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22 January 2009
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1.
CTH
Time
Assesment
Patient refered by PKM lingsar (dr Putu Sugiartha) with G1P0A0H0 40 Weeks/S/L/IU head presentation + neglected labor chronologis : 06.30 (22-1-09) Patient confess abdominal discomfort . Examination in PKM: General status: well BP: 120/80 mmHg RR: 22 x/mnt PR: 90 x/mnt t: 36,5C UFH: 32 cm FHB: 154 x/mnt 02.30 (22-1-09) VT: DC 2 cm eff 20 % AM(+), head palpable, descensus HI, umbilical cord or small part of fetal unpalpable, 06.30 (22-1-09) VT: DC 3 cm, eff 30 % AM(+), head palpable, descensus HII, umbilical cord or small part of fetal unpalpable, 11.30 (22-1-09) VT: DC 6 cm, eff 60 %, AM(+), head palpable, descensus HII, umbilical cord or small part of fetal unpalpable, 15.30 (22-1-09) VT: DC complete, eff 100 % AM(-), head palpable, descensus HIII, umbilical cord or small part of fetal unpalpable, Tx: IVFD RL injection ampicilin Obstetric history: 1.This
G1P0A0H0 A/S/L/IU head presentation neglected in 2nd stage of labor + fetal disstres.
LMP : forgot
Time
18.00
Subject
abdominal discomfort(+)
Object
General condition: weak BP: 120/80 mmHg FHB: 16-16-17
Assesment
G1P0A0H0 A/S/L/IU head presentation neglected in 2nd stage of labor + fetal disstres.
Planning
Skin test cefotaxim (-) Injection cefotaxim 2 gram Applied douer catheter
19.00
19.30
Baby was born, male, AS: 7-9, W: 3400 g, caput (+), AF clear, placenta complete.
21.30
General status:well BP:110/70 mmHg PR: 84x/mnt UC: well Bleeding (-)
CTH
Time
Assesment Menorhagia + anemia
Patient came to emergency care unit with mensturasi day 7. mens contineu bleeding.involved 3 sarung per days.abdominal pain (-) Menstural history : reguler, once a month Family planning history: injection per 3 month for last 2 years Obstetric history: P7A0H6
Time
22.50
Object
Assesment
G2P1A0H1 38-39 weeks/S/L, breech presentation, 1st stage of labor active phase
Planning
Observation mother and fetal well being. Laboratory examination : DL, HBsAg Report to supervisor: advice : o Labor pervaginam.
23.10
Baby was born, female, AS: 7-9, W: 3000 g, L: 48 cm, kongenital anomali (-)
admited
: 23-01-09 : 00.00 pm
Object
Planning Observation mother and fetal well being. Test ampi Injection ampicillin 1 g/IV Laboratory examination : DL, HBsAg Report to supervisor: advice : purposed : induction with oxy drip. Advice: agreed
12.50
Patient refered from PKM Teratak with G2P0A1 A/S/L +PROM chronologis : Pasient confess watery vaginal discharge since 01.00 pm (21-1-09) + Abdominal discomfort (+), fetal movement (+). Then she went to PKM teratak at 09.30 pm. From PKM teratak, patient refered to RSU Praya at 10.00 pm . Because at RSU Praya, patient refered to RSU mataram Therapy from PKM teratak -Infus RL -Amoxilin 3x1 gr/IV
General status : General condition: well, Conciousness: CM BP: 120/80 mmHg RR: 30 x/mnt Pulse :90 x/mnt T: 37,1 C Eyes : an(-) ikt (-) Cor -Pulmo : in normal range Obstetric status : L1 : breech L2 : left back L3 : head L4 : was pelvic inlet 4/5 UFH 29 cm EFW : 2790 g UC : (+) 2x/1020-30 Fetal Heart Beat : 10-11-10 Inspection : active bleeding (+) VT : P 1 cm, eff 25% AM (-), clear, head palpable, denom unclear, descend H1, small organ and umbilical cord unpalpable. Pelvic evaluation : Spina ischiadica: unpalpable Coxigis: mobile Distansia tuberum: >90
LMP: forgot ANC : routine in posyandu + puskesmas, last ANC at 21-01-09 Obstetric history: 1. Abortus 2. This
Time
Subject
Object
Assesment
Planning
planing
Bishop score: 5 Dilatation cervix: 0 Length of cervix: 1 Station: 1 Consistensi: 2 Position of cervix: 5
FHB : 10-11-10 UC (+) : 2x/1010-20
01.30 am
Start drip oxytocin 8 drop/mnt Observation mother fetal wellbeing drip oxytocin 12 drop/mnt Observation mother fetal wellbeing drip oxytocin 16 drop/mnt Observation mother fetal wellbeing drip oxytocin 20 drop/mnt Observation mother fetal wellbeing drip oxytocin 20 drop/mnt Observation mother fetal wellbeing
02.00 am
02.30 am
03.00 am
03.30 am
Time
Subject
Object
Assesment
Planning
04.00 am
04.30 am
05.00 am
FHB : 11-11-11 UC (+) : 4x/1050 VT: P 7 cm. eff 75%, AM (-) clear, head palpable, denom fontanella minor , descend HII
G2P0A1 H0 A/T/H Active phase II stage of labor + history of watery vaginal discharge
03.00 am
Start drip oxytocin 8 drop/mnt Observation mother fetal wellbeing drip oxytocin 12 drop/mnt Observation mother fetal wellbeing
03.30 am
Time
Subject
Object
Assesment
Planning
Time
Subject
Object
Assesment
Planning
Time
Subject
Object
Assesment
Planning