Morning Report

July 4th 2012

Supervisor : dr. Juliawan,
Sp.OG
Medical Students :
Yan, Ardin, Vivia, Dwityo, Fadil,
Zaky, Lanira
CASE RESUME
NORMAL LABOR -
PATHOLOGY 1.G1P0A0L0 40-41 weeks S/L/IU with severe
LABOR pre-eclampsia and prolonged 2nd stage of
labor.
2.G1P0A0L0 A/S/L/IU with neglected active
phase first stage of labor.
3.Eclampsia Puerperium
 Case Report
Name : Mrs. AH
RM : 044829
Age : 26 years old
Address : Sesela, Gunung Sari
Admitted : July 2nd 2012 at 11.50
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
02/07 Patient referred from Gunung General Status : G1P0A0L0 39-40 Observation
/2012 Sari PHC with G1P0A0L0 40 GC : well weeks S/L/IU with mother & fetal
weeks S/L/IU head BP : 160/110 mmHg latent phase 1st well being.
11.50
presentation with latent PR : 96 bpm stage of labor & Observation
phase 1st stage of labor and RR : 20 bpm severe progress of labor.
severe preeclampsia. T : 36,1OC preeclampsia Continue drip
Patient confessed abdominal Eye : anemis (-), icteric (-) MgSO4 40% 6
pain that spread to frank Cor : S1S2 single regular, gram 28 tpm from
since 10.00 (01/07/2012). murmur (-), gallop (-). PHC.
History rupture of membrane Pulmo : vesicular (+/+), Insert DC
(-), bloody slim (+) since wheezing (-/-), DM co to SPV,
07.00 (02/07/2012), FM (+). ronkhi (-/-). advice : continue
No history of nausea, Abdomen : scar (-), striae therapy of severe
vomiting, headache, visual gravidarum (+), linea nigra (+). preeclampsia and
disturbance and epigastric Extremity : edema (-/-), warm observation.
pain. acral (+/+).
No history of DM, HT,
asthma. Obstetrical Status :
L1 : breech
LMP : 26/09/2011 L2 : back on the right side
EDD : 03/07/2012 L3 : head
L4 : 4/5
History of ANC : > 4x at UFH : 31 cm
Posyandu EFW : 3100 gram
Last ANC : 01/07/2012 UC : 2x/10~30
History of USG : never FHB : 12-12-12 (144 bpm)
VT : 2 cm, effacement 25%,
History of family planning : amnion (+), head palpable
(-) HI+, denominator unclear,
Next family planning : impalpable small part and
Injection 3 months umbilical cord.

Obstetrical History :
I.This
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
Chronologist at Gunung Sari PHC Pelvic Evaluation :
(02/07/2012) Spina ischiadica not
prominent
06.30
Os coccygeus mobile
S : Patient confessed abdominal pain
Arcus pubis > 90o
that spread to frank.
O : GC : well
BP : 120/80 mmHg Lab Examination :
HGB : 11,8 g/dl
PR : 82 bpm
HCT : 40,1 %
RR : 20 bpm
RBC : 5,46 M/uL
T : 36,6OC
WBC : 11,30 K/uL
L1 : breech
L2 : back on the left side PLT : 488 K/uL
HbSAg : (-)
L3 : head
Protein urine : +2
L4 : 3/5
GDS : 102 mg/dl
UFH : 30 cm
SC : 0,5 mg/dl
EFW : 2945 g
UC : (+) Ureum : 23 mg/dl
SGOT : 24 mg/dl
FHB : (+) 136 x/min
SGPT : 21 mg/dl
VT : 2 cm, eff 25%, amnion (+),
head palpable, denominator unclear,
HI, impalpable small part /
umbilical cord.
A : 1st stage of labor
P:
Explain result of examination
Suggest mother to eat & drink
Observation 4 hours
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
10.30
S : Patient confessed abdominal
pain more frequently.
O : GC : well
BP : 170/110 mmHg
PR : 84 bpm
RR : 20 bpm
T : 36,6OC
UC : (+) 2x/10 ~ 35
FHB : (+) 136 bpm
VT : 2 cm, eff 25%, amnion (+),
head palpable, denominator
unclear, HI, impalpable small
part /umbilical cord.
Proteinuria : +2
A:
G1P0A0L0 40 weeks S/L/IU head
presentation, mother & fetal well,
latent phase 1st stage of labor
with severe preeclampsia.
P:
Explain result of examination
Observation progress of labor
Therapy :
Infus RL : bolus MgSO4 40% 4 g,
drip MgSO4 40% 6 g.
Nifedipine tab 10 mg
Refer to NTB GH
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
15.50 (-) GC : well G1P0A0L0 39-40 Observation mother &
BP : 160/110 mmHg weeks S/L/IU with fetal well being.
PR : 80 bpm latent phase 1st stage Observation progress
RR : 20 bpm of labor & severe of labor.
T : 36,7OC preeclampsia Continue drip MgSO4
UC : 2x/10 ~ 20 40% 6 gram 28 tpm.
FHB : 12-11-11 (136 bpm)
VT : 2 cm, effacement
25%, amnion (+), clear, head
palpable HI+, denom
unclear, impalpable small
part and umbilical cord.
UO : 75 cc/hours

19.50 (-) GC : well G1P0A0L0 39-40 Patient receive

BP : 180/100 mmHg weeks S/L/IU with Nifedipin tab 10 mg at
PR : 84 bpm prolonged latent phase 18.30.
RR : 24 bpm 1st stage of labor & Observation mother &
T : 36,5OC severe preeclampsia fetal well being.
UC : 2x/10 ~ 20 Continue drip MgSO4
FHB : 12-12-12 (144 bpm) 40% 6 gram 28 tpm.
VT : 3 cm, effacement DM consult to GP,
25%, amnion (+), clear, head advice : acceleration
palpable HI+, denom with oxytocin drip if
unclear, impalpable small CTG reactive.
part and umbilical cord.
UO : 50 cc/hours

Pelvic Score : 6
Cervix dilatation 3 cm : 2
Cervix length 2 cm : 1
Cervix consistency moderate
:1
Cervix position posterior : 1
Station -2 : 1
 TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
02/07/1 Abdominal pain UC : 3 x 10 ~ 30 Flash I
2 FHB : 12-12-13 (148 Drip oxytocin began 8
21.30 bpm) tpm
22.00 Abdominal pain came and UC : 4 x 10 ~ 40 Drip oxytocin 12 tpm
relieved FHB : 12-13-13 (152 Maintenance
bpm)
22.30 Abdominal pain came and UC : 4 x 10 ~ 40 Drip oxytocin 12 tpm
relieved FHB : 12-12-12 (144
bpm)
23.00 Abdominal pain came and UC : 4 x 10 ~ 40 Drip oxytocin 12 tpm
relieved FHB : 12-12-12 (144
bpm)
23.30 Abdominal pain came and UC : 4 x 10 ~ 40 Drip oxytocin 12 tpm
relieved FHB : 12-12-11 (140
bpm)
03/07/1 Abdominal pain came GC : well G1P0A0L0 39-40 weeks Drip oxytocin 12 tpm
2 more frequently BP : 180/110 mmHg S/L/IU with active phase Observation mother
00.00 PR : 92 bpm 1st stage of labor & and fetal well being.
RR : 24 bpm severe preeclampsia Observation
T : 36,2OC progress of labor
UC : 4 x 10 ~ 40 with partograf.
FHB : 12-12-13 (148 Continue drip MgSO4
bpm) 40% 6 gram 28 tpm.
VT : 6 cm, eff 75%,
amnion (+), head
palpable HI+,
denominator ROA,
impalpable small part
and umbilical cord.
UO : 50 cc/hours

00.30 Abdominal pain came and UC : 4 x 10 ~ 45 Drip oxytocin 12 tpm

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
02.00 Abdominal pain came and UC : 4 x 10 ~ 45 Drip oxytocin 12 tpm
relieved FHB : 12-12-12 (144
bpm)
02.30 Abdominal pain came and UC : 4 x 10 ~ 45 Drip oxytocin 12 tpm
relieved FHB : 12-12-13 (148
bpm)
03.00 Abdominal pain came and UC : 4 x 10 ~ 40 Drip oxytocin 12 tpm
relieved FHB : 12-12-12 (144
bpm)
03.30 Abdominal pain came and UC : 4 x 10 ~ 40 Drip oxytocin 12 tpm
relieved FHB : 12-12-11 (140
bpm)
04.00 Abdominal pain (+++) GC : well Drip oxytocin 12 tpm
Patient confessed water BP : 170/100 mmHg Observation mother &
came out from her womb. PR : 80 bpm fetal well being.
RR : 20 bpm Continue drip MgSO4
T : 36,4OC 40% 6 gram 28 tpm.
UC : 3 x 10 ~ 40 DM consult to GP,
FHB : 12-12-13 (148 advice : observe
bpm) progress of labor in 2
VT : 8 cm, eff 75%, hours.
amnion (-), head
palpable HII,
denominator ROA,
impalpable small part
and umbilical cord.
UO : 60 cc/hours

04.30 Abdominal pain came and UC : 3 x 10 ~ 40 Drip oxytocin 12 tpm

relieved FHB : 12-11-11 (136
bpm)
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
03/07 Abdominal pain (+++) GC : well 2nd stage of labor Drip oxytocin 12 tpm
/2012 BP : 170/100 PR : 80 bpm with severe Observation mother &
06.00 RR : 20 bpm T : 36,5OC preeclampsia fetal well being.
UC : 3 x 10 ~ 40 Continue drip MgSO4
FHB : 12-12-13 (148 bpm) 40% 6 gram 28 tpm.
VT : complete, amnion
(-), head palpable HII,
impalpable small part and
umbilical cord.
UO : 50 cc/hours

08.00 Abdominal pain (+++) GC : well Prolonged 2nd Drip oxytocin 12 tpm
BP : 190/110 PR : 80 stage of labor with Observation mother &
bpm severe fetal well being.
RR : 20 bpm T : preeclampsia Continue drip MgSO4
36,5OC 40% 6 gram 28 tpm.
UC : 3 x 10 ~ 40 GP consult to SPV : pro
FHB : 12-11-12 (140 bpm) VE SPV advice : Acc VE.
VT : complete, amnion
(-), head palpable HIII,
caput (+), impalpable small
part & umbilical cord.

08.45 Abdominal pain came GC : well Drip oxytocin 12 tpm

frequently BP : 220/130 mmHg Continue drip MgSO4
Mother wants to bearing PR : 112 bpm 40% 6 gram 28 tpm.
down RR : 24 bpm VE began :
UC : 3 x 10 ~ 40 VE succeed in 1x
FHB : 12-13-13 (152 bpm) traction
09.05 Perineum episiotomy
Baby was born, male,
2800 gram, 50 cm, A-S
7-9 caput (+) on
occiput, anus (+),
anomaly congenital (-).
Placenta was born
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
03/07 Abdominal pain and GC : well 2 hours post VE Observed mother well being
/2012 delivery wound pain BP : 170/110 mmHg Observed bleeding & VS
11.10 PR : 84 bpm mother
RR : 20 bpm Suggest mother to
T : 36,5OC mobilisation, eat and drink.
UC : (+) well Continue drip MgSO4 40% 6
UFH : 2 fingers below gram 28 tpm.
umbilicus
Lochea rubra : (+)
UO : 80 cc/hours

04/07 Delivery wound pain GC : well One day post VE Observed mother well being
/2012 BP : 150/100 mmHg Suggest mother to
07.00 PR : 80 bpm mobilisation, eat, and drink,
RR : 20 bpm medication.
T : 36,7OC Breast feeding
UC : (+) well
UFH : 2 fingers below
umbilicus
Lochea rubra : (+)

Baby in NICU :
GC : well
PR : 132 bpm
RR : 44 bpm
T : 36,2OC