MORNING REPORT

August 17th, 2012

Supervisor : dr. Edi Prasetyo W., Sp.OG

Medical Students :
Zaky, Lanira, Jun, Aten, Erma, Diah, Dini F, Jatna,
Sesar
CASES RESUME
NORMAL LABOR

PATHOLOGY
LABOR

1.G3P0A2L0 42-43 weeks S/L/IU with Mild

Pre-eclampsia + Oxytocin Drip Failed +
CPD

Case Report

Name
: Mrs. A
Age : 29 years old
Address
: Ampenan
Admitted : August, 16th 2012 at
12.30

TIME

SUBJECTIVE

16/08
/2012

Patient
from
Pregnancy
Policlinic of NTB GH with
G3P0A2L0 42-43 weeks S/L/IU
with mild preeclampsia.
Abdominal pain (-), history
rupture of membrane (-),
bloody slim (+) since 20.00
WITA (15/8/2012), FM (+).
No history of DM, HT, asthma.

12.30

LMP : 24/10/2011
EDD : 01/08/2012
History of ANC : >4x at PHC &
NTB GH
Last ANC : 16/08/2012
History of USG : 1x at NTB GH
Result (16/08/2012) :
Fetal : S/L/IU
Placenta at fundus gr. III
Amnion : enough, clear
Age of pregnancy : 38-39
weeks
EFW : 3869 g
History of family planning : (-)
Next family planning : IUD
Obstetrical History :
I. Abortus 2 months
II. Abortus 4 months
III. This

OBJECTIVE
General Status
GC : well
GCS : E4V5M6
BP : 140/100 mmHg
PR : 88 bpm
RR : 20 bpm
T : 36,0oC
Eye : palor (-/-), icteric (-/-)
Cor : S1S2 single reguler, murmur
(-), gallop (-).
Pulmo : vesikuler (+/+), wheezing
(-/-), ronkhi (-/-).
Abdomen : scar (-), striae (+), linea
nigra (+)
Extremity : edema (-/-), warm acral
(+/+)
Obstetrical Status
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH : 33 cm
EFW : 3410 g
UC : (-)
FHB : 12-12-12 (144 bpm)
VT : 1 cm, eff 10%, amnion (-),
head palpable HI, impalpable
small part and umbilical cord.
PE :
Spina ischiadica not prominent
Os coccygeus mobile

ASSESSMEN
T

PLANNING

G3P0A2L0
42-43 weeks
S/L/IU with
mild
preeclampsia

vaginal
Pro
delivery
DM co to SPV, pro
termination
(oxytocin
drip).
SPV advice : Acc

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

Pelvic Score : 5
Cervix dilatation 1 cm : 1
Cervix length 2 cm : 1
Cervix consistency
moderate : 1
Cervix position posterior :
1
Station -2 : 1
Lab Examination :
HB : 12,6 g/dl
RBC : 4,52 (10^6/L)
WBC : 13,45 (10^3/L)
PLT : 224 (10^3/L)
HbSAg : (-)
Proteinuria : +2
17.00

(-)

UC : (-)
FHR : 12-13-13

G3P0A2L0 42-43 weeks

S/L/IU with mild
preeclampsia

Flash I began
Oxy drip 8 dpm

17.30

(-)

UC : (-)
FHR : 12-12-11

G3P0A2L0 42-43 weeks

S/L/IU with mild
preeclampsia

Oxy drip 12 dpm

18.00

(-)

UC : (-)
FHR : 11-12-13

G3P0A2L0 42-43 weeks

S/L/IU with mild
preeclampsia

Oxy drip 16 dpm

18.30

Abdominal pain (+)

UC : 2x10-15
FHR : 11-11-12

G3P0A2L0 42-43 weeks

S/L/IU with mild
preeclampsia

Oxy drip 20 dpm

19.00

Abdominal pain came

and relieved

UC : 2x10-15
FHR : 13-12-13

G3P0A2L0 42-43 weeks

S/L/IU with mild
preeclampsia

Oxy drip 24 dpm

TIME

SUBJECTIVE

20.30

Abdominal pain
came and
relieved

21.00

OBJECTIVE

ASSESSMENT

PLANNING

UC : 3x10-20
FHR : 12-11-11

G3P0A2L0 42-43 weeks

S/L/IU with mild
preeclampsia

Oxy drip 36 dpm

Abdominal pain
came and
relieved

UC : 3x10-20
FHR : 12-12-12

G3P0A2L0 42-43 weeks

S/L/IU with mild
preeclampsia

Oxy drip 40 dpm

Maintenance

21.30

Abdominal pain
came and
relieved

UC : 3x10-25
FHR : 13-13-12

G3P0A2L0 42-43 weeks

S/L/IU with mild
preeclampsia

Oxy drip 40 dpm

22.00

Abdominal pain
came and
relieved

UC : 3x10-25
FHR : 12-12-12

G3P0A2L0 42-43 weeks

S/L/IU with mild
preeclampsia

Oxy drip 40 dpm

22.30

Abdominal pain
came and
relieved

UC : 3x10-25
FHR : 11-12-13

G3P0A2L0 42-43 weeks

S/L/IU with mild
preeclampsia

Oxy drip 40 dpm

23.00

Abdominal pain
came and
relieved

UC : 3x10-30
FHR : 11-12-12
VT : 1 cm, eff 10%, amnion
(-),
head
palpable
HI,
impalpable
small
part
/
umbilical cord.

G3P0A2L0 42-43 weeks

S/L/IU with mild
preeclampsia

Flash II began
Oxy drip 40 dpm

23.30

Abdominal pain
came and
relieved

UC : 3x10-35
FHR : 12-13-12

G3P0A2L0 42-43 weeks

S/L/IU with mild
preeclampsia

Oxy drip 40 dpm

17/08/1
2
00.00

Abdominal pain
came and
relieved

UC : 3x10-35
FHR : 11-12-13

G3P0A2L0 42-43 weeks

S/L/IU with mild
preeclampsia

Oxy drip 40 dpm

00.30

Abdominal pain
came and
relieved

UC : 3x10-35
FHR : 13-12-13

G3P0A2L0 42-43 weeks

S/L/IU with mild
preeclampsia

Oxy drip 40 dpm

01.00

Abdominal pain

UC : 3x10-35

G3P0A2L0 42-43 weeks

Oxy drip 40 dpm

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

02.30

Abdominal pain
came and relieved

UC : 3x10-30
FHR : 13-13-12

G3P0A2L0 42-43 weeks

S/L/IU with mild
preeclampsia

Oxy drip 40 dpm

03.00

Abdominal pain
came and relieved

UC : 3x10-35
FHR : 12-12-12

G3P0A2L0 42-43 weeks

S/L/IU with mild
preeclampsia

Oxy drip 40 dpm

03.30

Abdominal pain
came and relieved

UC : 3x10-35
FHR : 11-12-13

G3P0A2L0 42-43 weeks

S/L/IU with mild
preeclampsia

Oxy drip 40 dpm

04.00

Abdominal pain
came and relieved

UC : 3x10-35
FHR : 11-12-12
VT : 1 cm, eff 10%, amnion
(-),
head
palpable
HI,
impalpable
small
part
/
umbilical cord.

G3P0A2L0 42-43 weeks

S/L/IU with mild
preeclampsia + oxytocin
drip failed

Oxy drip 40 dpm

Flash II finished
Changed with infuse
RL

UC : 2x10-20
FHR : 12-12-12

G3P0A2L0 42-43 weeks

S/L/IU with mild
preeclampsia + oxytocin
drip failed

DM co to SPV,
advice : Report to
SPV in the morning.

06.00

At 08.00 : SPV
visite and advice :
prepare CS.
09.00

CS began :
Baby
was
born,
female, A-S 7-9, BW
3900 grams, BL 50
cm.
Anus
(+),
congenital anomaly
(-).
Placenta was born
manually
and

TIME

SUBJECTIVE

17/08
/2012

Abdominal pain and

delivery wound pain

Delivery wound pain

11.20

18/08
/2012
07.00

OBJECTIVE

ASSESSMENT

PLANNING

GC : well
BP : 110/70 mmHg
PR : 84 bpm
RR : 20 bpm
T : 36,5OC
UC : (+) well
UFH : 2 fingers below
umbilicus
Active bleeding : (-)
UO : 80 cc/hours
Operation wound good

2 hours post CS

Observed mother well being

Observed bleeding & VS
mother
mother
to
Suggest
mobilisation, eat and drink.

GC : well
BP : 120/70 mmHg
PR : 80 bpm
RR : 20 bpm
T : 36,7OC
UC : (+) well
UFH : 2 fingers below
umbilicus
Lochea rubra : (+)
Operation wound good

One day post

CS

Baby in NICU :
GC : well
PR : 132 bpm
RR : 44 bpm
T : 36,2OC

Observed mother well being

Suggest mother to
mobilisation, eat, and drink,
medication.
Breast feeding