NAME/AGE : Mrs.

M/ 30Years old ADDRESS : Lape, Sumbawa

Admitted: 30/oct/09 at 07.00

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30oct-09 07.00 Patient referred from sumbawa GH with G2P1A0L1 39-40 weeks/S/L with APB susp.placenta previa. She confess vaginal bleeding since 07.00 (29-10-09), pain (-), watery vaginal discharge (-), fetal movement (+). History of DM and HT (-) LMP : 28-01-09 EDD : 04-11-09 Obstetric status : 1.Aterm, 3500 g, male, midwife, 7 years old 2. This Chronologist : 07.00 (29-10-09) Patient confess vaginal bleeding slightly and few minutes later vaginal bleeding turn out again about 100 cc and no pain. She came to midwife, and midwife referred her to Sumbawa GH 10.00 Patient at Sumbawa GH, referred to Mataram GH History of family planing : Plan of family planing : -

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General status : General condition: good, Conciousness: CM BP: 110/60mmHg RR: 24x/mnt Pulse :84 x/mnt T: 36,8 C Eyes : an(-) ikt (-) Cor -Pulmo : in normal range Abdomen : in normal range Obstetric status : L1 : breech, UFH : 27 EFW : 3240 g L2 : left back L3 : head L4 : wasnt in pelvic inlet UC : (-) FHR : 140 bpm VT: didnt do Lab result : Hb = 10,4 Leu = 11.300 Plt = 202.000 Hct = 31,1

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G2P1A0L1 39-40 weeks/S/L with APB susp. placenta previa

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1. 2. 3. 4. obs. Mother and fetal well being Lab examination: DL, HbsAg Infuss RL 28 dpm USG

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09.30

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General condition: good Conciousness: CM BP: 110/70mmHg RR: 24x/mnt Pulse :88 x/mnt T: 37 C FHR : 148 bpm USG : Fetal S/L/IU head presentation 35 weeks 3 days, male EDD : 01-12-09 Plasenta at corpus anterior until SBR (little part of plasenta close the OUI) Conclusion : plasenta previa marginalis

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G2P1A0L1 39-40 weeks/S/L with APB e.c placenta previa marginalis

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Report to supervisor : advise prepare to SC -Injection ampicilin 1 gr -DC

11.10

G2P0A0L1 39-40 weeks/S/L with APB e.c placenta previa marginalis Intraoperative : Placenta at corpus anterior until SBR with hematoma part of placenta Amniotic fluid clear

SC begun

11.20

Baby was born male, weight 2900g, length 45 cm, AS 79, anus (+), Placenta was born complete,weight 500 g, length 50 cm Hemorrage : 250cc

S 11.40

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G2P0A0L1 39-40 weeks/S/L with APB e.c placenta previa marginalis

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13.40

General status : well BP : 110/60 mmHg PR : 80 x/mnt RR : 20 x/mnt UC : good UFH : 2 fingers below umbilical General status : well BP : 110/70 mmHg PR : 84 x/mnt RR : 18 x/mnt UC : good UFH : 2 fingers below umbilical Operation wet : still wet
Lab result : Hb = 8,5 Leu = 8200 Plt = 156.000 Hct = 26,0

2 hours post SC

Baby admitted to NICU Observation mother well being KIE to eat and drink if not nausea or vomitting

07.00

1st day post SC

Observation mother well being KIE to eat and drink KIE to give the baby mother feeding