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Age: 31 yo
Address: Jonggat
Admitted: June 2nd, 2012 at 10.25
TIME
02/06/
2012
10.25
SUBJECTIVE
Patient pregnant 9 months
came to Policlinic NTB GH
confessed water leaked out
from her womb since 03.30
(17/05/2012). Abdominal
pain (-), Bloody slim (-), FM
(+).
No history of nausea,
vomiting, headache, visual
disturbance and epigastric
pain.
No history of DM, HT,
asthma.
LMP: 16/09/2011
EDD: 23/06/2012
History of ANC: >4x at
Posyandu & PHC
Last ANC: 02/06/2012
History of USG: History of family planning: Pil
Next family planning:
Injection 3 months
Obstetrical history:
I., 7 mo, spontan, midwife,
2000 g, 6 yo, L
II.This
OBJECTIVE
General status:
GC: well
BP: 180/130 mmHg
PR: 92 bpm
RR: 24
T: 36,5
Eye : palor (-), icteric (-)
Thorax :
Cor : S1S2 single reguler
(murmur -), (gallop -)
Pulmo : vesikuler (+/+),
wheezing (-/-),
Ronkhi (-/-).
Abdomen : scar (-), striae (+),
linea nigra (+)
Extremity : edema (-/-), warm
acral (+/+)
Obstetrical status:
L1: breech
L2: back on the left side
L3: head
L4: 4/5
UFH: 31 cm
EFW: 3100 g
UC: FHB: 12-12-12 (144 x/min)
VT: 1 cm, eff 25%, amnion
(+), head palpable HI,
impalpable small part /
umbilical cord.
PS : 5
ASSESTMENT
G2P1A0L1 37
weeks S/L/IU
with PROM +
severe
preeclampsia
PLANNING
Obs mother & fetal
well being
Infus MgS04 40% 4
g bolus, then drip
MgSo4 40% 6 g
Infus RL 28 tpm
Insert DC
Skin test Ampi (-),
inj Ampi 1 g IV
CTG: reactive
DM co SPV, advice:
- Conservative
therapy
- Termination: drip
oxytocin
TIME
SUBJECTIVE
OBJECTIVE
ASSESTMENT
PLANNING
Lab:
HB: 10,9 g/dl
RBC: 4,08 M/dl
WBC: 14,80 K/dl
PLT: 236
HbSAg: (+)
Protein urine : +3
GDS: 88 mg/dl
SC: 0,5
Ureum : 12
Uric acid: 3,8
SGOT : 19
SGPT : 11
15.30
Flash I
Dryp oxy began 8
tpm
16.00
16.30
17.00
17.30
UC: 1x/10 ~ 20
FHB: 11-11-12 (136)
18.00
UC: 2x/10 ~ 30
FHB: 11-11-12 (136)
18.30
UC: 2x/10 ~ 30
FHB: 11-11-11 (132)
19.00
UC: 3x/10 ~ 30
FHB: 11-11-11 (132)
19.30
UC: 3x/10 ~ 30
TIME
SUBJECTIVE
OBJECTIVE
ASSESTMENT
PLANNING
20.00
UC: 3x/10 ~ 35
FHB: 11-11-12 (136)
20.30
UC: 3x/10 ~ 35
FHB: 11-11-11 (132)
21.00
UC: 3x/10 ~ 35
FHB: 11-11-11 (132)
21.30
UC: 3x/10 ~ 40
FHB: 11-11-11 (132)
VT: 6 cm, eff 75%, amnion
(-), clear, head palpable HII,
impalpable small part /
umbilical cord.
22.00
UC: 3x/10 ~ 40
FHB: 11-11-12 (136)
Flash II
Dryp oxy 40 tpm
22.30
UC: 4x/10 ~ 40
FHB: 11-12-12 (140)
23.00
Abdominal pain ++
Mother wants to bearing
down
UC: 4x/10 ~ 45
FHB: 12-12-12 (144)
doranteknusperjolvulka
23.15
G2P1A0L1 37
weeks S/L/IU
active phase 1st
stage of labor
with history
rupture of
membrane +
severe
preeclampsia
G2P1A0L1 37
weeks S/L/IU 2nd
stage of labor
with history
rupture of
membrane +
severe
preeclampsia
TIME
SUBJECTIVE
OBJECTIVE
ASSESTMENT
PLANNING
03/06/
2012
01.15
GC: well
Cons: CM
BP: 170/110
HR: 84 bpm
RR: 22 tpm
T: 36,5 C
UC: +
UFH: 2 fingers below
umbilicus
AB: -
2 hours post
partum
Observed mother
and baby well being
Observed bleeding &
VS mother
Suggest mother to
mobilisation, eat &
drink.
07.00
GC: well
BP: 140/90
Observed mother
and baby well being
Suggest mother to
mobilisation, eat,
and drink,
medication.
Observed mother
and baby well being
Suggest mother to
mobilisation, eat,
and drink,
medication.
Cons: CM
HR : 80 bpm
RR : 20 tpm
T : 36,4 C
UFH : 2 fingers below
umbilicus
UC : +
AB : Baby rooming in:
PR:144
RR: 46
T: 36,4
04/06/
2012
07.00
GC: well
BP: 110/80
Cons: CM
HR : 80 bpm
RR : 20 tpm
T : 36,4 C
UFH : 2 fingers below
umbilicus
UC : +
AB : Baby rooming in:
PR:144
RR: 46
T: 36,4