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Supervised by : dr.A.Rusdhy H. Hamid Sp.OGMedical Student:

gerisa

sahrun

Ririn

Morning Report

30 agustus 2009

Cases resume :

1. G1P0A0H0 A/S/L/IU head presentation,

Neglected 2nd stage of labor

1

2. G5P4A0H4 A/S/L/ IU, mild pre-eclampsi,

makrosomia, fetal distress

1

3 G1P0A0H0 A/S/L/ IU, arrested active phase

first stage of labor

1

4 G2P1A0H1 39-40 week/S/L/IU head

presentation, Prolonged active phase first

stage of labor + history watery vaginal

discharge

1

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Name : Mrs. St. Hafsah/Pemenang Admitted : 30-08-2009

age : 24 years : 20.50 wita

Address : LEMBUAK Narmada

Time Subject Object Assesment Planning

20.50 Patient reffered from pemenang PHC

with G1P0A0 A/S/L/IU with prolonged

second stage

Chronology:

Os came to pemenang PHC with

abdominal discomfort since 20.00

(29/08/09), bloody show and watery

pervaginam discharge (+) at 13.30

(30/08/09). History of DM (-), Icterus (-

), HT (-).

LMP: 27/11/08EDD:0 4/09/09

Examination in Pemenang PHC

(10.00):

General condition: well

TFU: 24cm

BP: 100/70 mmhg

Pulse: 80x/mnt

T: 36,6C

RR: 20x/mntHis: (+) 2x/10~20

FHR: 136x/mnt

VT: CD 6cm, AM(+), head palpable,

HI, unpalpable smallpart of fetus and

umbilical cord.

Obstetry status:

1. This

ANC : 6 times in PHC

General status:

General condition: well

GCS: E4V5M6

Vital sign:BP: 120/80

Pulse: 80x/mnt

T: 36,8C

RR: 20x/mnt

Cor/Pulmo: normal

Eye: an-/-, ict-/-

Akral: warm, edema -/-

Obstetry status:LI: breech

LII: left back

LIII: head

LIV: 1/5 PAP

UFH: 29cm

EBW: 2790 gr

His: 3x/10~40

FHR: 148x/mnt

VT: CD complete, AM(-), green,

head palpable, HIII, caput (+),unpalpable small part of fetus and

umbilical cord.

Lab result:

HB: 12.4gr%

WBC: 24.000/mm3

PLT: 312.000/mm3

HCT: 35.9%

HbsAg: (+)

G1P0A0H0 39-40

W/S/L/IU with neglected

2nd stage of labor with

Hepatitis

Resusitation intrauterine

Ceftriakson inj 1gr IV

Lateral position

Report to supervisor Proposoed to VE Agree

Pro consult to internist

Motivate to eat and drink

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13.00:

VT: CD 9 cm, eff 90%, AM(+), head

palpable, HII, unpalpable smallpart

of fetus and umbilical cord

13.50:

Os camplain watery pervaginamdischarge, clear

VT: CD complete, AM(-), clear, head

palpable, HII, unpalpable small

part of fetus and umbilical cord.

Lateral position, motivate to eat and

drink

14.00: os feel to bearing down

His: 2x/10mnt~30Conduct to bearing down for 2

hours but not progress, the baby

wasnt born

16.00:

Insert Inf. RL 1 fls max drop

Try to conduct bearing down with

episiotomi, the wasnt born.

FHR: 136x/mntLateral position, motivate to eat and

drink, inf. RL 1 fls maximal drop,

and maintenance RL 20 dpm.

18.00: os reffered to Mataram GH

21.20 Abdominal pain >>> Pulse: 90x/mntHis: 3x/10~40

FHR: 150x/mnt

Try to Vacum Ekstraksi :

2 times with episiotomy, the

baby was born with AS 6-8,female, weight 3000gr,

meconial (+), umbilical cord

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06.00 Subjective complain (-) BP : 120/80 mmHg

Pulse: 88 x/

RR: 18 x/

Temp: 36.8C

UC: good

UFH: 1 fbu

1st day of puerperalis Motivate mother to eat and

drink

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s

Name : Mrs. Ruminah Admitted toHospital

30 august 2009

Age 45 years old 11.00 WITA

Address

Narmada

Time

Subject Object Assesment Planning

11.00

Patient referred from Lingsar PHC with

G5P4A0H4 A/S/L/IU, active phase first

stage of labor, hypertension in pregnancy

Chronology :

patient reffered from Lingsar PHC

confess pregnant 9 month, abdominal

pain (+), bloody show (+), watery vaginal

discharge (+), oedem (+/+), fetal

movement (+). Hypertension history (-)

DM (-)

LMP : forgotten

EDD : -

ANC : 5x in PHC

Obs. History :

1. Female, 22 yo, TA



4. Male, 12 yo, TA5. This

Family planing : -

Planning of family planing : MOW

General status:

General condition : well

BP : 170/100mmHgPR : 88x/

RR : 20x/

Temp : 37C

Eyes : an-/-, ict -/-

Cor : s1s2 single, m -, g

Pulmo : Ves +/+, rh -/-, whz -/-

Ext : oedem +/+, warm +

Status obstetric

L1 : breech

L2 : right back

L3 : head

L4 : was in pelvic inlet 3/5

UFH : 39 cm

EFW : 4340 gram

FHB : 98 bpm, irreguler

UC : 3x/10~

40VT : CD 5cm, eff 50%, AM (-), dry,

head palpabed descended HII, small

part of fetal/umbilical cord

unpalpabed

PE : arcus pubis >90 degrees, spina

ischiadica not prominent,

os.coccygeus mobile

G5P4A0H4 A/S/L/

IU, mild pre-

eclampsi, makrosomia,fetal distress

Observation mother

and fetal well being

Lab. Check Resusitation : D 5% :

RL = 1 : 2, O2 5 lpm,

left lateral position

CTG : peak : 180

bpm, lowest : 95 bpm

Inj. Ampicillin 1 gr/IV

(skin test -)

Report to supervisor :

propose SC

(supervisor agree)

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Examination in PHC

General status : well

BP : 160/100 mmHg

PR : 84x/

Temp : 36,6C

UFH : 38 cm

EFW : 4185gr

FHB : 144 bpm, regulerUC : 3x/10~40

VT : CD 4 cm, eff 40%, head

palpabed descended HI, small part

of fetal and umbilical cord

unpalpabed

Therapi in PHC : -

Lab :

Hb : 10 gr%

Leuko : 12.000/mm3

Trombosit : 277.000/mm3

Hct : 33,6%

HbSAg (-)

Proteinuri (+) 1

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12.00 Prepare SC : inj.

Ampicillin 1 gr/IV,

DC has been inserted

14.15

16.00

07.00

(31/8

/09)


BP : 130/90mmHgPR : 88x/

RR : 18x/

Temp : 36,7C

SC wound : good, no active

bleeding, dry


BP : 150/100mmHg

PR : 84x/RR : 18x/

Temp : 36,7C


bleeding, dry

4 th of labor

P5A0H5 1st day of

puerpuralis

SC has begun

The baby was born,female, A-S : 7-9,

3750 gr, placenta was

complete, amniotif

fluid : greenish,

nuchal cord (-)

MOW been done

-Mother and the baby in

melati room- nifedipin 3x1

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s

Name : Mrs. Iin Nurhayati Admitted toHospital

30 august 2009


Address Narmada


22.00

Patient referred from a midwife with

G1P0A0H0 A/S/L/IU, prolong active

phase first stage of labor

Chronology :

patient came to a midwife practice at

11.30 confess pregnant 9 month,

abdominal pain (+), bloody show (+),

watery vaginal discharge (-), fetal

movement (+).

LMP : forgotten

EDD : -

ANC : routine in PHC

Obs. History :

1. This

Family planing : -

Examination :(11.30)


BP : 120/70 mmHg

FHB : 140 bpm, reguler

UC : 3x/10~38

VT : CD 4 cm, eff 40%, AM (+), head

palpabed descended HII

General status:


BP : 110/70mmHgPR : 84x/

RR : 18x/

Temp : 36,7C




Ext : oedem +/+, warm +

Status obstetric

L1 : breech

L2 : left back

L3 : head


UFH : 29 cm

EFW : 2790 gram


UC : 3x/10~

30

VT : CD 6cm, eff 50%, AM (+),

head palpabed descended HI, small


unpalpabed



os.coccygeus mobile

G1P0A0H0 A/S/L/

IU, arrested active

phase first stage oflabor

Observation mother


Lab. Check Educated mother to

eat and drink


advice : amniotomy

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(15.30)


BP : 120/70 mmHg


UC : 4x/10~40

VT : CD 6 cm, eff 40%, AM (+),

head palpabed descended HII

(19.30)


BP : 120/70 mmHg


UC : 4x/10~40

VT : CD 6 cm, eff 40%, AM (+),

head palpabed descended HII

Therapy :- IUFD RL

- motivated to reffered to Mataram

GH

Lab :

Hb : 10,8 gr%

Leuko : 13.300/mm3

Trombosit : 180.000/mm3

Hct : 35,8%

HbSAg (-)

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23.00 G1P0A0H0 A/S/L/ IU,

arrested active phase first

stage of labor , fetal

distress

Amniotomy been

done, amniotic fluid

green, 10cc

Inj. Amicillin 1 gr/IV

CTG : peak : 140

bpm, lowest : 105

bpm, FHB irreguler Report to the

supervisor : advice : -

- resusitation : RL : D

5% = 2 : 1, O2 5 lpm,


- repeat to CTG

23.45

03.30

03.35 Conduct to bearingdown


UC : 4x/10~45

VT : CD complete, AM (-), green,

head palpabed, anterior minor

fontanella, descended HII, small


unpalpabed


VT : CD complete, AM (-), green,

head palpabed, anterior minorfontanella, descended HIII, small


G1P0A0H0 A/S/L/ IU,

arrested active phase first

stage of labor

Repost to supervisor :

CTG result : peak 155

bpm, lowest : 115

bpm, FHB reguler.

Advice : continue to

observation

-The baby was born,

male, A-S : 7-9, 3000 gr,

nuchal cord (-),- placenta complete

(03.45)

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05.30

31/08

/09


BP : 110/60mmHg

PR : 80x/

RR : 18x/

Temp : 36,8C

Episiotomy wound : good, no

active bleeding, dry


BP : 150/100mmHg

PR : 84x/

RR : 18x/

Temp : 36,7C


bleeding, dry

4 th of labor

P1A0H1 1st day of

puerpuralis

Mother and the baby in

melati room

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s

Name : Mrs. Nyoman dewi Admitted toHospital

30 Agustus 2009


Address Sweta timur

Waktu Subject Object Assesment Planning

18.00 Patient reffered from Taliwang PHC with

G2P1A0H1 43W/S/L/IU head presentation,laten phase first stage of labor+big baby

Chronology :

Patient came to Taliwang PHC at 17.00

(30/08/09) confess pregnant 9 month Watery

vaginal discharge at 17.00 (30/08/09), bloody

show (-). Abdominal pain (-).

She still felt the fetal movment (+).

HPHT : 27-11-08EDD : 4-09-09

ANC : 9x in midwife

History obstetry

1. aterm, male, spontan, midwife,

3400gram, 3,5yo.

2. This

History family planing : injection 3 month

Family planing : injection/3month

Examination in PHC

BP : 120/90mmHg

TFU : 41cm

EFW : -

UC : 3x/10-30

FHB : 11-12-12

VT : CD 3cm, eff 30%, AM (-), head

palpabed descended in HI, small part of

fetal/umbilical cord unpalpabed.

General status

General condition : wellBP : 120/80mmHg

PR : 84x/

RR : 18x/

Temp : 36,5C

Eyes : an -/-, ict -/-

Cor/pulmo : in normal range

Ext : warm, oedem (-)

Status obstetry :

L1 : breechL2 : left back

L3 : head


TFU : 36cm

EFW : 3875 gram

UC : 2x/10-30

FHB : 12-12-13

VT : CD 3cm, eff 30%, AM (-),

fontanella minor left anterior, head

palpabed descended HI, small part of


Lab :

Hb : 11,3gr%

Leu : 11.100/mm3

Trombo : 288.000/mm3

Hct : 37,4

HbSAg : (-)

G2P1A0H1 39-40

week/S/L/IU headpresentation, laten phase

first stage of labor +

history watery vaginal

discharge

Observation mother andfetal well being

educated mother to eat

and drink

Educated mother to left

lateral position

injection ampicillin 1gr

IV

Cek lab DL, HbSAg

Evaluation in 4 hours

again

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Wak

tu


18.30

19.00

19.30

UC : 2x/10-30

FHB : 12-12-13

UC : 2x/10-30

FHB : 12-12-12

UC : 3x/10-30

FHB : 12-13-12

educated mother to

eat and drink

Educated mother to


20.00

20.30

21.00

21.30

22.00

Abdominal pain

Abdominal pain

UC : 3x/10-30

FHB : 13-12-12

UC : 3x/10-30

FHB : 12-12-12

UC : 3x/10-30

FHB : 12-12-12

UC : 3x/10-30

FHB : 12-12-12

UC : 3x/10-30

FHB : 12-12-13

VT : CD 4 cm, eff 50%, AM (-),fontanella minor left anterior, head

palpabed descended in HI, small

part of fetal and umbilical cord

unpalpabed.

G2P1A0H1 39-40

week/S/L/IU head

presentation, activephase first stage of labor

educated mother to

eat and drink

Educated mother to


educated mother to

eat and drink

Educated mother to


educated mother to

eat and drink

Educated mother toleft lateral position

evaluation in 4 hours

again

W k S bj Obj Pl i

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Wak

tu

Subject Object

Assesment

Planning

22.30

23.00

23.30

UC : 3x/10-30

FHB : 12-12-12

UC : 3x/10-30

FHB : 12-12-12

UC : 3x/10-30

FHB : 12-13-12

educated mother to

eat and drink

Educated mother to


00.00

00.30

01.00

01.30

02.00

03.00

UC : 3x/10-30

FHB : 12-12-13

UC : 3x/10-30

FHB : 12-13-12

UC : 3x/10-40

FHB : 12-12-13

UC : 3x/10-40

FHB : 12-12-13

UC : 3x/10-40

FHB : 12-12-12

VT : CD 6cm, eff 60%, AM (-,

denom fontanella minor, head

palpabed HI, small part of


G2P1A0H1 39-

40week/S/L/IU head

presentation, prolonged

active phase first stage

of labor

educated mother to

eat and drink

Educated mother to



and drink

Educated mother to


Observstion mother

and fetal well being.


Advice observation until

tomorrow morning.

W k S bj t Obj t A t Pl i

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Wak

tu


03.30 UC : 3x/10-30

FHB : 13-12-13

UC : 3x/10-30

FHB : 12-11-12

UC : 3x/10-30

FHB : 12-12-12


and drink

Educated mother to


0bservation mother


04,00

04.30

05.00

06.00

06.15

Mother want to bearing down

UC : 3x/10-30

FHB : 12-12-12

UC : 3x/10-40

FHB : 12-12-11

UC : 3x/10-40

FHB : 12-12-12

Doran teknus perjol vulka Second stage of labor

Third stage of labor


and drink

Educated mother to


Observation mother


Conduct mother to

bearing down.

Baby was born , male, A-

S 7-9, 3500gram

Placenta born complete,

weight not measured.

W k S bj t Obj t A t Pl i

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Wak

tu


07.00 BP : 120/80mmHg

PR : 80x/

RR : 18x/

Temp : 36.9C

UC : good

UFH : 2 fingers under umbilicus

Active bleeding (-).

Fourth stage of labor. Observation vital sign,

bleeding, UC.

Name : Mrs Sukmiyati Admitted to 30 Agustus 2009

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s

Name : Mrs. Sukmiyati Admitted toHospital

30 Agustus 2009


Address Labuapi

Wakt

u


20.00 Patient came to emergency MataramGH confess pregnant 7 month and

bleeding from vaginal since 19.00

(30/8/09). The blood colour is fresh

red. Stolsel (-). She confess

abdominal pain since morning but the

pain is rare

Trauma (-), coitus (-), history of

bleeding before (-)

HPHT : forgot

EDD : (-)

ANC : -

Obstetry history :

1. A, female, spontan, TA,

3000gram, death 3 day.

2. A, female, spontan, TA,

2500gram, 15 yo3. This

History family planing : ( -)

Family planing : injection /3 month

General statusGeneral condition : well

BP : 110/70mmHg

PR : 80x/

RR : 18x/

Temp : 37C

Eyes : an -/-, ict -/-

Cor/pulmo : in normal range

Ext : oedem -/-, warm

Status obstetry :L1: breech

L2 : right back

L3 : head

L4 : was not in pelvic inlet

TFU : 27 cm

EFW : 2325gram

UC : (-)

FHB : 12-13-12

VT : not done

G3P2A0H1preterm/S/L/IU head

presentation +APB

susp Placenta

Previa

observation motherand fetal well being

observation

bleeding.

bed rest

pro USG

Wakt Subject Object Assesment Planning

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Wakt

u


20.30

21.00

21.30

22.00

UC : (-)

FHB : 12-12-12, active bleeding (-)

UC : (-)

FHB : 12-12-12

UC : (-)

FHB : 12-11-12

UC : (-)FHB : 11-12-12, active bleeding (-)

observation mother and

fetal well being

observation bleeding.

bed rest

22.30

23.00

23.30

00.00

00.30

01.00

01.30

02.00

02.30

03.00

UC : (-)

FHB : 12-12-13

UC : (-)

FHB : 11-11-12, active bleeding (-)

UC : (-)

FHB : 12-12-12

UC : (-)

FHB : 12-12-12

UC : (-)

FHB : 12-12-12 ,active bleeding (-)

UC : (-)

FHB : 12-12-11

UC : (-)

FHB : 12-12-12

UC ; (-)FHB : 12-12-11, active bleeding (-)

UC : (-)

FHB : 12-12-12

UC : (-)

FHB : 12-12-12


fetal well being


bed rest


fetal well being


bed rest


fetal well being observation bleeding.

bed rest


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Wakt

u


04.00 UC : (-)

FHB : 12-12-12

BP : 110/70mmHg

Temp : 36,5C

RR : 20x/

Active bleeding (-)

06.00

07.00

(31/0

8/09)

UC : (-)

FHB : 12-12-12

UC : (-)

FHB : 12-12-13

BP : 110/80mmHg

RR : 20x/

Temp : 36,8C

Active bleeding (-)

G3P2A0H1 preterm/S/L/IU

head presentation +APB

susp Placenta Previa


fetal well being


bed rest

Pro USG

Name : Mrs Hamidah Admitted to 26 July 2009

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s

Name : Mrs. Hamidah Admitted toHospital

26 July 2009


Address Sekarbela

Wakt

u


13.30Patient reffered from Batu Dawe PHCwith G1P0A0H0 A/S/L/IU head

presentation + severe Preeclamsia

Chronology :

Patient came to PHC batu dawe 12.00

(30/08/09) confess pregnant 9 month.

Abdominal pain since 10.00 (30/08/09),

bloody slym (-), watery vaginal discharge

(-).Bluured vision (-), epigastrial pain (-),

dizzines (-),.

she said that tensi high start at 9 month

of pregnant.

HPHT : 3-12-2008

EDD : 10-09-2009

ANC : 6x

Examination in PHC :General condition :good

BP : 170/110mmHg

Temp : 36,5C

PR : 88x/

Lab : protein urine +2

Therapy in PHC :

RL infus 28 dpm

Bolus MgSO4 40% 4gr, drip MgSO4

40% 6 gr

General statusGeneral condition : well

BP : 150/100mmHg

RR : 20x/

PR : 80x/

Temp : 36,7C


Cor : s1s2 singgle, reguler (-

)murmur (-), gallop (-)

Pulmo : ves +/+, rh -/-, whz -/-Ext : oedem -/-, warm.

Status obstetry :

L1 : breech

L2 : right back

L3 : head


TFU : 29cm

EFW : 2790gramUC: 3x/10-30

FHB : 12-12-12

VT : CD 3 cm, eff 25%, AM (+).

Denom SS transveres, head

palpabed descended H1, small part

of fetal /umbilical cord upalpabed.

G1P0A0H0 A/S/L/IUhead presentation,

First stage of labor

laten phase + mild pre

eclamsia.

Educated mother toeat and dringk

Educated mother to


Observation mother


Cek Lab DL, HbSAg,

UL

Ti S bj t Obj t A t Pl i

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PS : 5

PE : arcus pubis >90

Spina ischiadica not prominent

Os cocygeus mobile.

Lab :Hb : 12,5

Leu : 7500/mm3

Trombo : 245.000/mm3

HCT : 35,3

HbSAg (-)

Protein urine : +1


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Wakt

u


14.30

15.00

15.30

16.00

UC : 3x/10-30

FHB : 12-11-12

UC : 3x/10-30, BP : 140/90mmHg

FHB : 12-12-12

UC : 3x/10-30

FHB : 12-12-12

UC : 3x/10-30

FHB : 12-12-11

Educated mother to eat

and dringk


lateral position

Observation mother and

fetal well being

17.30

18.00

18.30

19.00

19.30

20.00

20.30

21.00

21.30

22.00

UC : 3x/10-30

FHB : 12-11-12

UC : 3x/10-30

FHB : 12-12-12

UC : 3x/10-30

FHB : 12-12-12

UC : 3x/10-30

FHB : 12-12-11

UC : 3x/10-30

FHB : 12-12-12

UC : 3x/10-30, BP : 140/90mmHg

FHB : 12-12-12

UC : 3x/10-30

FHB : 12-11-11

UC : 3x/10-30

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

FHB : 12-12-12

UC : 3x/10-30

FHB : 12-12-12

VT : CD 3 cm, eff 25%, AM (+),

denom SS transveres, head palpabed

descended HI, small part of

fetal/umbilical cord unpalpabed


and dringk


lateral position


fetal well being


and dringk


lateral position


fetal well being


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Wakt

u


22.30

23.00

23.30

00.00

Abdominal pain UC : 3x/10-30

FHB : 12-12-12

UC : 3x/10-30

FHB : 11-11-12

UC : 3x/10-30

FHB : 12-11-12

UC : 3x/10-30, BP : 140/90mmHg

FHB : 12-12-12


and dringk


lateral position


fetal well being

01.30

02.00

02.15

02.30

Abdominal pain

UC : 3x/10-30

FHB : 12-12-12

UC : 3x/10-30

FHB : 12-12-12

VT : CD 3cm, eff 25%, AM (+),

denom SS transveres, head palpabed

descended in HI, small part of fetal

and umbilical cord unpalpabed

G1P0A0H0 A/S/L/IU head

presentation + aressted

First stage of labor laten

phase + mild pre eclamsia.


advice drip oxitosine 5IU.

-CTG : 140

Suspecious

-KIE :

-Educated mother to eat

and drink

- left lateral position

- CTG ulang

Wak Subject Object Assesment Planning

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Wak

tu


03.00 UC : 3x/10-30

FHB : 12-12-12

-KIE :

-Educated mother to eat

and drink

- left lateral position

- CTG ulang

03.30

04.00

04.30

UC : 3x/10-30

FHB : 12-12-11

UC : 3x/10-30

FHB : 12-12-11

BP : 140/90mmH

CTG : baseline 140

(suspecious)


advice tunda drip,

observasi.

Name : Mrs. Koo Jumhar Admitted to 27 august 2009

7/29/2019 18-08-09 Kasep

25/30

s

Name : Mrs. Ko o JumharHospital

27 august 2009


Address Narmada


10.30

Patient referred from pregnant poly with

G1P0A0H0 40-41 weeks/S/L/IU, head

presentation

Chronology :

patient reffered Dasan Cermen PHC to

pregnant poly confess pregnant 9 month,

abdominal pain (-), bloody show (-),

watery vaginal discharge (-), fetal

movement (+).

LMP : 15-11-08

EDD : 22-08-09ANC : routine in PHC

Obs. History :

1. This

Family planing : -

Examination in PHC

Not mentioned

Therapi in PHC : -

General status:


BP : 120/90mmHgPR : 80x/

RR : 20x/

Temp : 36,7C




Ext : oedem -/-, warm +

Status obstetricL1 : breech

L2 : right back

L3 : head


UFH : 29 cm

EFW : gram

FHB : 155 bpm,reguler

UC : 2x/10~20

VT : CD 2cm, eff 25%, AM (+),

head palpabed descended HI, small


unpalpabed



os.coccygeus mobile

Lab :Hb : 11 gr%

Leuko : 13.100/mm3

G1P0A0H0 40-41

weeks/S/L/ IU, obs.

inpartu

Observation mother


Educated mother toeat and drink

Lab. Check


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j j g

14.30 FHB : 144 bpm, reguler

UC : 2x/10~20

G1P0A0H0 40-41

weeks/S/L/ IU, obs.

inpartu

Observation mother


Educated mother to

eat and drink

18.30

22.30

02.30

(28/08/09)

06.30

10.00

11.00

11.30

12.00


UC : 2x/10~20


UC : 2x/10~20


UC : 3x/10~20


UC : 3x/10~20


UC : 3x/10~20


UC : 3x/10~20


UC : 3x/10~20

FHB : 146 bpm,regulerUC : 3x/10~25

G1P0A0H0 40-41

weeks/S/L/ IU, obs.inpartu

Observation mother

and fetal well being Educated mother to

eat and drink

- Report to the supervisor

: advice : induction by

oxytocin drip 5 UI in

500cc D 5%

- started oxytocin drip 8

dpm (first flash)

- oxytocin drip 12 dpm

- oxytocin drip 16dpm


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j j g

13.00

13.30


UC : 3x/10~25


UC : 3x/10~25

- Oxytocin drip 24 dpm


14.00

14.30

15.00

16.00

16.30

17.00

20.00

07.00

(29/8

/09)

FHB : 150 bpm,regulerUC : 3x/10~25


UC : 3x/10~30


UC : 3x/10~30


UC : 3x/10~30


UC : 3x/10~30


UC : 3x/10~30


UC : 3x/10~30


BP : 120/70mmHg

PR : 80x/

RR : 18x/

Temp : 36,7C


G1P0A0H0 40-41

weeks/S/L/ IU, obs.

inpartu


- oxytocin drip 36dpm



(second flash)



- patient move to melati

room


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j j g

14.00

20.00


BP : 120/70mmHg

PR : 80x/

RR : 18x/

Temp : 36,7C


UC : 2x/10~30


BP : 120/80mmHg

PR : 84x/

RR : 18x/

Temp : 36,5C


UC : 2x/10~

30

G1P0A0H0 40-41

weeks/S/L/ IU, obs.

inpartu

G1P0A0H0 40-41

weeks/S/L/ IU, obs.

inpartu

Observation mother


Educated mother to

eat and drink

Observation mother


Educated mother to

eat and drink

08.30

(30/0

8/09)

The patient told that AM was break at

00.00 and she confess nausea and

vomiting

Temp : 37 C


UC : 2x/10~30

VT : CD 3 cm, eff 30%, AM (-),

dry, head palpabed descended HI,

small part of fetal/umbilical cord

unpalpabed

G1P0A0H0 40-41

weeks/S/L/ IU, PROM

- patient move to teratai

room (VK)

Observation mother


Educated mother to

eat and drink

CTG : baseline 150,

non-reactive

Inj. Ampicillin 1 gr/IV

Report to the

supervisor : advice :

resusitation : D 5% :

RL = 1:2, O2 5 lpm,

left lateral position,

repeat CTG


7/29/2019 18-08-09 Kasep

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j j g

10.30 FHB : 150 bpm,reguler

UC : 2x/10~25

VT : CD 3cm, eff 30%, AM (-),

dry, head palpabed descended HI,

small part of fetal/umbilical cord

unpalpabed

G1P0A0H0 40-41

weeks/S/L/ IU, PROM

Observation mother


Educated mother to

eat and drink

CTG : peak 155 bpm,

lowest 145 bpm

Report to the

supervisor : propose

induction by oxytocin

5 UI in D 5% 500 cc

(supervisor agree)

12.00

12.30

13.40


UC : 2x/10~25


UC : 2x/10~25

G1P0A0H0 40-41

weeks/S/L/ IU, PROM,

fetal distress

-Started oxytocin drip at

8 dpm

-CTG : peak 160 bpm,

lowest 98 bpm

- report to the supervisor

: propose SC (supervisor

agree)

- prepare for SC :

inserting DC, inj.

Ampicillin 1 gr/IV

-SC has begun

- the baby was born,

male, A-S : 1-3, 3100 gr,

nuchal cord (-), amniotic

fluid green thick

-Placenta was born

complete


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31/08/09


BP : 110/70mmHg

PR : 84x/

RR : 18x/

Temp : 36,8C


bleeding, dry

P1A0H1 1st day of

puerpuralis

- Mother in melati room

- The baby in NICU

18-08-09 kasep

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