peb + vakum
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8/13/2019 PEB + Vakum
1/8
-Evaluate mother and fetal well
being
-Obs. VS
-Report to superviser for
planning VE,
-Advis : evaluate again and
report again
G1P0A0L0 A/S/L/IU
with head presentation +
negleted 2 nd stage of
labor + eclampsia +
history of watery vaginal
discharge+fetal
tachicardia
General condition : well
BP : 160/100 mmHg
Pulse : 80x/mnt
RR : 22x/ mnt
Temp : 37.5 C
UP : 45 cc/hr
FHR : 164x/mntUC : 2x/10-20
Headhache (+), epigastricpain (+), blur vision (-).Abdominal pain (+) rare
21.00
-Evaluate mother and fetal well
being
-Obs. VS
G1P0A0L0 A/S/L/IU with
head presentation + negleted
2 nd stage of labor +
eclampsia + history of watery
vaginal discharge+fetal
tachicardia
General condition : wellBP : 160/100 mmHgPulse : 88x/mntRR : 20x/mntTemp : 37. 8 CFHR : 168x/mnt
UC : 2x/10-20
Headhache (+), epigastricpain (+), blur vision (-).Abdominal pain (+) rare
20.30
-Evaluate mother and fetal well
being
-Obs. VS
-Nifedipin 10 mg p.o
G1P0A0L0 A/S/L/IU
with head presentation +
negleted 2 nd stage of
labor + eclampsia +
history of watery vaginal
discharge
General condition : well
BP : 160/100 mmHg
Pulse : 84x/mnt
RR : 22x/mnt
Temp : 37. 8 C
UP : 60 cc/hr
FHR : 148x/mnt
UC : 2x/10-20
Headhache (+), epigastric pain
(+), blur vision (-).
Abdominal pain (+) rare
20.00
-Evaluate was done but not
improve so report to superviser
again and propose SC
Proposed agreed
G1P0A0L0 A/S/L/IU
with head presentation +
negleted 2 nd stage of
labor + eclampsia +
history of watery vaginaldischarge
General condition : well
BP : 140/100 mmHg
Pulse : 80x/mnt
FHR : 150x/mnt
UC : 2x/10-20
Subjectiv complain (+)22.00
subect planningassesmentobjectTime
-
8/13/2019 PEB + Vakum
2/8
-SC begun at 23.10 wita
Baby was born with head presentation
and coiled placenta 2x : Male, 3200 gr,
length 49 cm, AS 7-9, anus (+)
Placenta complete, weight not
measure, AM green thick, little
amount.
23.00
-Evaluate VS of mother
-Evaluate Subjective complain
-Evaluate wound operation
-Evaluate UC
-Educate mother to breast
feeding
P1A0L1 with 4 th stage of
labor
General condition : well
BP : 150/100 mmHg Pulse : 84x/mnt
RR : 20x/mnt Tax: 37C
UC : good
Wound of operation : dry, bleeding (-),
UFH : 2 fbu
UP : 60 cc
00.30
headhache (-), epigastric pain
(+)
subect
-Evaluate mother and fetal well
being
-Obs. VS
1 day post SCGeneral condition : well
BP : 150/100 mmHg Pulse : 84x/mntRR : 20x/mnt Tax: 37CUC : goodWound of operation : dry, bleeding (-),
UFH : 2 fbuUP : 60 cc
06.00
-Prepare SCG1P0A0L0 A/S/L/IU
with head presentation +
negleted 2 nd stage of
labor + eclampsia +
history of watery vaginal
discharge
General condition : well
BP : 150/100 mmHg
Pulse : 80x/mn
Tax : 37.4 C
UC : 2x/10-20
22.30
planningassesmentobjectTime
P1A0L1 with 3 rd stage
of labor
-
8/13/2019 PEB + Vakum
3/8
Subjectiv complain (+)
VT : CD 4 cm, eff 50 %, AM (+),
head palpable, H2+,
small organ and
umbilical cord wasnt
palpable
History of obstetry:
1. thisLab :
Proteinuria (+)3
Therapy in kr taliwang PHC :
Infus RL
Nifedipine 10 mg sublingual
In VK :
Blur vision (+), epigastric pain (-),
headhache (+)
,
subect
-Evaluate mother and fetal
well being
-Obs. VS
G1P0A0L1 P/S/L/IU with HEAD
presentation +prolong active
phase 1 stage labor+ PEB
General condition : well
BP : 150/100 mmHg
Pulse : 80x/mnt
RR : 18x/ mnt
Temp : 36,4 C
UC : 3x/10-30
FHR : 140x/mnt
12.30
Pelvic evaluate :
Spina ischiadica not prominent
Os coxigeus mobile
Distansia tuberum >90
Hb : 15.0 gr%Leukosit : 11600
Hematorit : 36.9
trombosit :235000
HbSAg (-)
Proteinuria : (+)2
planningassesmentobjectTime
-
8/13/2019 PEB + Vakum
4/8
-Report to supervisor
-Proposed amniotomy, propose
agree
-Amniotic fluid : 30 cc, clear
G1P0A0L1 P/S/L/IU withHEAD presentation + prolongactive phase 1 stage labor+PEB
BP : 160/100 mmHg
Pulse : 76x/mnt
FHR : 130x/mnt
UC : 3x/10-35VT : CD 5 cm, eff 50 %, AM (+),
head palpable, H2+, small organ
and umbilical cord wasnt palpable
Subjectiv complain (+)16.00
-Evaluate mother and fetal well
being
-Obs. VS
-O2 5 lpm
-Resusitasi RL : D5% 2:1 max
drop
-Left lateral position
-CTG
G1P0A0L1 P/S/L/IU with
HEAD presentation +
prolong active phase 1
stage labor+ PEB
General condition : well
BP : 140/110 mmHgPulse : 84x/mntTemp : 36,7 CUC : 3x/10-35FHR : 118x/mnt
Subjective complain (+)16.30
Convulsi 3 minute
Subjectiv complain (+)
subect
-Bolus MgSo4 2 gr IVG1P0A0L1 P/S/L/IU with
HEAD presentation +
prolong active phase 1
stage labor+ eclampsia
17.00
-Evaluate mother and fetal well
being
-Obs. VS
G1P0A0L1 P/S/L/IU with
HEAD presentation + prolong
active phase 1 stage labor+
PEB
General condition : well
BP : 140/110 mmHg
Pulse : 84x/mnt
Temp : 36,7 C
UP : 70 cc/hr
FHR : 128x/mnt
UC : 3x/10-35
1430
planningassesmentobjectTime
-
8/13/2019 PEB + Vakum
5/8
-Evaluate mother
-Obs. VS
4 stage of laborGeneral condition : wellBP: 100/60 mmHgP: 88x /mRR:18x/mT : 36,9CUC : goodUFH = 2 finger belowumbilical
Subjectiv complain (+)20.10
Baby was born with vacuumextraction, male, AS : 3-5 , W: 3500 gr, caput + baby sentto NICU-Placenta was born,completed, spontaneouslyepisiotomi
P1A0L1 + 3 rd stage oflabor
General condition : well
BP : 140/100 mmHg
Pulse : 88x/mnt
UC 4x/10 40
Abdominal pain >>18.10
Report to supervisor
Proposed VE
Propose agree
G1P0A0L1 P/S/L/IU with
HEAD presentation 2 nd
stage of labor+ eklampsia
BP : 150/70 mmHg
Pulse : 84x/mnt
Temp : 37 C
UC : 4x/10 40
FHR : 128x/mntVT : CD complete, AM (-), head
palpable, H3+, small organ andumbilical cord wasnt palpable
Convulsi
Abdominal pain +
17.45
-Evaluate mother
-Obs. VS
1 day of VEBP : 100/60 mmHg
Pulse : 80x/mnt
Rr : 16 x/mnt T: 37
Active bleeding (-)
UC : good UFH : 2 fbu
Wound of episiotomi : bleeding
Subjectiv complain (+)07.00
subect planningassesmentobjectTime
-
8/13/2019 PEB + Vakum
6/8
-Evaluate mother
-Obs. VS
4 stage of laborGeneral condition : wellBP: 100/60 mmHgP: 88x /mRR:18x/mT : 36,9CUC : goodUFH = 2 finger belowumbilical
Subjectiv complain (+)20.10
Baby was born with vacuumextraction, male, AS : 3-5 , W: 3500 gr, caput + baby sentto NICU-Placenta was born,completed, spontaneouslyepisiotomi
Second stage of labor
Third stage of labor
General condition : well
BP : 140/100 mmHg
Pulse : 88x/mnt
UC 4x/10 40
Abdominal pain >>18.10
Report to supervisor
Proposed VE
Propose agree
G1P0A0L1 P/S/L/IU with
HEAD presentation +
eklampsia
BP : 150/70 mmHg
Pulse : 84x/mnt
Temp : 37 C
UC : 4x/10 40
FHR : 128x/mntVT : CD complete, eff 100 %, AM (-),
head palpable, H3+, small organand umbilical cord wasnt palpable
Convulsi
Abdominal pain +
17.45
-Evaluate mother
-Obs. VS
1 day of VEGeneral condition : well
BP : 100/60 mmHg
Pulse : 80x/mnt
Rr : 16 x/mnt
T: 37
Active bleeding (-)
Subjectiv complain (+)07.00
subect planningassesmentobjectTime
-
8/13/2019 PEB + Vakum
7/8
Obs. VS
Report superviser :
Uterotonika
antibiotika
Post partum day-13 with
HPP secunder e.c rest
placenta
General condition :weaknessBP : 100/50 mmHgPulse : 100/mntRR : 22x/mntTax : 37.8 C
Dizziness (+), weakness (+),
active bleeding (-)
22.00
General condition : moderate
BP : 100/50 mmHg
Pulse : 108x/mnt
RR : 20x/mnt
Tax : 37.8 C
Abdominal pain >>
Inspekulo in ER room :OUE CD (+), show tissue of
placenta (+)VT : OUE CD (+), palpabletissue of placenta,CUAF b/c 14-16APCD taaTherapy :
Double line infus RL maxdrop.Insert catheter
Dizziness (+), weakness (+)
Active bleeding (-)
-Drip oxytocin 1 amp in 500 cc
RL : 20 dpm
-Ampicillin 1 gr IV
-Obs. VS
22.15
subect planningassesmentobjectTime
21.00 Post partum day-13
with HPP secunder e.c
rest placenta
Obs. VS
Was infus 3000 cc
-
8/13/2019 PEB + Vakum
8/8
Obs. VS
Pro USG
4 Post partum day-13with HPP secunder e.crest placenta
General condition : moderateBP : 100/60 mmHgPulse : 92x/mntRR : 18x/mntTax : 37 C
Dizziness (+), active bleeding
(-) weakness (+)
07.00
Patient was sleep00.00-
06.00
Obs. VSPost partum day-13 with
HPP secunder e.c rest
placenta
General condition : moderateBP : 100/50 mmHgPulse : 96x/mntRR : 20x/mntTax : 37,5 C
Dizziness (+), active bleeding
(-), weakness (+)
23.00
-Evaluate mother
-Obs. VS
1 day of VEGeneral condition : well
BP : 100/60 mmHg
Pulse : 80x/mnt
Rr : 16 x/mnt
T: 37
Active bleeding (-)
Subjectiv complain (+)07.00
subect planningassesmentobjectTime
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