Morning Report

September 1st 2014

Supervisor :
DM: Dayu, Rila, Faisol
 Name : Ms. K
Age : 27 th
Address : Karang Raden, KLU
Admitted : 31st August 2014
RM : 54-56-90
Diagnose : G1P0A0L0 40-41 weeks S/L/IU
head presentation with neglected 2nd stage of
labor + history of ROM
Time Subjective Objective Assessment Planning

31st August Patient come to NTB GH referred from General status G1P0A0L0 Obs. Mother
2014 KLU GH with G1P0A0L0 40 weeks GC : well 40-41 weeks and fetal
S/L/IU head presentation PROM + GCS : E4V5M6 S/L/IU head well being
14.00 macrosmia + LHM BP : 110/80 mmHg presentation CIE family
Patient confessed intermiten PR : 92 bpm with PROM >
abdominal pain (-), water leak out RR : 20 tpm 12 hours + DM Co to GP,
from her womb (+) since 22.00 WITA T : 36,1 0C LHM GP co to SPV,
(30-08-2014), bloody slim (-), FM (+) Eye : anemis (-/-), ikteric (-/-) SPV advice :
History : DM (-), HT (-), Asthma (-), Cor : S1S2 single, M (-), G (-) pro CTG. If
allergy (-) Pulmo : Vez (+/+), Whz (-/-), CTG reactive,
Rh (-/-) pro
LMP : 22 11 2013 Abdomen : striae gravidarum induction
EDD : 29 08 2014 (+), linea nigra (+), scar (-) (oxytocin
Extremity : drip)
ANC history : 3 X at Tanjung PHC Upper : oedem (-/-), warm Inj. Ampicilin
Last ANC : 31st August 2014, BP : (+/+) 1 gr i.v / 6
110/80 mmHg, BW : 65 kg, 40 weeks, Lower : oedem (-/-), warm hours
UFH : 40 cm, Presentation : head, (+/+)
back at lef
Obstetrical Status
USG History : - L1 : breech
L2 : back at lef
Familiy planning history : - L3 : head
Next family planning : inj. 3 month L4 : 5/5
UFH : 33 cm
Obstetrical history : EFW : 3410 gr
I. This UC : -
FHB : 11-11-12 (136 bpm)
BH : 148 cm
Time Subjective Objective Assessment Planning

Chronologist 31st of August 2014 at VT : 1 cm, Eff : 10%,

KLU GH (10.15) Amnion (-) clear, head
S/ presentation, denom unclear,
Patient came to KLU GH referred from HI, Impapable small part of
Tanjung PHC with G1P0A0L0 40 fetus/umbillical cord
weeks S/L/IU head presentation with
PROM 11 hours PS : 4
Patient confessed abdominal pain (-), Cervix Dilatation : 1
water leak out from her womb (+) Cervix length : 0
since 22.00 WITA (30-08-2014), Cervix position : 1
bloody slim (-), FM (+) Station : 1
Cervix Consistency : 1
O/
GC : well PE : seems normal
GCS : E4V5M6 Spina ischiadica : not
BP : 120/80 mmHg prominent
PR : 80 bpm Os coxygeus : mobile
RR : 20 tpm Arcus pubis : >90o
T : 36,70C
BH : 148 cm Lab result :
HB : 11,3 g/dL
HCT : 34,6 %
WBC : 10,79 x 103/uL
PLT : 190 x 103/uL
HbsAg : (-)
Time Subjective Objective Assessment Planning
UFH : 33 cm
EFW : 3410 gr
L1 : breech
L2 : back at lef
L3 : head
L4 : 4/5
HIS : -
FHR : 12-12-12 (144 bpm)

VT : 1 cm, Eff : 25%, Amnion (-)

clear, head presentation, denom
unclear, HI, Impapable small part of
fetus/umbillical cord

A/
G1P0A0L0 40 weeks S/L/IU head
presentation PROM > 12 hours +
macrosmia + LHM

P/
IVFD RL flash I 28 dpm
Inj. Ampicilin 1 gr i.v / 6 hours
(09.30 WITA)
 FOTO CTG

14.30 General status Obs. Mother and

GC : well fetal well being
GCS : E4V5M6 Co to GP, advice :
BP : 120/80 mmHg Resuscitation
PR : 80 bpm intrauterine
RR : 20 tpm Re-CTG, if reactive
T : 36,8 0C start drip oxy

UC : -
FHR : 12-12-13 (148
bpm)
14.45 Resuscitation
intrauterine
RL : D5% (2 :1)
O2 5 lpm
 FOTO CTG ke 2

17.30 General status DM co to GP,

GC : well GP co to SPV,
GCS : E4V5M6 advice :
BP : 1 mmHg Start Oxy
PR : 84 bpm drip 8 dpm
RR : 22 tpm
T : 35,8 0C

UC : -
FHR : 13-13-12 (152 bpm)
CTG was reactive
Time Subjective Objective Assessment Planning
18.00 HIS : 3x10~35 Observation mother n fetal well
FHB : 11-11-12 being
VT : . 3cm, eff 50%, Observation progres of labor
amnion (-), head 12 tpm
presentation, H1, denom
unclear, impapable small
part of fetus/umbillical
cord
18.30 HIS : 4 x 10~40 Observation mother n fetal well
FHB : 12-12-12 being
12 tpm
19.30 HIS : 4 x 10~40 Observation mother n fetal well
FHB : 12-13-12 being
12 tpm
20.00 HIS : 4 x 10~40 Observation mother n fetal well
FHB : 12-12-12 being
12 tpm
20.30 HIS : 4 x 10~45 Observation mother n fetal well
FHB : 12-12-13 being
12 tpm
21.00 HIS : 4 x 10~45 Observation mother n fetal well
FHB : 12-12-11 being
12 tpm
Time Subjective Objective Assessment Planning
21.30 HIS : 4x10~45 12 tpm
FHB : 12-11-12
22.00 HIS : 4x10~45 2nd stage of
FHB : 12-11-12 labor -CIE patient and
VT : . 10 cm, eff 100 %, amnion (-), head family
presentation, H2, denom unclear, impapable -Obs. Mother and
small part of fetus/umbillical cord fetal well being
- Suggest mother to
drink and eat

24.00 HIS : 4x10~45 Prolonged 2nd 12 tpm

FHB : 11-11-12 stage of labor Use cateter
General status DM co to GP, GP
GC : well co to SPV, advice :
GCS : E4V5M6 observation 2hr
BP : 110/70 mmHg more, if H3 pro
PR : 84 bpm vacum, if still H2
RR : 20 tpm pro CS
T : 36,70C
OU : 300 cc
VT : . 10 cm, eff 100 %, amnion (-), head
presentation, H2, denom unclear, impapable
small part of fetus/umbillical cord
Time Subjective Objective Assessment Planning
24.30 Abdominal pain (+) HIS : 2x10~15 DM co to GP
FHB : 11-12-12 pro CS, GP co
to SPV: acc CS
Preparation
operation

02.30 CS began
Baby was born
(03.47):
male, 3900 gram,
BL : 53 cm, as: 7-9
anus (+), anomali
congenital (-)

Plasenta was born

manually,
complete, 500 gr,
bleeding + 150cc

Baby in NICU
Time Subjective Objective Assessment Planning
05.30 General status 2 hours post CS Obs. Mother and
GC : well fetal well being
GCS : E4V5M6 Bed rest for next
BP : 210/110 mmHg 8 hour
PR : 92 bpm
RR : 20 tpm
T : 36 0C
OU : 450 cc
UC : (+) well
UFH : umbilicus
6.30 General status 1 day post CS Continue
GC : well observation
GCS : E4V5M6 Tab.
BP : 150/110 mmHg As.Mefenamat
PR : 92 bpm 3x1
RR : 20 tpm Tab. Amoxicilin
T : 36 0C 3x1
OU : 600 cc Suggest mother
UC : (+) well to mobilization
UFH : 1 below of
umbilicus
Baby In NICU
GC : well
HR : 138 bpm
RR : 48 x/mnt
T : 36,4 C