Download - PEB + Vakum

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


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


being

-Obs. VS

-Nifedipin 10 mg p.o

G1P0A0L0 A/S/L/IU



labor + eclampsia +


discharge


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



labor + eclampsia +

history of watery vaginaldischarge


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


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


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



labor + eclampsia +


discharge


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


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


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



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


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


being

-Obs. VS


HEAD presentation + prolong

active phase 1 stage labor+

PEB


BP : 140/110 mmHg

Pulse : 84x/mnt

Temp : 36,7 C

UP : 70 cc/hr

FHR : 128x/mnt

UC : 3x/10-35

1430


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


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


BP : 140/100 mmHg

Pulse : 88x/mnt

UC 4x/10 40

Abdominal pain >>18.10

Report to supervisor

Proposed VE

Propose agree


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



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


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


BP : 140/100 mmHg

Pulse : 88x/mnt

UC 4x/10 40

Abdominal pain >>18.10

Report to supervisor

Proposed VE

Propose agree


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 (-)



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


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 (-)



Download - PEB + Vakum

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