Morning Report

July 16th 2014

Supervisor : dr. I Made Putra
Juliawan, Sp.OG
Medical Students :
Yid, Ayu, Zia, Santi
CASE RESUME
NORMAL LABOR

PATHOLOGY
LABOR

G5P4A0L4 with head presentation 41 wks S/L/IU with

neglected active phase of labor

Case Report
Name: Mrs. N
RM
Age

: 542525
: 37 years old

Address : Narmada
Admitted : July, 15th 2014 (22.45)
Diagnose

: G5P4A0L4 with head presentation

41 wks S/L/IU with neglected active phase of
labor

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

15/07/
2014
22.45
wita

Patient was reffer from Narmada

PHC with G5P4A0L4 head
presentation 41 wks S/L/IU with
neglected Active Phase of Labor.
Patient came to VK IRD NTB GH
confess lower abdominal pain that
spread to flank region since 19.00
wita (15/07/2014), history of
membrane ruptured at 16.00 wita
(15/07/2014), bloody slim (+).
Fetal movement (+).
No history of DM, HT, asthma or
allergy.

General Status :
GC : moderate GCS : E4V5M6
BP : 120/80 mmHg
PR : 84 bpm
RR : 22 bpm
T : 36,8oC
Eye : anemis (-), icteric (-)
Cor : S1S2 single regular, murmur
(-), gallop (-).
Pulmo : vesiculer (+/+), wheezing
(-/-), ronkhi (-/-).
Abdomen : scar (-), stria
gravidarum (+), linea nigra (+).
Extremity : edema (-/-), warm acral
(+/+).

G5P4A0L4 with
head presentation
41 wks S/L/IU
with neglected
active phase of
labor

Observation mother &

fetal well being.
Lab exam

LMP : 01/10/2013
EDD : 08/07/2014
History of ANC : never
History of USG : never
History of family planning : tablet
Next family planning : IUD
Obstetrical History :
I. Aterm/female/2500g/normal/
14yo
II. Aterm/female/3000g/normal/
13yo
III. Aterm/female/3100g/normal/
10yo
IV. Aterm/female/3600g/normal/
4,5yo
V. This

Obstetrical Status :
L1 : breech
L2 : back on the right side
L3 : head
L4 : 3/5
UFH : 33 cm
EFW : 3410 gram
UC : 3x10~35
FHB : 13-13-14 (160 bpm)
VT : 8 cm, eff. 75%, Amnion (-),
head palpable, caput (+), HII,
impalpable small part of fetus or
umbilical cord .

DM co to GP pro
resucitation and CS,
GP advice:
resucitation
GP co to SPV pro CS
and SPV advice :
Observe. Progres of
labor
If his no adequate,
Accelaration till 20
dpm

TIME

SUBJECTIVE
Chronologist at Narmada PHC:
20.25 wita (15/07/2014)
S/ Patient come to Poskesdes
with lower abdominal pain refer to
flank region and history of bloody
slim, mother wants to bearing
down.
O/
BP : 120 / 80 mmHg
HR: 84 bpm
RR: 21 tpm
T: 36,5
UFH: 31 cm
FHB : 11-12-11 (136 x/minute)
UC: (+) 4x10~40
VT : 9 cm, eff. 90%, amnion
(-), head palpable, HIII, denom
LOA, portio oedema (+),
impalpable small part / umbilical
cord.
A/ G5P4A0L4 40 wks S/L/IU with
head presentation, mother and
fetal well being with neglected
labor
P/
KIE family
Infus RL
Reffer to PHC narmada

OBJECTIVE
PE :
Spina ischiadica not prominent,
Os coccygeus mobile,
Arcus pubis > 900
Lab Examination :
HB : 9,6 g/dl
RBC : 3,46 x 106/L
HCT : 28,7 %
WBC : 16,16 x 103/L
PLT : 327 x 103/L
HbSAg : (-)

ASSESSMENT

PLANNING

TIME

SUBJECTIVE
21.30 wita (15/07/2014)
S/ Patient came from polindes
dasan tereng with neglected labor,
patient confess abdominal pain
since 19.00 wita. FM (+), water
leaked out from her vagina since
20.25 at polindes
LMP : 01/10/2013
O/
BP : 120 / 80 mmHg
HR: 88 bpm
RR: 20 tpm
T: 37,6
UFH : 34 cm
FHB : 14-14-13 (168 x/minute)
UC: (+) 3x10~35
VT : 8 cm, eff. 75%, amnion
(-), head palpable, portio oedema
(+), head HII, denom. LOA,
impalpable small part / umbilical
cord.
A/ G5P4A0L4 41 wks S/L/IU with
head presentation, mother and
fetal well being with neglected
labor
P/
KIE family
Inj. Ampisilin 1 gr /IV
Paracetamol 500 mg
Reffer to GH NTB with O2 4 lpm

OBJECTIVE

ASSESSMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

23.30 wita

UC : 3x10~30
FHB : 13-13-14 (160 bpm)

Drip oxy 8 dpm

23.45 wita

UC : 3x10~30
FHB : 13-14-14 (148 bpm)

Drip oxy 12 dpm

16/07/2014
00.00 wita

UC : 3x10~30
FHB : 12-13-12 (148 bpm)

Drip oxy 16 dpm

00.15 wita

UC : 3x10~35
FHB : 12-13-12 (148 bpm)

Drip oxy 20 dpm

00.30 wita

UC : 3x10~30
FHB : 13-13-12 (152 bpm)

Drip oxy 20 dpm

00.45 wita

UC : 3x10~30
FHB : 12-13-12 (148 bpm)

Drip oxy 20 dpm

01.00 wita

GC : well
GCS : E4V5M6
BP : 110/80 mmHg
PR : 88 bpm
RR : 20 bpm
T : 36,4oC
UC : 3x10~30
FHB : 14-14-15 (172 bpm)
VT : 8 cm, eff. 75%, Amnion (-),
head palpable, caput (+), HII,
oedema portio (+), molase
(+)impalpable small part of fetus or
umbilical cord

01.30 wita

G5P4A0L4 with
head presentation
41-42 wks S/L/IU
with neglected
active phase of
labor

DM co to GP pro CS, co
to SPV , advice:
Prepare for CS
KIE family about CS
Inj. Cefotaxime 2 gr I.V
(skin test before injection)
DC

Send patient to operation

room

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

02.30
wita

PLANNING
CS began
(02.36) Baby was
born, male, BW 3900
gr, BL 54 cm, AS 7-9 ,
anus (+), kongenital
anomaly (-)
Placenta delivered
completed, bleeding
150 cc.

04.30
wita

General condition: Good

BP : 120/80 mmHg
HR : 84 bpm
RR : 22 tpm
T : 36,7oC
UFH : at umbilical
UC : (+) well
Lochea rubra +
UO : 70 cc/ho

07.00
wita

General condition: Good

BP : 110/80 mmHg
HR : 84 bpm
RR : 20 tpm
T : 36oC
UFH : 2 finger bellow umbilikus
UC : + well
Lochea rubra +
UO : 60 cc/ho
Baby in NICU

2 hours Post CS

Observation Mother
and baby well being
Suggest mother to
mobilazation
Suggest mother to eat
and drink

1 day post CS

Observation Mother
and baby well being
Suggest mother to
mobilazation
Suggest mother to eat
and drink

THANKYOU