Morning Report

May 31th 2014

Supervisor : dr. Agus Thoriq
Sp,OG
DM:
Dandi, Ardi, Yos, Ryan, Vendi

Name
: Mrs. S
Age : 18 th
Address
: Batu layar
Admitted : 30th May 2014
RM
: 11 16 36

Time

Subjective

Objective

Assessm
ent

Planning

30/5/14
11.30

Patient come from polyclinic

with G1P0A0L0 40-41 weeks
S/L/IU head presentation laten
phase 1st stage of labor
Patient conffessed abdominal
pain since 02.00 wita
(30/05/14), water leaked out
(-), Bloody slime (-), FM (+)
History :
DM : (-)
HT : (-)
Asthma : (-)

General status
GC : well
GCS : CM
BP : 110/70 mmHg
PR : 80 bpm
RR :20 tpm
T : 36,4 C

G1P0A0L0
40-41
weeks
S/L/IU
Laten
phase 1st
stage of
labor

Obs mother
and fetal
well being

Family history :
DM : (-)
HT (-)
LMP : 20/08/13
EDD : 27/05/14
ANC history : X at PHC
Last ANC :
BP :
BW :
UK :
UFH :
Presentation :
USG History : -

Eye : anemis (-), ikterus

(-)
Cor : S1S2 single
regular, murmur (-),
gallop (-)
Pulmo : vesicular, rhonki
(-), Wheezing (-)
Abdomen : scar (-),
Striae Gravidarum (+),
linea nigra (+)
Extremity :
Upper : oedem (-/-)
Lower : oedem (-/-)
Obstetrical Status
L1 : breech
L2 : back on the right
side
L3 : head
L4 : 4/5

Suggest
mother to
eat and
drink
DM co to GP
adv: obs
proggres of
labor

Time

Subjective

Objective

Familiy planning history : (-)

Next family planning :
injection 3 months

VT

Obstetrical history :
I. this
Chronologist at meninting PHC
(30/05/14)(09.30) WITA
S/Patient conffessed
abdominal pain since 02.00
wita (29/05/14), water leaked
out (-), bloody slime (-), FM
(+)
O/
GC : well
GCS : CM
BP : 110/70 mmHg
PR : 80 bpm
RR : 36,5 tpm
T : 20 C
UFH : 35 cm
L1 : breech
L2 : back on the right and
left side
L3 : head
L4 : 3/5
UC : 2x10-25

:
: 2cm
Eff : 50%
Presentation : head
Hodge : 1
Denominator :
unclear

Pelvic Examination :
Sacrum
convexity
normal
Spina
ischiadica
not
prominent
Os coccygeus mobile
Arcus pubis > 90
Lab result :
HB : 9,6
HCT : 30,1
WBC : 16,78
PLT : 401
HbsAg :-

Assessm
ent

Planning

Time

Subjective

Objective

Assessme
nt

Planning

UC : 2x 10- 25
FHR : 12-13-12
VT : : 3cm, Eff :
50%, Amnion +, head
presentation, Hodge :
1, Denominator :
unclear, smal part of
fetal and umbilical
cord not palpable

Laten
phase 1st
stage of
labor

-Obs mother and fetal

well being

UC : 2x 10- 30
FHR : 154 tpm
VT : : 3cm, Eff :
50%, Amnion +, head
presentation, Hodge :
1, Denominator :
unclear, small part of
fetal and umbilical

Laten
phase 1st
stage of
labor > 8
hours

VT : A/
G1P0A0L0 40-41
weeks S/L/IU head
presentation laten
phase 1st stage of
labor + susp gemeli
P/
Reffered to NTB GH
15.30

19.30

-DM co lab result for

WBC 16,78 to GP
pro inj ampicillin, GP
adv : inj ampicillin
- Skin test (- ), inj.
Ampi 1gr
Obs mother and fetal
well being
DM co to GP, GP co to
SPV, SPV advise
accelleration
CIE family: acc

Time

Subjective

Objective

Assessment

20.30

Planning
Do CTG, CTG
reactive, Drip
oxy 5 IU

21.00

HIS : 2x 10- 30
FHR : 11-12-11

Drip oxy begin

flash I, 8 dpm

21.30

HIS : 3x10-35
FHR :11-11-11

Drip oxy 12
dpm

22.00

HIS : 3X10-35
FHR :12-12-12

Drip oxy 16
dpm

22.30

HIS : 3X10-40
FHR : 11-12-11

Drip oxy 20
dpm

23.00

HIS : 4X10-45
FHR :11-12-12
VT : : 5cm, Eff : 75%,
Amnion -, head
presentation, Hodge : 1,
smal part of fetal and
umbilical cord not
palpable

Active phase 1st

stage of labor +
drip oxy

Drip oxy 24
dpm
obs mother
and fetal well
being
Obs. Progress
of labor,
evaluation 4
hours again
Maintenance
24 dpm

Time

Subjective

Objective

23.30

HIS : 4x 10- 40
FHR : 11-12-11

Drip oxy 24 dpm

00.00

HIS : 4x10-45
FHR :11-11-11

Drip oxy 24 dpm

(31-52014)
00.30

HIS : 4X10-45
FHR :12-12-12

Drip oxy 24 dpm

01.00

HIS : 4X10-50
FHR : 11-12-11

Drip oxy 24 dpm

01.30

HIS : 4X10-50
FHR :11-12-13

Drip oxy 24 dpm

02.00

Mother want to
bearing down

HIS : 4X10-50
FHR :11-12-12
VT : : 10cm, head
presentation, Hodge :
II

2nd stage of
labor

HIS : 4X10-50
FHR : 12-13-12
VT : : 10cm , head
presentation, Hodge :
II , molage (+3)

Arrested 2nd
stage of
labor +
suspect
CPD

03.00

Assessme
nt

Planning

obs mother and fetal well

being
Squad position

obs mother and fetal well

being
Do CTG
DM co to GP, result CTG and
pro SC,
CTG reactive, GP co to SPV,
SPV adv: prepare SC

Time

Subjective

Objective

Assessme
nt

Planning

04.00

05.00

SC began
Baby was born, male, A-S :
3-5, BW 4100 gr, BL 51 cm,
UAC 13cm, HC 36cm, Anus
(+), Congenital Anomaly
(-).
Recusitation baby.
Co to NICU
Active management 3rd
stage of labor.
was
born
Placenta
complete,
500
g,
bleeding 150 cc.
Perineum rupture grade
II,
do
hecting
of
perineum.

Time

Subjective

Objective

Assessme
nt

Planning

Dizzy (-),
nausea (-),
vomit (-)

GC : Well
GCS : E4V5M6
BP : 110/70 mmHg
PR : 88 x/m
RR : 22x/m
Temp : 36,5 C

2 hours post
SC

Observation general status ,

vital sign

UC : (+) well
UFH : 1 finger bellow
umbilicus
Locea rubra : (+)
UO: 120cc/hours
BABY in NICU
HR : 148 bpm
RR : 51 bpm
Temp : 36,70C

CIE patient for eat and drink