MORNING REPORT

MARCH 20, 2012

Supervisor : dr. Agus Thoriq Sp.OG
Medical Student:
Nisia, rikhana, fahmi, ira
Cases resume :

Normal Labor
Pathologic labor

4
1. G2P1A0L1 A/S/L/IU head presentation
with prolonged 2nd stage of labor
2. G3A1P1L1 26-28 week S/L/IU with
placenta previa totalis and fetal
1.
distress
3. G1P0A0L0 A/S/L/IU breech
presentation

Name : mrs. Y A

Admitted to GH NTB

Age : 25 years old

time
Subjective

March 20, 2012 at 13.00 WITA

Assestment

20/03/2012
13.30

Patien referred from narmada PHC

G2P1A0L1 A/S/L/IU head
presentation with protacted active
phase of stage one of labor,
patient confessed abdominal pain,
bloody slim (+), history of rupture
membrane (+) since 20/02/12 at
09.00 , clear, odorless, fetal
movement (+), history of DM (-),
hypertension (-)
LMP : forget
EDD: History of ANC : once a time at
midwife
last ANC : 1/3/2012
History of USG : (History of family planning : 3
month injection
Next family planning: IUD
Obstetrical history:
1. aterm, spontan, 3200 gr,
female 2 y0
2. This

Objective

General status :
GC: -, GCS: E4V5M6
BP:130/90 mmHg
RR: 20 x/mnt
Pulse :80 x/mnt
T: 36,4 C
Eyes : an(-) ikt (-)
Cor : S1S2 single regular Murmur
(-), Gallop (-)
Pulmo : Vesiculer (+/+), rh (-/-),
wh (-/-)
Abd : scar (-), striae (+)
Extremity edema (-/-)
Obstetric status :
L1 : breech
UFH: 35cm
L2 : back on right
L3 : head
L4 : 3/5
EFW : 3720
UC : 4x10,30
FHB : 156 x/mnt
VT : completed, head palpable
denominaor LOA , amnion (-)
hodge II+, unpalpable small part of
umbilcal cord

G2P1A0L1
A/S/L/IU head
presentation with
prolonged 2nd
stage of labor

Planning
DM co to GP
GP adivce to motivate
patient to suatting and
rehidration
evaluate in 2 hours, if
there is no progressing
of labor VE

Chronologist :
Patien came to midwife 20 march
2012 at 04.00 complained flank
pain without vaginal discharge
BP : 120/80 PR : 88 temp 37
UFH :33cm, back on the right, 4/5
with head presentation, UC : 3x
10, 20
VT : 4 cm eff 50%, amnion intact
, hodge I
At 09.00 ruptured of membrane
amnion, with clear leakeage 100
cc, UC increased to 4x10, 45 and
VT: 9 cm, hodge I then at
11.00 patient refer to NTB GH

16.30

18.00

Patient inadeuquate to bear

down

Lab exam :
WBC : 14,2
RBC : 3,65%
HGB :10,0
PLT : 310
Hct : 28,5
HbsAg (-)

UC : 4x10,30
FHB : 156 x/mnt
VT : completed
opening , effacement
100%, amnion (-)
hodge II+

G2P1A0L1 A/S/L/IU
head presentation
with prolonged 2nd
stage of labor

Consult supervisor prepare for

SC

SC begun
Baby was born AS 6-8, 3750
gram, female, oblique lie, amnion
fluid clear, anus (+), congenital
anomali (-), edema of uterus ,
and distention of VU bleeding
300cc,

time

subjektive

Objective

assestment

Planning

19.00-20.00

Wound operation pain

GC : well
BP : 110/70 mmHg
PR : 80 bpm RR : 20 tpm
T : 36,5C
TFU: 3 fingers above umbilicus
UC :+
AB: UO: 2200cc

2 hours post SC

Observe mother
and fetal well
being
Suggest mother
to eat and drink

07.00

Wound operation pain

GC : well
BP : 100/70 mmHg
PR : 88 bpm RR : 20 tpm
T : 36 C
UFH: umbilicus
UC : +
AB: UO: 500cc

1 day post SC

Observe mother
and fetal well being
Suggest mother to
mobilisation, eat
and drink

Baby in NICU :
PR: 120x/minute
RR: 40x/minute
T: 36,7C