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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. Jero Ardiani / 25 years old : Lingsar


Subject Object with General status : General condition: well, Conciousness: CM BP: 110/70 mmHg RR: 20 x/mnt PR: 80 x/mnt T: 36,6 C Eyes : an(-), ikt (-) Cor -Pulmo : in normal range Obstetric status : L1 : breech L2 : left back L3 : head L4 : head descencus4/5 UFH 30 cm EFW : 2945 g UC : (-) Fetal Heart Rate : 148 x/mnt VT : DC (-), fornix palpable, estimate head Bishop score: 5 Dilatation cervix: 0 Length of cervix: 1 Station: 1 Consistensi: 2 Position of cervix: 1 Pelvic evaluation: Spina ischiadica: unpalpable

CTH Time
Assesment

: 19 January 2009 : 12.45


Planning Observation mother and fetal well being. Laboratory examination : DL, HBsAg Advice from poliklinik: Drip oxytocin

Patient came to poliklinik pregnancy more than 9 month.

G1P0A0H0 41-42 weeks/S/L

chronologis : Patient came to poliklinik with pregnancy more than 9 month. Abdominal discomfort (-), vaginal discharge (-).

LMP: 24-4-08 EDD: 11-1-09


Obstetric history: 1.This

Time
13.30

Subject
Abdominal discomfort (-)

Object
General status: well FHB: 140 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: 146 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: 146 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: 146 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: 143 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: 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: 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: 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