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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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Time Subject Object Assesment Planning
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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Time Subject Object Assesment Planning
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
2. Female, 19 yo, TA
3. Female, 17 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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Time Subject Object Assesment Planning
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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Time Subject Object Assesment Planning
12.00 Prepare SC : inj.
Ampicillin 1 gr/IV,
DC has been inserted
14.15
16.00
07.00
(31/8
/09)
General condition : well
BP : 130/90mmHgPR : 88x/
RR : 18x/
Temp : 36,7C
SC wound : good, no active
bleeding, dry
General condition : well
BP : 150/100mmHg
PR : 84x/RR : 18x/
Temp : 36,7C
SC wound : good, no active
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
Age 25 years old 22.00 WITA
Address Narmada
Time Subject Object Assesment Planning
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)
General status : well
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:
General condition : well
BP : 110/70mmHgPR : 84x/
RR : 18x/
Temp : 36,7C
Eyes : an-/-, ict -/-
Cor : s1s2 single, m -, g
Pulmo : Ves +/+, rh -/-, whz -/-
Ext : oedem +/+, warm +
Status obstetric
L1 : breech
L2 : left back
L3 : head
L4 : was in pelvic inlet 4/5
UFH : 29 cm
EFW : 2790 gram
FHB : 136 bpm, irreguler
UC : 3x/10~
30
VT : CD 6cm, eff 50%, AM (+),
head palpabed descended HI, small
part of fetal/umbilical cord
unpalpabed
PE : arcus pubis >90 degrees, spina
ischiadica not prominent,
os.coccygeus mobile
G1P0A0H0 A/S/L/
IU, arrested active
phase first stage oflabor
Observation mother
and fetal well being
Lab. Check Educated mother to
eat and drink
Report to supervisor :
advice : amniotomy
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Time Subject Object Assesment Planning
(15.30)
General status : well
BP : 120/70 mmHg
FHB : 148 bpm, reguler
UC : 4x/10~40
VT : CD 6 cm, eff 40%, AM (+),
head palpabed descended HII
(19.30)
General status : well
BP : 120/70 mmHg
FHB : 148 bpm, reguler
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 (-)
7/29/2019 18-08-09 Kasep
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Time Subject Object Assesment Planning
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,
left lateral position
- repeat to CTG
23.45
03.30
03.35 Conduct to bearingdown
FHB : 148 bpm, reguler
UC : 4x/10~45
VT : CD complete, AM (-), green,
head palpabed, anterior minor
fontanella, descended HII, small
part of fetal/umbilical cord
unpalpabed
FHB : 143 bpm, reguler
VT : CD complete, AM (-), green,
head palpabed, anterior minorfontanella, descended HIII, small
part of fetal/umbilical cord
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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Time Subject Object Assesment Planning
05.30
31/08
/09
General condition : well
BP : 110/60mmHg
PR : 80x/
RR : 18x/
Temp : 36,8C
Episiotomy wound : good, no
active bleeding, dry
General condition : well
BP : 150/100mmHg
PR : 84x/
RR : 18x/
Temp : 36,7C
SC wound : good, no active
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
Age 25 years old 18.00 WITA
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
L4 : was in pelvic inlet 4/5
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
fetal/umbilical cord unpalpabed.
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
7/29/2019 18-08-09 Kasep
13/30
Wak
tu
Subject Object Assesment Planning
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
left lateral position
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
left lateral position
educated mother to
eat and drink
Educated mother to
left lateral position
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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14/30
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
left lateral position
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
fetal/umbilical cord unpalpabed.
G2P1A0H1 39-
40week/S/L/IU head
presentation, prolonged
active phase first stage
of labor
educated mother to
eat and drink
Educated mother to
left lateral position
educated mother to eat
and drink
Educated mother to
left lateral position
Observstion mother
and fetal well being.
Report to supervisor :
Advice observation until
tomorrow morning.
W k S bj t Obj t A t Pl i
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15/30
Wak
tu
Subject Object Assesment Planning
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
educated mother to eat
and drink
Educated mother to
left lateral position
0bservation mother
and fetal well being
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
educated mother to eat
and drink
Educated mother to
left lateral position
Observation mother
and fetal well being
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
Subject Object Assesment Planning
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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17/30
s
Name : Mrs. Sukmiyati Admitted toHospital
30 Agustus 2009
Age 40 years old 21.00 WITA
Address Labuapi
Wakt
u
Subject Object Assesment Planning
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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18/30
Wakt
u
Subject Object Assesment Planning
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
observation mother and
fetal well being
observation bleeding.
bed rest
observation mother and
fetal well being
observation bleeding.
bed rest
observation mother and
fetal well being observation bleeding.
bed rest
Wakt Subject Object Assesment Planning
7/29/2019 18-08-09 Kasep
19/30
Wakt
u
Subject Object Assesment Planning
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
observation mother and
fetal well being
observation bleeding.
bed rest
Pro USG
Name : Mrs Hamidah Admitted to 26 July 2009
7/29/2019 18-08-09 Kasep
20/30
s
Name : Mrs. Hamidah Admitted toHospital
26 July 2009
Age 19 years old 13.30 WITA
Address Sekarbela
Wakt
u
Subject Object Assesment Planning
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
Eyes : an-/-, ict -/-
Cor : s1s2 singgle, reguler (-
)murmur (-), gallop (-)
Pulmo : ves +/+, rh -/-, whz -/-Ext : oedem -/-, warm.
Status obstetry :
L1 : breech
L2 : right back
L3 : head
L4 : was in pelvic inlet 4/5
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
left lateral position
Observation mother
and fetal well being
Cek Lab DL, HbSAg,
UL
Ti S bj t Obj t A t Pl i
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Time Subject Object Assesment Planning
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
Wakt Subject Object Assesment Planning
7/29/2019 18-08-09 Kasep
22/30
Wakt
u
Subject Object Assesment Planning
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
Educated mother to left
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
Educated mother to eat
and dringk
Educated mother to left
lateral position
Observation mother and
fetal well being
Educated mother to eat
and dringk
Educated mother to left
lateral position
Observation mother and
fetal well being
Wakt Subject Object Assesment Planning
7/29/2019 18-08-09 Kasep
23/30
Wakt
u
Subject Object Assesment Planning
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
Educated mother to eat
and dringk
Educated mother to left
lateral position
Observation mother and
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.
Report to supervisor :
advice drip oxitosine 5IU.
-CTG : 140
Suspecious
-KIE :
-Educated mother to eat
and drink
- left lateral position
- CTG ulang
Wak Subject Object Assesment Planning
7/29/2019 18-08-09 Kasep
24/30
Wak
tu
Subject Object Assesment Planning
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)
Report to supervisor :
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
Age 27 years old 10.30 WITA
Address Narmada
Time Subject Object Assesment Planning
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:
General condition : well
BP : 120/90mmHgPR : 80x/
RR : 20x/
Temp : 36,7C
Eyes : an-/-, ict -/-
Cor : s1s2 single, m -, g
Pulmo : Ves +/+, rh -/-, whz -/-
Ext : oedem -/-, warm +
Status obstetricL1 : breech
L2 : right back
L3 : head
L4 : was in pelvic inlet 4/5
UFH : 29 cm
EFW : gram
FHB : 155 bpm,reguler
UC : 2x/10~20
VT : CD 2cm, eff 25%, AM (+),
head palpabed descended HI, small
part of fetal/umbilical cord
unpalpabed
PE : arcus pubis >90 degrees, spina
ischiadica not prominent,
os.coccygeus mobile
Lab :Hb : 11 gr%
Leuko : 13.100/mm3
G1P0A0H0 40-41
weeks/S/L/ IU, obs.
inpartu
Observation mother
and fetal well being
Educated mother toeat and drink
Lab. Check
Time Subject Object Assesment Planning
7/29/2019 18-08-09 Kasep
26/30
j j g
14.30 FHB : 144 bpm, reguler
UC : 2x/10~20
G1P0A0H0 40-41
weeks/S/L/ IU, obs.
inpartu
Observation mother
and fetal well being
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
FHB : 148 bpm, reguler
UC : 2x/10~20
FHB : 149 bpm,reguler
UC : 2x/10~20
FHB : 150 bpm,reguler
UC : 3x/10~20
FHB : 144 bpm,reguler
UC : 3x/10~20
FHB : 152 bpm,reguler
UC : 3x/10~20
FHB : 142 bpm,reguler
UC : 3x/10~20
FHB : 140 bpm,reguler
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
Time Subject Object Assesment Planning
7/29/2019 18-08-09 Kasep
27/30
j j g
13.00
13.30
FHB : 142 bpm,reguler
UC : 3x/10~25
FHB : 149 bpm,reguler
UC : 3x/10~25
- Oxytocin drip 24 dpm
- Oxytocin drip 28 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
FHB : 155 bpm,reguler
UC : 3x/10~30
FHB : 150 bpm,reguler
UC : 3x/10~30
FHB : 146 bpm,reguler
UC : 3x/10~30
FHB : 152 bpm,reguler
UC : 3x/10~30
FHB : 149 bpm,reguler
UC : 3x/10~30
FHB : 151 bpm,reguler
UC : 3x/10~30
General condition : well
BP : 120/70mmHg
PR : 80x/
RR : 18x/
Temp : 36,7C
FHB : 142 bpm,reguler
G1P0A0H0 40-41
weeks/S/L/ IU, obs.
inpartu
- oxytocin drip 32 dpm
- oxytocin drip 36dpm
- oxytocin drip 40 dpm
- oxytocin drip 40 dpm
(second flash)
- Oxytocin drip 40 dpm
- Oxytocin drip 40 dpm
- patient move to melati
room
Time Subject Object Assesment Planning
7/29/2019 18-08-09 Kasep
28/30
j j g
14.00
20.00
General condition : well
BP : 120/70mmHg
PR : 80x/
RR : 18x/
Temp : 36,7C
FHB : 142 bpm,reguler
UC : 2x/10~30
General condition : well
BP : 120/80mmHg
PR : 84x/
RR : 18x/
Temp : 36,5C
FHB : 152 bpm,reguler
UC : 2x/10~
30
G1P0A0H0 40-41
weeks/S/L/ IU, obs.
inpartu
G1P0A0H0 40-41
weeks/S/L/ IU, obs.
inpartu
Observation mother
and fetal well being
Educated mother to
eat and drink
Observation mother
and fetal well being
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
FHB : 152 bpm,reguler
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
and fetal well being
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
Time Subject Object Assesment Planning
7/29/2019 18-08-09 Kasep
29/30
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
and fetal well being
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
FHB : 145 bpm,reguler
UC : 2x/10~25
FHB : 160 bpm, irreguler
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
Time Subject Object Assesment Planning
7/29/2019 18-08-09 Kasep
30/30
Time Subject Object Assesment Planning
31/08/09
General condition : well
BP : 110/70mmHg
PR : 84x/
RR : 18x/
Temp : 36,8C
SC wound : good, no active
bleeding, dry
P1A0H1 1st day of
puerpuralis
- Mother in melati room
- The baby in NICU
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