Morning Report

July 8th, 2016

Supervisor : dr. Juliawan Sp.OG
Medical Students :
Ayu, Dimas, Siti Shabrina
CASES RESUME
Normal Labor -

Pathology Labor 1. G3P2A0H2 40-41 weeks S/L/IU head presentation with

prolonged active phase of labor
2. G1P0A0L0 preterm S/L/IU head presentation with
eclampsia and fetal tachycardi

Remain Patient 1. G1P0A0 35-36 weeks, S/IUFD/IU head presentation

Case
Name : Mrs. H
Age : 35 yo
Addrs : Lingsar
Admitted : 08-07-2016
 Time Subject Object Assessment Planning

8/07/16 Patient referred from Lingsar PHC with General status G3P2A0H2 40-41 DM Planning:
10.00 G3P2A0H2 40 weeks S/L/IU head GC : well weeks S/L/IU head Diagnostic:
presentation,mother and fetal in good condition, GCS: CM (E4V5M6) presentation with CBC, HbsAg
with inpartu arrest active phase of labor. Patient BP : 110/70mmHg prolonged active phase CTG
confessed abdominal pain spread to the flank PR: 88 tpm of labor
since 01.00 (08-07-2016 ), Bloody slime (+), RR: 20 tpm Observation:
water leak out from her womb (-) FM (+). T: 36,8C Obs. Mother and fetal well being.
Obs. Progress of labor with WHO
History of DM (-), HT (-), asthma (-). Local status partograph
Family history DM (-), HT (-), asthma (-). Eye : an (-/-), ict (-/-)
Pulmo: ves (+/+), rh (-/-), wh (-/-)
LMP : 30-09-2015 Cor : S1S2 single regular M(-), G(-) CIE patient to eat and drink
EDD : 07-07-2016 Abd : striae gravidarum (+), linea nigra (+), Inform patient about the diagnostic
GW : 40-41 weeks scar (-), BU (+) N planning
Ext : edema (-/-), warm (+/+)
History of ANC: 14x at PHC
last ANC:07-07-2016 Obstetric status DM co to GP, GP co to SPV,
Result L1 : breech advice :
BP: 110/70, L2 : back on the left side Amniotomy
GW: 40 weeks, L3 : head
UFH: 31 cm, head presentation, back on the L4 : 4/5
right side, FHB + UFH: 34 cm
VT : 2cm, eff. 25 %, Amnion (+), HI, head EFW : 3565 gr
palpable, denominator unclear, impalpable small UC : 2X10-30
part of fetal & umbilical cord. FHB : 12.11.112 (140 x/min)
VT : 6cm, eff. 75 %, Amnion (+), HI,
head palpable, denominator ROA,
impalpable small part of fetal & umbilical
cord.
Time Subject Object Assessment Planning
History of USG: 1x at SpOG, Pelvic examination
Last USG:19-12-2015 Spina ischiadica non prominent
F/I/S/L 11-12 weeks Sacrum convex
FHB (+) Os coccygeus mobile
EDD 06-07-2016 Arcus pubis >90o

Obstetrical History: Lab:

1.Aterm/female/spt/midwife/3000g/18 yo/L HB 10,4
2.Aterm/female/spt/midwife/2700g/15 yo/L RBC 3,68
3.This HCT 33,0
WBC 8,44
History of family planning: Implan PLT 277
Next family planning: - HbSAg non reactive
PTT 12,2
APTT 34,4
Time Subject Object Assessment Planning
Chronologist at LingsarPHC

S/ Patient pregnant 9 months, abdominal

pain
O/ GC : well
GCS: CM (E4V5M6)
BP : 120/80mmHg
PR: 84 tpm
RR: 20 tpm
T: 36,5C

Obstetric status
L1 : breech UFH: 31 cm
L2 : back on the right side
L3 : head
L4 : 4/5
EFW : 3100 gr UC : 3X10-35
FHB : 12.11.12 (140 x/min)
VT : 4cm, eff. 25 %, Amnion (-+) HI, head
palpable, denominator unclear, impalpable
small part of fetal & umbilical cord.

A/ G3P2A0H2 40 weeks S/L/IU head

presentation,mother and fetal in good
condition, with inpartu active phase of labor

P/ CIE patient the result of examination

Inform consent
Suggest mother to eat and drink
Lay to the left side
Obs mother and fetal well being
Time Subject Object Assessment Planning
Chronologist at Lingsar PHC

S/ patient confess abdominal pain

O/
GC : well
GCS: CM (E4V5M6)
BP : 110/80mmHg
PR: 80 tpm
RR: 22 tpm
T: 36,8C

Obstetric status
UC : 3x10-35
FHB : 11.12.11 (136 x/min)

VT : 4cm, eff. 25 %, Amnion (-+) HI, head palpable,

denominator unclear, impalpable small part of fetal &
umbilical

A/ G3P2A0H2 40 weeks S/L/IU head presentation,mother

and fetal in good condition, with inpartu arrest active phase
of labor.

P/ CIE patient the result of examination

Inform consent
Inf RL : D5 = 2:1
Obs mother and fetal well being
Referred to NTB GH
 Time Subject Object Assessment Planning
14.00 Abdominal pain + GC : well G3P2A0H2 40-41 weeks S/L/IU head Obs mother and fetal well being
GCS: CM (E4V5M6) presentation arrest active phase of labor Co to SPV, advice
BP : 110/70mmHg Acceleration wih oxytocin drip
PR: 92 tpm Move to vk teratai
RR: 20 tpm
T: 36,7C

UC : 2X10-35
FHB : 12-12-12 (144 bpm)

VT : 6cm, eff. 75 %, Amnion (-) meoneal, HI,

head palpable, denominator ROA, impalpable small
part of fetal & umbilical cord.

15.00 Abdominal pain + FHB: 12-11-11 Oxytocin drip 8 tpm

UC: 3X10-35

15.30 Abdominal pain + FHB: 12-12-11 Oxytocin drip 12 tpm

UC: 3X10-340

16.00 Abdominal pain + FHB: 12-12-12 Oxytocin drip 16 tpm

UC: 3X10-45
16.30 Abdominal pain ++ FHB: 12-12-13 Oxytocin drip 16 tpm
UC: 4X10-45

17.00 Abdominal pain ++ FHB: 11-12-12 Oxytocin drip 20 tpm

UC: 4X10-45

17.30 Abdominal pain ++ FHB: 12-12-12 Oxytocin drip 20 tpm

UC: 4X10-45
 Time Subject Object Assessment Planning
18.00 Abdominal pain ++ FHB: 11-11-11 Oxytocin drip 20 tpm
UC: 4X10-45

18.30 Patient want to bearing FHB: 12-12-11 Second phase of labor Coduct labor
down UC: 4X10-45
The baby was born, 19.00, spt,
male, AS 5-7, BW 2800gr, BL
49cm, anus (+), anomaly
congenital (-), meconeal (+)

Placenta was born complete. at

19.03
Rupture perineum gr I
hecting

21.00 Confessed (-) GC : well 2 hours post partum Obs. Mother and baby well
GCS: CM (E4V5M6) being
BP : 120/70mmHg
PR: 88 tpm Amox tab 3x1
RR: 18 tpm Mef acid tab 3x1
T: 37C

UC : well
UFH : 2 finger below umbilicus
Active bleeding (-)
Lokia rubra (+)

06.00 Confessed (-) GC : well 1 day post partum Obs. Mother and baby well
GCS: CM (E4V5M6) being
BP : 110/70mmHg Suggest mother to eat and
PR: 84 tpm drink
RR: 18 tpm Amox tab 3x1
T: 36,8C Mef acid tab 3x1

UC : well Mobilization
CTG
Case Report
Name : Mrs. HL
Age : 22 yo
Address : Embung Village Raja Terora, East Lombok
Admitted : July 3th, 2016
MR : 58-01-72
Time Subject Object Assesment Planning
8/7/16 Patient came from Gili Moyo health GC : weak G1P0A0L0 preterm Dm planning
10.00 care room with convulsion. Patient GCS : E4V4M6 S/L/IU head Diagnostic
complained convulsion 2 times at this BP : 180/110 HR: 120 bpm presentation with Check lab CBC,
morning (8/7/16) with duration at T : 36,8C RR : 24 bpm eclampsia and fetal HbsAg, urinalysis,
least 10 minutes, unconscious and General Status : tachycardi PTT, APTT
happened to all her body. Patient Eye : an (-/-) , ict (-/-) CTG
confessed blurred vision (+), Thorax :
headhace (+), epigastric pain (+) and C : S1S2 single reguler, murmur (-), Therapy
vormiting 2 times from tonight gallop (-). Stabilisation
(7/7/16). Abdominal pain (+), water P : ves +/+ , wh (-/-). Rh (-/-) O2 4-6 lpm
leaked out from her womb (-), bloody Abdomen : scar (-) , striae (+), linea nigra Obs. Mother and fetal
slime (-), fetal movement (+). (+). well being
Extremity : warm acral +/+, edema at Monitoring urine
No history of HT, DM, and asthma lower extrimity (+/+) output
Bolus IV 4 g MgSO4
LMP : Forgot Obstetrical status : within 5 minutes, then
EDD : - L1 : breech continiues drip 6 g
GW : - L2 : back on the left side MgSO4 in RL 28 dpm
L3 : head Pro C-section
History of ANC : 7x at PHC L4 : 4/5 Observation post C-
Last ANC : 30-06-2016 UFH : 27 cm section at ICU
Result : Confessed headhace; BP EFW : 2480 g
140/90; BW 51kg; GW aterm; UFH UC : 1x10~20 DM co to GP, GP co to
28 cm; head presentation; FHB (+) FHR : 15-15-15 (180 bpm) SPV, SPV advice:
121 bpm VT : 1cm, eff 25%, amnion (+) - Pro C-section
denominator unclear, H1, unpalpable - Observation post C-
USG : 0x small part of fetus or umbilical cord section at ICU

History of family planning : - Urine Output: 10 cc

Next family planning : IUD

Obstetrical history :
1. this
Time Subject Object Assesment Planning
Pelvic Score = 4
Dilatation of cervix : 1
Length of cervix : 1
Station : 1
Consistency : 1
Position : 0

Pelvic Examination:
Promontorium unpalpable
Spina ischiadica not prominent
Os sacrum convex
Os coccygeus mobile
Arcus pubis > 90

Lab :
HGB : 10
RBC : 4,64
HCT : 33,5
WBC : 11,59
PLT : 148
Time Subject Object Assesment Planning
2/7/16 Chronology at Selong General
Hospital:

S: Patient confessed fatigue,

headhace and pallor.

O:
General status
BP : 100/70mmHg
PR: 82 x/m
RR: 20 x/m
T: 36,5C

A :G1P0A0L0 gravid 33-34 weeks

anemiagravis DD thalasemia

P:
- IVFD NS 20 dpm
- SF tab 2x1
- O2 3 lpm
Time Subject Object Assesment Planning
3/7/16 Chronology at NTB General
Hospital:

S: Patient confessed headhace since

afternoon, fatigue (-), bleeding
from her whomb (-).

O:
General status
Eye: Pallor +/+
BP : 130/60mmHg
PR: 100 x/m
RR: 22 x/m
T: 37C

Obstetrical status
L1: Breech
L2: Back on the right side
L3: Head
L4: 5/5
UFH: 27 cm
EFW: 2.325 g
UC: -
FHB: 13-13-13 (156 bpm)
VT: Doesnt performed

A :G1P0A0L0 gravid 33-34 weeks

anemia DD iron deficiency

P:
- Co to internist, advice:
Transfusion PRC 6 kolf (2 kolf each
day)
Time Subject Object Assesment Planning

11.00 Convulsion (-) GC : weak Drip 6 g MgSO4 28 dpm

GCS : E4V4M6
BP : 170/110 HR: 116 bpm
T : 36,6C RR : 22 bpm
FHB: 14-15-14
Urine Output: 50 cc

12.00 Convulsion (-) GC : weak Drip 6 g MgSO4 28 dpm

GCS : E4V5M6
BP : 170/110 HR: 112 bpm
T : 36,7C RR : 22 bpm
FHB: 14-15-15
Urine Output: 75 cc

13.00 Convulsion (-) GC : weak Drip 6 g MgSO4 28 dpm

GCS : E4V5M6
BP : 170/110 HR: 120 bpm
T : 36,7C RR : 24 bpm
FHB: 14-14-14
Urine Output: 100 cc

13.10 Convulsion (-) GC : weak Patient move to operating

GCS : E4V4M6 room
BP : 170/110 HR: 120 bpm
T : 36,8C RR : 24 bpm
Urine Output: 100 cc
Time Subject Object Assesment Planning

13.30 Convulsion (+) with duration Operation begin

5 minutes, vomitting (+)
The baby was born at 13.55,
female, with BW 2200 gram,
BL 44 cm, HC 30 cm, A-S 5-
7, Anus (+), congenital
anomaly (-).

Plasenta was born complete

at 14.00

14.30 Convulsion (-) GC : weak Post C-section Patient move to ICU

GCS : Cannot evaluated
BP : 160/110 HR: 128 bpm
T : 36,8C RR : 24 bpm
Urine Output: 100 cc

16.30 Convulsion (-) GC : weak 2 hours post C-section - Observe mother well being
GCS : Cannot evaluated - Drip 6 g MgSO4 28 dpm
BP : 160/110 HR: 132 bpm
T : 36,7C RR : 24 bpm
Urine Output: 200 cc
UC: good
UFH: 1 fingers below umbilicus

9/7/16 Convulsion (-) GC : weak 1 days post C-section - Observe mother well being
06.00 GCS : Cannot evaluated - Drip 6 g MgSO4 28 dpm
BP : 170/120 HR: 130 bpm
T : 36,7C RR : 24 bpm
Urine Output: 10 cc
 3

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Kurva Lubchenco
Case 2
Name : Mrs. R
Age : 28 yo
Address : Lingsar
Admitted : 8th July 2016
RM : 580466
 TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
8/7/2016 Patient refered from Sigerongan PHC with GC : well G1P0A0 35-36 weeks, DM planning:
21.30 G1P0A0L0 A/S/D/IU head presentation, Consciousness: CM S/IUFD/IU head Diagnostic :
mother in good condition with IUFD. BP : 120/70 mmHg presentation - DL
Patient 8 months pregnant confessed the PR: 88 tpm
fetal movement decreased since 4 days RR: 18 tpm Therapy :
ago (5/07/2016) and confessed that the T: 37.1C - Ampicillin 1 gr IV / 6 hours
fetal movement cannot be felt at all since - Termination with Misoprostol
yesterday (8/07/16). Abdominal pain (-), Local status 50g/6 hours
water leak from her womb (-), bloody slime Eye : an (-/-), ict (-/-) - Obs. progress of labor
(-). Pulmo : ves (+/+), rh (-/-), wh (-/-) - Monitoring : VS mother, UC
Cor : S1S2 single regular, m (-), g (-) - CIE : CIE mother and family
History of DM (-), HT in pregnancy (-), Abd : scar (-), striae gravidarum (+), linea about the fetal condition and
asthma (-) and allergy (-). nigra (-), ballottement (+) therapeutic planning
History of HT (+), asthma (+) in family Ext : edema (-/-), warm acral (+/+).

LMP : ?-10-2015 Obstetric status DM co to GP, GP co to SPV,

EDD: ? L1 : breech advice:
GW : ? L2 : back on the right side - Misoprostol 50 ug / vaginam /
L3 : head 6
History of ANC : 7x at Posyandu L4 : 4/5
Last result: (8/7/2016) Patient cant feel UFH: 27 cm
the fetal movement since 3 days ago, EFW : 2480 g
BP 110/70 mmHg, weight 56 kg, GW 8 UC : (-)
month, UFH 30 cm, head presentation, FHB : (-)
FHB (?), Pro USG VT : 1 cm, eff 10%, amnion (+), head
palpable, denom unclear, H1, small
parts and umbilical cord not palpable
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
History of USG :1x Lab (8/7/2016)
Result: (8/07/2016) Hb 10,6 g/dL
Fetal/S/IUFD, 35-36 weeks Placenta at RBC 3,82 x 10^6/uL
fundus. Advice : termination of pregnancy HCT 31,1 %
WBC 6,39 x 10^3/uL
History of family planning: - PLT 234 x10^3/uL
Next family planning : - HBsAg = non-reactive

Obstetrical history
I. This
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
Chronology at Sigerongan PHC (8/07/2016)

17.45
S:
Patient 8 month pregnant cant feel the fetal
movement since 4 days ago

O:
GC : well
BP : 110/70 mmHg
HR: 80 bpm
RR: 20 bpm
T: 37.0C
UFH 30 cm, breech palpable in the fundus, head
presentation, 2/5, back on the left side, UC (-)

A: G1P0A0L0 GW A/S/D/IU, head presentation,

mother in good condition with IUFD

P:
- Inform the mother about examination results
- Co GP, advice : obs. Mother condition
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
Chronology at Sigerongan PHC (8/07/2016)

19.00
S : (-)

O:
GC : well
BP : 110/70 mmHg
HR: 80 bpm
RR: 20 bpm
T: 37.1C

A: G1P0A0L0 GW A/S/D/IU, head presentation,

mother in good condition with IUFD

P:
- Inform the mother about examination results
- Co GP, advice :
- obs. Mother condition, if body temperature
increased >37.5 C refer to NTB GH. If not,
observation until tomorrow morning and refer to
policlinic
- Amoxicillin 1 tab (19.45)
- Infuse RL
 TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
23.00 pm Patient was sent to vk teratai GC : well G1P0A0 35-36 weeks,
(8/07/16) Consciousness : CM S/IUFD/IU head
BP: 120/70 mmHg presentation
HR : 80 bpm
T : 36.8 C
RR : 18 x/min
UC : (-)
FHB: (-)

24.00 No complaint. G1P0A0 35-36 weeks, - Insertion of misoprostol 50 ug / vaginam (I)

S/IUFD/IU head -Obs mother well being
presentation -Obs uterus contraction

06.00 Abdominal pain (+) GC : well -Ins. Misoprostol 50 ug/ vaginam (II)
(9/07/16) Consciousness : CM -Obs mother well being
BP: 120/70 mmHg -Obs uterus contraction
HR : 80 bpm
T : 37.0 C
RR : 18 x/min
UC : (-)
FHB: (-)
UC : (+) 1x10 ~ 10
VT: 2 cm, eff 25%, amnion
(+), head palpable, denom
unclear, H1, small parts and
umbilical cord not palpable
Buku KIA
USG
Surat Rujukan
Kronologi