MORNING REPORT

JULY, 7TH 2014

CASE RESUME
NORMAL LABOR 0

PATHOLOGIES LABOR 1. G1P0A0L0 39-40 weeks/S/L/IU head presentation

with PROM + induction drip oxytocyn
Name : Mrs.I
Age : 18 years old
Address : Lilir Mekarsari, Lobar
Admitted : 12-07-2014
No. RM : 11-26-44
G1P0A0L0 39-40 weeks/S/L/IU head
presentation with PROM + oligohidramnion
 Time Subject Object Assessment Planning
12-07- Patient reffered from poly General status G1P0A0L0 39- Obs. Mother and fetal
2014 pregnancy NTB GH with GC : well 40 weeks well being
13.00 G1P0A0L0 39-40 weeks/S/L/IU GCS: CM (E4V5M6) A/S/L/IU head DM co to GP pro CTG,
head prsentation with PROM >12 BP : 110/70 mmHg presentation inj. Antibiotic,
hours HR: 88 x/m with PROM + acceleration GP, GP co
RR: 22 x/m oligohidramnion to SPV, SPV acc and
Patient confessed abdominal pain T: 36,6 C advice:
with water come out from her Acceleration
vagina (+) since 04-07-2014 Local status Inj. Ampi 1 g/6 h
(11.00), bloody slim (-), and FM Eye : an (-/-), ict (-/-)
(+). Pulmo: ves (+/+), rh (-/-), wh (-/-)
Cor : S1S2 single regular, M(-), G(-)
History of DM (-), HT (-), asthma Abd : striae gravidarum (+), linea nigra
(-). (+), scar (-)
Ext : edema (-/-), warm (+/+)
LMP : 11-10-2013
EDD : 18-07-2014 Obstetric status
L1 : breech
History ANC : 5x at posyandu L2 : back on the right side
Last ANC : 12-07-2014 L3 : head
result: BP : 120/90, 39-40 weeks, L4 : 4/5
FHB (+) 136 x/min, mothers and UFH: 29 cm
fetals condition is well EFW : 2790 gram

UC : -
FHB : 12-11-11 (136x/min)
Time Subject Object Assessment Planning
History of USG : 3 times VT : 1 cm, eff. 10 % amnion
Last USG: 11 Juli 2014 (+) thin, head palpable, HI, denom
Result: G1P0A0L0 39-40 unclear, unpalpable small part of
mg S/L/IU with fetus/ umbilikal cord
olighidramnion
Pelvic examination:
History of family planning Promontorium unpalpable
:- Spina ischiadica not prominent
Next family planning : Os coccygeus mobile
IUD Arcus pubic > 90 degree

History of obstetric : PS :
I. This Cervic dilatation 1 cm : 1
Cerviks length 3cm: 1
cerviks consistency soft: 1
Cerviks position mid: 1
Station H I: 1
Total: 5

Lab:
HGB = 9.5 g/dl
RBC = 3.91 K/ul
WBC = 8.80 M/ul
HCT : 30.3 %
PLT = 440 M/ul
HBsAg = (-)
Time Subject Object Assessment Planning

14.30 UC : - With Induction Start drip oxytocin at 8 dpm

FHB : 12-12-11 (140x/min)

15.00 UC : - Oxy drip: 12 dpm

FHB : 11-12-11 ( 136x/min)

15.30 UC :- Oxy drip: 16 dpm

FHB : 11-12-12 ( 140x/min)

16.00 Abdominal pain UC : 1 x 10 ~ 20 Oxy drip: 20 dpm

FHB : 11-12-11 (136 x/min)

16.30 UC : 2 x 10 ~ 20 Oxy drip: 24 dpm

FHB : 11-12-11 (136 x/min)

17.00 UC : 2 x 10 ~ 30 Oxy drip: 28 dpm

FHB : 11-12-11 (136 x/min)

17.30 UC : 3 x 10 ~ 40 Oxy drip: 28 dpm

FHB : 11-12-12 (140 x/min)
VT : 6 cm, eff. 75 % amnion (-),
head palpable, HI, denom unclear,
unpalpable small part of fetus/
umbilikal cord
Time Subject Object Assessment Planning

18.00 UC : 3 x 10 ~ 40 Oxy drip: 28 dpm

FHB : 12-12-11 (140x/min)

18.30 Mother wont to UC : 4 x 10 ~ 40 Oxy drip: 28 dpm

bearing down FHB : 11-12-12 ( 140x/min)

19.00 Mother wont to UC : 4 x 10 x 40 2nd of labor Conduct Labor

bearing down FHB : 11-12-12 ( 140x/min)
Inspection : opening of vulva,
bulging of perineum, pressure
of anus

19.35 Baby was born. Male.

2800 gram. 48 cm, AS 7-
9. Anus (+). Congenital
anomaly(-).
19.50 UC : well 3rd of labor Placenta was born
UFH : 2 finger bellow complete. 300gram.
umbilicus Bleeding 200 cc
episiostomy (perineum
rupture grade 2)
 Time Subject Object Assessment Planning
22.00 GC: well cons:E4V5M6 2 hours post partum Observation mother and baby well
BP: 110/70 mmHg being
PR: 80x/m Suggest mother to eat and drink
RR: 20x/m Suggest mother to mobilitation
T: 36 0C
UC: (+) well
UFH: 2 fingers below umbilicus
13-07- GC: well cons:E4V5M6 1 day post post partu Observed mother and baby well
2014 BP: 110/70 mmHg being
07.00 PR: 84x/m Suggest mother to eat and drink
RR: 20x/m suggest mother to breast feeding
T: 36,4 0C Suggest mother to mobilisation.
UC: (+) well
UFH: 2 fingers below umbilicus
Active bleeding: (-)
Lokea rubra +
Baby rooming
14-07- GC: well cons:E4V5M6 2 day post partum Observed mother and baby well
2014 BP: 110/70 mmHg being
07.00 PR: 84x/m Suggest mother to eat and drink
RR: 20x/m suggest mother to breast feeding
T: 36,4 0C Suggest mother to mobilisation.
UC: (+) well
UFH: 3 fingers below umbilicus
Active bleeding: (-)
Baby rooming