Beruflich Dokumente
Kultur Dokumente
Identity
Name : Mrs. R Age : 25 years Old Address : Kayangan, North Lombok Admitted on: December, 10th 2012 (01.30 wita)
SUBJECTIVE Patient referred from Kayangan PHC with G1P0A0H0 36-37 weeks S/L/IU with PROM > 12 hours Patient confessed abdominal pain that spread to waist since 23.00 (08/12/2012). History water leaked from her womb (+). Bloody slim (+), FM (+). No history of DM, HT, asthma. LMP : 29-3-2012 EDD : 05-01-2012 History of ANC : >4x at Posyandu History of USG : never History of family planning : (-) Next family planning : Injection 3 months. Obstetrical History : I. This
OBJECTIVE General Status GC : well Consciusness : CM BP : 130/80 mmHg PR : 80 bpm RR : 24 bpm T : 37oC Eye : anemis (-/-), icteric (-/-) Cor : S1S2 single reguler, M (-), G (-) Pulmo : vesikuler (+/+), wheezing (/-), ronkhi (-/-). Abdomen : scar (-), striae (+), linea nigra (+). Extremity : edema (-/-), warm acral (+/+) Obstetrical Status L1 : breech L2 : back on the left side L3 : head L4 : 5/5 UFH : 36 cm EFW : 3565 g UC :FHB : 10-11-14 (140 bpm) VT : 1 cm, eff 10%, amnion (-), head palpable H I, denominator unclear, impalpable small part / umbilical cord.
ASSESSMENT G1P0A0H0 36-37 weeks S/L/IU head presentation with PROM> 12 hours
PLANNING Observe mother and fetal well being. Observe progress of labor. Inj Ampi (at PHC) GP consult to SPV: induction with oxytosin drip Observation proggress of labour CTG Rehydration
TIME
SUBJECTIVE Chronologist at Kayangan PHC : 22.15 (08/12/2012) S : Abdominal pain spread to frank since 23.00 (8/12/2012). History rupture of membrane (+), bloody slim (+),FM (+). O : GC : well BP : 100/60 mmHg PR : 86 bpm RR : 20 bpm T : 38oC L1 : breech L2 : back on the left side L3 : head L4 : 4/5 UFH : 32 cm UC : 1x/10~20 FHB : 11-11-12 (136 bpm) VT : 1 cm, amnion (+) , head palpable HI , denom unclear, unpalpable small part / umbilical cord. A : G1P0A0H0 36-37 weeks S/L/IU head presentation with PROM > 12 hours P: Tell mother and family about examination Consurlt GP: advice RL 20 tpm Inj. Ampi Reffered to GH NTB (22.40 wita)
OBJECTIVE Pelvic Evaluation : Spina ischiadica not prominent Os coccigeous mobile Pubic arch > 900 PS: 5 Dilatation cervix : 1 Cervix Length: 2 Station: 0 Consistency: 1 Position: 1 Lab Evaluation HB : 9,4g/dl RBC : 4,19 M/dl HCT : 30,9 % WBC : 20,1 K/dl PLT : 349 K/dl HbSAg : (-)
ASSESSMENT
PLANNING
SUBJECTIVE
OBJECTIVE
ASSESTMENT
8 dpm 12 dpm
04.30
05.00 05.30 06.00 06.30
16 dpm
20 dpm 24 dpm 28 dpm 32 dpm - Observation mother and fetal well being - Observe patient 4 hours later
07.30
Result of USG: Fetal S/L/IU head presentation BPD: 35 w 6 d AC: 39 w 6 d FL: 88 mm Amnion (+), polihydramnion placenta at posterior fundus
TIME 10.30
OBJECTIVE UC: 3x/10~40 FHR: 158 bm VT: 2 cm, eff 50%, amnion (-), head alpable, HI, impalpable small part of fetal and umbilical cord
ASSESTMENT G1P0A0H0 3637 weeks S/L/IU head presentation Latent Phase, 1st stage of labour with history ROM + polyhidramnion
14.00
UC: 3x/10~30 FHR: 12-13-13 VT: 2 cm, eff 50%, amnion (-), head palpable, HI, impalpable small part of fetal and umbilical cord
14.30
15.00
16.00
20.30
TIME 21.10
SUBJECTIVE
OBJECTIVE
ASSESTMENT
PLANNING CS began Baby was born (21.30), Male, BW:3250 g/50 cm, anus (+), AS: 7-9 Placenta was born manually, complete, bleeding 500 cc
10.00
GC: well Cons: CM BP: 110/80 HR: 84 bpm RR: 24 tpm T: 36,5 C UC: + UFH: 2 finger below umbilicus Urine output: 100 cc Baby in NICU PR: 120 RR: 50 T: 36,7
2 hours post SC
GC: well BP: 110/80 HR: 80 bpm RR: 20 tpm T: 36,5 C UC: + UFH: 2 finger below umbilicus Urine output: 100 cc
1 day post SC
Observed mother and baby well being Suggest mother to mobilisation, eat, and drink, medication.