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27-10-09 11.30 Patient reffered from Pringgerate PHC with G2P1A1L1 43-44 weeks/S/L/IU postterm pregnancy. she felt abdominal pain rarely, bloody show (-), watery vaginal discharge (-), fetal movement (+). History of DM and HT (-). LMP : 16-12-2008 EDD : 23-09-2009 Obstetric status : 1.Aterm, 3500, male, Spt., TA, 8 years 2.This History of family planing : Plan of family planing : IUD
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General status : General condition: good, Conciousness: CM BP: 120/80mmHg RR: 24x/mnt Pulse :84 x/mnt T: 36,5 C Eyes : an(-) ikt (-) Cor -Pulmo : in normal range Abdomen : in normal range Obstetric status : L1 : breech, UFH : 36cm, EFW : 3875g L2 : left back L3 : head L4 : was in pelvic inlet 4/5 UC : (-) CTG : patologis with baseline 180, decelerasi 124, accelerasi 184 VT: 1cm, eff 10 %, AM (+), head palpable, denom unclear , descend HI, unpalpable small organ and umbilical cord.
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G2P1A1L1 43-44 weeks/S/L/IU postterm pregnancy
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1. 2. obs. Mother and fetal well being Advise from polyclinic : induction with oxytocin Report to supervisor : advise SC
3.
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Laboratory result: Blood : HBsAg (-) HB = 11,1 gr% WB = 10.000 PLT = 166.000 HCT = 30,3
12.00 12.30
12.50
SC begun
S 13.03
O Intraoperative : 1. Baby was born male, weight 3800g, length 54 cm, AS 7-9. anus (+), nuchal cord (-), 2. Placenta was born complete,weight 500 g, length 50 cm 3. Hemorrage : 200cc 4. Insertion IUD General status : well BP : 110/60 mmHg PR : 80 x/mnt RR : 20 x/mnt UC : good UFH : 2 cm below umbilical General status : well BP : 110/70 mmHg PR : 84 x/mnt RR : 18 x/mnt UC : good UFH : 2 cm below umbilical
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G2P1A1L1 43-44 weeks/S/L/IU postterm pregnancy
15.00
2 hours post SC
28-10-09 06.30