28-02-14 pk i f.laten
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SUPERVISOR:DR. EDY P.W, SPOG
DM:AKBAR, ARIQ, ASRI
Morning reportFebruary, 28th 2014
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Name : Mrs. MAge : 28 yoAddress : SelagalasAdmitted : February, 27th 2014 at 10.39 pm
Name : Mrs. MAge : 28 yoAddress : SelagalasAdmitted : February, 27th 2014 at 10.39 pm
PATIEN IDENTITY
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TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
27/02/2014
10.39 pm
Patient came to GH NTB confessed abdominal pain since 08.00 pm (27/02/2014), water come out from her vagina (-), bloody slim (-), FM (+).
History of DM (-), HT (-), asthma (-).
LMP : 19-05-2013EDD: 26-02-2014
History of ANC: 14x at doctor, last: 25-02-2014, result: normal.
History of USG:4x, last: 25-02-2014
History of family planning: - Next family planning: IUD
Obstetrical history:
I.4 month, abortus, 1 year agoII.this
General status:GC: wellGCS: E4V5M6BP: 100/70 mmHgPR: 82 bpmRR: 18 rpm T: 37,00 C
Eye : anemis (-), icteric (-)Thorax :Cor : S1S2 single reguler, murmur (-), gallop (-)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: 31 cm EFW: 3100 gUC: 2x10’~25”FHB: 12-11-11(132 x/min)
G2P0A1L0 40-41 weeks S/L/IU head presentation with laten phase of labor
• Obs mother & fetal well being
• Obs. progression of labor
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TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
VT: Ø 2 cm, eff 25 %, amnion (+), head palpable H1, denominator unclear, impalpable small part and umbilical cord.
PE:Promontorium unpalpable, spina ischiadika not prominent, os coccygeous mobile, pubic arch >90º
Lab. result:HB : 10,9 g/dl RBC : 3,77 M/dl WBC : 5,44 K/dlPLT : 162 K/dlHbSAg : (-)
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TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
28/02/2014
02.40 am
Abdominal pain UC : 2x10’ ~25”FHB : 12-12-12 (144 bpm)VT: Ø 2 cm, eff 25 %, amnion (+), head palpable H1, denominator unclear, impalpable small part and umbilical cord.
- -
06.40 am
Abdominal pain UC : 2x10’ ~20-25”FHB : 12-12-11 (140 bpm)VT: Ø 2 cm, eff 25 %, amnion (+), head palpable H1, denominator unclear, impalpable small part and umbilical cord.
G2P0A1L0 40-41 weeks S/L/IU head presentation with laten phase of labor > 8 h
• Pro CTG
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TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
08.20am
Abdominal pain UC : 2x10’ ~25”FHB : 12-12-12 (144 bpm)
G2P0A1L0 40-41 weeks S/L/IU head presentation with laten phase of labor > 8 h
•DM co to GP result of CTG is reactive, suggest acceleration by drip oxytocin, GP co to SPV result of CTG, advice drip oxytocin
•CIE to family about condition and next planning to drip oxytocin
08.30 am
- BP: 100/70 mmHgPR: 82 bpmRR: 18 rpm T: 37,00 CUC : 2x10’ ~15”FHB : 12-12-11 (140 bpm)
G2P0A1L0 40-41 weeks S/L/IU head presentation with laten phase of labor > 8 h
•Flash 1st Drip oxy began 8 dpm
09.00 am
- UC : 2x10’ ~15”FHB : 12-12-12 (144 bpm)
•Drip oxy 12 dpm
09.30 am
- UC : 2x10’ ~15”FHB : 12-12-11 (140 bpm)
•Drip oxy 16 dpm
10.00 am
- UC : 2x10’ ~15”FHB : 12-12-11 (140 bpm)
•Drip oxy 20 dpm
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TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
10.30 am
- UC : 2x10’ ~15”FHB : 12-12-13 (148 bpm)VT: Ø 2 cm, eff 25 %, amnion (+), head palpable H1, denominator unclear, impalpable small part and umbilical cord.
•Drip oxy 24 dpm
11.00 am
- UC : 2x10’ ~15”FHB : 12-12-12 (144 bpm)
•Drip oxy 28 dpm
11.30 am
- UC : 2x10’ ~15”FHB : 12-11-11 (136 bpm)
•Drip oxy 32 dpm
12.00 am
- UC : 2x10’ ~15”FHB : 12-12-11 (140 bpm)
•Drip oxy 36 dpm
12.30 pm
Abdominal pain UC : 2x10’ ~15”FHB : 13-12-12 (148 bpm)
•Drip oxy 40 dpm
01.00 pm
Abdominal pain UC : 2x10’ ~20”FHB : 12-12-12 (144 bpm)
•Drip oxy 40 dpm
01.30 pm
Abdominal pain UC : 2x10’ ~20”FHB : 12-12-12 (144 bpm)
•Drip oxy 40 dpm
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TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
02.00 pm
Abdominal pain UC : 2x10’ ~20”FHB : 12-12-12 (144 bpm)
•Drip oxy 40 dpm
02.30 pm
Abdominal pain increased BP: 100/70 mmHgPR: 82 bpmRR: 18 rpm T: 37,00 C
UC : 3x10’ ~35”FHB : 12-12-11 (140 bpm)VT: Ø 4 cm, eff 50 %, amnion (+), head palpable H1, denominator unclear, impalpable small part and umbilical cord.
G2P0A1L0 40-41 weeks S/L/IU head presentation inpartu with active phase of labor
•Obs. Mother and fetal well being
•Suggest mother to eat and drink
•Obs. progress of labor with WHO partograf
•Flash 2nd Drip oxy 40 dpm
•Pro CTG
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TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
03.40 pm
Patient confessed water come out from her vagina
UC : 4x10’ ~45”FHB : 12-12-12 (144 bpm)VT: Ø 10 cm, eff 100 %, amnion (-), head palpable HII, denominator SS transverse, impalpable small part and umbilical cord.
G2P0A1L0 40-41 weeks S/L/IU head presentation wth second stage of labor
•Obs. Mother and fetal well being
•Suggest mother to eat and drink
•Suggest mother to squat down and lying down to the left.
04.30 pm
Abdominal pain increase, mother want to bearing down
UC : 4x10’ ~45”FHB : 12-12-12 (144 bpm)VT: Ø 10 cm, eff 100 %, Inspection’Bulging of perineum, opening vulva, anus presure
G2P0A1L0 40-41 weeks S/L/IU head presentation wth second stage of labor
•Conduct labor
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TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
04.40 pm
- - - Baby was born, male, 7-9, BW/BL = 2900/49
Placenta was born with MAK IIIWeight 500 grBleeding 100 cc
06.40pm
- Cons: wellGCS: CMBP: 100/70 mmHgPR: 82 bpmRR: 18 rpm T: 37,00 CUC: (+) goodUFH: 1 finger below umbiliccalBleeding -
2 hours post partum
•Obseation Mother and baby well being
•Suggest mother eat and drink and mobilitation
•Move patient to melati ward
04.30 pm
- Cons: wellGCS: CMBP: 110/70 mmHgPR: 84 bpmRR: 20 rpm T: 37,30 CUC: (+) goodUFH: 2 finger below umbiliccalBleeding –Baby rooming in is normal.HR : 148 bpmRR : 54 bpmTemp : 36,70C
1 day post partum
•Obseation Mother and baby well being
•Suggest mother eat and drink and mobilitation
•Suggest mother to breast feeding.
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Thank you…