PATIENT IDENTITY
Name
Age
Address
Admitted
: Mrs. R
: 20 yo
: Lengkot
: March, 20th 2014 at 04.30 pm
TIME
SUBJECTIVE
20/03/
2014
Patient
referred
from
Narmada PHC with G1P0A0
39 40 weeks S/L/IU with
PROM + preeclampsia.
Patient confessed water
came out from her vagina
since
11.30
pm
(19/03/2014).
Abdominal
pain (-), bloody slim (-), fetal
movement (+).
General status:
GC: well
GCS: E4V5M6
BP: 140/90 mmHg
PR: 88 bpm
RR: 22 rpm
T: 37,80 C
History of ANC : 9x
Last
ANC:
20/02/2014,
result: BP: 120/80 mmHg,
40-41 wk, FHB (+), UFH: 30
cm
Obstetrical status:
L1: breech
L2: back on the left side
L3: head
L4: 4/5
UFH: 31 cm
EFW: 3100 g
UC: FHB: 12-12-13(148x/min)
04.30
pm
OBJECTIVE
ASSESTMENT
G1P0A0 39
40 weeks
S/L/IU head
presentation
with
PROM>12h +
gestational
hypertension
PLANNING
Obs mother & fetal
well being
DM co to GP pro
induction with drip
oxy if PROM>12 h,
GP advice :
Pro CTG
Continue Antibiotic
Ampicilin inj 1 gr/
12 h
Paracetamol tab 3
x 500 mg
TIME
SUBJECTIVE
History of USG : History of Family Planning: Next
Family
Planning:
injection
History of obstetry:
1.This
Chronologist :
Narmada PHC
20/03/2014
S/
Patient confessed water
came out from her vagina
since 11,30 pm
(19/03/2014). Abdominal
pain (-), bloody slim (-), fetal
movement (+).
O/
General status:
GC: well
GCS: E4V5M6
BP: 140/100 mmHg
PR: 90 bpm
RR: 24 rpm
T: 36,50 C
OBJECTIVE
VT : 1 cm, eff 25%, amnion
(-), head presentation, denom
unclear, HI, smallest part of
fetal
or
umbilical
cord
unpalpable
PS: 6
Servic dilatatiion: 1cm (1)
Servic length:1cm (2)
Station: mid (1)
Consistency: average(1)
Potition : -2cm (1)
PE:
Promontorium
unpalpable,
spina ischiadika not prominent,
os coccygeous mobile, pubic
arch >90
Lab Result
Hb : 9,9 x 106/ L
WBC : 9,73 x 103/ L
PLT : 396 x 103/ L
HCT : 30,9%
Proteinuria (-)
HBsAg : (-) non reactive
ASSESTMENT
PLANNING
TIME
SUBJECTIVE
Status Obstetric
L1 : head
L2 : back on the left side
L3 : breech
L4 : 4/5
UFH : 31 cm
EFW : 3100 gram
FHR : 12-11-12, reguler
(140bpm)
UC : VT : 1 cm, eff 25 %, amnion (-)
clear,
head
palpable
H1,
denominator unclear, impalpable
small part and umbilical cord.
Lab examination:
Protein in urine : +1
A/
G1P0A0 39 40 weeks S/L/IU
general condition of mother and
fetus well with PROM > 12h +
preeclampsia.
P/
-KIE patient and family to referred
to GH NTB
-IVFD RL 20 tpm
-Inj. Ampicillin 1 gr/ 12h
-Referred to GH NTB
OBJECTIVE
ASSESTMENT
PLANNING
TIME
06.00
pm
SUBJECTIVE
OBJECTIVE
ASSESTMENT
PLANNING
Result of CTG:
DM co to GP result
of CTG, GP advice
rehidration
intrauterine
CTG again after
RIU
06.30
Rehidration
intrauterine IVFD
RL:Dex 5 % 2:1
TIME
08.00
pm
SUBJECTIVE
-
OBJECTIVE
GC: well
GCS: E4V5M6
BP: 140/90 mmHg
PR: 88 bpm
RR: 22 rpm
T: 36,70 C
UC: FHB: 12-12-12
(144x/min)
ASSESTMENT
G1P0A0 39
40 weeks
S/L/IU head
presentation
with
PROM>12h +
gestational
hypertention
PLANNING
Pro CTG
DM co result GP,
GP
advice
observation
4
hours, repeat CTG
TIME
12.00
pm
SUBJECTIVE
-
OBJECTIVE
GC: well
GCS: E4V5M6
BP: 130/90 mmHg
PR: 88 bpm
RR: 22 rpm
T: 36,70 C
UC: FHB: 12-12-12
(144x/min)
ASSESTMENT
G1P0A0 39
40 weeks
S/L/IU head
presentation
with
PROM>12h +
gestational
hypertension
PLANNING
Pro CTG
Co to GP, CTG
normal,
observation.
TIME
21/03/
14
05.30
am
SUBJECTIVE
OBJECTIVE
GC: well
GCS: E4V5M6
BP: 140/90 mmHg
PR: 88 bpm
RR: 22 rpm
T: 36,70 C
UC: FHB: 12-12-12 (144x/min)
ASSESTMENT
G1P0A0 39
40 weeks
S/L/IU head
presentation
with
PROM>12h +
gestational
hypertension
PLANNING
Obs. Mother and
fetal well being
Pro CTG
DM co to GP, GP
advice pro co to
SPV at morning.
TIME
SUBJECTIVE
08.00
am
09.30
am
OBJECTIVE
GC: well
GCS: E4V5M6
BP: 140/90 mmHg
PR: 88 bpm
RR: 22 rpm
T: 36,70 C
UC: FHB: 12-12-12 (144x/min)
ASSESTMENT
G1P0A0 39
40 weeks
S/L/IU head
presentation
with
PROM>12h +
gestational
hypertension
PLANNING
DM co to GP, GP
co to SPV, SPV
advice pro USG
USG result:
SPV advice drip
oxytocin
CIE
to
family
about
condition
and next planning
to drip oxytocin
TIME
SUBJECTIVE
OBJECTIVE
ASSESTMENT
PLANNING
10.00
am
Flash 1st
Drip oxy began 8
dpm
10.30
am
11.00
am
11.30
am
Abdominal pain
GC: well
GCS: E4V5M6
BP: 140/90 mmHg
PR: 88 bpm
RR: 22 rpm
T: 36,70 C
UC: 2x10 ~25
FHB: 12-12-12 (144x/min)
VT : 3 cm, eff 25%, amnion
(-), head presentation, denom
unclear, head HI, smallest
part of fetal or umbilical cord
unpalpable.
G1P0A0 39
40 weeks
S/L/IU head
presentation
with history
ROM + laten
phase 1st stage
of labor +
gestational
hypertension
TIME
SUBJECTIVE
OBJECTIVE
ASSESTMENT
PLANNING
12.00
am
Abdominal pain
UC : 3x10 ~25
FHB : 12-12-12 (144 bpm)
12.30
pm
Abdominal pain
UC : 3x10 ~25
FHB : 12-11-12 (144 bpm)
01.00
pm
Abdominal pain
UC : 3x10 ~25
FHB : 12-12-12 (144 bpm)
01.30
pm
Abdominal pain
UC : 3x10 ~25
FHB : 12-11-12 (144 bpm)
02.00
pm
Abdominal pain
UC : 3x10 ~25
FHB : 12-12-12 (144 bpm)
02.30
pm
Abdominal pain
UC : 3x10 ~25
FHB : 12-11-12 (144 bpm)
03.00
pm
Abdominal pain
UC : 3x10 ~25
FHB : 12-12-12 (144 bpm)
TIME
SUBJECTIVE
OBJECTIVE
ASSESTMENT
G1P0A0 39
40 weeks
S/L/IU head
presentation
with history
ROM + active
phase 1st stage
of labor +
gestational
hypertension
PLANNING
03.30
pm
Abdominal pain
GC: well
GCS: E4V5M6
BP: 140/90 mmHg
PR: 88 bpm
RR: 22 rpm
T: 36,70 C
UC: 3x 10~35
FHB: 12-12-12 (144x/min)
VT : 6 cm, eff 75%, amnion
(-), head presentation, HII,
denom unclear, smallest part
of fetal or umbilical cord
unpalpable
04.00
pm
Abdominal pain
UC: 3x 10~35
FHB: 12-12-12 (144x/min)
04.30
pm
Abdominal pain
UC: 3x 10~35
FHB: 12-12-12 (144x/min
05.00
pm
Abdominal pain
UC: 3x 10~35
FHB: 12-12-12 (144x/min
05.30
pm
Abdominal pain
UC: 3x 10~35
FHB: 12-12-12 (144x/min
06.00
pm
Abdominal pain
UC: 3x 10~35
FHB: 12-12-12 (144x/min
TIME
SUBJECTIVE
OBJECTIVE
ASSESTMENT
PLANNING
06.30
pm
Abdominal pain
UC: 3x 10~35
FHB: 12-12-12 (144x/min)
07.00
pm
Abdominal pain
UC: 3x 10~35
FHB: 12-12-12 (144x/min)
07.30
pm
UC : 4x10 ~40
FHB : 12-12-12 (144 bpm)
VT: complete, eff 100%,
amnion (-), head presentation,
HII, denom unclear, smallest
part of fetal or umbilical cord
unpalpable.
08.10
pm
Inspection:
Bulging of perineum, opening
vulva, anus presure
G1P0A0 39
40 weeks
S/L/IU head
presentation
with 2nd stage of
labor +
gestational
hypertension
Conduct labor
08.20
pm
08.30
pm
MAK III
TIME
SUBJECTIVE
OBJECTIVE
ASSESTMENT
PLANNING
08.45
pm
Retentio uteri
08.50
pm
UC well
UFH 2 finger bellow umbilical
Active bleeding BP: 110/80 mmHg
Post Partum
09.05
pm
UC well
UFH 2 finger bellow umbilical
Active bleeding BP: 110/80 mmHg
15 minutes PP
09.20
pm
UC well
UFH 2 finger bellow umbilical
Active bleeding BP: 110/80 mmHg
30 minutes PP
09.35
pm
UC well
UFH 2 finger bellow umbilical
Active bleeding BP: 110/80 mmHg
45 minutes PP
TIME
SUBJECTIVE
OBJECTIVE
ASSESTMENT
PLANNING
09.50
pm
UC well
UFH 2 finger bellow umbilical
Active bleeding BP: 120/80 mmHg
1 hour PP
10.20
pm
UC well
UFH 2 finger bellow umbilical
Active bleeding BP: 120/80 mmHg
1 hour 30
minutes PP
10.50
pm
UC well
UFH 2 finger bellow umbilical
Active bleeding +
BP: 110/80 mmHg
2 hours PP +
HPP ec Rest
placenta
Exploration uteri
Continue drip oxy 2
amp
30 minutes post
HPP
UC well
UFH 2 finger bellow umbilical
Active bleeding BP: 120/80 mmHg
Lab Result
Hb : 9,7 x 106/ L
WBC : 26,92x 103/ L
TIME
07.00
pm
SUBJECTIVE
-
OBJECTIVE
Cons: well
GCS: CM
BP: 120/80 mmHg
PR: 84 bpm
RR: 20 rpm
T: 37,30 C
UC: (+) well
UFH: 2 finger below umbiliccal
Bleeding
Baby rooming in is normal.
HR : 148 bpm
RR : 54 bpm
Temp : 36,70C
ASSESTMENT
1 day post
partum
PLANNING
Obseation Mother
and baby well
being
Suggest mother eat
and drink
Suggest mother to
breast feeding.
Thank you