Morning Report

4 November 2008

Supervisor : dr. Punarbawa, Sp.OG

Dokter Muda Jaga:
1.Nasrullah
2.Sulistiawati
3.Zikrul Haikal
Cases resume :
1.

2.

3.

4.

1.

5.

6.

Name

: Mrs. Tunah

Age

: 17 years

Address

: Ampenan

Wakt
u

Subject

11.1
5
am

Patient refered by Tanjung Karang

with
G1P0A0H0
aterm/single/life/intra uterine with
CPD.
cronologis :
Patient felt intermitten abdominal
pain since 08.00 am (07-11-2008),
then she went to Tanjung Karang
Community Health Center at
09.00 pm (07-11-2008), rupture of
amnion membrane (-), bloody show
(-), and the fetal movement was
active. The examination in Tanjung
Health

General status : well

BP : 120/80 mmHg
Pulse = 96 x/mnt
RR: 24 x/mnt
Temp = 36C
Head presentation, not entered
pelvic inlet yet.
VT : 2 cm, eff 25 %, membran of
amnion fluid (+), desend H1.

: 07 11 - 2008
: 11.15 am

Object

Community Health Center

Karang
Community
Center found :

CTH

General status :
General condition: well,
Conciousness: CM
BP: 110/70
RR: 20 x/mnt
Pulse :90 x/mnt
T: 36,5 C
Eyes : an(-) ikt (-)
Cor -Pulmo : in normal range
Obstetric status :
L1 : breech
L2 : right back
L3 : head not entered pelvic inlet yet.
Uterine Fundal Length : 38 cm
EFW : 4030 g
His : (+) 2x/10~15
Fetal Heart Rate : 134 x/mnt
VT : 2 cm, eff 50 %, amniotic
membrane (+), descend HI, small organ
and umbilical cord havent clear.
-Muller munro kerr test : head entered to
pelvic inlet.
-Pelvic evaluation :
promontorium not touch
spina ischiadica not prominen
the pelvic wall is simetric
os coxygeuos mobile.

Assesment
G1P0A0H0
aterm/single/life/intra
uterine

Planning
Observation
mother
and fetal well being.
Laboratory
examination : DL, UL,
HBsAg
Reported
supervisor :
Advice : observation

to

Wakt
u

Subject

Last menstrual period : 07-02-08

EDD : 14-11-08
History of family planning : Family planning : IUD
ANC : routine in public health
center, 6x.
Obstetric history: now

Object

Lab. result:
HBsAg (-)
HB = 8,4
WB = 11.900
PLT = 244.000

Assesment

Planning

Time

Subjec
t

Object

Assesment

Planning

03.15
pm

BP: 110/70
RR: 20 x/mnt
Pulse :90 x/mnt
T: 36,5 C
FHR : 156x/mnt
His : -

G1P0A0H0
aterm/single/life/intra
uterine

Observation mother
fetal well being.

07.15
pm

BP: 110/70
RR: 20 x/mnt
Pulse :90 x/mnt
T: 36,5 C
His : 2x/10~15
FHR : 140x/mnt

G1P0A0H0
aterm/single/life/intra
uterine

Observation mother and

fetal well being.

11.15
pm

BP: 110/70
RR: 20 x/mnt
Pulse :90 x/mnt
T: 36,5 C
His : 2x/10~20
FHR : 148x/mnt
VT : 2 cm, eff 50 %, amniotic
membrane (+), descend HI, small organ
and umbilical cord havent clear.

G1P0A0H0
aterm/single/life/intra
uterine + laten fase of
stage 1.

Observation mother and

fetal well being.

08-1108

BP: 110/70
RR: 20 x/mnt
Pulse :90 x/mnt
T: 36,5 C
His : 2x/10~20
FHR : 146x/mnt
VT : 2 cm, eff 50 %, amniotic
membrane (+), descend HI, small organ

G1P0A0H0
aterm/single/life/intra
uterine + laten fase of
stage 1.

Observation mother and

fetal well being.

03.15
am

and

Time

Subject

Object

Assesment

Planning

07.00
am

Patient felt
abdominal pain

BP: 110/70
RR: 20 x/mnt
Pulse :90 x/mnt
T: 36,5 C
His : 2-3x/10~35
FHR : 140x/mnt
VT : 6 cm, eff 75 %,
membran of amnion (+),
descend HI, small organ
and umbilical cord
havent clear.

G1P0A0H0
aterm/single/life/intra uterine +
active fase of stage 1.

Observation mother and

fetal well being.

07.30
am

Patient felt
abdominal pain

Pulse = 92 x/mnt
His :3x/10~35
FHR : 140x/mnt

G1P0A0H0
aterm/single/life/intra uterine +
active fase of stage 1.

Observation mother and

fetal well being.

08.00 am

Patient said that

there was water

Pulse = 96 x/mnt
His : 3-4x/10~40
FHR : 140x/mnt
VT : 7 cm, eff 75 %,
membran of amnion (-)
amniotic fluid (+) clear,
descend
HI+,
occiput
anterior, small organ and
umbilical cord havent
clear.

- G1P0A0H0 aterm/single/life/intra
uterine + active fase of stage 1.

Observation mother and

fetal well being.

08.30 am

Patient felt abdominal

pain

Pulse = 96 x/mnt
His : 3-4x/10~40
FHR : 140x/mnt

- G1P0A0H0 aterm/single/life/intra
uterine + active fase of stage 1.

Observation mother and

fetal well being.

09.00 am

Patient felt abdominal

pain

Pulse = 96 x/mnt
His : 3-4x/10~40
FHR : 140x/mnt

- G1P0A0H0 aterm/single/life/intra
uterine + active fase of stage 1.

Observation mother and

fetal well being.

Time

Subject

Object

Assesment

Planning

10.00
am

Patient
felt
abdominal pain

Pulse = 96 x/mnt
His : 3-4x/10~40
FHR : 140x/mnt

- G1P0A0H0
aterm/single/life/intra uterine +
active fase of stage 1.

Observation mother and

fetal well being.

10.30
am

Patient
felt
abdominal pain

Pulse = 96 x/mnt
His : 3-4x/10~40
FHR : 140x/mnt

- G1P0A0H0
aterm/single/life/intra uterine +
active fase of stage 1.

Observation mother and

fetal well being.

11.00 am

Patient want to
bearing down

- G1P0A0H0
Pulse = 96 x/mnt
aterm/single/life/intra uterine +
His : 3-4x/10~40
stage II.
FHR : 140x/mnt
VT : completed, eff 75 %,
membran of amnion (-)
amniotic fluid (+) clear,
descend HI+, occiput anterior,
small organ and umbilical
cord havent clear.

Observation mother and

fetal well being.
Conduct the patient to
had left side position.
Conduct the patient to
eat and drink.

11.30 am

Pulse = 96 x/mnt
His : 3-4x/10~40
FHR : 140x/mnt

- G1P0A0H0
aterm/single/life/intra uterine +
stage II.

Observation mother and

fetal well being.
Conduct the patient to
had left side position.

12.00
am

Pulse = 96 x/mnt
His : 3-4x/10~40
FHR : 140x/mnt

- G1P0A0H0
aterm/single/life/intra uterine +
stage II.

Reported to supervisor :
Not connected

01.00
pm

Pulse = 96 x/mnt
His : 3-4x/10~40
FHR : 140x/mnt

- G1P0A0H0
aterm/single/life/intra uterine +
prolonged stage II.

Reported to supervisor :
Supervisor
was doing
sholat jumat.

Time

Subject

Object

Assesment

Planning

01.30
pm

Patient
felt
abdominal pain

Pulse = 96 x/mnt
His : 3-4x/10~40
FHR : 140x/mnt

- G1P0A0H0
aterm/single/life/intra uterine +
prolonged stage II.

Observation mother and

fetal well being.
Conduct the patient to
had left side position.

02.00
pm

Patient
felt
abdominal pain

Pulse = 96 x/mnt
His : 3-4x/10~40
FHR : 140x/mnt

- G1P0A0H0
aterm/single/life/intra uterine +
prolonged stage II.

Observation mother and

fetal well being.
Reported to supervisor :
advice : SC

02.30
pm

Patient
felt
abdominal pain

Pulse = 96 x/mnt
His : 3-4x/10~40
FHR : 140x/mnt

- G1P0A0H0
aterm/single/life/intra uterine +
prolonged stage II.

Observation mother and

fetal well being.
Conduct the patient to
had left side position.

03.00
pm

Patient
felt
abdominal pain

Pulse = 96 x/mnt
His : 3-4x/10~40
Bundle of His (+)
FHR : 140x/mnt

- G1P0A0H0
aterm/single/life/intra uterine +
stage II + RUI

Observation mother and

fetal well being

Baby was born with

SC, female, 3300 g,
body length 51 cm,
AS = 6-8.

03.15
pm

Placenta was born

spontaneously,
complete.
dx. Post-op :
neglected labor
04.00
am

BP = 120/80
RR= 20 x/mnt
Tax = 36,7

stage IV of labor

Observation mother and

fetal well being.

Waktu

Subject

Object

Assesment

Planning

04.15 pm

BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Uterus contraction :
well, Fundal uterine
length = 2 finger below
umbilical
Bleeding = -, lochia (+)

stage IV of labor

Observation maternal well

being
Observation for hemorrhage
sign

04.30 pm

BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Uterus contraction :
well, Fundal uterine
length = 2 finger below
umbilical

stage IV of labor

Observation maternal well

being
Observation for hemorrhage
sign

04.45 pm

BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Uterus contraction :
well, Fundal uterine
length = 2 finger below
umbilical

stage IV of labor

Observation maternal well

being
Observation for hemorrhage
sign

05.00 pm

BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Uterus contraction :
well, Fundal uterine
length = 2 finger below
umbilical
Lochia rubra (+)

stage IV of labor

Observation maternal well

being
Observation for hemorrhage
sign

Waktu

Subject

Object

Assesment

Planning

05.15 pm

BP = 110/80
RR= 20 x/mnt
Pulse = 80 x/mnt
Uterus contraction :
well, Fundal uterine
length = 2 finger below
umbilical

stage IV of labor

Observation maternal well

being
Observation for hemorrhage
sign

05.30 pm

BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Uterus contraction :
well, Fundal uterine
length = 2 finger below
umbilical

stage IV of labor

Observation maternal well

being
Observation for hemorrhage
sign

05.45 pm

BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Uterus contraction :
well, Fundal uterine
length = 2 finger below
umbilical

stage IV of labor

Observation maternal well

being
Observation for hemorrhage
sign

06.00 am

BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Uterus contraction :
well, Fundal uterine
length = 2 finger below
umbilical
Bleeding = Lochia rubra (+)

1 daay post labor

Observation maternal well

being
Observation for hemorrhage
sign