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Cultura Documentos
9 February 2009
1 1 1 1 5
CTH
Time
Assesment
12.45
Patient came to out patients departement of Mataram General Hospital. with pregnancy more than 9 month.
chronologis : At 6-2-09 came to out patient departement with pregnancy 9 month. Patient had USG. The doctor than advice her to control at 9-2-09 if until that date patient did not got sign of labor. At 9-2-09 patient came to out patient departement of Mataram General hospital with pregnancy more than 9 month. Abdominal discomfort (), vaginal discharge (-). Patient also said that she had married since 14 years ago. Patient had LMP: 29-4-08 EDD: 6-2-09 Obstetric history: 1.This USG (6-2-09): Fetal S/L/IU head presentation, male BPD: 36 weeks AC: 33 weeks FL: 38 weeks
General status : General condition: well, Conciousness: CM BP: 110/70 mmHg RR: 22 x/mnt PR: 80 x/mnt T: 36,7 C Eyes : an(-), ikt (-) Cor -Pulmo : in normal range
Obstetric status : L1 : breech UFH: 33 cm L2 : left back L3 : head L4 : head descencus 4/5 EFW : 3410 g UC : (-) Fetal Heart Rate : 11-12-12 x/mnt VT : CD 2 cm, eff 25 %, AM (+), head palpable, denominator unclear, descensus HI, umbilical cord or small part of fetal unpalpable Bishop score: 6 Dilatation cervix: 1 Length of cervix: 2 Station: 1 Consistensi: 1 Position of cervix: 1
Observation mother and fetal well being. Laboratory examination : DL, HBsAg CTG Advice from poliklinik: If until 9-2-09 termination with oxytocin drip
Report to supervisor Delivery room, advive ACC drip oxytocin
Time 12.45
Subject
Object Pelvic evaluation: Spina ischiadica: unpalpable Coxigis: mobile Simpisis: > 90O Lab: Hb: 9 g% WBC: 9.000/mm3 PLT: 275.000/mm3 HCT: 25,4 % HBsAg: (-)
Assesment
Planning
Time
11.00
Subject
Abdominal discomfort (-).
Object
General status: well FHB: 12-12-12 UC : (-)
Assesment
Planning
Start drip oxytocin 8 drop/mnt Observation mother fetal well being
11.30
12.00
12.30
Time
13.00
Subject
Abdominal discomfort (+)
Object
General status: well FHB: 12-12-12 UC : 2x/10 ~ 35
Assesment
Planning
Drip oxytocin 20 drop/mnt Observation mother fetal well being
13.30
14.00
14.30
Time
15.00
Subject
Abdominal discomfort (+)
Object
General status: well FHB: 11-12-12 UC : 3x/10 ~ 40
Assesment
Planning
Drip oxytocin 20 drop/mnt Observation mother fetal well being
15.30
16.00
16.30
Time
17.00
Subject
Abdominal discomfort (+)
Object
General status: well FHB: 11-12-12 UC : 3x/10 ~ 40
Assesment
Planning
Drip oxytocin 20 drop/mnt Observation mother fetal well being
17.30
18.00
18.30
Time
19.00
Subject
Abdominal discomfort (+)
Object
General status: well FHB: 11-12-12 UC : 3x/10 ~ 40
Assesment
Planning
Drip oxytocin 20 drop/mnt Observation mother fetal well being
19.30
20.00
16.30
Time
21.00
Subject
Abdominal discomfort more often
Object
General status: well FHB: 12-13-13 UC: 4x/10 ~ 45 VT: CD complete, eff 100%, AM (-) clear, head palpable, denom: left occiput anterior, descensus HIII, umbilical cord or small part of fetal unpalpable Doran teknus perjol vulka
Assesment
G3P1A1H1 43 weeks/S/L/IU in 2nd stage of labor
Planning
Drip oxytocin 28 drop/mnt Observation mother and fetal well being
21.20 21.30
Conducted mother to labor Baby was born, male, AS: 7-9, W: 3300 g, L: 50 cm. Placenta was born spontaneusly, complete. Serotinus sign (-): Umbilical cord fress Dry skin (-) Wrinkle skin (-) Meconium (-)
22.00
General status: well BP: 110/70 mmHg PR: 84 x/mnt UC: well UFH: 2 finger under umbilical Active bleeding (-)
23.30
General status: well BP: 110/70 mmHg PR: 84 x/mnt UC: well UFH: 2 finger under umbilical
Puerperium
Time
Subject
Object
Assesment
Planning
Time
21.30
Subject
Abdominal discomfort (+), rare
Object
General status: well FHB: 148 x/mnt UC : 2x/10 ~ 25
Assesment
G1P0A0H0 41-42 weeks/S/L Induction labor seri 1 failure
Planning
induction labor seri 2 after 24 hour later Patient remove to melati room