29-10-2012 ppi
TRANSCRIPT
-
8/13/2019 29-10-2012 PPI
1/6
Name : Mrs. V
Age : 23 yo
Adress : PagesanganAdmitted : October, 28th2012 at 20.00
-
8/13/2019 29-10-2012 PPI
2/6
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
28/10/
2012
20.00
Patient referred from Permata
Hati clinic with G1P0A0L0 30-31
weeks S/L/IU head presentation
with latent phase 1st stage of
labor . Patient complaint
abdominal pain since 10.00(27/10/2012). History of rupture
of membrane (-), bloody slim (+)
since 10.00 (27/10/2012).
No history of DM, HT, asthma.
LMP : 01/04/2012
EDD : 08/01/2013
History of ANC : 3xLast ANC : (-)
History of USG : 1x
History of family planning : (-)
Next family planning :(-)
Obstetrical History :
I. Ini
Chronologist (-)
General Status
GC : well
Consciusness : CM
BP : 130/80 mmHg
PR : 112 bpm
RR : 24 bpm
T : 37 C
Eye : anemis (-/-), icteric (-/-)
Cor : S1S2single reguler, M (-), G (-)
Pulmo : vesikuler (+/+), wheezing (-
/-), ronkhi (-/-).
Abdomen : scar (-), striae (+), linea
nigra (+).Extremity : edema (-/-), warm acral
(+/+)
Obstetrical Status
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH : 33 cmEFW : 3410 g
UC :2x/10 ~ 25
FHB : 11-10-10 (124 bpm)
VT : 2 cm, eff 20%, amnion (+),
head palpable HI +, denominator
unclear, impalpable small part /
umbilical cord.
G1P0A0L0 40-41
weeks S/L/IU with
latent phase 1st
stage of labor and
gestational
hypertension
Observe pervaginam
delivery using
partograf
-
8/13/2019 29-10-2012 PPI
3/6
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
Pelvic Evaluation :
Spina ischiadica not prominent
Os coccigeous mobile
Pubic arch > 900
Lab Evaluation
HB : 8,6 g/dl
RBC : 5,39 M/dl
HCT : 31,1 %
WBC : 12,83 K/dl
PLT : 487 K/dl
HbSAg : (-)Proteinuria : (-)
13/08/
2012
00.00
Mother confessed water
came out from her womb
GC well
BP : 130/90 mmHg
PR : 80 bpm
RR : 20 bpm
T : 36oC
UC : 3x/10~30
FHB : 12-12-12(144 bpm)VT : 4 cm, eff 50%, amnion
(-), head palpable HI, denom
unclear, unpalpable small part /
umbilical cord.
G1P0A0 40-41
weeks S/L/IU head
presentation with
active phase 1ststage
of labor + ROM +
gestational
hypertension
Suggest mother lay to the
sideways, eat, and drink.
Observe pervaginam
delivery using partograf
Inj. Ampicilin 1 g/IV
-
8/13/2019 29-10-2012 PPI
4/6
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
13/08/
2012
04.00
Mother confessed abdominal
pain (+++)
GC : well
BP : 130/90 mmHg
PR : 80 bpmRR : 20 bpm
T : 36,7oC
UC : 3x/10~35
FHB : 13-12-12 (148 bpm)
VT : 4 cm, oedem on portio,
amnion (-), head palpable,
caput (+), HI, unpalpable
small part / umbilical cord.
G1P0A0 40-41 weeks
S/L/IU head
presentation witharrested active phase
1st stage of labor and
gestational
hypertension
Suggest mother lay to the
sideways, eat, and drink.
Observe pervaginamdelivery using partograf
DM co to SPV, pro
acceleration. Advice :
Rehydration and
evaluation 2 hours again
06.00 Mother confessed abdominal
pain (+++)
GC well
BP : 130/80 mmHg
PR : 82 bpm
RR : 20 bpm
T : 37oC
UC : 2x/10~25
FHB : 13-12-12 (148 x/min)
VT : 4 cm, oedem on portio,amnion (-), head palpable,
caput (+) H-II, unpalpable
small part / umbilical cord.
G1P0A0 40-41 weeks
S/L/IU head
presentation with
arrested active phase
1st stage of labor and
gestational
hypertension
DM co to SPV, advice :
acceleration with drip
oxytocin began 16 tpm
-
8/13/2019 29-10-2012 PPI
5/6
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
06.30 Abdominal pain (+) UC : 2x/10~25
FHB : 11-11-11(132 bpm)
Drip oxytocin began
16 tpm
07.00 Abdominal pain came and relieved UC : 3x/10~30
FHB : 12-11-11 (136 bpm)
Drip oxytocin 20 tpm
07.30 Abdominal pain came and relieved UC : 3x/10~30
FHB : 12-11-12 (140 bpm)
Drip oxytocin 24 tpm
08.00 Abdominal pain came and relieved UC : 3x/10~35
FHB : 12-12-12 (144 bpm)
Drip oxytocin 28 tpm
08.30 Abdominal pain came and relieved UC : 4x/10~40
FHB : 11-12-12 (140 bpm)
Drip oxytocin 32 tpm
Maintenance
09.00 Abdominal pain came and relieved
A : G1P0A0 40-41 weeks S/L/IU head
presentation with inpartu active phase 1ststage of labor + ROM
P :
Suggest mother lay to the sideways, eat,
and drink.
Observe mother and fetal well being
Observe progress of labor
GC well
BP : 140/90 mmHg
PR : 108 bpmRR : 22 bpm
T : 37oC
UC : 4x/10~35
FHB : 12-13-12 (148 bpm)
VT : 8 cm, oedem on
portio, amnion (-), head
palpable, caput (+), HI,
unpalpable small part /
umbilical cord.
G1P0A0 40-41
weeks S/L/IU
headpresentation with
arrested active
phase 1st stage
of labor and
gestational
hypertension
Drip oxytocin 32 tpm
Observe pervaginam
delivery usingpartograf
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
-
8/13/2019 29-10-2012 PPI
6/6
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
11.55 Baby was born
Spontan, female, BB 3500
g, PB 54 cm, AS 7-9, anus
(+), congenital anomaly (-),
Plasenta was born
Spontaneus, completed
Bleeding : 150 cc
Perineum Episiotomy (+)
14.00 GC : well
BP : 130/80 mmHg
PR : 88 bpm
RR : 20 bpm
T : 37o
CUC : (+) well
UFH : 2 finger below umbilicus
Active bleeding : (-)
2 hours post
partum
Observed mother and
baby well being.
Suggest mother to
mobilisation.
14/08/
2012
07.00
Delivery wound pain GC : well
BP : 110/80 mmHg
PR : 88 bpm
RR : 20 bpm
T : 36,40CUFH : 3 finger below umbilicus
UC : (+) well
Lochea rubra : (+)
Baby rooming in :
PR :144 bpm
RR : 46 bpm
T : 36,40C
One day post
partum
Observed mother and
baby well being
Suggest mother to
mobilisation, eat, and
drink, medication.