23-10-12 serotinus, drip
TRANSCRIPT
Case Report
Name : Mrs. MRM : 062334Age : 20 years oldAddress : Batu Penyu, Batu LayarAdmitted : October 22th 2012
TIME SUBJECTIVE OBJECTIVE ASSESSMENT
PLANNING
22/10/2012
13.00
Patient referred from Policlinic NTB GH with G4P1A2L1 42-43 weeks S/L/IU head presentation with mother & fetal well. Patient confessed > 9 mounth pregnancy. History rupture of membrane(-).Blood slim (-). Abdominal pain (-). FM (+).No history of DM, HT, asthma.
LMP : 01/01/2012EDD : 08/10/2012
History of ANC : > 4x at Posyandu, PHC.Last ANC : 20/10/2012History of USG : 1xResult :
History of family planning : Injection 3 monthsNext family planning : Injection 3 months
Obstetrical History :I.Abortus II.♂, spontan, midwife, 3800 g, live, 6 years old.III.AbortusIV.This
General Status :GC : wellBP : 120/60 mmHgPR : 80 bpmRR : 20 bpm T : 36,5oCEye : anemis (-), icteric (-)Cor : S1S2 single regular, murmur (-), gallop (-).Pulmo : vesiculer (+/+), wheezing (-/-), ronkhi (-/-).Abdomen : scar (-), striae (+), linea nigra (+).Extremity : edema (-/-), warm acral (+/+).
Obstetrical Status :L1 : breechL2 : back on the left sideL3 : headL4 : 5/5UFH : 30 cm EFW : 2945 gramUC : (-)FHB : 12-12-11 (140 bpm)VT : Ø (-), head palpable at the fornix
G4P1A2L1 42-43 weeks
S/L/IU head presentation with mother & fetal well
• Observation mother & fetal well being.• RL 500 cc, 28 tpm• DM co GP pro CTG, advice : ACC CTG → reactive, termination• If PS < 5, termination with Misoprostol 25 mcg/8 hours• If PS > 5, termination with Oxytosin Drip
TIME SUBJECTIVE OBJECTIVE ASSESSMENT
PLANNING
Chronologist :-
PS : 5Cervix dilatation 1 cm : 1Cervix length 1 cm : 1Cervix consistency moderate : 1Cervix position posterior : 0Station H I : 1
Lab Examination (05/06/2012) :HB : 9,4 g/dl RBC : 4,21 x 106/µL HCT : 31,5 % WBC : 8,9x 103/µLPLT : 338 x 103/µLHbSAg : (-)
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
14.00
UC : (-)FHB : 12-12-12 (148 bpm)
Misoprostol 25 mcg/6 hours
20.00
UC : (-)FHB : 12-12-11 (140 bpm)
Misoprostol 25 mcg/6 hours
23/10/2012
04.00
UC (-)FHB : 11-12-11 (136 bpm)
Misoprostol 25 mcg/6 hours
07.00
UC : (-)FHB : 12-12-12 (140 bpm)VT : Ø 1 cm, eff 25%, amnion (+), head palpable ↓HI, denominator unclear, impalpable small part and umbilical cord.
SPV Visit:Advice:
CTGDrip oxytocin
10.30
UC : 1 x 10’ ~ 15”FHB : 12-12-11 (140 bpm)
Coo GP result CTG CTG reactive
Acc Drip Oxytocin
11.00
UC : 2 x 10’ ~ 15”FHB : 11-11-11 (132 bpm)
Flash IDrip oxytocin began
8 tpm
11.30
Abdominal pain came and relieved
UC : 2 x 10’ ~ 20”FHB : 11-12-11 (136 bpm)
Drip oxytocin 12 tpm
12.00
Abdominal pain came and relieved
UC : 2 x 10’ ~ 20”FHB : 11-12-11 (136 bpm)
Drip oxytocin 16 tpm
12.30
Abdominal pain came and relieved
UC : 2 x 10’ ~ 20”FHB : 12-12-11 (140 bpm)
Drip oxytocin 20 tpm
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
13.00
Abdominal pain came and relieved
UC : 3 x 10’ ~ 35”FHB : 11-12-11 (136 bpm)VT : Ø 2 cm, eff 30%, amnion (+), head palpable ↓HI, denominator unclear, impalpable small part and umbilical cord.
G4P1A2L1 42-43 weeks S/L/IU head presentation with Latence phase 1st
stage of labor
Drip oxytocin 24 tpm
13.30
Abdominal pain came and relieved
UC : 3 x 10’ ~ 35”FHB : 11-12-12 (140 bpm)
Drip oxytocin 28 tpm
14.00
Abdominal pain came and relieved
UC : 3 x 10’ ~ 35”FHB : 12-12-12 (146 bpm)
Drip oxytocin 32 tpm
14.30
Abdominal pain came and relieved
UC : 3 x 10’ ~ 35”FHB : 11-11-11 (132 bpm)
Drip oxytocin 36 tpm
15.00
Abdominal pain came and relieved
UC : 3 x 10’ ~ 40”FHB : 12-12-11 (140 bpm)
Drip oxytocin 40 tpm
15.30
Abdominal pain came and relieved
UC : 4 x 10’ ~ 40”FHB : 11-11-11 (132 bpm)
Drip oxytocin 40 tpmMaintenance
16.00
Abdominal pain came and relieved, Rupture of
membrane
UC : 4 x 10’ ~ 40”FHB : 11-12-11 (136 bpm)VT : Ø 5 cm, effacement 50%, amnion (-), head palpable ↓HII, denominator unclear, impalpable small part and umbilical cord.
G4P1A2L1 42-43 weeks S/L/IU head presentation with
c
Drip oxytocin 40 tpm
Maintenance
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
16.30
16.40
Abdominal pain +++Mother wants to bearing down
UC : 4 x 10’ ~ 40”FHB : 12-12-13 Doran teknus perjol vulka
2nd stage of labor • Drip oxytocin 40 tpm• Conduct mother to bearing down :
Baby was born :female, AS 7-9, 2500 gram, 51 cm. Anus (+), congenital anomaly (-).
Placenta was born spontaneous, complete, bleeding ±150 cc.
UFH : 2 fingers below umbilicus.
19.00
- GC : wellBP : 110/70 PR : 84 bpmRR : 20 bpm T : 36,1oCUFH : 2 fingers below umbilicusUC : (+)Lochea rubra : (+)
2 hours post partum
•Observed mother and baby well being•Observed bleeding & VS mother•Suggest mother to mobilisation, eat & drink.
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
24/10/2012
07.00
- GC : wellBP : 120/60 PR : 88 bpmRR : 20 bpm T : 36,4oCUFH : 2 fingers below umbilicusUC : (+) Lochea rubra : (+)
Baby rooming in :PR : 140 bpmRR : 44 bpmT : 36,6oC
One day post partum
•Observed mother and baby well being•Suggest mother to mobilisation, eat, and drink, medication.•Breast feeding