Morning Report

April 17th 2009

Supervisor : dr. H. Doddy AK., SpOG (K)

Medical Student:
Astri Meisyafitri
Dedy Tesna Amijaya
Is Muttaqien
Vika handayani
Cases resume :
1.

PROM > 12 hours

2.

Severe Preeklamsia + prolong 1st stage

3.

Bleeding Antepartum

4.

3
1
1

Name

: Mrs. Hetty

Admitted

: April 16th 2009

Age

: 32 years

Time

21.35 WITA

Address

: Karang Sukun

Time

Subject

Object

Assesmen
t

Planning

21.35

Patient came to ECU RSU

Mataram with G2P1A0H1 38
weeks/S/L/IU with PROM

General status :
General condition : well
Consiousness : E4V5M6
BP : 110/60 mmHg
Pulse : 88/mnt
RR : 20 x/menit
T : 36.5 C
Eye : an -/- ikt -/Cor & Pulmo :
in normal
range

G2P1A0 38
weeks/S/L/IU
with PROM

observation mother
and fetal well being

Cronologist :
patient came to ECU with watery
vaginal discharge since 20.00
(16/4/09) She feel abdominal
dissomfort (+) bloody show (+),
fetal movement (+), active.
Examination
(-)

in ECU mataram

Last menstrual period : 23/7/08

Estimate delivery date : 30/4/09 ANC : were routine in midwife
>4x,
History of Family planning = (-)
Family planning = inj of three
months
Obstetrical history :
1. Aterm, 2700 g, 3 years, at
midwife
2. This

Obstetrical status :
L1 : breech UFH : 29 cm
L2 : right back
L3 : head
L4: wasnt enter the pelvic
inlet. 5/5
EFW : 2635g
Uterine contraction = (-)
FHB = 12-12-13
VT : 1 cm, eff 10%,
amniotic
membrane
(-),
clear, head presentation,
denom unclear, H I, small
part organ /umbilical cord
wasnt palpatet

Laboratory test (DL,

HBsAg)
Report to supervisor
, advice inj. antibotic
Test ampicilin
Inj. Ampicillin 1 gr

Lab:
Hb= 10,5 gr%
Leu= 11.900 /mm3
Tromb= 348.000 /mm3
HCT= 3
HBsAg (-)

22.35

General condotion : well

UC : (-)
FHR : 12-12-13

Observation mother
and fetal well being

02.35

General condition : well

UC : (-)
FHR : 12-12-12

Observation mother
and fetal well being

04.35

General condition : well

UC : (-)
FHR : 12-12-12

Observation mother
and fetal well being

06.35

General condition : well

UC : (-)
FHR : 12-12-11

Observation mother
and fetal well being

08.00

General condition : well

UC : (-)
FHR : 12-12-13
Bishop score =
Dilatation of cervix : 1
Length of cervix :
Station :
Consistency :
Position of cervix :

G2P1A0 38
weeks/S/L/IU with
PROM > 12 hours

Observation mother
and fetal well being
CTG =
Report to supervisor :
Propose:
induction
with drip oxytocin
Propose : aggreed
Start drip oxy 8
drop/mnt

General condotion :
well
UC : (-)
FHR : 12-12-13

Observation mother
fetal well being
Elevate
drip
oxy
drop/mnt

.00

General condotion :
well
UC : (-)
FHR : 12-12-11

Observation mother and

fetal well being
Elevate drip oxy 16
drop/mnt

19.30

General condition :
well
UC : (+) 1x/10- 20
FHR : 12-12-12

Observation mother
fetal well being
Elevate
drip
oxy
drop/mnt

and

General condition :
well
UC : (+) 2-3x/1030
FHR : 12-12-12

Observation mother
fetal well being
Elevate
drip
oxy
drop/mnt

and

General condition :
well
UC : (+) 3x/10-35
FHR : 12-12-11

Observation mother
fetal well being
Elevate
drip
oxy
drop/mnt

and

20.00

20.30

Abdominal discomfort
(+)

Abdominal discomfort
(+)

and
12

20

24

28

21.00

Abdominal discomfort
(+)

General condition :
well
UC : (+) 3x/10-45
FHR : 12-11-12

Observation mother and

fetal well being
Maintenance drip oxy 28
drop/mnt

21.30

Abdominal discomfort
>>

General condition :
well
UC : (+) 3x/10-45
FHR : 12-12-13

Observation mother and

fetal well being
Maintenance drip oxy 28
drop/mnt

22.00

Abdominal discomfort
>>

General condition :
well
UC : (+) 3x/10-45

Observation mother and

fetal well being
Maintenance drip oxy 28

23.00

Abdominal discomfort
>>

General condition : well

UC : (+) 3-4x/10-45
FHR : 13-13-12
VT : 1 cm, eff 75%,
amniotic membrane (-),
clear,
head
presentation,
denom
unclear, H I, small part
organ /umbilical cord
wasnt palpated.

23.30

Abdominal discomfort
>>

General condition : well

UC : (+) 4x/10-45
FHR : 13-13-13

observation mother and

fetal well being
Maintenance drip oxy 28
drop/mnt

00.00

Abdominal discomfort
>>

General condition : well

UC : (+) 4x/10-45
FHR : 13-13-12

observation mother and

fetal well being
Maintenance drip oxy 28
drop/mnt

00.30

Abdominal discomfort
>>

General condition : well

UC : (+) 4x/10-45
FHR : 13-12-12

observation mother and

fetal well being
Maintenance drip oxy 28
drop/mnt

01.00

Abdominal discomfort
>>

General condition : well

UC : (+) 4x/10-45
FHR : 13-12-13

observation mother and

fetal well being
Maintenance drip oxy 28
drop/mnt

01.30

Abdominal discomfort
>>

General condition : well

UC : (+) 4x/10-45
FHR : 13-12-12

observation mother and

fetal well being
Maintenance drip oxy 28
drop/mnt

02.00

Abdominal discomfort
>>

General condition : well

UC : (+) 4x/10-45
FHR : 13-12-12

observation mother and

fetal well being
Maintenance drip oxy 28
drop/mnt

G1P0A0 37
weeks/S/L/IU with
PROM > 12 hours

observation mother and

fetal well being
Maintenance drip oxy 28
drop/mnt

03.00

03.10

Abdominal discomfort
>>
Mother
want
to
bearing down

Abdominal discomfort
>>>
Mother
want
to
bearing down

General condition : well

UC : (+) 4x/10-45-50
FHR : 13-13-12
VT : 10 cm, eff
100%, amniotic
membrane (-), clear,
head presentation, LOA,
H II, small part organ
/umbilical cord wasnt
palpated.
Doran
vulka

teknus

G1P0A0 37
weeks/S/L/IU 2nd
stage of labor

Propose patient to left tilt

perjol

Conduct mother to bearing

down

03.20

2nd stage f labor

03.30

3rd stage of labor

04.30

General status : well

BP : 130/90 mmHg
Uterine
contraction
:good
UFH : 3 cm below
umbilical
Lochea (+)
Bleeding : 50 cc

05.30

General status : well

BP : 120/90 mmHg
Uterine
contraction
:good
UFH : 3 cm below
umbilical

observation mother and

fetal well being
Maintenance drip oxy 28
drop/mnt

4th stage of labor

Baby was born, spontan,

male, W : 2500 g, L : 48, AS
: 7-9, Anus (+)
Placenta was born spontan,
complete
W : 460g, L : 48 cm
Observation vital sign &
hemorrhagic sign

Observation vital
hemorrhagic sign

sign

&

Name

: Mrs. Yuhana

Admitted

: April 5th 2009

Age

: 21 years

Time

16.15

Address

: Sandik

Time

Subject

Object

Assesmen
t

Planning

16.15

The patient referred from PHC

Meninting with G1P0A0H0 43
weeks/S/L/IU head presentation
with serotinus
Cronologist :
15.00 patient came to PHC
Meninting with more than 9
month pregnancy. Patient felt
abdominal discomfort + watery
vaginal discharge + bloody show
since 02.00.
Examination in PHC
General condition : well
BP : 110/70mmHg
Pulse : 80 x/mnt
T : 36 C
UFH : 32 cm
EFW : 3255 g
UC : (+) rare
FHR : 11-12-11 (136 x/mnt)
VT : (-)
Patient sent to RSU Mataram

General status :
General condition : well
Consiousness : E4V5M6
BP : 110/70 mmHg
Pulse : 80/mnt
RR : 22 x/menit
T : 36,3 C
Eye : an -/- ikt -/Cor & Pulmo :
in normal
range

G1P0A0 4243 weeks

/S/L/IU head
presentation

observation mother
and fetal well being

Last menstrual period : 12/6/08

Estimate delivery date : 19/3/09

Pelvic evaluation: normal

Obstetrical status :
L1 : breech UFH : 33 cm
L2 : left back
L3 : head
L4: was enter the pelvic
inlet 4/5
EFW : 3410g
Uterine contraction = (-)
FHB = 12-12-11
VT :
(-), head
presentation

ANC : were routine in midwife

>4x,

Spina
ischiadika
isnt
prominent, concavity
os
sakrum is enough, os coxygis
mobile, arcus pubis >90.

History of Family planning = (-)

Lab :

Laboratory
test
(DL,HBsAg)
CTG baseline 125160
Report
to
supervisor
,
proposed : pro USG
tomorrow morning
proposed aggreed.

Name / Age

: Mrs. Mariah / 29 years old

CTH

: April 5th 2009

Address

: Batu Layar

Time

: 04.15

Time
04.15

Subject

Object

Patient came to ECU with 7 month

pregnancy

General status :
General condition: well,
Conciousness: CM
BP: 120/70 mmHg
RR: 22 x/mnt
PR: 88 x/mnt
T: 36,5 C
Eyes : an(-/-), ikt (-/-)
Cor -Pulmo : in normal range
Obstetric status :
L1 : breech, UFH : 20 cm
L2 : right back
L3 : head
L4 : wasnt enter pelvic inlet
EFW : 1240g
UC : (-)
Fetal Heart Rate : 12-11-12 x/mnt
VT : 1 cm, eff 10%, AM (-), clear,
head palpable, denom unclear, H I,
small part organ /umbilical cord wasnt
palpated.

chronologis :
Patient felt watery & bloody vaginal
discharge since 01.00.
Examination in ECU :
BP : 120/80 mmHg
Pulse : 88x/mnt
RR : 20 x/mnt
T : 36,5 C
UFH : 5 cm atas umbilicus
UC : (-)
FHR : 135x/mnt
VT : (-), remains amniotic fluid
Dx : G1P0A0 28 weeks S/L/IU +
PROM + bloody vaginal discharge
Patient sent to delivery rooms

Pelvic evaluation:
Promontorium unpalpable
Spina ischiadica: isnt prominent
Concavity os sacrum enough
Coxigis: mobile
Distansia tuberum: >90
Lab examination:
Hb : 12,5, Leu : 17.500
PLT : 485.000, HCT : 38,4

Assesment
G1P0A0 26-27
weeks/S/L/IU with
PROM

Planning
Observation mother
and fetal well being.
Laboratory
examination : DL,
HBsAg
Test ampi (-)
Inj ampi 1g/IV
Pro USG tomorrow
morning

Time

Subject

Object

Assesment

Planning

Last menstrual period : 26/10/08

Estimate delivery date : 3/8/09
ANC : (-)
History of Family planning = (-)
Family planning = inj of 3 months
Obstetrical history :
1. this is the first pregnancy

08.00

Fetal movement (-)

General condition : well

UC (-)
FHR : (-)

G1P0A0 26-27 weeks

+ KJDR

Observation vital sign

mother
Report to supervisor :
Advice : pro USG
tomorrow morning

00.25

Mother want to bearing down

General condition : well

UC : 3x/10-45
FHR : (-)
VT : 10 cm, eff 100%, AM (-),
clear, breech palpable, H III,
umbilical cord wasnt palpated.

G1P0A0 26-27 weeks

breech presentation
with 2nd stage of labor
+ KJDR

Conduct
mother
bearing down

2nd stage of labor

baby was born, spontan,

male, death, W : 1100g,
L : 40cm
Placenta
was
born,
spontan, complete, W :
310g, L : 36cm

00.30

3rd stage of labor

to

Time

Subject

Object

01.30

General status: well

BP: 110/70 mmHg PR: 88 x/mnt
RR : 24 x/mnt, T : 36,5 C
UC: good
UFH: 6 cm under umbilical
Lochea (+)
bleeding 100 cc

02.30

General status: well

BP: 110/70 mmHg PR: 84 x/mnt
RR : 24 x/mnt
UC: good
UFH: 6 cm under umbilical
Lochea (+)
bleeding 25 cc

07.00

General status: well

BP: 110/70 mmHg PR: 84 x/mnt
RR : 22x/mnt
UC: good
UFH: 6 cm under umbilical
Lochea (+)
bleeding (-)

Assesment
4th stage of labor

Planning
Observation vital sign &
hemorrhagic sign

Observation vital sign &

hemorrhagic sign

1st day of puer

Observation vital sign &

hemorrhagic sign