MORNING REPORT

August 13th 2013

Supervisor : dr. Dody Aryo Kumboyo, Sp.OG
DM :
Ika, Dyan, Linda, Dian
Case Resumes
Normal labor: 1
Pathologic labor: 1

Case Report
Mrs. S, 19 years old, from Ampenan,
Hospitalization on 15.22, 12/08/2013.
G2P0A1H0 33-34 wk S/L/IU head presentation with PROM > 12 hours.

Time

Subject

12/08/13
15.30
WITA

Patient reffered from Tanjung

Karang PHC with G2P0A1L0 36
weeks S/L/IU head presentation,
with PROM. Patient confessed
abdominal pain since 03.00
(11/08/20132). History rupture of
membrane (+ ) since 11.30
(11/82013) clear, Bloody slim (-) ,
FM (+). History of DM (-), HT (-),
asthma (+).
Family health history : DM (-), HT (), asthma (-)
LMP : 24-12-2012
EDD : 1- 10-2013
History ANC : 3x PHC
History of USG : +, 13/8/2013
Fetus S/L/IU head presentation
BPD : 31W 2D
AC : 30W 6D
FL : 32W 6D
EFW : 1600 g
EDD : 10 10- 2013
Placenta at fundus, amnion fluid less
History of family planning: Next family planning: Obstetric History:
1. Abortion
2. This

Object
General status
GC : well
GCS: E4V5M6
BP : 110/70 mmHg
PR: 82 tpm
RR: 20 tpm
T: 36,3C
Local status
Eye : an (-/-), ict (-/-)
Pulmo: ves (+/+), rh (-/-), wh (-/-)
Cor /S1S2 single reg. M(-), G(-)
Abd : striae gravidarum (+), linea
nigra (+), scar (-)
Ext : edema (-/-), warm (+/+)
Obstetric status
L1 : breech
UFH: 28 cm
L2 : back on the right side
L3 : head
L4 : 4/5
UC : FHB : 12.12.12 (144bpm)
EFW :2635 gram
VT : CD 1 cm, eff 10%, amnion
(+), head presentation, denom
unclear, H I, small part of fetus
or umbilical cord unpalpabled.
PE:
Promontorium unpalpable
Spina ischiadica not prominent
Os coccygeous mobile
Pubic arch > 90

Assessment
G2P0A1L0 33-34
weeks S/L/IU head
presentation with
PROM > 12 hours

Planning
-Obs. Mother and fetal
well being.
- Ceck CBC and HBsAg
- DM co. to GP, advice :
pro CTG
- GP co. CTG result to
SPV, advice:
- Obs. and move to VK
Teratai.
-Inj. Dexamethason 1
ampul/ 6 hours
-Inj. Ampicillin 1 g/24 h
-Pro USG

Time

Subject
Cronologist :
10.19 (11/8/2013) at PHC
Patient came to Tanjung Karang
PHC confessed abdominal pain since
03.00 (11/8/2013), history of water
leakage 9-), bloody slim (-), FM (+).
General status : well
BP : 100/80 mm Hg
P :84 x/m
RR :20 xm
Temp : 36,7C
UFH : 27 cm , palpable breech on
fundus, back on right side, head on
pelvic inlet 4/5 part.
EFW : 2480 g
UC: 1x 10 20
FHB : 12-11-11 (136 bpm)
VT : CD icm, eff 25%, amnion (+),
head presentation, denom unclear,
H I, small part of fetus or umbilical
cord unpalpabled.
A : G1P0A0L0 36 weeks S/L/IU
head presentation, mother and fetal
are well being, inpartu observation.
11.30
Ruptur of amnion membran
spontaniously, clear, 100 cc.
VT : CD icm, eff 25%, amnion (+),
head presentation, denom unclear,
H I, small part of fetus or umbilical
cord unpalpabled.
T : Skin test (-),

Object
Lab:
Hgb : 9,9
Rbc : 3,77
Hct : 29,1
Wbc : 16,47
Plt : 394
HBsAg : -

Assessment

Planning

Time

Subject
11.45
Inj. Vicillin 1 g/IV/6 hours
FHB : 146 bpm
UC : 1x 10 25
15.30
UC : 3x10 30
FHB : 12-11-12 (140 bpm)
VT : CD 1 cm, eff 25%, amnion (-),
head presentation, denom unclear,
H I, small part of fetus or umbilical
cord unpalpabled.
17.45
Inj. Vicillin 1 g/IV/ 6 hours
19.30
UC : : 3x10 30
FHB : 12-12-12 (144 bpm)
VT : : CD icm, eff 25%, amnion (-),
head presentation, denom unclear,
H I, small part of fetus or umbilical
cord unpalpabled.
23.30
UC : seldom
FHB : 11-12-12 (144 bpm)
Inj. Vicillin 1 g/IV/6 hours
03.30 (12/8/2013)
UC : seldom
FHB : 11-12-12 (140 bpm)

Object

Assessment

Planning

Time

Subject

Object

Assessment

Planning

05.45
Inj. Vicillin 1 g/IV/6 hours
07.30
FHB : 11-12-11 (136 bpm)
UC : seldom
11.30
FHB : 11-11-12
UC : +
14.00
FHB : 12-11-11
UC : BP : 110/70 mmHg
P : 80 x/m
Tax : 37C
Co. dr. advice : Reffered to RSM

13/08/
2013
08.00

General status : well

GCS : E4V5M6
BP : 110/70 mmHg
P : 84 x/m
RR : 22x/m
Temp : 36,9C
UC : FHB : 12-12-11 (140 bpm)
USG Result :
Fetus S/L/IU head presentation
BPD : 31W 2D
AC : 30W 6D
FL : 32W 6D
EFW : 1600 g

G2P0A1L0 33-34
weeks S/L/IU head
presentation with
PROM > 12 hours

- SPV advice :
Termination with
oxytocin drip.
-CIE patient and family
-Obs. Mother and fetal
well being
- Suggest mother to drink
and eat

Time

Subject

Object

20.00

General status : well

BP : 120/80 mmHg
P : 86x/m
RR: 20 x/m
Temp: 36,8C
UC : FHB : 12-12-13

13/08/
2013

BP : 110/70 mmHg
P : 80x/m
RR: 20 x/m
Temp: 36,5C
UC : FHB : 12-12-12

06.00

Assessment

G2P0A1L0 33-34
weeks S/L/IU head
presentation with
PROM > 12 hours

Planning

-Obs. Mother and fetal

well being
-Inj. Dexamethasone
1ampul/6 hours
-Suggest mother to eat
and drink
-Pro USG

Time

Subject

Object

Assessment

Planning

09.45

UC : FHB : 12-11-12

-Drip Oxytocin 8 dpm

first flash

10.15

UC : 1 x 10 10
FHB : 13-13-12

-Drip Oxytocin 12 dpm

10.45

UC : FHB : 13-13-12

-Drip Oxytocin 16 dpm

11.15

UC : FHB : 13-12-13

-Drip Oxytocin 20 dpm

11.45

UC : FHB : 12-12-12

-Drip Oxytocin 24 dpm

12.15

UC : 1 x 10 20
FHB : 13-12-13

-Drip Oxytocin 28 dpm

12.45

UC : 1 x 10 20
FHB : 12-13-12

-Drip Oxytocin 32 dpm

13.15

UC : 1 x 10 20
FHB : 12-13-12

-Drip Oxytocin 36 dpm

13.45

UC : 2 x 10 20
FHB : 12-11-12

-Drip Oxytocin 40 dpm

14.15

Abdominal pain increase

UC : 2 x 10 25
FHB : 12-13-12

-Drip Oxytocin 40 dpm

14.45

UC : 2 x 10 25
FHB : 12-12-12

-Drip Oxytocin 40 dpm

Time

Subject

Object

Assessment

Planning

15.15

UC : 3 x 10 30
FHB : 11-12-12

-Drip Oxytocin 40 dpm

15.45

UC : 3x 10 35
FHB : 11-11-12

-Drip Oxytocin 40 dpm

16.00

Abdominal pain increase and more

frequently

General status : well

BP : 100/70 mmHg
RR : 20 x/m
P : 82 x/m
Temp : 36, 6C
UC : 43x 10 35
FHB : 13-12-12 (148 bpm)
VT : CD 6 cm, eff 75%, amnion
(-), head presentation, fontanela
minor anterior, H II, small part
of fetus or umbilical cord
unpalpable.

16.15

UC : 4 x 10 40
FHB : 11-12-12

16.45

Mother wants to bearing down

General status : well

FHB : 12-12-12 (144 bpm)
UC : UC : 4 x 10 40-45
Doran, teknus, perjol, vulka

16.50

G2P0A1L0 33-34
weeks S/L/IU head
presentation with 1st
stage of labor active
phase with history of
water leakage

-Obs. Progress of labor

-Obs. Mother and fetal
well being
-Suggest mother to drink
and eat
- Suggest mother lie
down to left

-Drip Oxcytocin 40 dpm

second flash
G2P0A1L0 33-34
weeks S/L/IU head
presentation with 2nd
stage of labor

-Conduct mother to
delivery the baby

-Baby was born, spt.B,

female, A-S:7-9,
bw:1900 g, bl : 49 cm,
anus (+), anomaly
congenital (-), the baby
room in NICU

Time

Subject

Object

Assessment

Planning

17.00

3rd stage of labor

-Placenta was born

spontaniously,
completetly, weight:500 g
bleeding : 150 cc

18.50

General status: well

GCS:E4V5M6
BP: 110/70 mmHg
P: 80 x/m
RR: 20 x/m
Tax: 36,4C
UC: +,
UFH: 2 finger below umbilicus

P1A1L1 2 hours post

partum

-Obs. mother condition

-Obs. bleeding
- Suggest mother to eat
and drink

07.00

General status : well

GCS : E4V5M6
BP : 110/80 mmHg
P : 82x/m
RR : 20 x/m
Tax : 36,7C
UC : +
UFH : 2 finger below umbilicus
Lochea rubra : +

1 day post partum

- Obs.mother condition
-Mobilitation
-Suggest mother to eat
and drink.