Name: Mrs.

H J
Age: 31 yo
Adress: Narmada
Admitted: May, 27th 2012 at 22.55
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27/05/ Patient referred from Narmada PHC General status: G1P0A0L0 39 Obs mother & fetal
2012 with G1P0A0 38-39 weeks/T/H/IU GC: well weeks/S/L/IU well being
22.55 inpartu latent phase 1st stage of BP: 140/90 mmHg latent phase 1st DM co to SPV, advice:
labor with severe preeclampsia. PR: 88 bpm stage of labor with - Obs progress of labor
Patient confessed abdominal pain RR: 24 T: 36,2 gestational - Infus RL without
that spread to frank since 17.00 Eye : palor (-), icteric (-) hypertension MgSO4
(26/05/2012). Bloody slim (+). Thorax :
History rupture of membrane (-), FM Cor : S1S2 single reguler (murmur -),
(+). (gallop -)
No history of nausea, vomiting, Pulmo : vesikuler (+/+), wheezing (-/-),
headache, visual disturbance and Ronkhi (-/-).
epigastric pain. Abdomen : scar (-), striae (+), linea
No history of DM, HT, asthma. nigra (+)
Extremity : edema (-/-), warm acral
LMP: 27/08/2011 (+/+)
EDD: 04/06/2012
Obstetrical status:
History of ANC: >4x at PHC L1: breech
Last ANC: 27/05/2012 L2: back on the right side
History of USG: - L3: head
L4: 4/5
History of family planning: - UFH: 28 cm
Next family planning: Injection 3 EFW: 2635 g
months UC: 2x10 ~ 30
FHB: 12-12-13 (148 x/min)
Obstetrical history: VT: 3 cm, eff 25%, amnion (+), head
I. This palpable HI, denominator unclear,
impalpable small part / umbilical
cord.
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Chronologist: Lab:
At Polindes 21.00 (27/05/2012) HB: 11,9 g/dl
S: Patient confessed abdominal pain that RBC: 4,39 M/dl
spread to frank. WBC: 12,62 K/dl
O: PLT: 361 K/dl
GC: well SGOT: 16 mg/dl
BP: 160/110 mmHg SGPT: 12 mg/dl
PR: 80 bpm Creatinin: 0,6 mg/dl
RR: 20 T: 36,5 Ureum: 13 mg/dl
Head presentation, back on the right, 4/5 HbSAg: (-)
UFH: 29 cm Proteinuria: -
UC: +
FHB: 12-12-11 (140 x/min)
VT: 3 cm, eff 25%, amnion (+), head palpable
HI, impalpable small part / umbilical cord.
Proteinuria +2
A:
G1P0A0 38-39 weeks/T/H/IU inpartu latent
phase 1st stage of labor with severe
preeclampsia.
P:
Infus RL
MgSo4 40% bolus
Reffered to Narmada PHC
At Narmada PHC 21.45 (27/05/2012)
S: Patient confessed frank pain & lower
abdominal pain since 17.00 (27/05/2012) with
bloody slim (+). No history of nausea, vomiting,
headache, visual disturbance and epigastric
pain. FM (+).
O:
GC: moderate
BP: 160/110 mmHg
PR: 86 bpm
RR: 20 T: 36,4
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UFH: 28 cm
UC: 2 x 10~ 35
FHB: 12-12-11 (140 x/min)
22.00
VT: 3 cm, eff 25%, amnion (+), head palpable HI,
denominator unclear, impalpable small part / umbilical
cord.
A:
G1P0A0 38-39 weeks/T/H/IU inpartu latent phase 1st
stage of labor with severe preeclampsia.
P:
co to GP:
-MgSO4 40% 28 tpm
-Nifedipine 10 mg
reffered to NTB GH
28/05/ Patient confessed abdominal pain UC: 2x10 ~ 20
2012 FHB: 12-12-11 (140 x/min)
02.55 VT: 3 cm, eff 25%, amnion
(+), head palpable HI,
denominator unclear,
impalpable small part /
umbilical cord.
03.25 Patient confessed abdominal pain came & relieved UC: 2x10 ~ 30 G2P0A1L0 Obs mother &
FHB: 12-12-11 (140s x/min) A/S/L/IU with fetal well being
VT: 8 cm, eff 75%, amnion arrested active DM co to SPV,
(+), head palpable HI, phase 1st stage pro SC; SPV
denominator LOT, of labor. acc SC at
impalpable small part / 07.30
umbilical cord. Prepare SC at
06.30
- Insert DC
- Inj ampi 2 g IV
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09.50 SC began
Female, W : 2900 gram,
BL: 48 cm, AS 7-9
Anus (+), Congenital
anomali (-),
Plasenta was born
manually, complete
Bleeding 300 cc
11.50 GC: well Cons: CM 2 hours post SC Observed mother and
BP: 110/70 HR: 84 bpm baby well being
RR: 20 tpm T: 36 C Suggest mother to
UC: + mobilization.
UFH: at umbilicus
AB: -
29/05/ GC: well Cons: CM 1 day post SC Observed mother and
2012 BP: 110/80 HR : 82 bpm baby well being
07.00 RR : 20 tpm T : 36,2 C Suggest mother to
UFH : 1 finger below umbilicus mobilization, eat, and
UC : + drink, medication.
AB : -

Baby in NICU:
PR:144
RR: 46
T: 36,4