Morning Report

August, 25th 2014

Supervisor:
dr. Agus Thoriq, SpOG
DM VK Pagi:
Santi, Faisol, Aluh

Morning Report
th
August 25 2014
Case Resume
NORMAL
LABOR

PATHOLOGIES 1. G1P0A0L0 40-41 weeks/S/L/IU

LABOR
breech presentation + PROM
2. G2P1A0L1 39-40 weeks/S/L/IU
with PROM + susp. Macrosomia

Case 1
Name
: Ny. A
Age
: 20 years old
Address : Praya
RM
: 545211
Admitted: August 25th 2014 at
04.30 am
G1P0A0L0 40-41 weeks /S/L/IU
breech presentasion with PROM

TIME

SUBJECTIVE

25/8/1
4

Patient referred from Praya

PHC to NTB GH with G1P0A0L0
A/S/L/IU
with
breech
presentation.
Patient
confessed water leaked out
since
03.00
(25/8/2014).
Abdominal
pain
since
23.00(24/08/2014),
bloody
slim (-), FM (+).
No history of DM, HT, and
asthma.

05.30

LMP : 16-11-2013
EDD : 23-8-2014
History ANC : >4x at PHC
Last ANC : BP : 110/70
History of USG : (+) at SpOG
Last USG : 24/8/14
S/L/IU breech presentation
AFL enough
Placenta at posterior of fundus
female
History of family planning : (-)
Next family planning : IUD
Obstetric History :
1. This

OBJECTIVE
General Status
GC : well
GCS : E4V5M6
BP : 110/70 mmHg
PR : 80 bpm
RR : 20 bpm
T : 37,2 C
Locally Status
Eye : anemis (-/-), icteric
(-/-)
Pulmo : vesicular (+/+),
rhonki (-/-), wheezing (-/-).
Cor : S1S2 single regular M
(-), G (-).
Abdomen
:
striae
gravidarum (+), linea nigra
(+), scar (-).
Extremities : edema (-/-),
warm acral (+/+).
Obstetric Status
L1 : head
L2 : back on the right side
L3 : breech
L4 : 4/5
UFH: 30 cm
AC : 107 cm
EFW : 3210 gram
UC : 3x10~30
FHB : 12 -11-12(140 bpm).
VT : 3 cm, eff 25%,
amnion
(-),breech
presentation, denominator
sacrum , H1, impalpable
small pat/ umbilical cord

ASSESSMENT

PLANNING

G1P0A0L0 4041 /S/L/IU breech

presentation +
PROM

Observe mother and

fetal well being.
Check Lab
Inj Ampicillin 1 gr/ 6 h

Time

Subjective

Objective

Chronologist :
S/ Patient 9 month pregnancy
confessed water leaked out since
03.00 (25/8/2014). Abdominal pain
since 23.00(24/08/2014), bloody slim
(-), FM (+).
Result
of
usg
was
breech
presentation.
No history of DM, HT, and asthma.

Pelvic Evaluation :
Spina ischiadica not
prominent
Os coccigeous mobile
Arcus pubis > 900

O/ A/ G1P0A0L0 A/S/L/IU with breech

presentation
P/ Referred to NTB GH

Lab Evaluation :
Hb : 11,9 gr/dl
HCT : 35,7%
RBC : 4,21 M/uL
PLT : 277 K/uL
WBC : 15,96K/uL
HBsAg : (-)

Assessment

Planning

Time

Subject

08.45

Object

Assessment

GC : well
BP : 110/70
PR : 82 bpm
RR : 24 bpm
T : 37, 1oC

Co to SPV, adv: CS
Preop

09.35

12.40

Planning

CS began + IUD
Baby was born (10.05 am),
female, 3250 gram, 48 cm,
A-S 7-9, anus (+), anomaly
congenital (-).
Placenta was born,
complete.
Bleeding 350 cc
Patient confessed
abdominal wound
pain

GC: well
GCS: E4V5M6
BP: 110/70 mmHg
PR: 80x/m
RR: 20x/m
T: 36,2 0C
UC: (+)
UFH: 2 fingers above umb
UO: (+) 200 cc

Baby in NICU:
GC : well
HR : 128 bpm
RR : 48 x/mnt
T : 36,0 C

2 hours Post
CS

Observation mather and

fetal well being
Suggest eat and drink
Early breast feeding
Observation of bleeding

TIME
26/08/
14
07.00

SUBJECTIVE
-

OBJECTIVE
GC : well
BP : 110/70
PR : 82 bpm
RR : 24 bpm
T : 36,5oC
UC : (+) well
UFH : 2 fingers below
umbilicus
Lochea rubra (+)
Baby in NICU:
HR : 148
RR : 40
T : 36,2oC

ASSESTMENT
1 day post partum

PLANNING
Observed mother and baby
well being
Suggest mother to
mobilization, eat and drink,
and medication.
Breast feeding

Case 2
Name : Mrs. Y
Age : 27 years old
Address : Aiq Bukaq, Loteng
Admitted : 25-08-2014
No. RM : 54-52-05
G2P1A0L1 39-40
history of ROM +

weeks/S/L/IU with
susp. Macrosomia

Time

Subject

25-082014
1.50
am

Patient come to NTB GH,

referred from Praya GH
with G2P1A0L1 39-40
weeks/S/L/IU head
presentation with PROM
< 12 hours.
Patient confessed water
come out from her
womb since 24-08-2014
(7.00 pm), bloody slim
(-), abominal pain (-) and
FM (+).
No history of DM, HT,
asthma.
LMP : 20-11-2013
EDD : 27-8-2014
History ANC : 10x at PHC
Last ANC : 18-08-2014
result: BP : 110/70, BW
70 kg, 40 weeks, UFH 35
cm, head presentation,
FHB (+)

Object
General status
GC : well
GCS: CM (E4V5M6)
BP : 100/70 mmHg
HR: 96 x/m
RR: 24 x/m
T: 36,3 C
Local status
Eye : an (-/-), ict (-/-)
Pulmo: ves (+/+), rh (-/-),
wh (-/-)
Cor : S1S2 single regular,
M(-), G(-)
Abd : striae gravidarum
(+), linea nigra (+), scar
(-)
Ext : edema (-/-), warm
(+/+)
Obstetric status
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH: 38 cm
EFW : 4185 gram
UC : (-)
FHB : 11-12-11
(140x/min)

Assessment

Planning

G2P1A0L1 39-40
weeks/S/L/IU
with PROM < 12
hours + susp.
Macrosomia

Obs. inpartu
Inj. Ampicillin
1gr/6 hours
(PHC 8.20 pm ~
24-08-14)

Time

Subject
History of USG : 1x
Last USG (24-082014): S/L/IU head
presentation, female,
placenta at fundus,
39-40 weeks , EFW
4480 gr, EDD :
21/08/2014
History of family
planning : injection 3
months
Next family planning :
IUD
History of obstetric :
I. /9m/2800
gr/Polindes/midwife/
7 yo/live
II.This
Cronologist (PKM
Teratak:
24/08/2014)
8.25 pm
S: patient come with
family confessed
water come out
since 6.30 pm

Object
VT: 2 cm, eff. (-),
amnion(-), head palpable,
denom unclear, H1,
unpalpable small
part/umbilical cord
Lab (25-08-2014):
HGB = 11.2 g/dl
RBC = 4.73 K/ul
WBC = 11.65 M/ul
HCT : 35,7 %
PLT = 52 M/ul
HBsAg = (-)
BT = 130
CT = 800

Assessment

Planning

Time

Subject
O:
GC : well
BP : 140/100
HR : 82
T: 36,5
RR : 20
Abd: UFH 40, FHB (+)
Obs: VT 4 cm, eff
40%, amnion (-),
head presentation,
H1, unpalp small
part & umb
A: G2P1A0L1 39-40
weeks/S/L/IU head
presentation with
PROM < 12 hours
P:
- IVFD RL 20/dpm
- Inj. Ampicillin 1
gr/IV
- Reffered to NTB GH

Object

Assessment

Planning

Time
6.30
am

Subject
Patient
confessed
abdominal pain

Object

Assessmen
t

GC: well
BP: 110/70 mmHg
HR: 80 bpm
T 36,50C
RR 20 x/m
UC: 1x/10 ~ 15
FHB: 11-12-12 (140x/m)
VT: 3 cm, eff. 25%,
amnion(-) clear, head
palpable, denom unclear,
H1, unpalpable small
part/umbilical cord

Observation of mother &

fetal well being
Co to SPV (8.50 am),
adv: CS
Preop

10.50
am

11.30
am

Planning

CS began
Baby was born (11.05
am), female, 4800 gram,
53 cm, A-S 7-9, anus
(+), anomaly congenital
(-).
Placenta was born,
complete.
Bleeding 500 cc
Patient
confessed
headache

GC: weak
GCS: E4V5M6
BP: 80/70 mmHg
PR: 100x/m
RR: 24x/m
T: 36,2 0C
UC: (+)
UFH: 2 fingers above umb

Post CS

Loading RL 1 fl (30
minute)

Time
11.45
am

Subject
Patient
confessed
headache +
nausea

Object

Assessmen
t

Planning

GC: weak
GCS: E4V5M6
BP: 70/40 mmHg
PR: 68x/m
RR: 28x/m
T: 36 0C
Conj. Anemic (+)
UC: (-)
Active bleeding (+) 500 cc
UFH: 2 fingers above umb
UO: (+) 200 cc

P2A0L2 post
CS + HPP ec
Atonia Uteri

Co to SpAn, adv inj.

Ephedrine 3 cc, obs. In
10 minute
Double line, loading RL 2
fl
Leb examination
Massase uterus (cont. -),
IBC 5 minute, active
bleeding (-)

12.00
pm

GC: weak
BP: 90/60 mmHg
HR: 80 bpm
T 350C
RR 25 x/m
UC: (-)

Oxy drip 2 fl
Inj. Metergin
Misoprostol 4 tab IR

12.15
pm

GC: weak
BP: 70/p mmHg
HR: 80 bpm
T 350C
RR 27 x/m
UC: (-)

Inj. Tranexamate acid +

vit. K
Condom catheter
Co to SPV, adv: IBC
continue, planning
hysterectomy

12.20
pm

BP: 70/p mmHg

HR: 80 bpm
T 350C
RR 28 x/m
UC: (-)

Loading widahes 1 fl

Time

Subject

Object

12.30
pm

GC: weak
BP: 110/70 mmHg
PR: 102x/m
RR: 28x/m
T: 36 0C
UFH: umbilical
UC: (+) well
Active bleeding (-)

12.45
pm

GC: weak
BP: 140/70 mmHg
PR: 112x/m
RR: 28x/m
T: 36 0C
Active bleeding (-)

Assessmen
t

Planning

Transfusi WB 3 colf

Lab (25-08-2014):
HGB = 6 g/dl
RBC = 2,50 K/ul
WBC = 14.68 M/ul
HCT : 19,3 %
PLT = 186 M/ul
1.00
pm

1.20
pm

GC: weak
BP: 120/70 mmHg
PR: 80x/m
RR: 24x/m
T: 36 0C

Spv pro hysterectomy

Hysterectomt began

Time

Subject

2.00

26-082014
6.30
am

Abdominal pain

Object

Assessment

Planning

BP: 110/70 mmHg

PR: 80x/m
RR: 20x/m
T: 37 0C
Active bleeding: (-)
UO: +

Post op
hysterecomy

Observation at ICU

GC: well
cons:E4V5M6
BP: 120/70 mmHg
PR: 94x/m
RR: 20x/m
T: 36,7 0C
Active bleeding: (-)
UO: (+) 300 cc/4 hours

1 day post SC +
hysterectomy

Observed mother and

baby well being
Suggest mother to
mobilization
Suggest mother to
eat and drink

Baby in NICU:
Pulse : 144 bpm
RR : 68x/m
T : 36,7 C

.. Thank
You ..