You are on page 1of 5

Name: Mrs.

S
Age: 17 yo
Address: Batu Layar, Lobar
Admitted: October, 29th 2012 at 21.15

TIME

SUBJECTIVE

29/10
/2012
(21.1
5)

Patient referred from


Meninting PHC with G1P0A0L0
39-40 weeks S/L/IU head
presentation with prolonged
active phase, eneglected,
with portio eodema. Patient
confessed abdominal pain
since 05.00 WITA
(29/10/2012),
rupture of membrane since
18.30 WITA (01/09/2012).
Bloody Slim (+)
FM (+).
No history of DM, HT, asthma.
LMP: 28-1-2012
EDD: 4-11-2012
History of ANC: >4x at
Posyandu and doctor
Last ANC:
History of USG: 3x at doctor
Last USG: 06/08/2012
Result: well
History of family planning: Next family planning: Obstetrical history:
I.This

OBJECTIVE
General status:
GC: well
Consciousness: E4V5M6
BP: 130/80 mmHg
PR: 88 bpm
RR: 20 tpm
T: 37,7oC
Eye : anemic (-), icteric (-)
Thorax :
Cor : S1S2 single reguler,
murmur (-), gallop (-)
Pulmo : vesikuler (+/+),
wheezing (-/-),
Ronkhi (-/-).
Abdomen : scar (-), striae (+),
linea nigra (+)
Extremity : edema (-/-), warm
acral (+/+)
Obstetrical status:
L1: breech
L2: back at the right side
L3: head
L4: 3/5
UFH: 33 cm
EFW: 3410 gr
UC: 3x10~35
FHB: 12-11-12 (140x/min)
VT: 9 cm, eff 75%, amnion (-),
green cloudy, head palpable
HII, denom unclear,
unpalpable small part /
umbilical cord, portio oedema
(+).

ASSESTMENT

PLANNING

G1P0A0L0 3940 weeks S/L/IU


head
presentation
with prolonged
ative phase +
eneglected.

Obs mother & fetal


well being
CBC Check
Ampicilin Inje
DM announce to
SPV : SPV advice
CS

TIME

SUBJECTIVE
Chronology :
(29/10/2012)
S:
Patient 9 month pregnancy
came to Meninting PHC at
9.30. Patient confessed
abdominal pain since 05.00
WITA blood slim (-), water
came out from her womb
since 18.30 WITA
(29/10/2012).
O:
GC : well
BP : 120/80 mmHg
PR : 80 bpm
RR : 20 tpm
Temp : 36,6OC
UFH : 32 cm, head
presentation.
FHB : 140 bpm
VT: 8 cm, eff 75%, amnion
(-), head palpable HII,
denom unclear, unpalpable
small part / umbilical cord.
A:
G1P0A0L0 39-40 weeks S/L/IU
head presentation with
prolonged ative phase
P:
co GP reffered to NTB GH
IVFD RL:D5 2:1 fast drip

OBJECTIVE

ASSESTMENT

PLANNING

TIME
21.45

SUBJECTIVE
Abdominal pain (+++)

OBJECTIVE

ASSESTMENT

PLANNING

UC: 3x10~35
FHB: 12-12-12 (144x/min)
Lab Examination :
HGB : 9,7 g/dl
HCT : 30,6 %
RBC : 3,43 M/uL
WBC : 24,69 K/uL
PLT : 282 K/uL
HbSAg : (-)

22.00

22.25

Abdominal pain (+++)

Inspection : Crowning (+)

GP consult to
SPV : pro VE. SPV
advice : Acc VE.
Tell patient and
family : OK

GC: well
Consciousness: E4V5M6
BP: 130/80 mmHg
PR: 88 bpm
RR: 20 tpm
T: 37,7oC

VE began :
VE succeed in 1x
traction
Perineum
episiotomy
Baby was born,
male,
3500
gram, 50 cm, A-S
7-9 caput (+) on
occiput,
anus
(+),
anomaly
congenital (-).
Placenta was born
spontan,
complete.
Bleeding 200 cc

UC: 3x10~35
FHB: 11-12-12 (140x/min)

GC: well
Consciousness: E4V5M6
BP: 130/80 mmHg
PR: 100 bpm
RR: 20 tpm
T: 37,2oC
UC : (+) well
UFH : 1 fingers below
umbilicus
Lochea rubra : (+)

2 hours post VE

Observed mother well


being
Observed bleeding & VS
mother
Suggest
mother
to
mobilisation, eat and
drink.

GC : well
BP : 120/80 mmHg
PR : 80 bpm
RR : 20 bpm
T : 36,7OC
UC : (+) well
UFH : 1 fingers below
umbilicus
Lochea rubra : (+)

1 day post VE

Observation vital sign and


bleeding
Suggest mother to eat,
drink, mobilization

Baby in NICU :
GC : well
PR : 132 bpm
RR : 44 bpm
T : 36,2OC

You might also like