Name : Mrs. V Age : 23 yo Adress : Pagesangan Admitted : October, 28th 2012 at 20.

00

TIME 28/10/ 2012 20.00

SUBJECTIVE Patient referred from Permata Hati clinic with G1P0A0L0 30-31 weeks S/L/IU head presentation with latent phase 1st stage of labor . Patient complaint abdominal pain since 10.00 (27/10/2012). History of rupture of membrane (-), bloody slim (+) since 10.00 (27/10/2012). No history of DM, HT, asthma. LMP : 01/04/2012 EDD : 08/01/2013 History of ANC : 3x Last ANC : (-) History of USG : 1x History of family planning : (-) Next family planning :(-) Obstetrical History : I. Ini

OBJECTIVE General Status GC : well Consciusness : CM BP : 130/80 mmHg PR : 112 bpm RR : 24 bpm T : 37 C Eye : anemis (-/-), icteric (-/-) Cor : S1S2 single reguler, M (-), G (-) Pulmo : vesikuler (+/+), wheezing (/-), ronkhi (-/-). 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 : 33 cm EFW : 3410 g UC :2x/10 ~ 25 FHB : 11-10-10 (124 bpm) VT : 2 cm, eff 20%, amnion (+), head palpable H I +, denominator unclear, impalpable small part / umbilical cord.

ASSESSMENT G1P0A0L0 40-41 weeks S/L/IU with latent phase 1st stage of labor and gestational hypertension

PLANNING Observe pervaginam delivery using partograf

Chronologist (-)

TIME

SUBJECTIVE

OBJECTIVE Pelvic Evaluation : Spina ischiadica not prominent Os coccigeous mobile Pubic arch > 900 Lab Evaluation HB : 8,6 g/dl RBC : 5,39 M/dl HCT : 31,1 % WBC : 12,83 K/dl PLT : 487 K/dl HbSAg : (-) Proteinuria : (-)

ASSESSMENT

PLANNING

13/08/ 2012 00.00

Mother confessed water came out from her womb

GC well BP : 130/90 mmHg PR : 80 bpm RR : 20 bpm T : 36oC UC : 3x/10~30 FHB : 12-12-12(144 bpm) VT : 4 cm, eff 50%, amnion (-), head palpable HI , denom unclear, unpalpable small part / umbilical cord.

G1P0A0 40-41 weeks S/L/IU head presentation with active phase 1st stage of labor + ROM + gestational hypertension

Suggest mother lay to the sideways, eat, and drink. Observe pervaginam delivery using partograf Inj. Ampicilin 1 g/IV

TIME 13/08/ 2012 04.00

SUBJECTIVE Mother confessed abdominal pain (+++)

OBJECTIVE GC : well BP : 130/90 mmHg PR : 80 bpm RR : 20 bpm T : 36,7oC UC : 3x/10~35 FHB : 13-12-12 (148 bpm) VT : 4 cm, oedem on portio, amnion (-), head palpable, caput (+), HI, unpalpable small part / umbilical cord. GC well BP : 130/80 mmHg PR : 82 bpm RR : 20 bpm T : 37oC UC : 2x/10~25 FHB : 13-12-12 (148 x/min) VT : 4 cm, oedem on portio, amnion (-), head palpable, caput (+) H-II, unpalpable small part / umbilical cord.

ASSESSMENT G1P0A0 40-41 weeks S/L/IU head presentation with arrested active phase 1st stage of labor and gestational hypertension

PLANNING Suggest mother lay to the sideways, eat, and drink. Observe pervaginam delivery using partograf DM co to SPV, pro acceleration. Advice : Rehydration and evaluation 2 hours again

06.00

Mother confessed abdominal pain (+++)

G1P0A0 40-41 weeks S/L/IU head presentation with arrested active phase 1st stage of labor and gestational hypertension

DM co to SPV, advice : acceleration with drip oxytocin began 16 tpm

TIME 06.30 07.00 07.30 08.00 08.30 09.00

SUBJECTIVE Abdominal pain (+) Abdominal pain came and relieved Abdominal pain came and relieved Abdominal pain came and relieved Abdominal pain came and relieved Abdominal pain came and relieved A : G1P0A0 40-41 weeks S/L/IU head presentation with inpartu active phase 1st stage of labor + ROM P: Suggest mother lay to the sideways, eat, and drink. Observe mother and fetal well being Observe progress of labor

OBJECTIVE UC : 2x/10~25 FHB : 11-11-11(132 bpm) UC : 3x/10~30 FHB : 12-11-11 (136 bpm) UC : 3x/10~30 FHB : 12-11-12 (140 bpm) UC : 3x/10~35 FHB : 12-12-12 (144 bpm) UC : 4x/10~40 FHB : 11-12-12 (140 bpm) GC well BP : 140/90 mmHg PR : 108 bpm RR : 22 bpm T : 37oC UC : 4x/10~35 FHB : 12-13-12 (148 bpm) VT : 8 cm, oedem on portio, amnion (-), head palpable, caput (+), HI, unpalpable small part / umbilical cord.

ASSESSMENT

PLANNING Drip oxytocin began 16 tpm Drip oxytocin 20 tpm Drip oxytocin 24 tpm Drip oxytocin 28 tpm Drip oxytocin 32 tpm Maintenance

G1P0A0 40-41 weeks S/L/IU head presentation with arrested active phase 1st stage of labor and gestational hypertension

Drip oxytocin 32 tpm Observe pervaginam delivery using partograf

TIME 11.55

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING Baby was born Spontan, female, BB 3500 g, PB 54 cm, AS 7-9, anus (+), congenital anomaly (-), Plasenta was born Spontaneus, completed Bleeding : 150 cc Perineum Episiotomy (+)

14.00

GC : well BP : 130/80 mmHg PR : 88 bpm RR : 20 bpm T : 37oC UC : (+) well UFH : 2 finger below umbilicus Active bleeding : (-)

2 hours post partum

Observed mother and baby well being. Suggest mother to mobilisation.

14/08/ 2012
07.00

Delivery wound pain

GC : well BP : 110/80 mmHg PR : 88 bpm RR : 20 bpm T : 36,40C UFH : 3 finger below umbilicus UC : (+) well Lochea rubra : (+)
Baby rooming in : PR :144 bpm RR : 46 bpm T : 36,40C

One day post partum

Observed mother baby well being Suggest mother mobilisation, eat, drink, medication.

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