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    Name: Mrs. N.S. Age: 20 Yo Address: Narmada Admitted: October, 29 2012 at 10.30 Wita

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    Laili Khairani
    This document contains the medical records of a 20-year-old female patient admitted on October 29th 2012 for labor and delivery. She was referred from another facility with premature rupture of membranes for over 12 hours. During her admission, she received oxytocin to induce labor and delivered a baby boy via normal spontaneous vaginal delivery. Both mother and baby were observed and found to be in good condition following delivery.

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    Name: Mrs. N.S. Age: 20 Yo Address: Narmada Admitted: October, 29 2012 at 10.30 Wita

    Uploaded by

    Laili Khairani
    14 views6 pages
    This document contains the medical records of a 20-year-old female patient admitted on October 29th 2012 for labor and delivery. She was referred from another facility with premature rupture of membranes for over 12 hours. During her admission, she received oxytocin to induce labor and delivered a baby boy via normal spontaneous vaginal delivery. Both mother and baby were observed and found to be in good condition following delivery.

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    29-10-2012 KPD 12 jam

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    This document contains the medical records of a 20-year-old female patient admitted on October 29th 2012 for labor and delivery. She was referred from another facility with premature rupture of membranes for over 12 hours. During her admission, she received oxytocin to induce labor and delivered a baby boy via normal spontaneous vaginal delivery. Both mother and baby were observed and found to be in good condition following delivery.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    14 views6 pages

    Name: Mrs. N.S. Age: 20 Yo Address: Narmada Admitted: October, 29 2012 at 10.30 Wita

    Uploaded by

    Laili Khairani
    This document contains the medical records of a 20-year-old female patient admitted on October 29th 2012 for labor and delivery. She was referred from another facility with premature rupture of membranes for over 12 hours. During her admission, she received oxytocin to induce labor and delivered a baby boy via normal spontaneous vaginal delivery. Both mother and baby were observed and found to be in good condition following delivery.

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    Name: Mrs. N.S. Age: 20 yo Address: Narmada Admitted: october, 29th 2012 at 10.

    30 wita

    TIME 11/07/2 012 10.45

    SUBJECTIVE Patient referred from Poli Hamil with G2P1A0H1 A/S/L/IU head presentation with PROM. Patient confessed rupture of membrane since 06.00 (10/07/2012) clear. Abdominal pain (-). Bloody slim (), FM (+). No history of DM, HT, asthma. LMP: Forgot EDD: History of ANC: >4x History of USG: History of family planning: injection 3 months Next family planning : Injection 3 months Obstetrical history: I. Female, aterm, spontaneous, midwife, 2500 gram, 5 yo, alive. II. This

    OBJECTIVE General status: GC: well BP: 110/80 mmHg PR: 88 bpm RR: 24 T: 36,5 General Satus: Eye : anemis (-), icteric (-) Thorax : Cor : S1S2 single regular (murmur ), (gallop -) Pulmo : vesicular (+/+), wheezing (/-), Ronchi (-/-). Abdomen : scar (-), striae (+), linea nigra (+) Extremity : edema (-/-), warm acral (+/+) Obstetrical status: L1: breech L2: back on the right side L3: head L4: 4/5 UFH: 37 cm EFW: 4030 g UC: FHB: 12-12-12 (144 x/min) VT: 2 cm, eff 25%, amnion (-) clear, head palpable HI, impalpable small part / umbilical cord.

    ASSESTMENT G2P1A0L1 A/S/L/IU with PROM > 12 hours + Susp. macrosomia

    PLANNING Obs mother & fetal well being skin test ampi (-)Inj. Ampicillin 1 gr /6 hour IV Cek DL, HBsAg. DM co GP pro induction with oxytocin drip if CTG reactive, advice: acc induction with drip oxytocin if CTG reactive

    TIME Chronology: -

    SUBJECTIVE

    OBJECTIVE PS: 5 Cervic dilatation 1 cm : 1 Cervix length 1 cm : 2 Cervix consistency moderate : 1 Cervix position posterior : 0 Station H I : 1

    ASSESTMENT

    PLANNING

    PE: Promontorium impalpable Spina ischiadica not prominent Os coccygeus mobile Arcus pubis >90 Lab: HB: 10,3 g/dl RBC: 4,53 M/dl WBC: 6,93 K/dl PLT: 69,7 K/dl HbSAg: (-)

    TIME 11.00 -

    SUBJECTIVE

    OBJECTIVE GC: well BP: 120/80 mmHg PR: 88 bpm RR: 20 T: 36,5 CTG: reactive UC: FHR: 11-12-12 (140)

    ASSESTMENT G2P1A0L1 A/S/L/IU with PROM > 12 hours + Susp. macrosomia

    PLANNING Drip oxy began 8 dpm flash I

    11.30

    UC: FHR: 11-11-10


    UC: 2x/10 ~ 10 FHR: 11-11-12 UC: 3x/10 ~ 10 FHR: 11-12-11 UC: 3x/10 ~ 10 FHR: 11-12-12 UC: 4x/10 ~ 10 FHR: 12-11-11 UC: 4x/10 ~ 15 FHR: 12-12-12 (144)

    Drip oxy 12 dpm

    12.00

    Abdominal pain came and relieved

    Drip oxy 16 dpm

    12.30

    Abdominal pain came and relieved

    Drip oxy 20 dpm

    13.00

    Abdominal pain came and relieved

    Drip oxy 24 dpm

    13.30

    Abdominal pain came and relieved

    Drip oxy 28 dpm

    14.00

    Abdominal pain came and relieved

    Drip oxy 32 dpm

    TIME 14.30

    SUBJECTIVE Abdominal pain came and relieved Abdominal pain came and relieved

    OBJECTIVE UC: 4x/10 ~ 20 FHR: 12-12-12 (144) UC: 4x/10 ~ 30 FHR: 12-12-12 (144)

    ASSESTMENT

    PLANNING Drip oxy 36 dpm

    15.00

    Drip oxy 40 dpm

    15.30

    Abdominal pain came and relieved


    Abdominal pain came and relieved Abdominal pain came and relieved

    UC: 4x/10 ~ 30 FHR: 12-12-12 (144)


    UC: 4x/10 ~ 35 FHR: 12-12-12 (144) UC: 4x/10 ~ 35 FHR: 12-11-12 (140) VT: 4 cm, eff 50%, amnion membrane (-) , head palpable HI, denominator ROA, impalpable small part / umbilical cord UC: 4x/10 ~ 40 FHR: 12-12-12 (144) UC: 4x/10 ~ 40 FHR: 12-12-12 (144)

    Drip oxy 40 dpm

    16.00

    Drip oxy 40 dpm

    16.30

    Drip oxy 40 dpm

    17.00

    Abdominal pain came and relieved Abdominal pain came and relieved

    Drip oxy 40 dpm

    17.30

    Drip oxy 40 dpm

    TIME 18.00

    SUBJECTIVE Abdominal pain ++ Mother want to bearing down

    OBJECTIVE UC: 4x/10 ~ 40 FHR: 12-12-12 (144) Teknusperjolvulka

    ASSESTMENT 2nd stage of labor

    PLANNING Drip oxy 40 dpm Conduct mother to bearing down Baby was born, male, AS 7-9, 4200 gram, 52 cm, Anus (+), congenital anomaly (-) Amnion: clear Placenta was born spontaneous, complete, episiotomi bleeding 150cc

    10.00

    Delivery wound pain

    GC: well Cons: CM BP: 120/80 HR: 84 bpm RR: 24 tpm T: 36,5 C UC: + UFH: 2 finger below umbilicus GC: well Cons: CM BP: 120/80 HR : 80 bpm RR : 20 tpm T : 36,4 C UFH : 2 finger below umbilicus UC : + Baby in NICU PR: 120 RR: 50 T: 36,7

    2 hours post partum

    Observed mother and baby well being Suggest mother to mobilisation. Suggest mother to breash feeding Observed mother and baby well being Suggest mother to mobilisation, eat, and drink, medication. Suggest mother to breash feeding

    30/10/ 2012 07.00

    Delivery wound pain

    One day post partum

    SaO2: 99%

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