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23-10-12 Serotinus, Drip
23-10-12 Serotinus, Drip
Name
: Mrs. M
RM
Age
: 062334
: 20 years old
SUBJECTIVE Patient referred from Policlinic NTB GH with G4P1A2L1 42-43 weeks S/L/IU head presentation with mother & fetal well. Patient confessed > 9 mounth pregnancy. History rupture of membrane(-). Blood slim (-). Abdominal pain (-). FM (+). No history of DM, HT, asthma. LMP : 01/01/2012 EDD : 08/10/2012 History of ANC : > 4x at Posyandu, PHC. Last ANC : 20/10/2012 History of USG : 1x Result : History of family planning : Injection 3 months Next family planning : Injection 3 months Obstetrical History : I. Abortus II. , spontan, midwife, 3800 g, live, 6 years old. III. Abortus IV. This
OBJECTIVE General Status : GC : well BP : 120/60 mmHg PR : 80 bpm RR : 20 bpm T : 36,5oC Eye : anemis (-), icteric (-) Cor : S1S2 single regular, murmur (-), gallop (-). Pulmo : vesiculer (+/+), wheezing (-/-), ronkhi (-/-). Abdomen : scar (-), striae (+), linea nigra (+). Extremity : edema (-/-), warm acral (+/+).
ASSESSMENT G4P1A2L1 4243 weeks S/L/IU head presentation with mother & fetal well
PLANNING Observation mother & fetal well being. RL 500 cc, 28 tpm DM co GP pro CTG, advice : ACC CTG reactive, termination If PS < 5, termination with Misoprostol 25 mcg/8 hours If PS > 5, termination with Oxytosin Drip
Obstetrical Status : L1 : breech L2 : back on the left side L3 : head L4 : 5/5 UFH : 30 cm EFW : 2945 gram UC : (-) FHB : 12-12-11 (140 bpm) VT : (-), head palpable at the fornix
TIME
SUBJECTIVE Chronologist : -
OBJECTIVE PS : 5 Cervix dilatation 1 cm : 1 Cervix length 1 cm : 1 Cervix consistency moderate :1 Cervix position posterior : 0 Station H I : 1 Lab Examination (05/06/2012) : HB : 9,4 g/dl RBC : 4,21 x 106/L HCT : 31,5 % WBC : 8,9x 103/L PLT : 338 x 103/L HbSAg : (-)
ASSESSMEN T
PLANNING
TIME 14.00
SUBJECTIVE
OBJECTIVE UC : (-) FHB : 12-12-12 (148 bpm) UC : (-) FHB : 12-12-11 (140 bpm) UC (-) FHB : 11-12-11 (136 bpm) UC : (-) FHB : 12-12-12 (140 bpm) VT : 1 cm, eff 25%, amnion (+), head palpable HI, denominator unclear, impalpable small part and umbilical cord.
ASSESSMENT
20.00
10.30
UC : 1 x 10 ~ 15 FHB : 12-12-11 (140 bpm) UC : 2 x 10 ~ 15 FHB : 11-11-11 (132 bpm) Abdominal pain came and relieved UC : 2 x 10 ~ 20 FHB : 11-12-11 (136 bpm)
Coo GP result CTG CTG reactive Acc Drip Oxytocin Flash I Drip oxytocin began 8 tpm Drip oxytocin 12 tpm
11.00
11.30
12.00
12.30
TIME 13.00
OBJECTIVE UC : 3 x 10 ~ 35 FHB : 11-12-11 (136 bpm) VT : 2 cm, eff 30%, amnion (+), head palpable HI, denominator unclear, impalpable small part and umbilical cord.
ASSESSMENT G4P1A2L1 42-43 weeks S/L/IU head presentation with Latence phase 1st stage of labor
13.30
UC : 3 x 10 ~ 35 FHB : 11-12-12 (140 bpm) UC : 3 x 10 ~ 35 FHB : 12-12-12 (146 bpm) UC : 3 x 10 ~ 35 FHB : 11-11-11 (132 bpm) UC : 3 x 10 ~ 40 FHB : 12-12-11 (140 bpm) UC : 4 x 10 ~ 40 FHB : 11-11-11 (132 bpm) UC : 4 x 10 ~ 40 FHB : 11-12-11 (136 bpm) VT : 5 cm, effacement 50%, amnion (-), head palpable HII, denominator unclear, impalpable small part and umbilical cord. G4P1A2L1 42-43 weeks S/L/IU head presentation with c
14.00
14.30
15.00
15.30
16.00
TIME 16.30
PLANNING Drip oxytocin 40 tpm Conduct mother to bearing down : Baby was born : female, AS 7-9, 2500 gram, 51 cm. Anus (+), congenital anomaly (-). Placenta was born spontaneous, complete, bleeding 150 cc. UFH : 2 fingers below umbilicus.
16.40
19.00
GC : well BP : 110/70 PR : 84 bpm RR : 20 bpm T : 36,1oC UFH : 2 fingers below umbilicus UC : (+) Lochea rubra : (+)
Observed mother and baby well being Observed bleeding & VS mother Suggest mother to mobilisation, eat & drink.
TIME
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLANNING
GC : well BP : 120/60 PR : 88 bpm RR : 20 bpm T : 36,4oC UFH : 2 fingers below umbilicus UC : (+) Lochea rubra : (+) Baby rooming in : PR : 140 bpm RR : 44 bpm T : 36,6oC
Observed mother and baby well being Suggest mother to mobilisation, eat, and drink, medication. Breast feeding