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Morning Report 19 April 2009

Supervise by : dr. A.Rusdhy H , SpOG


Medical Student: 1. A.D. Irma Ramdani 2. Januarman 3. Silvia
Cases resume : 1

PROM > 12 hours

2
3 4 3

Severe preeclampsia
Neglacted I stage of labor + oligohydroamnion Placenta previa Normal labor

2
1 1 2

Name age Address

: Ny. Zahra : 20 years : Labuapi

Admitted

: 02-07-2009 : 11.00

Time 11.00

Subject Patient referred from labuapi PHC with G1P0A0 43 weeks / single/life with postterm pregnancy Chronologis : Patient came to labuapi PHC with pregnancy more than 9 month. Abdominal discomfort (-), vaginal discharge ().from examination found : BP : 120/70 mmHg Pulse : 84x/ RR : 18x/ T : 36,2 C LMP : 06/09/08 EDD : 13/06/09 Obstetri history : 1.This

Object General status : General condition: well, Conciousness: CM BP: 120/80 mmHg RR: 20 x/mnt PR: 88 x/mnt T: 36,8 C Eyes : an(-), ikt (-) Cor -Pulmo : in normal range Obstetric status : L1 : breech L2 : left back L3 : left back L4 : head UFH 28 cm EFW : 2635 g UC : (-) Fetal Heart Rate : 12 12 13 VT : servic dilatation 1 cm, AM (+), H1, wasnt not palpable small organ or umbilicus,

Assesment G1P0A0 42-43 weeks/single/life with post term pregnancy

Planning Observation mother and fetal well being. Laboratory examination : DL, HBsAg Report to supervisor propossed to drip oxytocin advice : CTG. if CTG good, drip oxytocin

Time

Subject

Object
Lab examination found :

Assesment

Planning

Hb : 13,1 Leu : 13.200 PLt : 227.000 HCT : 37,4 HBsAg : (-)


12.30

G1P0A0 42-43 weeks/single/life with post term pregnancy

CTG (base line 145, deselerasi 120) Report to supervisor (13.00), Propossed : drip oxytocin 5 UI in 500 cc D5% Propossed agree Start drip oxytocin seri I, flash 1 8 drops/mnt Observation mother and fetal well being

13.30

Abdominal discomfort (-)

General status : well FHB : 12 12 11 UC : -

G1P0A0 42-43 weeks/single/life with post term pregnancy

14.00

Abdominal discomfort (-)

General status : well FHB : 13 13 14 UC : -

G1P0A0 42-43 weeks/single/life with post term pregnancy

Start drip oxytocin seri I, flash 1 12 drops/mnt Observation mother and fetal well being

14.30

Abdominal discomfort (-)

General status : well FHB : 13 13 14 UC : -

G1P0A0 42-43 weeks/single/life with post term pregnancy

Start drip oxytocin seri I, flash 1 16 drops/mnt Observation mother and fetal

Time
15.00

Subject
Abdominal discomfort (-)

Object
General status : well FHB : 12 12 13 UC : General status : well FHB : 12 12 13 UC : General status : well FHB : 12 13 12 UC : -

Assesment G1P0A0 42-43 weeks/single/life with post term pregnancy G1P0A0 42-43 weeks/single/life with post term pregnancy G1P0A0 42-43 weeks/single/life with post term pregnancy G1P0A0 42-43 weeks/single/life with post term pregnancy

Planning
Start drip oxytocin seri I, flash 1 20 drops/mnt Observation mother and fetal well being Start drip oxytocin seri I, flash 1 24 drops/mnt Observation mother and fetal well being Start drip oxytocin seri I, flash 1 28 drops/mnt Observation mother and fetal well being Start drip oxytocin seri I, flash 1 32 drops/mnt Observation mother and fetal well being Start drip oxytocin seri I, flash 1 36 drops/mnt Observation mother and fetal well being

15.30

Abdominal discomfort (-)

16.00

Abdominal discomfort (-)

16.30

Abdominal discomfort (-)

General status : well FHB : 11 12 12 UC : -

17.00

Abdominal discomfort (-)

General status : well FHB : 13 13 12 UC : -

G1P0A0 42-43 weeks/single/life with post term pregnancy

17.30

Abdominal discomfort (-)

General status : well FHB : 13 13 12 UC : -

G1P0A0 42-43 weeks/single/life with post term pregnancy

Start drip oxytocin seri I, flash 1 40 drops/mnt Observation mother and fetal well being

Time
18.00

Subject
Abdominal discomfort (-)

Object
General status : well FHB : 13 13 12 UC : General status : well FHB : 13 13 12 UC : General status : well FHB : 12 13 12 UC : General status : well FHB : 13 13 13 UC : 2x/10 ~ 20

Assesment G1P0A0 41 weeks / single/life with postterm pregnancy G1P0A0 41 weeks / single/life with postterm pregnancy G1P0A0 41 weeks / single/life with postterm pregnancy G1P0A0 41 weeks / single/life with latent phase of Ind stage of labor.

Planning
maintenance drip oxytocin seri I, flash 1 40 drops/mnt Observation mother and fetal well being maintenance drip oxytocin seri I, flash 1 40 drops/mnt Observation mother and fetal well being maintenace drip oxytocin seri I, flash 1 40 drops/mnt Observation mother and fetal well being maintenace drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being

18.30

Abdominal discomfort (-)

19.00

Abdominal discomfort (-)

19.30

Abdominal discomfort (+)

VT : 1 cm, eff 25 %, amniotic membrane (+), head palpable, descend HI, unpalpable small organ and umbilical cord.
20.00 Abdominal discomfort (+) General status : well FHB : 12 12 13 UC : 2x/10 ~ 20

G1P0A0 41 weeks / single/life with latent phase of Ind stage of labor.

maintenance drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being

Time
20.30

Subject
Abdominal discomfort (+)

Object
General status : well FHB : 13 12 13 UC : 2x/10 ~ 20 General status : well FHB : 12 12 13 UC : 2x/10 ~ 20 General status : well FHB : 12 12 13 UC : General status : well FHB : 13 13 13 UC : 2x/10 ~ 20

Assesment G1P0A0 41 weeks / single/life with latent phase of Ind stage of labor. G1P0A0 41 weeks / single/life with latent phase of Ind stage of labor. G1P0A0 41 weeks / single/life with latent phase of Ind stage of labor. G1P0A0 41 weeks / single/life with latent phase of Ind stage of labor. G1P0A0 41 weeks / single/life with latent phase of Ind stage of labor. G1P0A0 41 weeks / single/life with latent phase of Ind stage of labor.

Planning
maintenace drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being maintenance drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being maintenace drip oxytocin seri I, flash 1 40 drops/mnt Observation mother and fetal well being maintenace drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being

21.00

Abdominal discomfort (+)

21.30

Abdominal discomfort (-)

22.00

Abdominal discomfort (+)

22.30

Abdominal discomfort (+)

General status : well FHB : 13 13 13 UC : 2x/10 ~ 20

maintenace drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being maintenance drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being

23.00

Abdominal discomfort (+)

General status : well FHB : 12 12 13 UC : 2x/10 ~ 20

Time
23.30

Subject
Abdominal pain (+)

Object
General status : well FHB : 13 12 13 UC : 2x/10 ~ 20 General status : well FHB : 12 12 13 UC : 2x/10 ~ 20

Assesment G1P0A0 41 weeks / single/life with latent phase of Ind stage of labor. G1P0A0 41 weeks / single/life with latent phase of Ind stage of labor. G1P0A0 41 weeks / single/life with latent phase of Ind stage of labor. G1P0A0 41 weeks / single/life with latent phase of Ind stage of labor.

Planning
Drip oxytocin failure Rest 24 hours Observation mother and fetal well being Observation mother and fetal well being Test ampi, injeksi ampicilin 1 gr Observation mother and fetal well being

21.45

Abdominal discomfort (+) Vaginal discarge (+)

08.30

Abdominal discomfort (-)

General status : well FHB : 12 11 12 UC : General status : well FHB : 13 13 13 UC : 2 - 3x/10 ~ 35

11.45

Abdominal discomfort (+)

Observation mother and fetal well being

VT : 3 cm, eff 25 %, amniotic membrane (-), head palpable, descend HI, unpalpable small organ and umbilical cord.

Time
15.00

Subject
Abdominal (+) discomfort

Object General status : well FHB : 12 12 12 UC : (-) VT : 1 cm, eff 10 %, amniotic membrane (+), head palpable, descend HI, unpalpable small organ and umbilical cord.
General status : well FHB : 12 12 11 UC : (-)

Assesment G1P0A0 41 weeks / single/life with aktive phase of Ind stage of labor.

Planning
Observation mother and fetal well being

17.30

Mother want to bearing down

VT : 1 cm, eff 10%, amniotic membrane (+), head palpable, descend HI, unpalpable small organ and umbilical cord.
17.45 Mother want to bearing down Doran teknus perjol vulka

G1P0A0 41 weeks / single/life with aktive phase of Ind stage of labor.

Observation mother and fetal well being

G1P0A0 41 weeks / single/life 2nd stage of labor.

Conduct mother to bearing down Observation mother and fetal well being every 2 hours Failure conduct bearing down mother to

22.30

Report to supervisor propossed to SC, propossed agree

Time 21.00

Subject Mother want bearing down to

Object Doran teknus perjol vulka

Assesment G1P0A0 41 weeks / single/life 2nd stage of labor. 2nd stage of labor.

Planning Conduct mother to bearing down

22.15

Baby was born female, weight 2800g, length 48 cm, AS 6-8

3nd stage of labor.

Placenta was born complete,weight 450 g, length 50 cm Hemorrage : 150cc

22.45

BP : 110/80 mmHg PR : 88 x/mnt RR : 20 x/mnt T : 36C UC : good UFH : 2 cm below umbilical


BP : 110/80 mmHg PR : 88 x/mnt RR : 20 x/mnt T : 36C UC : good UFH : 2 cm below umbilical

4nd stage of labor

Obs. Mother and baby well being

23.45

4nd stage of labor

Mother and baby rooming care

Name age Address

: Mrs. Humaini : 26 years : Ampenan

Admited

: 19/04/09 : 14.45

Time 14.45

Subject Patient referred from Ampenan PHC with G1P0A0 1st stage labor Cronologist : Patient came to PHC ( 14.00 /18 04 09) with vaginal discharge .+ abdominal discomfort. examination found in PHC : BP : 140/90 mmHg Pulse : 82x/ RR : 22x/ T : 36 C VT : Servic dilatation 3 cm, eff 25 %, AM (-), H1,wasnt not palpable small organ or umbilicus, oedema servic FHR : 12-121-12 UC : 2x/10~25
LMP = forgotten in VK : patient felt abdominal discomfort ++, fetal

Object General status General condition : well Consciousness : CM BP : 170/100 mmHg PR : 84x/mnt RR : 24x/mnt T : 36.8 C Eye : an (-), ict (-) Pulmo,cor : in normal range Extr : udem minimal Obstetric status L1 : breech, UFH : 35 cm L2 : right back L3 : head L4 : decendsus 4/5 UC : 2-3x/10~30 FHR : 12-13-13 EFW : 3720 g VT : servic dilatation 3 cm, servic oedema, AM (-), H1, wasnt not palpable small organ or umbilicus, Hb : 11.7 Leu : 20.700 PLt : 270.000

Assesment G1P0A0 A/S/L 1st stage labor latent fase+ severe preeclampsia+ vaginal discharge history

Planning Obs.mother and fetal well being Obs vital sign and urine produce CTG : BL 150 Check lab : UL, DL, HBs Ag Report to supervisor Supervisor not available

time
17.30

Subject

Object

Assesment

Planning
Report to supervisor : Advice inject antibiotic Bolus MgSO4 4 g in 20 cc aquabidest Drip MgSO4 6 g in infuse 28 drops/mnt Educated mother to left down

18.45

Patient felt abdominal discomfort ++

BP : 170/ 90 Pulse : 100x/ RR : 22x/ UC : 3x/10~ 30-40 VT : servic dilatation 4 cm, eff 50 %, AM (-), head palpable, H1, wasnt palpable small organ FHR : 12-13-12 BP : 170/80 Pulse : 120x/ RR : 22x/ Urine produce : 300 cc

G1P0A0 A/T/H 1st stage labor active fase + severe preeclampsia

Observation of mother and fetal well being Educated mother to eating and left down. Observation 4 h again.

21.00

G1P0A0 A/T/H 1st stage labor active fase + severe preeclampsia G1A0P0 protacted 1st stage labor active fase + severe preeclampsia + febris

Obs vital sign

22.45

Abdomnal discomfort +++, patient felt epigastrial pain , diplopia (-), vomiting (-),

BP : 160/100 Pulse : 100x/ RR : 22x/ T : 38,2 C VT : servic dilatation 4 cm, eff 50 % , AM (-), head presentation,

Report to supervisor : Advice prepare Sectio Caesaria prepare SC,

time
23.50

Subject

Object

Assesment

Planning
Baby was born, 3700 g, female, AS : 6-7 Placenta was born, complete Baby move to nicu

07.00

General conciousnes: well BP : 140/90 Pulse : 84x/ RR : 22x/ T : 37 C

Baby in nicu Mother in melati room,

Name age Address

: Ny. Sarini : 26 years : Golong, Narmada

Admitted

: 19-04-2009 : 16.00

Time
16.00

Subject
Patient came to Emergency Room G4P3A0H3 Aterm/single/life/intrauterin with hipertensi and bleeding from vagina et causa plasenta previa Cronologist: 15.54 (19/04/09) patient came to emergency room because bleeding from vagina since 01.30 (19-04-09), abdominal pain since 12.00 (19-04-09), from examination found : BP : 190/130 RR : 90 x/mnt LMP: forgot Obstetric Status: 1.Male, aterm, spontan, Traditional attendent, 15 years. 2.Female, aterm, spontan, traditional attendent, 13 years. 3.Male, aterm, spontan, traditional attendent, 7 years 4.This

Object
General Status:

Assesment
G4P3A0H3 Aterm/single/life/intr auterin with bleeding from vagina et causa plasenta previa

Planning
Observ mother and fetal Laboratorium examination: Blood, HBsAg Report to superisor, proposed: observation,antibiotik proposed: agree

General condition: well Conciousness: CM BP: 130/100 mmHg RR: 24 x/mnt PR: 88 x/mnt T: 37 C Eyes : an(-), ikt (-) Cor -Pulmo : in normal range Obstetric status: L1 : breech, UFH: 32 cm L2 : left back L3 : head L4: wasnt in Pelvic Inlet EFW : 3250 g UC : Fetal Heart Rate : 12-12-13 VT : not done Inspeculo: dilatation of cervix (-), bleeding (+) 200cc

Time
History of

Subject
family planning:

Object
Lab. Result: Hb: 9.3g % WBC: 11.100 /mm3 Trombosit : 221000 /mm3 Hct: 27.5 HBsAg: (-)

Assesment

Planning

injection 3 month
family planning: MOW

Active bleeding (-) 20.00 General condition: well

BP: 120/80 mmHg RR: 24 x/mnt PR: 84 x/mnt T: 37 C


FHB: 15-14-14 UC : Abdominal pain (+) Active bleeding (+)

G4P3A0H3 Aterm/single/life/intr auterin with bleeding from vagina et causa plasenta previa

Obs. Mother and fetal well being Ampicillin test (-) and injection ampicillin 1 g/IV

21.30

General condition: well

BP: 120/80 mmHg RR: 24 x/mnt PR: 84 x/mnt T: 37 C


FHB: 15-14-14 UC : 2x/10~20

G4P3A0H3 Aterm/single/life/intr auterin with bleeding from vagina et causa plasenta previa

Obs. Mother and fetal well being Report to supervisor, propossed SC, propossed agree Prepare to SC

Time
22.15

Subject

Object

Assesment
G4P3A0H3 Aterm/single/life/intr auterin with bleeding from vagina et causa plasenta previa

Planning
SC Begun

22.40

Baby was born male, weight 2450g, length 48 cm, AS 7-8. baby admited to NICU

Placenta was born complete,weight 450 g, length 50 cm


Hemorrage : 150cc
23.40 General status : well BP : 120/60 mmHg PR : 80 x/mnt RR : 20 x/mnt UC : good UFH : 2 cm below umbilical General status : well BP : 120/60 mmHg PR : 80 x/mnt RR : 20 x/mnt UC : good UFH : 2 cm below umbilical

4nd stage of labor

Obs. Mother and baby well being

4nd stage of labor

00.40

Obs. Mother and baby well being

Name age Address

: Ny. Teresia : 22 : Pagutan, Ampenan.

Admitted

: 18-04-2009 : 20.55

Time
20.55

Subject
Patient refered by dr. K. Tresna Sp.OG G1P0A0H0 39 - 40 weeks Single / life / intrauterine with oligohidramnion. Chronologiest : 19.00 pm (18 04 09) Patient came to dr. K. Tresna with intermitten abdominal pain since 16.00 (18 04 09). From examination found : UFH : 34 cm, FHR:140x/mnt UC : 1 - 2x/10 ~ 10 VT : 3 cm, eff 30 %, amniotic membrane (+), head palpable, descend HI, unpalpable small organ and umbilical cord. Advice from dr. K. Tresna : drip oxytocin and report to supervisor in VK Last menstrual period : 20-07-08 EDD : 27-04-09 History of family planning : Family planning : injection 3 month ANC : routine in polindes

Object
General Status:

Assesment
G1P0A0H0 39 - 40 weeks Single / life / intrauterine with

Planning
Observ mother and fetal Laboratorium examination: Blood, HBsAg Report to superisor, proposed: observation, proposed: agree

General condition: well Conciousness: CM BP: 110/70 mmHg RR: 20 x/mnt PR: 88 x/mnt T: 36,8 C Eyes : an(-), ikt (-) Cor -Pulmo : in normal range Obstetric status: L1 : breech, UFH: 34 cm L2 : left back L3 : head L4: was in pelvic inlet 4/5 EFW : 3565 g UC : 1 - 2x/10 ~ 10 Fetal Heart Rate : 12 - 11 - 12 VT : 3 cm, eff 30 %, amniotic
membrane (+), head palpable, descend HI, unpalpable small organ and umbilical cord.

latent phase of Ind stage of labor +


oligohidramnion.

USG (11/03/09): Fetal single/life presentation

with head

Time

Subject

Object Lab examination found : Hb : 13.6 gr% Leukosit : 9700/mm3 Trombosit : 178000/mm3 Hematocrit : 37.6

Assesment

Planning

01.00 (19/04/09)

Abdominal pain (+)

General condition: well BP: 110/70 mmHg FHR : 12 12 13 UC : 1 - 2x/10 ~ 10 VT : 3 cm, eff 40 %, amniotic membrane (+), head palpable, descend HI, unpalpable small organ and umbilical cord. General condition: well BP: 110/70 mmHg FHR : 12 12 13 UC : 1 - 2x/10 ~ 10 VT : 4 cm, eff 50 %, amniotic membrane (+), head palpable, descend HI, unpalpable small organ and umbilical cord. General condition: well BP: 110/70 mmHg FHR : 12 12 13 UC : 2 - 3x/10 ~ 20 - 25 VT : 4 cm, eff 50 %, amniotic membrane (+), head palpable, descend HI, unpalpable small organ and umbilical cord.

G1P0A0H0 39 - 40 weeks Single / life / intrauterine with

Obs. Mother and fetal well being

latent phase of Ind stage of labor +


oligohidramnion.

04.00

Abdominal discomfort (+)

G1P0A0H0 39 - 40 weeks Single / life / intrauterine with active phase of Ind

Obs. Mother and fetal well being

stage of labor +
oligohidramnion.

08.00

Abdominal discomfort (+)

G1P0A0H0 39 - 40 weeks Single / life / intrauterine with active phase of Ind

Obs. Mother and fetal well being

stage of labor +
oligohidramnion.

Time
10.00

Subject
Abdominal discomfort (+)

Object
General condition: well BP: 110/70 mmHg FHR : 12 12 13 UC : 2 - 3x/10 ~ 20 - 25 VT : 4 cm, eff 50 %, amniotic membrane (+), head palpable, descend HI, unpalpable small organ and umbilical cord.

Assesment
G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active

Planning
Obs. Mother and fetal well being Report to supervisor, propossed oxytocin drip 5 UI in 500 cc D5%, propossed agree

phase of Ind stage of labor +


oligohidramnion.

Bishop score : 6
10.30 Abdominal discomfort (+) General status : well FHB : 12 12 11 UC : 2 - 3x/10 ~ 20 - 25 G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active Start drip oxytocin seri I, flash 1 8 drops/mnt Observation mother and fetal well being

phase of Ind stage of labor +


oligohidramnion. 11.00 Abdominal discomfort (+) General status : well FHB : 12 12 11 UC : 2 - 3x/10 ~ 20 - 25 G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active Start drip oxytocin seri I, flash 1 12 drops/mnt Observation mother and fetal well being

phase of Ind stage of labor +


oligohidramnion. 11.30 Abdominal discomfort (+) General status : well FHB : 12 12 12 UC : 2 - 3x/10 ~ 20 - 25 G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active Start drip oxytocin seri I, flash 1 16 drops/mnt Observation mother and fetal well being

phase of Ind stage

Time
12.00

Subject
Abdominal discomfort (+)

Object
General status : well FHB : 12 12 11 UC : 2 - 3x/10 ~ 20 - 25

Assesment
G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active

Planning
Start drip oxytocin seri I, flash 1 20 drops/mnt Observation mother and fetal well being

phase of Ind stage of labor +


oligohidramnion. 12.30 Abdominal discomfort (+) General status : well FHB : 12 12 12 UC : 2 - 3x/10 ~ 20 - 25 G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active Start drip oxytocin seri I, flash 1 24 drops/mnt Observation mother and fetal well being

phase of Ind stage of labor +


oligohidramnion. 13.00 Abdominal discomfort (+) General status : well FHB : 12 12 11 UC : 2 - 3x/10 ~ 20 - 25 G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active Start drip oxytocin seri I, flash 1 28 drops/mnt Observation mother and fetal well being

phase of Ind stage of labor +


oligohidramnion. 13.30 Abdominal discomfort (+) General status : well FHB : 12 12 12 UC : 2 - 3x/10 ~ 20 - 25 G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active Start drip oxytocin seri I, flash 1 32 drops/mnt Observation mother and fetal well being

phase of Ind stage of labor +


oligohidramnion.

Time
14.00

Subject
Abdominal discomfort (+)

Object
General status : well FHB : 12 12 11 UC : 2 - 3x/10 ~ 20 - 25 VT : 4 cm, eff 50 %, amniotic membrane (+), head palpable, descend HI, unpalpable small organ and umbilical cord. General status : well FHB : 12 12 12 UC : 2 - 3x/10 ~ 20 - 25

Assesment
G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active

Planning
Start drip oxytocin seri I, flash 1 36 drops/mnt Observation mother and fetal well being

phase of Ind stage of labor +


oligohidramnion. G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active Start drip oxytocin seri I, flash 1 40 drops/mnt Observation mother and fetal well being

14.30

Abdominal discomfort (+)

phase of Ind stage of labor +


oligohidramnion. 15.00 Abdominal discomfort (+) General status : well FHB : 12 12 11 UC : 2 - 3x/10 ~ 20 - 25 G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active Start drip oxytocin seri I, flash 1 40 drops/mnt Observation mother and fetal well being

phase of Ind stage of labor +


oligohidramnion. 15.30 Abdominal discomfort (+) General status : well FHB : 12 12 12 UC : 2 - 3x/10 ~ 20 - 25 G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active Start drip oxytocin seri I, flash 1 40 drops/mnt Observation mother and fetal well being

phase of Ind stage of labor +


oligohidramnion.

Time
16.00

Subject
Abdominal discomfort (+)

Object
General status : well FHB : 12 12 11 UC : 2 - 3x/10 ~ 20 - 25 VT : 4 cm, eff 50 %, amniotic membrane (+), head palpable, descend HI, unpalpable small organ and umbilical cord. General status : well FHB : 12 12 12 UC : 2 - 3x/10 ~ 20 - 25

Assesment
G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active

Planning
Start drip oxytocin seri I, flash 1 finish Observation mother and fetal well being

phase of Ind stage of labor +


oligohidramnion. G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active Start drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being

16.30

Abdominal discomfort (+)

phase of Ind stage of labor +


oligohidramnion. 17.00 Abdominal discomfort (+) General status : well FHB : 12 12 11 UC : 2 - 3x/10 ~ 20 - 25 G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active maintenance drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being

phase of Ind stage of labor +


oligohidramnion. 17.30 Abdominal discomfort (+) General status : well FHB : 12 12 12 UC : 2 - 3x/10 ~ 20 - 25 G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active

phase of Ind stage of labor +


oligohidramnion.

maintenance drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being

Time
18.00

Subject
Abdominal discomfort (+)

Object
General status : well FHB : 12 12 11 UC : 2 - 3x/10 ~ 20 - 25

Assesment
G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active phase

Planning
maintenance drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being maintenance drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being maintenance drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being Report to supervisor, propossed SC, propossed agree. maintenance drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being

of Ind stage of labor +


oligohidramnion. 18.30 Abdominal discomfort (+) General status : well FHB : 12 12 12 UC : 2 - 3x/10 ~ 20 - 25 G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active phase

of Ind stage of labor +


oligohidramnion. 19.00 Abdominal discomfort (+) General status : well FHB : 12 12 11 UC : 2 - 3x/10 ~ 20 - 25 G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active phase

of Ind stage of labor +


oligohidramnion.

19.30

Abdominal discomfort (+)

General status : well FHB : 12 12 12 UC : 2 - 3x/10 ~ 20 - 25

G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active phase

of Ind stage of labor +


oligohidramnion.

Time
20.00

Subject
Abdominal discomfort (+)

Object
General status : well FHB : 12 12 11 UC : 2 - 3x/10 ~ 20 - 25

Assesment
G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active phase

Planning
maintenance drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being maintenance drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being maintenance drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being Report to supervisor, propossed SC, propossed agree. maintenance drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being

of Ind stage of labor +


oligohidramnion. 20.30 Abdominal discomfort (+) General status : well FHB : 12 12 12 UC : 2 - 3x/10 ~ 20 - 25 G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active phase

of Ind stage of labor +


oligohidramnion. 21.00 Abdominal discomfort (+) General status : well FHB : 12 12 11 UC : 2 - 3x/10 ~ 20 - 25 G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active phase

of Ind stage of labor +


oligohidramnion.

21.30

Abdominal discomfort (+)

General status : well FHB : 12 12 12 UC : 2 - 3x/10 ~ 20 - 25

G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active phase

of Ind stage of labor +


oligohidramnion.

Prepare to SC

Time
22.00

Subject

Object

Assesment

Planning
SC begun

23.08

Baby was born female, weight 3500g, length 50 cm, AS 7-8 Placenta was born complete,weight 450 g, length 50 cm

Hemorrage : 150cc
00.00 General status : well BP : 130/80 mmHg PR : 88 x/mnt RR : 20 x/mnt UC : good UFH : 2 cm below umbilical General status : well BP : 130/80 mmHg PR : 88 x/mnt RR : 20 x/mnt UC : good UFH : 2 cm below umbilical

4nd stage of labor

Obs. Mother and fetal well being

01.00

4nd stage of labor

Obs. Mother and fetal well being

Name age Address

: Ny. Bq yeni Susilarini : 29 years : Tempit, Ampenan.

Admitted

: 19-04-2009 : 11.10

Time
11.10

Subject
Patient referred from PKM Ampenan G4P3A0H0 Aterm/single/life with breech presentation + PROM > 12 hours Cronologist: 06.30 (19/04/09) patient came to PKM Ampenan because patient confess vaginal discharge since 02.00 (19-04-09). Abdominal discomfort (-). From examination found: BP : 100/70 mmHg PR : 84 x/mnt RR : 22 x/mnt T : 36,8C UC : FHR : 11 11 12

Object
General Status:

Assesment
G4P3A0H3 Aterm/single/life with breech presentation + PROM > 12 hours

Planning
Observ mother and fetal Laboratorium examination: DL, HBsAg Skin test ampi, injeksi ampicilin 1 gr Report to superisor, proposed: Oxytocin drip 5 UI in 500cc D5%, proposed: agree

General condition: well Conciousness: CM BP: 110/70 mmHg RR: 20 x/mnt PR: 84 x/mnt T: 36,6 C Eyes : an(-), ikt (-) Cor -Pulmo : in normal range Obstetric status: L1 : head L2 : left back L3 : breech L4: wasnt in pelvic inlet UFH: 30 cm AC : 98 cm EFW : 2940 g UC : Fetal Heart Rate : 12 - 11 - 11 VT : not done Bishop Score : 6

VT : 1 cm, eff 10 %, amniotic membrane (+), descend HI, palpable small organ

Time

Subject
Last menstrual period : forgot History of family planning : injection 3 month Family planning : injection 3 month ANC : routine in polindes Obstetric history: 1.This

Object
Lab examination found: Hb : 9,5 gr% Leukosit : 14.000/mm3 Trombosit : 392.000/mm3 Hematokrit : 28.5

Assesment

Planning

14.00

Abdominal discomfort (-)

General status : well FHB : 12 12 11 UC : -

G4P3A0H3 Aterm/single/life with breech presentation + PROM > 12 hours

Start drip oxytocin seri I, flash 1 8 drops/mnt Observation mother and fetal well being

17.

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