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2.
3.
Bleeding Antepartum
4.
3
1
1
Name
: Mrs. Hetty
Admitted
Age
: 32 years
Time
21.35 WITA
Address
: Karang Sukun
Time
Subject
Object
Assesmen
t
Planning
21.35
General status :
General condition : well
Consiousness : E4V5M6
BP : 110/60 mmHg
Pulse : 88/mnt
RR : 20 x/menit
T : 36.5 C
Eye : an -/- ikt -/Cor & Pulmo :
in normal
range
G2P1A0 38
weeks/S/L/IU
with PROM
observation mother
and fetal well being
Cronologist :
patient came to ECU with watery
vaginal discharge since 20.00
(16/4/09) She feel abdominal
dissomfort (+) bloody show (+),
fetal movement (+), active.
Examination
(-)
in ECU mataram
Obstetrical status :
L1 : breech UFH : 29 cm
L2 : right back
L3 : head
L4: wasnt enter the pelvic
inlet. 5/5
EFW : 2635g
Uterine contraction = (-)
FHB = 12-12-13
VT : 1 cm, eff 10%,
amniotic
membrane
(-),
clear, head presentation,
denom unclear, H I, small
part organ /umbilical cord
wasnt palpatet
Lab:
Hb= 10,5 gr%
Leu= 11.900 /mm3
Tromb= 348.000 /mm3
HCT= 3
HBsAg (-)
22.35
Observation mother
and fetal well being
02.35
Observation mother
and fetal well being
04.35
Observation mother
and fetal well being
06.35
Observation mother
and fetal well being
08.00
G2P1A0 38
weeks/S/L/IU with
PROM > 12 hours
Observation mother
and fetal well being
CTG =
Report to supervisor :
Propose:
induction
with drip oxytocin
Propose : aggreed
Start drip oxy 8
drop/mnt
General condotion :
well
UC : (-)
FHR : 12-12-13
Observation mother
fetal well being
Elevate
drip
oxy
drop/mnt
.00
General condotion :
well
UC : (-)
FHR : 12-12-11
19.30
General condition :
well
UC : (+) 1x/10- 20
FHR : 12-12-12
Observation mother
fetal well being
Elevate
drip
oxy
drop/mnt
and
General condition :
well
UC : (+) 2-3x/1030
FHR : 12-12-12
Observation mother
fetal well being
Elevate
drip
oxy
drop/mnt
and
General condition :
well
UC : (+) 3x/10-35
FHR : 12-12-11
Observation mother
fetal well being
Elevate
drip
oxy
drop/mnt
and
20.00
20.30
Abdominal discomfort
(+)
Abdominal discomfort
(+)
and
12
20
24
28
21.00
Abdominal discomfort
(+)
General condition :
well
UC : (+) 3x/10-45
FHR : 12-11-12
21.30
Abdominal discomfort
>>
General condition :
well
UC : (+) 3x/10-45
FHR : 12-12-13
22.00
Abdominal discomfort
>>
General condition :
well
UC : (+) 3x/10-45
23.00
Abdominal discomfort
>>
23.30
Abdominal discomfort
>>
00.00
Abdominal discomfort
>>
00.30
Abdominal discomfort
>>
01.00
Abdominal discomfort
>>
01.30
Abdominal discomfort
>>
02.00
Abdominal discomfort
>>
G1P0A0 37
weeks/S/L/IU with
PROM > 12 hours
03.00
03.10
Abdominal discomfort
>>
Mother
want
to
bearing down
Abdominal discomfort
>>>
Mother
want
to
bearing down
teknus
G1P0A0 37
weeks/S/L/IU 2nd
stage of labor
perjol
03.20
03.30
04.30
05.30
Observation vital
hemorrhagic sign
sign
&
Name
: Mrs. Yuhana
Admitted
Age
: 21 years
Time
16.15
Address
: Sandik
Time
Subject
Object
Assesmen
t
Planning
16.15
General status :
General condition : well
Consiousness : E4V5M6
BP : 110/70 mmHg
Pulse : 80/mnt
RR : 22 x/menit
T : 36,3 C
Eye : an -/- ikt -/Cor & Pulmo :
in normal
range
observation mother
and fetal well being
Obstetrical status :
L1 : breech UFH : 33 cm
L2 : left back
L3 : head
L4: was enter the pelvic
inlet 4/5
EFW : 3410g
Uterine contraction = (-)
FHB = 12-12-11
VT :
(-), head
presentation
Spina
ischiadika
isnt
prominent, concavity
os
sakrum is enough, os coxygis
mobile, arcus pubis >90.
Lab :
Laboratory
test
(DL,HBsAg)
CTG baseline 125160
Report
to
supervisor
,
proposed : pro USG
tomorrow morning
proposed aggreed.
Name / Age
CTH
Address
: Batu Layar
Time
: 04.15
Time
04.15
Subject
Object
General status :
General condition: well,
Conciousness: CM
BP: 120/70 mmHg
RR: 22 x/mnt
PR: 88 x/mnt
T: 36,5 C
Eyes : an(-/-), ikt (-/-)
Cor -Pulmo : in normal range
Obstetric status :
L1 : breech, UFH : 20 cm
L2 : right back
L3 : head
L4 : wasnt enter pelvic inlet
EFW : 1240g
UC : (-)
Fetal Heart Rate : 12-11-12 x/mnt
VT : 1 cm, eff 10%, AM (-), clear,
head palpable, denom unclear, H I,
small part organ /umbilical cord wasnt
palpated.
chronologis :
Patient felt watery & bloody vaginal
discharge since 01.00.
Examination in ECU :
BP : 120/80 mmHg
Pulse : 88x/mnt
RR : 20 x/mnt
T : 36,5 C
UFH : 5 cm atas umbilicus
UC : (-)
FHR : 135x/mnt
VT : (-), remains amniotic fluid
Dx : G1P0A0 28 weeks S/L/IU +
PROM + bloody vaginal discharge
Patient sent to delivery rooms
Pelvic evaluation:
Promontorium unpalpable
Spina ischiadica: isnt prominent
Concavity os sacrum enough
Coxigis: mobile
Distansia tuberum: >90
Lab examination:
Hb : 12,5, Leu : 17.500
PLT : 485.000, HCT : 38,4
Assesment
G1P0A0 26-27
weeks/S/L/IU with
PROM
Planning
Observation mother
and fetal well being.
Laboratory
examination : DL,
HBsAg
Test ampi (-)
Inj ampi 1g/IV
Pro USG tomorrow
morning
Time
Subject
Object
Assesment
Planning
08.00
00.25
Conduct
mother
bearing down
00.30
to
Time
Subject
Object
01.30
02.30
07.00
Assesment
4th stage of labor
Planning
Observation vital sign &
hemorrhagic sign