OBSTETRIC EMERGENCY ROOM REPORT

DUTY ON :

PLAN
ASSESS PROBLEM ICD
N0 DATA BASED OF
MENT LIST X
CARE
1. Anamnesis (ICD IX 89.03) :
Referred from Premagana Hospital with P1001 post
SVD day 0, vaginal hematoma.
Complained Vaginal bleeding (+), perineal pain (+)
Chronologist :
08.30 am : arrived at midwife cervical dilatation 4
cm
11.20 am : cervical dilatation was completed
11.25 am : born baby ♀, 2500g
08.00 pm : vaginal pain (+)  hematoma
referred to Premagana Hospital
09.30 pm : arrived at Premagana Hospital, done
blood clot evacuation but bleeding
source wasn’t found. Referred to
Sanglah
11.40 pm : arrived at Sanglah Hospital
LMP: 25/4/2016
EDD: 2/2/2017
PNC: Midwife
Obstetric History:
1. ♀, 2500 gr, SVD, 0 day
Married 1x~ 1 years
 OBSTETRIC EMERGENCY ROOM REPORT
DUTY ON :

N ASSESS PROBLEM ICD PLAN OF

DATA BASED
0 MENT LIST X CARE
2 Physical Examination (ICD IX 89.03) :
. Weight/Height : 54/153
Present state :
GCS E4V5M6 VAS 2
BP : 110/70 RR : 20
P : 90 Tax: 36.6
General state :
Eyes : Anemic (-)
Thorax : Cor : S1S2 single, regular, murmur(-)
Pulmo: Vesicular +/+, ronchi-/-, wheezing -/-
Abdomen : ~ obstetric state
Extremities : warm +/+
+/+

Obstetric state :
Abdomen:
Fundal Height 2 fingers below umbilicus
Uterine Ccontraction (+) good
Inspection : Seen perineal rupture gr II, active bleeding (-)

Inspeculo (MRG) 01.00 am :

Portio intact, lochia (+)
seen posterolateral vaginal wall laceration : 3 cm, active
bleeding (-)

VT : Palp tip of posterolateral vaginal wall laceration ± 3cm

depth 8 cm, clot (+)
 OBSTETRIC EMERGENCY ROOM REPORT
DUTY ON :

N ASSESS ICD
DATA BASED PROBLEM LIST PLAN OF CARE
0 MENT X
3. Laboratory Result P1001 post 1.Vaginal and O80 Intervention :
(ICD IX 99.07) : partum day perineal O72 1. Laceration repair with
WBC 14.55 0, Primary laceration general anesthesia
HGB 11.16 Post 2. Antibiotic
2.Risk of
HCT 34.36 Partum
PLT 256.90 Hemorhage infection Target:
ec 1. Stop bleeding
Laceration 2. No infection

Instruction:
Therapy:
- IVFD RL 20 dpm
- Ampicillin 2 gram (IV)
- Vaginal + perineal
repair with general
anesthesia

Monitoring: Complain,
Vital sign, Vaginal
bleeding

CIE