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Name: Mrs.N Age: 27 yo Address: Kapu, Jenggara, Tanjung, KLU Admitted: September, 14th 2012 at 11.00 wita
SUBJECTIVE Patient referred from Tanjung GH with G3P2A0L1 36-37 weaks/S/L/IU with PROM > 12 hours. Patient confessed rupture of membrane since 20.00 (13/09/2012). Abdominal pain (-). Bloody slim (-), FM (+). No history of DM, HT, asthma. LMP: forgot EDD : History of ANC: > 4 X posyandu Last ANC : 06-09-2012 Result : normal History of USG: never
OBJECTIVE General status: GC: well BP: 110/70 mmHg PR: 80 bpm RR: 20 T: 36,5OC Eye : anemis (-), icteric (-) Thorax : Cor : S1S2 single regular (murmur ), (gallop -) Pulmo : vesicular (+/+), wheezing (/-), Ronchi (-/-). Abdomen : scar (-), striae (+), linea nigra (+) Extremity : edema (-/-), warm acral (+/+) Obstetrical status: L1: breech L2: back on the left side L3: head L4: 4/5 UFH: 29 cm EFW: 2790 g UC : FHB: 11-11-11 (132 x/min) VT: 2 cm, eff 10 %, amnion (-), head palpable HI, impalpable small part / umbilical cord.
PLANNING Obs mother & fetal well being skin test ampi (-) Inj. Ampicillin 1 gr /6 hour IV DM announce to SPV pro induction with oxytocin drip if CTG reactive, advice: acc induction with drip oxytocin if CTG reactive
TIME
SUBJECTIVE Chronology: 09.30 (14/09/2012) S: Patient referred from midwife came to Tanjung GH confessed rupture of membrane since 19.30 (13/09/2012). Bloody Slim (-). Abdominal pain (-). History of DM (-), asthma (--), HT (-) LMP: forgot EDD: O: GC: well BP: 100/70 mmHg PR: 80 bpm RR: 20 bpm T: 36,4oc L1: breech TFU : 27 cm L2: back on the left side TBJ : 2480 g L3: head L4: 4/5 23.30 (13-09-2012) UC: FHB: 12-12-11 (140 x/min) VT: 1 cm, eff 25 %, amnion (-), head palpable HI, denom unclear, impalpable small part / umbilical cord. 08.30 (14-09-2012) UC: FHB: 11-12-12 (140 bpm) VT: 1 cm, eff 25 %, amnion (-), head palpable HI, denom unclear, impalpable small part / umbilical cord. A:G3P2A0L1 36-37 weaks/S/L/IU with PROM > 12 hours. P: infuse RL 20 dpm inj. Ampicillin 1 gr (IV) 23.20 wita Obs mother & fetal well being Refer to NTB GH
OBJECTIVE PS: 5 Cervic dilatation 2 cm : 1 Cervix length 1 cm : 2 Cervix consistency moderate : 1 Cervix position posterior : 0 Station H I : 1
ASSESTMENT
PLANNING
Lab: HB: 13,1 g/dl RBC : 4,46 M/dl WBC : 6,7 K/dl PLT : 165 K/dl HbSAg: (-)
TIME 13.00 -
SUBJECTIVE
OBJECTIVE GC: well BP: 120/80 mmHg PR: 88 bpm RR: 20 T: 36,5 CTG: reactive UC: FHR: 11-12-13 (144 bpm )
13.30
14.00
14.30
15.00
15.30
TIME 16.00
OBJECTIVE UC: 3x/10 ~ 30 FHR: 12-12-12 (144) VT: 3 cm, eff 25%, amnion (-), head palpable HI, impalpable small part of fetal/ umbilical cord UC : 3x/10 ~ 35 FHR : 12-12-13 (148 bpm) G3P2A0L1 A/S/L/IU head presentation latent phase 1st stage of labor with history rupture of membrane
16.30
17.00
17.30
UC: 4x/10 ~ 35 FHR: 12-12-12 (144 bpm) UC: 4x/10 ~ 35 FHR: 12-13-12 (148 bpm) UC: 4x/10 ~ 35 FHR: 12-11-13 (144 bpm)
18.00
18.30
19.00
UC: 4x/10 ~ 35 FHR: 12-12-12 (144 bpm) UC: 4x/10 ~ 35 FHR: 11-12-11 (136 bpm)
19.30
TIME 20.00
OBJECTIVE UC: 4x/10 ~ 35 FHR: 13-12-13 (152 bpm) VT: 8 cm, effacement 75 %, amnion (-), head palpable HII denominator LOA, impalpable small part of fetal / umbilical cord G3P2A0L1 A/S/L/IU head presentation active phase 1st stage of labor with history rupture of membrane
20.30
Abdominal pain came and relieved Abdominal pain ++ Mother want to bearing down doran
UC: 4x/10 ~ 45 FHR: 12-12-12 (144 bpm) UC: 4x/10 ~ 45 FHR: 12-12-12 (144 bpm) Teknus perjol vulka 2nd stage of labor
21.00
Drip oxy 40 dpm Conduct mother to bearing down Baby was born, male, AS 7-9, 2750 gram, 48 cm, Anus (+), congenital anomaly (-) Placenta was born spontaneous, complete, perineum intak bleeding 150cc
21.35
23.35
GC: well Cons: CM BP: 120/70 HR: 84 bpm RR: 24 tpm T: 36,5 C UC: + UFH: 1 finger below umbilicus GC: well Cons: CM BP: 120/80 HR : 80 bpm RR : 20 tpm T : 36,4 C UFH : 1 finger below umbilicus UC : + Baby rooming in PR: 120 RR: 44 T: 36,7
Observed mother and baby well being Suggest mother to mobilisation, eat, and drink, medication.