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  • Follow Up

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    Nur Amirah
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    The patient, 39 weeks pregnant, experienced increased frequent urination and fetal movements. She was in labor with 3 contractions every 10 minutes for 30 minutes. Ultrasound showed cephalic presentation, placenta in the posterior corpus, FHR 157 bpm, FM present, SDAV 2.23/ICA 3.3. She underwent an emergency cesarean section and IUD insertion for active labor dystocia due to a posterior placenta. She delivered a 3250 gram baby boy. On post-op days 1-2 she had no bleeding problems and was treated with antibiotics and analgesics. On day 3 her pain reduced and she was discharged with oral antibiotics.

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    CPD

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    follow up

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    The patient, 39 weeks pregnant, experienced increased frequent urination and fetal movements. She was in labor with 3 contractions every 10 minutes for 30 minutes. Ultrasound showed cephalic presentation, placenta in the posterior corpus, FHR 157 bpm, FM present, SDAV 2.23/ICA 3.3. She underwent an emergency cesarean section and IUD insertion for active labor dystocia due to a posterior placenta. She delivered a 3250 gram baby boy. On post-op days 1-2 she had no bleeding problems and was treated with antibiotics and analgesics. On day 3 her pain reduced and she was discharged with oral antibiotics.

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    8 views3 pages

    Follow Up

    Uploaded by

    Nur Amirah
    The patient, 39 weeks pregnant, experienced increased frequent urination and fetal movements. She was in labor with 3 contractions every 10 minutes for 30 minutes. Ultrasound showed cephalic presentation, placenta in the posterior corpus, FHR 157 bpm, FM present, SDAV 2.23/ICA 3.3. She underwent an emergency cesarean section and IUD insertion for active labor dystocia due to a posterior placenta. She delivered a 3250 gram baby boy. On post-op days 1-2 she had no bleeding problems and was treated with antibiotics and analgesics. On day 3 her pain reduced and she was discharged with oral antibiotics.

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    of 3

    Tgl S O A P

    12 Pasien merasa Ku: baik, CM - CPD pada G1 - Rencana SC


    Maret mules semakin TD : 110/70 mmHg, N : hamil 39 cito + IUD
    2018 sering, keluar 90 x menit, RR : 20 minggu
    x/menit, T : 36 C
    air- air (+), JPKTH,
    Pkl: - Stat. generalis: dalam
    gerak janin inpartu
    09:30 batas normal
    aktif
    - Stat. Obstetri:
    Kontraksi sebanyak 3 x
    dalam 10 mnt selama 30
    det, DJJ 140 dpm
    Inspeksi:
    Vulva uretra tenang,
    perdarahan aktif (-)
    VT:
    Pembukaan 7 cm, kepala
    H-I kaput di H-II, ketuban
    (-)
    - USG akut
    JPKTH, plasenta di
    korpus posterior, FHR (+)
    157 dpm, FM (+), SDAV
    2,23/ ICA 3,3 BPD 94,7/
    MC 342,8/ AC 333,2/ FL
    74,5/ EFW 3329 gr ~
    38—39 minggu
    - LAB
    Hb: 10.8/ HT: 31,7/ leu:
    23610/ tromb: 293000/
    GDS: 104
    12 Berlangsung - Rawat
    Maret SC + IUD atas ruangan
    2018 indikasi - Cek DPLpost
    plasenta PK I op
    Pkl:
    aktif ec CPD. - Oksitosin 20
    14:15
    Outcome lahir iu/ 500 cc
    bayi laki – laki RL/ 8 jam/ 24
    dengan BB jam
    3250 gr AS 8/9 - Ceftriaxone 1
    x 2 gr iv
    - Ketorolac 3 x
    30 mg iv
    - Asam
    tranexamat 3
    x 1 gr iv
    - Profenid 3 x
    100 mg supp
    - DC 1 x 24
    jam
    - GV hari ke 3
    - Mobilisasi
    13 Perdarahan Ku: baik, CM - Post SC 16 - Observasi
    maret aktif dari luka TD: 120/80 mmHg, N: 96 jam yang lalu ku/ TTV,
    2018 operasi atau x/ mnt, Rr: 20 x/ menit, T: atas indikasi kontraksi dan
    36,9 C.
    jalan lahir dystisoa PK 1 pendarahan,
    - Stat. generalis: dalam
    tidak ada, nyeri aktif ec CPD , aff DC
    batas normal
    oada jahitan akseptor IUD, - Profenid supp
    - Stat. Obstetri:
    operasi VAS perawatan hari 3 x 100 mg
    TFU teraba 2 jari
    2-3, BAK pertama - Ceftriaxon 1
    dibawah pusat, kontraksi
    terpasang x 2 gr iv
    baik
    kateter - Ketorolac 3 x
    Inspeksi:
    30 mg iv
    Vulva uretra tenang,
    perdarahan aktif (-)
    Status lokalis: - Asam
    Luka tertutup verban, tranexamat 3
    tidak ada rembesan darah x 50 mg iv
    atau rembesan pus - RL 500 cc
    Hasil lab opst op
    Hb: 11,1 g/dl
    Ht : 24.1 %
    Trombosit : 315.000 /ul
    14 Nyeri luka Ku: baik, CM Post SC - STOP:
    maret operasi VAS 2, TD: 110/70 mmHg, N: 88 indikasi Profenid
    2018 demam dan x/ mnt, Rr: 20 x/ menit, T: dystisoa PK 1 supp,
    36,3 C.
    perdarahan (-) aktif ec CPD , Ceftriaxon,
    - Stat. generalis: dalam
    akseptor IUD, Ketorolac,
    batas normal
    perawatan hari Asam
    - Stat. Obstetri:
    pertama tranexamat
    TFU teraba 2 jari
    - Ganti obat
    dibawah pusat, kontraksi
    oral
    positif
    - Cefixime 2 x
    Inspeksi:
    200 mg
    Vulva uretra tenang,
    - Asam
    perdarahan aktif (-)
    mefenamat 3
    Status lokalis:
    x 500 mg
    Luka tertutup verban,
    - Sulfas ferosus
    tidak ada rembesan darah
    1 x 360 mg
    atau rembesan pus
    - Pasien
    diperbolehkan
    pulang

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