Morning Report

10 January 2009

Supervisor : dr. Agus Thoriq , SpOG

Medical Student: 1. Amrul 2. Hadyan 3. Maman 4.Fira Cases resume : 1. 2. 3. 4. Retracted 1st stage of labor Retracted of 1st stage labor + febris Retracted 2nd stage of labor Normal labor

1 1 1 3

1.

Name / Age Address

Time 12.45

: Mrs. suryana / 22 years old : karang tapen

Subject Object General status : General condition: well, Conciousness: CM BP: 110/70 mmHg RR: 20 x/mnt PR: 84 x/mnt T: 36,7 C Eyes : an(-), ikt (-) Cor -Pulmo : in normal range Obstetric status : L1 : breech L2 : left back L3 : head L4 : head descencus 4/5 UFH 31 cm EFW : 3100 g UC : (-) Fetal Heart Rate : 140 x/mnt VT : DC 1 cm, eff 10 %, AM (+), head palpable, descensus HI, umbilical cord or small part of fetal unpalpable. Bishop score: 6 Dilatation cervix: 0 Length of cervix: 2 Station: 1 Consistensi: 2 Position of cervix: 1

CTH

: 19 January 2009 : 12.45

Planning Observation mother and fetal well being. Laboratory examination : DL, HBsAg Advice from poliklinik: Induction labor with Drip oxytocin 5 IU in 500 cc D5%.

Time
Assesment

Patient reffered by poliklinik with G1P0A0 42 weeks/S/L chronologis : Patient came to poliklinik with pregnancy more than 9 month. Abdominal discomfort (-), vaginal discharge (-).

G1P0A0H0 41-42 weeks/S/L

LMP: 29-3-08 EDD: 6-1-09

Obstetric history: 1.This

Time
13.30

Subject
Abdominal discomfort (-)

Object
General status: well FHB: 138 x/mnt UC : (-)

Assesment
G1P0A0H0 41-42 weeks/S/L

Planning
Start drip oxytocin 24 drop/mnt Observation mother fetal well being

14.00

Abdominal discomfort (-)

General status: well FHB: 140 x/mnt UC : (-)

G1P0A0H0 41-42 weeks/S/L

Start drip oxytocin 28 drop/mnt Observation mother fetal well being

14,30

Abdominal discomfort (-)

General status: well FHB: 140 x/mnt UC : (-)

G1P0A0H0 41-42 weeks/S/L

Start drip oxytocin 32 drop/mnt Observation mother fetal well being

15.00

Abdominal discomfort (-)

General status: well FHB: 144x/mnt UC : (-)

G1P0A0H0 41-42 weeks/S/L

Start drip oxytocin 36 drop/mnt Observation mother fetal well being

Time
15.30

Subject
Abdominal discomfort (-)

Object
General status: well FHB: 144 x/mnt UC : (-)

Assesment
G1P0A0H0 41-42 weeks/S/L

Planning
Start drip oxytocin 8 drop/mnt

16.00

Abdominal discomfort (-)

General status: well FHB: 144 x/mnt UC : (-)

G1P0A0H0 41-42 weeks/S/L

Start drip oxytocin 12 drop/mnt Observation mother fetal well being

16.30

Abdominal discomfort (-)

General status: well FHB: 154 x/mnt UC : (-)

G1P0A0H0 41-42 weeks/S/L

Start drip oxytocin 16 drop/mnt Observation mother fetal well being

17.00

Abdominal discomfort (-)

General status: well FHB: 146 x/mnt UC : (-)

G1P0A0H0 41-42 weeks/S/L

Start drip oxytocin 20 drop/mnt Observation mother fetal well being

Time
17.30

Subject
Abdominal discomfort (-)

Object
General status: well FHB: 146 x/mnt UC : (-)

Assesment
G1P0A0H0 41-42 weeks/S/L

Planning
Start drip oxytocin 40 drop/mnt Observation mother fetal well being

18.00

Abdominal discomfort (-)

General status: well FHB: 145 x/mnt UC : (-)

G1P0A0H0 41-42 weeks/S/L

Start drip oxytocin 40 drop/mnt Observation mother fetal well being

18.30

Abdominal discomfort (-)

General status: well FHB: 145 x/mnt UC : (-)

G1P0A0H0 41-42 weeks/S/L

Start drip oxytocin 40 drop/mnt Observation mother fetal well being

19.00

Abdominal discomfort (-)

General status: well FHB: 146 x/mnt UC : (-)

G1P0A0H0 41-42 weeks/S/L

Start drip oxytocin 40 drop/mnt Observation mother fetal well being

Time
19.30

Subject
Abdominal discomfort (-)

Object
General status: well FHB: 144 x/mnt UC : (-)

Assesment
G1P0A0H0 41-42 weeks/S/L

Planning
Start drip oxytocin 40 drop/mnt Observation mother fetal well being

20.00

Abdominal discomfort (+),rare

General status: well FHB: 148 x/mnt UC : 1x/10 ~ 20

G1P0A0H0 41-42 weeks/S/L

Start drip oxytocin 40 drop/mnt Observation mother fetal well being

20.30

Abdominal discomfort (+), rare

General status: well FHB: 148 x/mnt UC :1x/10 ~ 20

G1P0A0H0 41-42 weeks/S/L

Start drip oxytocin 40 drop/mnt Observation mother fetal well being

21.00

Abdominal discomfort (+), rare

General status: well FHB: 147 x/mnt UC : 2x/10 ~ 20

G1P0A0H0 41-42 weeks/S/L

Fls 2 drip ocytocin 5 IU Start drip oxytocin 40 drop/mnt Observation mother fetal well being

Time
21.30

Subject
Abdominal discomfort (+), rare

Object
General status: well FHB: 148 x/mnt UC : 2x/10 ~ 20

Assesment
G1P0A0H0 41-42 weeks/S/L

Planning
Start drip oxytocin 40 drop/mnt Observation mother fetal well being

22.00

Abdominal discomfort (+), rare

General status: well FHB: 145 x/mnt UC : 2x/10 ~ 20

G1P0A0H0 41-42 weeks/S/L

Start drip oxytocin 40 drop/mnt Observation mother fetal well being

22.30

Abdominal discomfort (+), rare

General status: well FHB: 146 x/mnt UC : 2x/10 ~ 25

G1P0A0H0 41-42 weeks/S/L

Start drip oxytocin 40 drop/mnt Observation mother fetal well being

23.00

Abdominal discomfort (+), rare

General status: well FHB: 146 x/mnt UC : 2x/10 ~ 25

G1P0A0H0 41-42 weeks/S/L

Start drip oxytocin 40 drop/mnt Observation mother fetal well being

Time
21.30

Subject
Abdominal discomfort (+), rare

Object
General status: well FHB: 148 x/mnt UC : 2x/10 ~ 25

Assesment
G1P0A0H0 41-42 weeks/S/L Induction labor seri 1 failure

Planning
induction labor seri 2 after 24 hour later Patient remove to melati room