 103/L
HbSAg : (-)

16.00

(-)

GC : well
BP : 110/80 mmHg
PR : 80 bpm
RR : 20 bpm
T : 36,5OC

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

30/10/1
2
17.00

UC : FHB : 12-11-12 (140

bpm)

Drip oxytocin 12 dpm

17.30

UC : FHB : 12-13-13 (152

bpm)

Drip oxytocin 16 dpm

18.00

Abdominal pain came and

relieved

UC : 2x10~15
FHB : 12-12-12 (144
bpm)

Drip oxytocin 20 dpm

18.30

Abdominal pain came and

relieved

UC : 2 x 10 ~ 25
FHB : 12-12-12 (144
bpm)

Drip oxytocin 24 dpm

19.00

Abdominal pain came and

relieved

UC : 2x 10 ~ 25
FHB : 12-12-11 (140
bpm)

Drip oxytocin 28 dpm

19.30

Abdominal pain came and

relieved

UC : 2x 10 ~ 25
FHB : 12-12-11 (140
bpm)

Drip oxytocin 32 dpm

20.00

Abdominal pain came and

relieved

UC : 2x 10 ~ 25
FHB : 12-11-12 (140
bpm)

Drip oxytocin 36 dpm

GC : well
BP : 120/80 mmHg
PR : 81bpm
RR : 20 bpm
T : 36,9OC
20.30

Abdominal pain came and

relieved

UC : 2x 10 ~ 25
FHB : 11-12-11 (136
bpm)

Drip oxytocin 40 dpm

21.00

Abdominal pain came and

UC : 2x 10 ~ 25

Drip oxytocin 40 dpm

TIME

SUBJECTIVE

OBJECTIVE

30/10/1
2
22.30

Abdominal pain came and

relieved

UC : 2x 10 ~ 25
FHB : 12-11-12 (140
bpm)

23.00

Abdominal pain came and

relieved

UC : 2x10~15
FHB : 12-12-12 (144
bpm)

Drip oxytocin 40 dpm

23.30

Abdominal pain came and

relieved

UC : 2 x 10 ~ 25
FHB : 12-12-12 (144
bpm)

Drip oxytocin 40 dpm

24.00

Abdominal pain came and

relieved

UC : 2 x 10 ~ 35
FHB : 12-12-11 (140
bpm)

Drip oxytocin 40 dpm

GC : well
BP : 120/80 mmHg
PR : 81bpm
RR : 20 bpm
T : 36,9OC

ASSESSMENT

PLANNING

G1P0A0L0 40-41 mg
S/L/IU head
presentation with
mother & fetal well
being.

Drip oxytocin 1st flash

end, continue with
2nd flash

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

31/10/1
2
00.30

Abdominal pain came and

relieved

UC : 2 x10~35
FHB : 12-12-12 (144
bpm)

Drip oxytocin 40 dpm

01.00

Abdominal pain came and

relieved

UC : 3 x 10 ~ 35
FHB : 12-12-12 (144
bpm)

Drip oxytocin 40 dpm

01.30

Abdominal pain came and

relieved

UC : 3x 10 ~ 35
FHB : 12-12-11 (140
bpm)

Drip oxytocin 40 dpm

02.00

Abdominal pain came and

relieved

UC : 3x 10 ~ 35
FHB : 12-12-11 (140
bpm)

Drip oxytocin 40 dpm

02.30

Abdominal pain came and

relieved

UC : 3x 10 ~ 35
FHB : 12-11-12 (140
bpm)

Drip oxytocin 40 dpm

03.00

Abdominal pain came and

relieved

UC : 3x 10 ~ 35
FHB : 11-12-11 (136
bpm)

Drip oxytocin 40 dpm

VT : 1 cm,
effacement 10%,
amnion (+), head
palpable HI,
denominator unclear,
impalpable small part
and umbilical cord.
03.30

Abdominal pain came and

relieved

UC : 3 x 10 ~ 35
FHB : 12-11-12 (140
bpm)

G1P0A0L0 40-41 weeks

S/L/IU head
presentation, mother &
fetal well being, with
dirp failure at first serial

Drip oxytocin 40 dpm

2nd flash finished,
change flash with
Ringer Lactat
Obs mother and fetal
well being

TIME

SUBJECTIVE

31/10/1
2
10.15

Abdominal pain came and

relieved

1/10/12
09.30

OBJECTIVE

ASSESSMENT

PLANNING

UC : FHB : 12-11-12 (140

bpm)

G1P0A0L0 40-41 weeks

S/L/IU head
presentation, mother &
fetal well being, with
dirp failure at first serial

Patient moved to
melati

Abdominal pain came and

relieved

UC : FHB : 12-12-12 (144

bpm)

G1P0A0L0 40-41 weeks

S/L/IU head
presentation, mother &
fetal well being, with
dirp failure at first serial

Patient come to VK
Teratai

10.00

Abdominal pain came and

relieved

UC : FHB : 12-12-12 (144

bpm)

Drip oxytocin 2nd

serial start at 8 dpm

10.30

Abdominal pain came and

relieved

UC : FHB : 12-12-11 (140

bpm)

Drip oxytocin 12 dpm

11.00

Abdominal pain came and

relieved

UC : 2x 10 ~ 10
FHB : 12-12-11 (140
bpm)

Drip oxytocin 16 dpm

11.30

Abdominal pain came and

relieved

UC : 2x 10 ~ 15
FHB : 12-11-12 (140
bpm)

Drip oxytocin 20 dpm

12.00

Abdominal pain came and

relieved

UC : 2x 10 ~ 15
FHB : 12-11-12 (140
bpm)

Drip oxytocin 24 dpm

12.30

Abdominal pain came and

relieved

UC : 2x 10 ~ 10
FHB : 12-12-11 (140
bpm)

Drip oxytocin 28 dpm

13.00

Abdominal pain came and

relieved

UC : 2x 10 ~ 15
FHB : 12-11-12 (140
bpm)

Drip oxytocin 32 dpm

13.30

Abdominal pain came and

UC : 2x 10 ~ 15

Drip oxytocin 36 dpm

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

31/10/1
2
15.30

Abdominal pain came and

relieved

UC : 2x 10 ~ 15
FHB : 12-11-12 (140
bpm)

Drip oxytocin 40 dpm

16.00

Abdominal pain came and

relieved

UC : 2x 10 ~ 15
FHB : 12-11-12 (140
bpm)

Drip oxytocin 40 dpm

16.30

Abdominal pain came and

relieved

UC : 2x 10 ~ 15
FHB : 12-11-12 (140
bpm)

Drip oxytocin 40 dpm

17.00

Abdominal pain came and

relieved

UC : 2x 10 ~ 25
FHB : 12-11-12 (140
bpm)

Drip oxytocin 40 dpm

17.30

Abdominal pain came and

relieved

UC : 2 x 10 ~ 25
FHB : 12-11-12 (140
bpm)

Drip oxytocin 40 dpm

18.00

Abdominal pain came and

relieved

UC : 3x 10 ~ 25
FHB : 12-11-12 (140
bpm)

Drip oxytocin 40 dpm

18.30

Abdominal pain came and

relieved

UC : 3x 10 ~ 35
FHB : 12-11-12 (140
bpm)

Drip oxytocin 40 dpm

19.00

Abdominal pain came and

relieved

UC : 3x 10 ~ 35
FHB : 12-12-12 (144
bpm)

Drip oxytocin 40 dpm

19.30

Abdominal pain came and

relieved

UC : 3x 10 ~ 35
FHB : 12-13-12 (148
bpm)

Drip oxytocin 40 dpm

20.00

Abdominal pain came and

relieved

UC : 3x 10 ~ 35
FHB : 12-11-12 (140
bpm)

Drip oxytocin 40 dpm

20.30

Abdominal pain came and

UC : 3x 10 ~ 35

G1P0A0L0 40-41 weeks

PLANNING

Drip oxytocin finished