Name: Mrs.

A
Age: 25 yo
Address: Tanjung, KLU
Admitted: October, 15th 2012 at 09.45

TIME
15/10/1
2
09.45

SUBJECTIVE
Patient referred from Tanjung GH
with G2P1A0L1 32-33
weeks/S/L/IU with PROM +
susp.Placeta Previa + History of CS
7 years ago because of Eclamsia.
Patient confessed abdominal pain
reffered to waist since and water
came out from her womb since
18.30 (12/10/12). Bloody slim (-)
and FM (+).
No history of nausea, vomiting,
headache, visual disturbance and
epigastric pain (+) and history of
seizure (-)
No history of DM, HT, asthma.
LMP: forget
History of ANC: >4x at PHC
Last ANC: 15/10/2012
130/90mmHg, edema +/+
History of USG: 1x at RSUP NTB
Result :
Fetal S/L/head presentation
BPD : 33w2d
AC : 34w6d
34 w
FL : 70
EFW : 2400 g
EDD : 22/11/2012
Amnion : enough
Placenta Posterior grade II
SPV advice : Manage KPD
conservative

OBJECTIVE
General status:
GC: well
BP: 140/100 mmHg
PR: 90 bpm
RR: 28 bpm T: 36, C
Eye : palor (-), 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

UFH: 31 cm

L2: back on the right side EFW: 3100g

L3: head
L4: 5/5
UC: (-)
FHB: 11-12-12 (140 x/min)
VT: 1 cm, eff 25%, amnion (-), head
palpable HI, denominator unclear,
impalpale small part/umbilical cord

ASSESTMENT
G2P1A0L1 34
weeks/S/L/IU with
PROM+History of
CS+Severe
Preeclamsia

PLANNING
Obs mother & fetal
well being
DM co to SPV
,suggest to
conservative therapy to
PEB with drip MgSO4
and manage PROM
appropriate SOPs
(conservative)
SPV adv :
Nifedipine give if BP >
160/110 mmHg
Drip MgSO4
Inj. Amphicillin (10.30)
If failed, CS tommorow
morning

TIME

SUBJECTIVE
History of family planning: injection 3 month
Next family planning: IUD
Obstetrical history:
I.Male, 9 month, CS, NTB GH, life, 7 years
II.This
Cronology :
Patient said pregnant 8 month ,confessed
abdominal pain and water came out from her
womb mixed blackhis blood since 18.30
(12/10/12 ), nausea (-), vomiting (-), headache
(-), epygastric pain (+), FM (+)
GC : well
BP : 140/90 mmHg
HR : 82x/m
RR :20 x/m
T : 36
UFH : 30 cm
EFW : 2945 g
UC : (-)
FHB : (+)
VT didnt do
Co doctor :
-IUVD RL 20 dpm
-Skintest ampicillin (-), inj. Ampicillin (12.55)
-Nifedipine 1x1 (21.40)
-Cek Hb, UL Hb 9,6 g/dL, protein urine +1
A : G2P1A0H1 32-33 weeks/S/L/IU head
presentation + PROM + susp. Placenta Previa
P : Reffered to NTB GH

OBJECTIVE
Lab:
HB: 11,2 g/dl
RBC: 5,00 M/dl
HCT: 34,35%
WBC: 7,81 K/dl
PLT: 247 K/dl
HbSAg: (-)
Proteinuria: +2
SGOT : 47
SGPT : 42
Urea : 12
Kreatinin : 0,6

ASSESTMENT

PLANNING

TIME
13.00

SUBJECTIVE
-

14.00

19.00

OBJECTIVE
GC: well
TD: 150/100 mmHg
HR: 84 x/mnt
RR: 20x/mnt
T: 36,5 C
UC: FHB: 12-12-11 (140 x/min)

GC: well
TD: 160/100 mmHg
HR: 88 x/mnt
RR: 20x/mnt
T: 36,5 C
UC: FHB: 12-12-11 (140 x/min)

GC: well
TD: 160/110 mmHg
HR: 88 x/mnt
RR: 20x/mnt
T: 36,5 C
UC: 2x10~20
UO : 400 cc
FHB: 12-12-11 (140 x/min)

ASSESTMENT

PLANNING
Drip MgSO4 40% 28
dpm
Insert DC

Inj.ampicillin 1 g (16.30)

TIME

ASSESTMENT

PLANNING

GC: well
TD: 160/100 mmHg
HR: 84 x/mnt
RR: 20x/mnt
T: 36,5 C
UC: 2x10~35
FHB: 12-12-11 (140 x/min)
VT: 3 cm, eff 50%, amnion (-),
head palpable HI, denominator
unclear, impalpale small
part/umbilical cord

G2P1A0L1 32-33
week S/L/IU latent
phase 1st stage of labor
with history
ROM+History of
CS+Severe
Preeclamsia

obs. Mother and fetal well

being
Obs.progress of labor

00.00

GC: well
TD: 160/100 mmHg
HR: 88 x/mnt
RR: 20x/mnt
T: 36,5 C
UC: 3x10~35
FHB: 12-12-11 (140 x/min)
VT: 6 cm, eff 90%, amnion (-),
head palpable HI, denominator
unclear, impalpale small
part/umbilical cord

G2P1A0L1 32-33
week S/L/IU active
phase 1st stage of labor
with history
ROM+History of
CS+Severe
Preeclamsia

obs. Mother and fetal well

being
Obs.sign of labor

16/10/1
2
04.00

GC: well
TD: 160/110 mmHg
HR: 88 x/mnt
RR: 20x/mnt
T: 36,5 C
UC: 3x10~40
FHB: 12-12-11 (140 x/min)
VT: 9 cm, eff 90%, amnion (-),
head palpable HI, denominator
unclear, impalpale small

20.00

SUBJECTIVE
-

OBJECTIVE

TIME
05.30

SUBJECTIVE
Mother want to bearing down

OBJECTIVE
UC : 3x 10~40
FHB : 12-12-11
Teknus perjol vulka

ASSESTMENT
2nd stage of labor

05.55

conduct mother tp bearing

down
Baby was born, female, BW :
3100 gram, BL: 50 cm, A-S :
7-9, anus (+), congenital
anomaly (-), Ballard score :
40
Placenta was born manually,
complete,.
Bleeding : 250 cc

07.00

17/10/2
012
07.00

PLANNING

Patient confessed delivery wound pain

GC: well
Cons: CM
BP: 140/100
HR : 88 bpm
RR : 20 tpm
T : 36,6 C
UFH : 2 finger below umbilicus
UC : + well

2 hours post partum

Observed mother and baby

well being
Suggest mother to
mobilisation.

GC: well
Cons: CM
BP: 130/90 mmHg
HR : 88 bpm
RR : 20 tpm
T : 36,6 C
UFH : 1 finger below umbilicus
UC : +

1 day post partum

Suggest mother to give

exlusive breast feeding
Observed mother and baby
well being
Suggest mother to
mobilisation, eat, and drink,
medication.

Baby rooming in:

PR:148
RR: 52
T: 36,4