Name : Mrs. RAge : 24 yoAdress : Bayan, KLUAdmitted : October, 14th 2012 at 16.10

Name : Mrs. RAge : 24 yoAdress : Bayan, KLUAdmitted : October, 14th 2012 at 16.10

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

14/10/2012

17.10

Patient referred from Bayan PHC with G1P0A0L0 A/S/L/IU head presentation with prolonged active phase 1st stage of labor. Patient confessed abdominal pain spread to back since 06.00 wita (13/10/2012). History rupture of membrane (-), bloody slim (+), FM (+). No history of DM, HT, asthma.

LMP : ForgotEDD : (-)

History of ANC : > 4 Last ANC : 29/09/2012History of USG : never

History of family planning : (-)Next family planning : IUD

Obstetrical History :I.This

General Status

GC : wellConsciusness : CMBP : 100/60 mmHgPR : 84 bpmRR : 22 bpmT : 37,8oC

Eye : anemis (-/-), icteric (-/-)Cor : S1S2 single reguler, M (-), G (-)Pulmo : vesikuler (+/+), wheezing (-/-), ronkhi (-/-).Abdomen : scar (-), striae (+), linea nigra (+).Extremity : edema (-/-), warm acral (+/+)

Obstetrical Status

L1 : breechL2 : back on the right sideL3 : headL4 : 4/5UFH : 28 cm EFW : 2635 gUC :2x/10’ ~ 25’’FHB : 12-12-11VT : Ø 6 cm, eff 75%, amnion (+), head palpable ↓H I +, denominator unclear, impalpable small part / umbilical cord.

G1P0A0L0 A/S/L/IU with

head presentation

with prolonged active phase 1st stage of labor.

Obs mother and fetal well being

Check lab CBC, HbsAg

DM Co SPV:Pro: Rehidrasi + Pro

SC at 21.00 WITA

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

Chronologist

At Bayan PHC :

10.00 (14/10/2012)

S : Patient refered abdominal pain since 06.00 (13/10/2012). History rupture of membrane (-)

O : GC : wellBP : 100/70 mmHgPR : 80 bpmRR : 18 bpmT : 36,5oCUFH: 31 cmback on the right sideHead palpable, 2/5UC : (+) 2x10’ ~ 10”FHB : (+) 138 bpmVT : Ø 6 cm, aff 50%, amnion (-)

head palpable, LOA, ↓ H II, impalpable small part of fetal and umbilical cord

A:G1P0A0L0 38-39 weeks /S/L/IU

with latent phase 1st stage of labor .

P:Obs mother and fetal well being- Refer patient to NTB GH

Pelvic Evaluation :•Spina ischiadica not prominent•Os coccigeous mobile•Arcus pubis > 90o

Lab Evaluation :Hb : 12,6 gr/dlHCT : 37,5%RBC : 4,11 M/uLPLT : 249 K/uLWBC : 25,60 K/uLHBsAg : (-)

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

21.00 Mother confessed abdominal pain (+++)

GC : wellBP : 110/90 mmHgPR : 80 bpmRR : 20 bpmT : 36,7oCUC : 2x/10’~25”FHB : 12-12-12 (148 bpm)VT : Ø 8 cm, eff 75%, amnion (+), head palpable ↓H I +, denominator unclear, impalpable small part / umbilical cord.

• Skin test Ampicillin (Inject 2 gram Amicillin)

• Prepare to CS.

22.00 Sc began

Amnion fluid: Meconeal

Baby was born. Male. 3000 g. AS 7-9. Anus (+). Congenital anomaly (-).

Placenta was born. Manually. Complete. ± 300 gram.

Bleeding ± 300 cc

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

00.00

GC : wellBP : 130/80 mmHg PR : 88 bpm RR : 20 bpm T : 37oCUC : (+) wellUFH : 2 finger below umbilicusActive bleeding : (-)

2 hours post partum

• Observed mother and baby well being.

• Suggest mother to mobilisation.

15/10/2012

07.00

Delivery wound pain GC : wellBP : 110/80 mmHg PR : 88 bpm RR : 20 bpm T : 36,40CUFH : 3 finger below umbilicusUC : (+) wellLochea rubra : (+)

Baby rooming in :PR :144 bpmRR : 46 bpmT : 36,40C

One day post partum

• Observed mother and baby well being

• Suggest mother to mobilisation, eat, and drink, medication.