mornign report obstetri 4

Morning Report

G2P0A1H0, 39 – 40 wk S/A/IU with PROM > 12 hours

Time Subject Object Assessment Planning

Chronology (24/12/2012, 21.20,in Narmada PHC):

S: Patient gestation 9 month came to Narmada PHC confessed Rupture of membrane(+) since 09.30 (24/12/2012). (+). Abdominal pain ( -). Blood slim (+). FM (+).

LMP : 23/08/2012

O: General status : GC well, con. CM, BP 120/70mmHg, PR 80 x/minute, RR 22 x/minute, T 36,5 ºC.

Obstetric status: L1: breech TFU: 35 cm EFW: 3756 gram L2 : back on the left L3 : head L4 : 4/5UC : 1x/10’-20”FHR : 11-11-12 (136x/mnt)VT : Ø 1 cm, eff. 10 %, Amnion

(-) clear, head palpable, denom: unclear, ↓HI.

A: G3P2A0H1 A/S/L/IU head presentation latent phase 1st stage of labor

- P: - Obs. Mother and fetal well being.

- Obs. Progress of labor.- Give parecetamol 3 x 500 mg

+ amoxicillin 3 x 500 mg

Lab result at 11.33 25/12/2012:Hb = 10,4 g/dlRbc = 3,98Leu = 10,04Plt = 334Hct = 32,1%HbSAg = (-)

Time Subject Object Assessment Planning

25-12-201201.02 pm

05.20 pm

O: General status : GC well, con. CM, BP 120/70mmHg, PR 80 x/minute, RR 22 x/minute, T 36,5 ºC.

UC : 1x/10’-20”FHR : 11-12-12 (140x/mnt)VT : Ø 1 cm, eff. 10 %, Amnion

(-) clear, head palpable, denom: unclear, ↓HI.

A: G3P2A0H1 A/S/L/IU head presentation latent phase 1st stage of labor

P: - Obs. Mother and fetal well being.

- Obs. Progress of labor.

General status : GC well, con. CM, BP 120/70mmHg, PR 80 x/minute, RR 22 x/minute, T 36,5 ºC.

UC : 1x/10’-20”FHR : 11-11-12 (136x/mnt)VT : Ø 1 cm, eff. 10 %, Amnion

(-) clear, head palpable, denom: unclear, ↓HI.

A: G3P2A0H1 A/S/L/IU head presentation latent phase 1st stage of labor

P: - Obs. Mother and fetal well being.

- Obs. Progress of labor.

Lab result at 12.00, 08/06/2012:Hb = 11,9 g/dlRbc = 4,19Leu = 12,6Plt = 350Hct = 39,3%HbSAg = (-)

Time Subject Object Assessment Planning

09.20 pm

O: General status : GC well, con. CM, BP 110/60mmHg, PR 80 x/minute, RR 22 x/minute, T 36,5 ºC.

UC : 1x/10’-10”FHR : 11-11-12 (136x/mnt)VT : Ø 1 cm, eff. 10 %, Amnion

(-) clear, head palpable, denom: unclear, ↓HI.

A: G3P2A0H1 A/S/L/IU head presentation white rupture of membrane > 12 h

P: - Obs. Mother and fetal well being.

- Obs. Progress of labor.- IV RL 1 flas- Injection ampicillin 1 gram /

IV- Referred to GH NTB.

Lab result at 12.00, 08/06/2012:Hb = 11,9 g/dlRbc = 4,19Leu = 12,6Plt = 350Hct = 39,3%HbSAg = (-)

Time Subject Object Assessment Planning

12.00

13.00

14.00

16.40

General status : GC well, con. CM, BP 120/80mmHg, PR 86 x/minute, RR 20 x/minute, T 37,3 ºC.UC : -FHR : 13-12-12 (148x/mnt)

General status : GC well, con. CM, BP 120/80mmHg, PR 80 x/minute, RR 20 x/minute, T 36,7 ºC.UC : -FHR : 12-12-12 (144x/mnt)

G2P0A1H0 39 – 40 wk S/L/IU with PROM > 12 hours.

G2P0A1H0 39 – 40 wk S/L/IU with PROM > 12 hours.

DM pro termination with oxytosin drip and SPV no answer.

- Observation began- DM co SPV result CTG and SPV require result CTG via MMS.

- IV D5 set- co repeatedly to SPV result CTG via MMS.

DM pro termination with oxytosin drip SPV advice to acc drip Oxytocin.

Time Subject Object Assessment Planning

16.45(at DR Teratai)

17.15

17.45

18.15

18.45

19.15

19.45

20.15 Patien complien to delivary

UC : -FHB : 12.12.12 (144 x/minute)

UC: 2 x 10” – 20’’FHB: 13.14.14 (164x/minute)

UC: 2 x 10” – 25”FHB: 13.14.14 (164x/minute)

UC: 4x/10’ ~ 30“FHB: 13.13.12 (152x/minute)

UC: 4x/10’ ~ 35“FHB: 13.13.13 (156x/minute)

UC: 4x/10’ ~ 45“FHB: 13.13.13 (156x/minute)

UC: 4x/10’ ~ 45“FHB: 13.12.13 (152x/minute)

UC: 4x/10’ ~ 45“FHB: 12.12.12.(144x/minute)VT : Ø 4 cm, eff. 50 %, Amnion (-) clear, head palpable, denom: clear, ↓HI.

PROM > 12 hours.

G2P0A1H0, 39 – 40 wk S/A/IU with active phase 1st stage of labor

-CTG, result reactive, Oxytocin Drip.Drip Oxytocin (1st flash):-8 dpm

-12 dpm

-16 dpm

- 20 dpm

-24 dpm

-28 dpm

-28 dpm

-28 dpm

Time Subject Object Assessment Planning

20.45

21.15

21.45

22.15

22.45

23.15

23.45

00.15

- UC: 4x/10’ ~ 45“FHB: 13.13.13 (156x/minute)

UC: 4x/10’ ~ 45“FHB: 13.13.13 (156x/minute)

UC: 4x/10’ ~ 45“FHB: 13.13.13 (156x/minute)

UC: 4x/10’ ~ 45“FHB: 13.12.13 (152x/minute)

UC: 4x/10’ ~ 45“FHB: 13.12.13 (152x/minute)

UC: 4x/10’ ~ 45“FHB: 12.12.12.(144x/minute)

UC: 4x/10’ ~ 45“FHB: 12.12.12.(144x/minute)

UC: 4x/10’ ~ 45“FHB: 12.12.12.(144x/minute)VT : Ø 10 cm, eff. 100 %, Amnion (-) clear, head palpable, denom: clear, ↓HI.

2nd stage of labor.

-28 dpm

-28 dpm

-28 dpm

-28 dpm

-28 dpm

-28 dpm

-28 dpm

- 28 dpm

- 28 dpm

Time Subject Object Assessment Planning

00.30

13.30

Patient want to bearing down.

-

Seen head’s fetus out from vulva.

GC : wellBP : 130/80 mmHgPR : 96 bpmRR : 20 dpmTemp : 36,6°CUC : + UFH : 2 finger below umbilicus.Lochea: +

Baby rooming in:PR: 144 x/mntRR: 44 x/mntT: 36,3 °C

2nd stage of labor.

2 hours post partum

-Lead mother to bearing down

Amnion fluid: clear

Baby was born (16.42). Male. 3500 gram. 50 cm, AS 7-9. Anus (+). Congenital anomaly (-).

Placenta was born spontan. Complete. ± 300gram.

Leukia ± 400ccPerineum laseration ( + )

-Obs. Mother and baby well being.-CIE mother to eat and drink.-Suggest mother to breast feeding.

Time Subject Object Assessment Planning

08/06/1207.00

- GC : wellBP : mmHgPR : bpmRR : dpmTemp : °CUC : + UFH : 2 finger below umbilicus.Lochea: +

Baby rooming in:PR: 130 x/mntRR: 36 x/mntT: 34,4 °C

1st day post partum -Obs. Mother and baby well being.- CIE mother to mobilization, eat and drink.-Suggest mother to breast feeding.