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Name: Mrs. EAge: 26 yoRM: 538866Adress: NarmadaAdmitted: May, 18th 2012 at 02.51
Name: Mrs. EAge: 26 yoRM: 538866Adress: NarmadaAdmitted: May, 18th 2012 at 02.51
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
18/05/201402.51
Patient referred from Narmada PHC with G2P1A0L1 38-39 with PROM > 12 jam. Patient confess water leaked out from her vagina since 13.00 WITA (17/05/14). Abdominal pain (-) Bloody slim (-),FM (+).No history of DM, HT, asthma.
LMP: 20/08/2013EDD: 27/05/2014
History of ANC: 5 x at PosyanduLast ANC: NormalHistory of USG: -
History of family planning: Injection 3 monthsNext family planning: IUD
Obstetrical history:I.Female, 2600 gram, spontan, aterm, midwife, live 6 yoII.This
General status:GC: wellCons: CM/E4V5M6BP: 110/70 mmHgPR: 88 bpmRR: 20 T: 36,5Eye : 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: breechL2: back on the right sideL3: headL4: 5/5UFH: 33 cm EFW: 3255 gUC: -FHB: 12-12-12 (144 x/min)VT: Ø 1 cm, eff 20%, amnion (-) clear,
G2P1A0L1 38-39 weeks S/L/IU head presentation with PROM > 12 hours
• Obs mother & fetal well being
• Obs progress of labor• DM co to GP advice induction with
misoprostol SPV advice CS
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
Chronologist at pkm narmada:01.30 (18/05/2014)S:Patient 9 month referred from midwife
confess abdominal pain since 13.00 WITA, (17/05/2014) fetal movement (+)
LMP : 20-08 13O:GC: wellBP: 110/70 mmHgPR: 80 bpmsRR: 16 T: 37
L1: breechL2: back on the right sideL3: headL4: 4/5UFH: 32 cm UC: -FHB: 12-12-12 (144 x/min)VT : Ø 1 cm, eff 10%, amnion (-), head
palpable ↓HI, unpalpable small part / umbilical cord
A: G2P1A0L1 ,38-39 weeks , S/L/IU with PROM > 12 hours
P: observation mother and fetal well being refer to NTB GH
Pelvic score :Serviks dilatation : 1 ( 0)Serviks length : 3 cm ( 0)Station : H0 (0)Consistency : mild (1)Posistion : anterior (2)
Total ps : 3
Lab:HB: 11,3 g/dl RBC: 3,81 M/dl HCT: 32,7 %WBC: 12,43 K/dlPLT: 207 K/dlHbSAg: (-)
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
04.00 SC beganBaby was born :Male, 3500 gram, BL : 51 cm, as: 7-9 anus (+), anomali congenital (-)
Placenta was born manually and complete
06.00 GC: wellGCS: E4V5M6BP: 110/70 mmHgPR: 88 bpmRR: 22 rpm T: 36,80 C
UC (+) wellUFH 2 finger bellow umbilicalActive bleeding (-)
2 hours post partum •Obs. Mother well being•Suggest mother to eat and drink
Baby in NICU
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
07.00 ( 18/05/2014)
GC: wellGCS: E4V5M6BP: 120/80 mmHgPR: 88 bpmRR: 22 rpm T: 36,80 C
UC (+) wellUFH 2 finger bellow umbilicalActive bleeding (-)Lochea rubra (+)
Baby in NICUGC : wellPR : 134 bpmRR : 46 bpmT : 36,5ºC
One day post CS •Obs. Mother well being•Suggest mother to eat and drink
