mr 04092015_drip ok

Morning ReportSeptember, 4th 2015

Supervisor:Dr. Made Putra Juliawan, SpOG

DM Jaga:Rian

Morning Reportseptember 4th 2015

Case ResumeNORMAL LABOR

1. G1P0A0L0 37-38 weeks S/L/IU head presentation with 2nd stage of labor

PATHOLOGIES LABOR

1. G2P0A1L0 39-40 weeks S/L/IU head presentation with PROM > 12 hours + oligohidramnion + suspect CPD

2. G1P0A0L0 38 weeks S/L/IU head presentation with APB e.c. suspect placenta previa marginalis

3. G1P0A0L0 37-38 weeks S/L/IU head presentation with PROM > 12 h

4. G4P3A0L2 A/S/L/IU, head presentation with severe oligohidramnion + fetal distress

Case 1Name : Mrs. RAge : 26 years oldAddress : Gunung SariAdmitted : 03-09-2015 No. RM : 56-62-70

G2P0A1L0 39-40 weeks S/L/IU head presentation with PROM > 12 hours + oligohidramnion + suspect CPD

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

01/09/2015

21.53 wita

Patient reffered from Penimbung PHC with G2P0A1L0 40 weeks S/L/IU head presentation. Patient did not confessed about abdominal pain, history of water leaked out (+) since 3 days ago. history of bloody slim (-), FM (+).

History of DM (-), HT in pregnancy (-), asthma (-) and allergy (-).

LMP : forgetEDD : -

History of ANC : 14x at PosyanduLast result: (28/08/2015) BP 100/70 mmHg, BW 56 kg, GW 39-40 wk, UFH 29 cm, head presentation, FHB (+)

History of USG : 4x, at SpOGLast : 03/09/2015S/L/IU head presentation, male, GW 38-39 weeks, placenta at fundus, AFI clear, minimal, EFW 3003 gPROM>24 hours, oligohidramnion pro termination

History of family planning: injection 3 monthNext family planning : injection 3 month

General statusGC : wellconsciousness: CMBP : 110/70 mmHgPR: 80 bpmRR: 20 bpmT: 36.3°C

Local statusEye : an (-/-), ict (-/-)Pulmo : ves (+/+), rh (-/-), wh (-/-)Cor : S1S2 single regular, m (-), g (-)Abd : striae gravidarum (+), linea nigra (+), scar (-)Ext : edema of lower extremity(-/-), warm acral (+/+).

Obstetric statusL1 : breechL2 : back on the right sideL3 : headL4 : 5/5UFH: 31 cmEFW : 2945 gUC : -FHB : 13-13-13VT : Ø 1 cm, eff 25%, amnion (-), clear, head presentation, ↓H0, denominator unclear, not palpable small part & umbilical cord


DM planning:Diagnostic : CBC,

HbsAg,, BT, CT, CTGTherapy :Pro cervix maturation

with misoprostol followed by oxytocin drip

Monitoring : VS mother, UC, FHB, observation progress of labor

CIE : CIE mother and family about diagnostic planning and therapeutic planning

DM co to GP co to SPV advice :

C-Section citoCIE Family


Obstetric History:I. AbortusII. This

PE : Promontorium unpalpableOs coccygeus mobileArcus pubis >90oSpina ischiadica non prominemt]

Pelvic score = 3Dilatation of cervix : 1Length of cervix : 0Station : 0Consistency : 1Position : 1

Laboratory (03/09/2015 22.19):HB: 10.2 g/dl RBC: 3.61HCT: 30.7 %WBC: 10.90PLT: 395HbsAg: non reactiveBT : 2’00”CT : 7’00”


Chronology at Penimbung PHC (03/09/2015)20.30S :Patient 9month of pregnancy come to PHC confessed water leaked out a little since 2th sept 2015 at 03.00. LMP 25-11-2015, EDD 1—9-2015, FM (+)O :GC : wellconsciousness: CMBP : 110/70 mmHgPR: 81 bpmRR: 20 bpmT: 36.7°C

Obstetric statusBreech palpable in fundus, back on the right side, head presentation, 3/5UFH: 29 cmEFW : 2945 gUC : 1x10’~20”FHB : 11-12-12VT : Ø 1 cm, eff 10%, amnion (-), clear, head presentation, ↓HI, denominator unclear, not palpable small part & umbilical cord

USG : oligohidramnion + PROM > 12 hours


A :G2P1A0L1 40-41 weeks S/L/IU head presentation with mother and fetal well being + PROM>12 hours + oligohidramnion

P :Explanation to the family about examination resultInfusion RL 20 dpmInjection ampicillin 1 grRefer to NTB GH


23.10 Patient transffered to OK GC : wellconsciousness: CMBP : 110/70 mmHgPR: 88 bpmRR: 20 bpmT: 36.6°C

UC : -FHB : 12-11-12VT : Ø 1 cm, eff 10%, amnion (+), head presentation, ↓H1, denominator unclear, not palpable small part & umbilical cord


DM planning:Diagnostic : -Therapy :CIE :Monitoring :C Section begin at

4/9/2015 00.00

At 00.10 Baby was born,male, BW 2800 g, BL 48 cm, A-S 7-9

Placenta was born completely at 00.20

Do the management of 4th stage of labor


04/09/20152.30

Patient confessed about abdominal wound pain

GC : wellconsciousness: CMBP : 100/70 mmHgPR: 88 bpmRR: 20 bpmT: 36.4°CUC : wellUFH : 2 fingers below umbilicalUO : 200 cc/2 hoursActive bleeding (-)

Baby in NICU :HR : 152x/minuteRR : 54x/minuteT : 36,3oC

2 hours post partum

DM planning:Diagnostic : Therapy :Injection ampicillin 1

gr/6 hoursInjection ketorolac 30

mg/8 hoursMonitoring : VS mother,

UC, UFH, UOCIE : suggest mother

to eat and drink

04/09/201507.00


GC : wellconsciousness: CMBP : 100/70 mmHgPR: 88 bpmRR: 20 bpmT: 36.7°CUC : wellUFH : 2 fingers below umbilicalUO : 500 cc/4 hoursActive bleeding (-)Lochea rubra (+)


1 day post partum DM planning:Diagnostic : Therapy :Injection ampicillin 1




to eat and drink

Case 2Name : Mrs. HAge : 27 years oldAddress : Batu LayarAdmitted : 03-09-2015 No. RM : 56-62-64

G1P0A0L0 38 weeks S/L/IU head presentation with APB e.c. suspect placenta previa marginalis


01/09/2015

21.53 wita

Patient reffered from Meninting PHC with G1P0A0L0 40 weeks S/L/IU head presentation mother and fetal well being with mild preeclampsia and placenta previa marginalis . Patient did not confessed about abdominal pain, history of water leaked out (-). history of bloody slim (-), FM (+).

History of DM (-), HT in pregnancy (-), asthma (-) and allergy (-).

LMP : 15-12-2015EDD : 22-9-2015

History of ANC : 11x at PosyanduLast result: (03/09/2015) BP 1400/100 mmHg, BW - kg, GW 38 wk, UFH 28 cm, head presentation, FHB (+)

History of USG : 3x, at NTB GHLast : 26/08/2015S/L/IU head presentation, male, GW 36-37 weeks, placenta at corpus posterior gr III anterior insertion in OUI, AFI clear, minimal, EFW 2846 gPlacenta previa marginalis

General statusGC : wellconsciousness: CMBP : 130/90 mmHgPR: 86 bpmRR: 20 bpmT: 36.7°C

Local statusEye : an (-/-), ict (-/-)Pulmo : ves (+/+), rh (-/-), wh (-/-)Cor : S1S2 single regular, m (-), g (-)Abd : striae gravidarum (+), linea nigra (+), scar (-)Ext : edema of lower extremity(-/-), warm acral (+/+).

Obstetric statusL1 : breechL2 : back on the left sideL3 : headL4 : 5/5UFH: 32 cmEFW : 3100 gUC : -FHB : 12-13-13Inspekulo : Ø OUE (-) fluxus (+), livide (+), active bleeding (-)

VT : not perform

G1P0A0L0 40 weeks S/L/IU head presentation with placenta previa marginalis

DM planning:Diagnostic : CBC,

HbsAg, BT, CT, Urinalisis,CTG

Therapy :Pro C-SectionMonitoring : VS mother,

UC, FHBCIE : CIE mother and

family about diagnostic planning and therapeutic planning

DM co to GP co to SPV advice :

C-Section citoCIE Family


History of family planning: injection 3 monthNext family planning : injection 3 month

Obstetric History:I. This

PE : Not perform

Pelvic score = not perform

Laboratory (03/09/2015 22.19):HB: 12.7 g/dl RBC: 4.58HCT: 37.5 %WBC: 12.87PLT: 239HbsAg: non reactive


Chronology at Meninting PHC (03/09/2015)20.30S :Patient 9 month of pregnancy come to PHC want to examinated her pregnancy complained (-), abdominal pain (-), history of vaginal bleeding (-), headache (-).

O :GC : wellconsciousness: CMBP : 140/100 mmHgPR: 84 bpmRR: 20 bpmT: 36.5°C

Obstetric statusBreech palpable in fundus, back on the right side, head presentation, ↓4/5UFH: 28 cmUC : -FHB : +VT : not perform

A : G1P0A0L0 40 weeks S/L/IU head presentation mother and fetal well being with mild preeclampsia and placenta previa marginalis


P :Explanation to the family about examination resultInfusion RL 28 dpmUrinalisis proteinuria (+1)Refer to NTB GH


22.30 Patient transffered to OK GC : wellconsciousness: CMBP : 130/90 mmHgPR: 88 bpmRR: 20 bpmT: 36.6°C

UC : -FHB : 12-11-12VT : Ø 1 cm, eff 10%, amnion (+), head presentation, ↓H1, denominator unclear, not palpable small part & umbilical cord


DM planning:Diagnostic : -Therapy :CIE :Monitoring :C Section begin at

3/9/2015 23.10

At 23.20 Baby was born, female, BW 2600 g, BL 47 cm, A-S 6-8

Placenta was born completely at 23.25

Do the management of 4th stage of labor


04/09/201500.30


GC : wellconsciousness: CMBP : 130/70 mmHgPR: 84 bpmRR: 20 bpmT: 36.4°CUC : wellUFH : 2 fingers below umbilicalUO : 200 cc/2 hoursActive bleeding (-)


2 hours post partum

DM planning:Diagnostic : Therapy :Injection ampicillin 1




to eat and drink

04/09/201507.00


GC : wellconsciousness: CMBP : 100/70 mmHgPR: 88 bpmRR: 20 bpmT: 36.7°CUC : wellUFH : 2 fingers below umbilicalUO : 500 cc/4 hoursActive bleeding (-)Lochea rubra (+)


1 day post partum DM planning:Diagnostic : Therapy :Injection ampicillin 1




to eat and drink

Case Report 3 Name : Mrs. S Age : 24 years old Address : Narmada Admitted : September 5th, 2015 RM : 566247

Time Subjective Objective Assessment Planning

03-09-2015 (15.00 WITA)

Patient referred from Sedau PHC with G3P2A0L2 34-38 weeks S/L/IU head presentation come to NTB GH, confessed water leaked out from her womb since 01.00 WITA (03/09/2015), abdominal pain spread to the flank since 10.00 WITA (09/08/2015) and bloody slim (+), FM (+). History of DM (-), HT (-), asthma (-), allergy (-)

LMP : 15/12/2014EDD :22/09/2015GW : 37-38 weeks

History of ANC : 8x in posyanduLast ANC at 20/08/2015 at posyanduResult : BP 110/70, BW: 58 kg, UFH: 30 cm, head presentation, FHB (+) GW: 36 weeks

History of USG : 1x, at SpOGLast : 31/08/2015Result : S/L/IU, head presentation GW: 35-36 weeks, FHB (+), E EDD:10/02/2015, EFW : 2680 g

History of family planning:-Next family planning:

General statusGC : wellGCS: E4V5M6BP : 100/60 mmHgPR: 84 tpmRR: 20 tpmT: 37,3°C

Local statusEye : an (-/-), ict (-/-)Pulmo: ves (+/+), rh (-/-), wh (-/-)Cor : S1S2 single regular m(-), g(-)Abd : striae gravidarum (+), linea nigra (+), scar (-)Ext : warm (-/-) edema (-/-)

Obstetric statusL1 : breech L2 : left sideL3 : headL4 : 5/5UFH: 29 cmEFW : 2635 gramUC : -FHB : 12-13-13 (152x/m)

VT : Ø 1cm, eff 25%, amnion (-) clear, head presentation, ↓HI, impalpable small part & umbilical cord

G1P0A0L0 37-38 weeks S/L/IU head presentation with PROM > 12 h

DM planning:

Diagnostic planning • Pro CTG • Check CBC, HbsAg,

BT, CT

Therapeutic planning : • Inj Ampicilin 2 gr/IV• Pro termination with

CS CIE planning • CIE mother and


• Obs. Mother and fetal well being

• Suggest mother to lie down the left side, eat and drink

• Obs. progress of labor


Obstetric History:I. This

Chronologist: At Sedau PHC

(03/09/2015) 06.30 WITAS : Patient confessed water

leaked out from her womb since 12.00 WITA (02/09/2015), abdominal pain spread to the flank since (-) and bloody slim (-), FM (+).

O : General statusGC : wellGCS: E4V5M6BP : 110/80 mmHgPR: 72 bpmRR: 20 tpmT: 36,6°CObsetrical status : FH : 29 cmUC : 2x10’~15”FHB ; 120 bpmVT: Ø 1 cm, eff 10%, amnion (-) clear, head presentation, ↓HI, impalpable small part & umbilical cord

PS : 3Cervix Dilatation : 1Cervix length : 1Station : 0Cervix Consistency : 0Cervix position : 1

PE : Promontorium unpalpableSpina ischiadica nonprominentOs coccygeus mobileArkus pubis > 90

Lab:HB: 10,5 g/dl HCT : 31,8% RBC: 4,07 M/dl WBC: 12,91 K/dlPLT: 370MCV : 78,1 fL MCH : 25,8 pg MCHC : 33,0 g/dl

BT : 2’ 00”CT : 6’00” HbSAg: non reactive


3/9/2015 10.30

S : abdominal pain (+)O :BP : 120/80 mmHgPR: 80 bpmRR: 20 bpmT: 36,5CUC : 2x10’~15”VT : Ø 1 cm, eff 10%, amnion (-) clear, head presentation, ↓HI, impalpable small part & umbilical cord

3/9/2015 14.00

S : abdominal pain (+)O :BP : 110/80 mmHgPR: 80 bpmRR: 20 bpmT: 36,6CUC : 2x10’~15”VT : Ø 1 cm, eff 10%, amnion (-) clear, head presentation, ↓HI, impalpable small part & umbilical cord


A : G1P0A0L0 37-38 weeks S/L/IU, head presentation, mother and fetal well being with PROM > 12 h

P : • IVFD RL• Inj. Ampicilin I (07.00)• Inj. Ampicilin II (14.00)

Case 4 Name : Mrs. T Age : 30 years old Address : Kekeri Timur Admitted : 3th of September

2015 RM : 12 25 87


3/09/201512.00 wita

Patient referred from Ggunung Sari PHC with G4P3A0L2 43 weeks S/L/IU head presentation, mother and fetal well being with serotinus. Patient not confessed abdominal pain spread to the flank (-), water leaked out from her womb (-), bloody slim (-), FM (+).History of DM (-), HT (-), asthma (-) and allergy (-).

LMP : forgot EDD :-

History of ANC : 6x at Posyandu Last result: (15/07/2015) BP 100/70 mmHg, GW: 32 weeks, UFH 25 cm, head presentation, FHB (+)

History of USG : 1x at SpOGLast result: (01/09/2015) Result : S/L/IU, head presentation GW: 42 weeks, FHB (+), EDD:20/08/2015, plasenta in fundus, AF: unclear and oligohidramnion

History of family planning: injection 3 monthsNext family planning : IUD

General statusGC : wellconsciousness: CMBP : 120/70 mmHgPR: 96 bpmRR: 20 bpmT: 36,3°C

Local statusEye : an (-/-), ict (-/-)Pulmo : ves (+/+), rh (-/-), wh (-/-)Cor : S1S2 single regular, m (-), g (-)Abd : striae gravidarum (+), linea nigra (+), scar (-)Ext : edema (-/-), warm acral (+/+).

Obstetric statusL1 : breechL2 : back on the left sideL3 : headL4 : 4/5UFH: 27 cmEFW : 2480 grUC : -FHB : 12-12-11

VT : Ø 1 cm, eff 10%, amnion (+), head presentation, denominator unclear, ↓HI, impalpable small part & umbilical cord

G4P3A0L2 A/S/L/IU, head presentation with severe oligohydramnion

DM planning:Diagnostic planning • Check CBC, HbsAg,

BT, CT• Check CTG

Therapeutic planning : • Pro termination

pervaginam, if PS>5 oxytocin drip

CIE planning • CIE mother and


• Obs. Mother and fetal well being

• Suggest mother to lie down the left side, eat and drink

DM co to GP, GP co to SPV, advice:

• Pro termination pervaginam with oxytocine drip

• If inpartu CTG


Obstetric History:I. A/female/BW ?/home/

traditional practitioner/ deathII. A/male/3300g/PHC/

midwife/14 y.o/liveIII. A/male/3300g/PHC/

midwife/4,5 y.o/liveIV. This

Chronologist at Gunung Sari PHC

09/08/2015 (08.00 WITA)

S :Patient 9 months pregnancy, not confessed abdominal pain spread to the flank, water leaked out from her womb (-), bloody slim (-), FM (+).

O :GC : wellBP :90/70 mmHgPR: 80 bpmRR: 20bpmT: 37,0°CObstetric status:UFH: 26 cmhead presentation, back on the left side, 4/5UC : -FHB : +

PS : 5Cervix Dilatation : 1Cervix length : 1Station : 1Cervix Consistency : 1Cervix position : 1

Laboratory:HB:10,9 g/dl RBC: 4,50HCT: 33,3 %WBC: 9,72PLT: 367BT: 2’20”CT: 5’35”HbsAg: non reactive


A :G4P3A0L2 43 weeks S/L/IU, head presentation , mother and fetal well being with serotinus

P : -


13.00 wita Abdominal pain (+) UC : -FHB : 11-11-11

G4P3A0L2 A/S/L/IU, head presentation with severe oligohidramnion

• Induction using oxytocin drip 8 dpm

14.00 wita Abdominal pain (+) UC :-FHB : 7-6-7

G4P3A0L2 A/S/L/IU, head presentation with severe oligohidramnion + fetal distress

• Stop oxytocin drip

• Co to SPV : advice - stop Oxy drip change

with RL 28 dpm,- insert Oxygen 5 lpm, - Suggest mother to lie

down the left side

14.30 wita Abdominal pain (+) UC : -FHB :10-10-10

• Observation mother and fetal condition


- Observation mother and fetal condition



















• Observation mother and fetal condition





- Prepare for CS

22.15 wita Abdominal pain (+) CS was beganbaby was born (22.25

WITA), female, BW:2400 gr, BL : 46 cm, HC : 36 cm, A-S:7-9 , anomaly congenital (-), anus(+), amnion clear

Placenta born complete manual

CS finished at 23.00


01.00 wita Mother feeling abdominal pain (+) and numbness

GC :wellGCS: E4V5M6BP : 120/70mmHgPR: 84 bpmRR: 20 tpmT: 36.7°CUC: wellUFH: 2 finger below umbilicusUO : 150 cc/2jam

Baby in NICUHR: 148 bpmRR : 50 tpmT: 36,6°C

2 hours post SC • Observation general condition and vital sign

• Observation UC, UFH, and bleeding

04/09/201507.00

Mother feeling abdominal pain (+)

GC :wellGCS: E4V5M6BP : 110/70mmHgPR: 80 bpmRR: 20 bpmT: 36.9°CUC: wellUFH: 2 finger below umbilicusUO : 350cc/5jam

Baby in NICUHR: 146 bpmRR : 50 tpmT: 36,5°C

1 day post Sc • Observation general condition and vital sign

• Observation UC, UFH, and lochea

• CIE mother to eat and drink

• CIE mother to breast feeding

• CIE mother to mobilization

.. Thank You ..

mr 04092015_drip ok

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