29-10-2012 ppi

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Name : Mrs. V

Age : 23 yo

Adress : PagesanganAdmitted : October, 28th2012 at 20.00

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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

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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

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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

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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


FHB : 12-11-12 (140 bpm)



FHB : 12-12-12 (144 bpm)



FHB : 11-12-12 (140 bpm)


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


Observe pervaginam

delivery usingpartograf


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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.

29-10-2012 ppi

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