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Morning Report

February 10th 2015

Supervisor : dr. Agus Thoriq ,


Sp.OG
Medical Students :
CASE RESUME
NORMAL LABOR
PATHOLOGY
LABOR

Case Report
Name

: Mrs. UK

RM

: 555028

Age

: 36 years old

Address

: Abian Tubuh, Cakranegara

Admitted : February 10th 2015

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMEN
T

PLANNING

10/2/
2015

Patient referred from


Risa GH with G4P3 4142 week S/L. Patient
confessed abdominal pain
since 10/02/2015 at
02.00, history of water
leaked out(-), bloody slim
(-), FM (+).
No history of DM, HT,
asthma.

General Status :
GC : well
BP : 110/80 mmHg
PR : 80 bpm
RR : 16 bpm
T : 36,5oC
Eye : anemis (-), icteric (-)
Cor : S1S2 single regular,
murmur (-), gallop (-).
Pulmo : vesiculer (+/+),
wheezing (-/-), ronkhi (-/-).
Abdomen : scar (-), striae
(+), linea nigra (+).
Extremity : edema (-/-),
warm acral (+/+).

G4P3A0L3
41-42 week
S/L/IU head
presentation

Observation
mother & fetal
well being.
DM co GP pro
CTG, advice :
ACC CTG
reactive,
termination with
oxytocin drip.

08.0
0

LMP : forget
EDD : History of ANC : > 4x at
PHC
Last ANC : 5/02/2015
Result: BP:120/80,
GW:39-40 week, FHB:+
(140x/m)
History of USG : 3x
Last USG : 09/02/2015
Result GW:41-42 week
History of family planning
: Oral contraception
Next family planning :
Injection 3 months
Obstetrical History :
I. Aterm/spontan/house/3

Obstetrical Status :
L1 : breech
L2 : back on the right side
L3 : head
L4 : 4/5
UFH : 34 cm
EFW : 3565 gram
UC : (-)
FHB : 12-12-13 (148 bpm)
VT : 1 cm, effacement
25%, amnion (+), head
palpable HI,
denominator unclear,
impalpable small part and

TIME

SUBJECTIVE

OBJECTIVE

Chronologist :
Risa GH (9-2-2015) 18.30

PS : 5
Cervix dilatation 1 cm : 1
Cervix length 1 cm : 2
Cervix consistency
moderate : 1
Cervix position posterior :
0
Station H I : 1

S :O:USG :
A : G4P3 41-42 weeks S/L
P : Pro termination and
refer to NTB GH

Lab Examination
(10/02/2015)
HB : 11,4 g/dl
RBC : 4,51 x 106/L
HCT : 36,4 %
WBC : 8,12 x 103/L
PLT : 355 x 103/L
HbSAg : (-)

ASSESSME
NT

PLANNING

10-2-2015 (09.30)

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

10.1
5

Abdominal pain came


and relieved

UC : 1x10-10
FHB : 11-11-11
(132 bpm)

DM co CTG to GP, GP
advice induction
ocxtocyn 5 IU in D5%
8 dpm

10.3
0

Abdominal pain came


and relieved

UC : 1x10-10
FHB : 12-12-11
(140 bpm)

Drip oxytocin 8 tpm


began

11.0
0

Abdominal pain came


and relieved

UC : 2 x 10 ~ 25
FHB : 11-11-11
(132 bpm)

11.3
0

Abdominal pain
frequently

UC : 3 x 10 ~ 35
FHB : 12-11-11
(136 bpm)
VT : 2 cm, eff
50%, amnion (+),
head palpable HI,
denominator
unclear, impalpable
small part and
umbilical cord

12.0
0

Abdominal pain
frequently

UC : 3 x 10 ~ 40
FHB : 12-12-11
(140 bpm)

Drip oxytocin 16 tpm

12.3
0

Abdominal pain
frequently

UC : 4 x 10 ~ 40
FHB : 11-11-11
(132 bpm)

Drip oxytocin 16 tpm

Drip oxytocin 12 tpm

G4P3A0L3 41-42
week S/L/IU head
presentation
Laten phase 1st
Stage of labor

-Drip oxytocin 16
tpm maintanance
-Observation mother
and fetal well being
-Observation
progress of labor

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

14.0
0

Abdominal pain
frequently

UC : 4 x 10 ~ 40
FHB : 11-12-11 (136
bpm)

Drip oxytocin 16 tpm

14.3
0

Abdominal pain
frequently

UC : 4 x 10 ~ 40
FHB : 11-12-11 (136
bpm)

Drip oxytocin 16 tpm

15.0
0

Abdominal More
frequently

UC : 4 x 10 ~ 45
FHB : 12-12-11 (140
bpm) VT : 6 cm, eff
75%, amnion (+),
head palpable HI,
denominator unclear,
impalpable small part
and umbilical cord

Drip oxytocin 16 tpm

15.3
0

Water leaked out from


her womb

UC : 4 x 10 ~ 45
FHB : 12-12-11 (140
bpm) VT : 10 cm, eff
100%, amnion (-),
head palpable, HIII,
small part of fetus /
umbilical cord

TIM
E

SUBJECTIVE

OBJECTIVE

15.
40

Abdominal pain
frequently

UC : 4 x 10 ~ 45
FHB : 11-12-11 (136
bpm)
Baby shown on vulva,
with diameter 5 cm.
pressure of anus,
opening vulva

ASSESSMENT
nd

stage of labor

15.
50

PLANNING

Conduct of Labor

Baby was born,


female 2800 gr, BL:
48 cm, Anus +,
Anomali (-), A-S 7-9.
Placenta was born
complete. Bleeding
about 200 cc.

18.
00

GC: well
GCS: E4V5M6
BP: 110/70 mmHg
PR: 88 bpm
RR: 22 rpm
T: 37,10 C
UC (+) well

2 hours post
partum

-Obs. Mother well being


-Observation GC, VS,
bleeding

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4
4

24

Kurva Lubchenco

THANK YOU

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING