Name: Mrs. LAge: 20 yoRM: 048300

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING23/07/201204.05Patient referred from Narmada PHC with G2P1A0H1 36 weeks S/L/IU head presentation with HDK and history of CS. Patient confess Abdominal pain that spread to the frank since 12.30 (22/07/12). Bloody slim (+) since 19.00 (22/07/12). History rupture of membrane (+) at 18.30 (22/07/12), FM (+).No history of DM, HT, asthma.

LMP: 16/11/2011EDD: 23/08/2012

History of ANC: >4x at PosyanduLast ANC: 20/07/2012, result150/90mmHgHistory of USG: -

History of family planning: Injection 3 monthsNext family planning: Injection 3 months

Obstetrical history:Male, BW: 3200, 9 month, CS at RSUP NTB, live 15 yoIni

General status:GC: wellCons: CM/E4V5M6BP: 130/100 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: 4/5UFH: 26 cm EFW: 2325 gUC: 3x10 ~ 30FHB: 12-12-12 (144 x/min)VT: 3 cm, eff 25%, amnion (-) dry, head palpable HI, denominator unclear, unpalpable small part / umbilical cord.

G2P1A0L1 36 weeks S/L/IU head presentation with laten phase 1st stage of labor with history rupture of membrane, gestational hypertention and history of CSObs mother & fetal well beingCek DL HbSAgObs progress of laborSkin test ampi (-) inj.ampi 1 gr/iv

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNINGChronologist:02.30 (23/07/2012)S:Patient 9 month confess Abdominal pain that spread to the frank since 12.30 (22/07/12). Bloody slim (+) since 19.00 (22/07/12). History rupture of membrane (+) at 18.30 (22/07/12) and want to bearing down.LMP: 16/11/2011EDD: 23/08/2012Obstetrical history:Male, CS at RSUP NTB, 15 years agoIniO:GC: wellBP: 160/120 mmHgPR: 92 bpmsRR: 18 T: 36,7

Eye : palor (-), icteric (-)Cor : S1S2 single reguler (murmur -), (gallop -)Pulmo : vesikuler (+/+), wheezing (-/-),Ronkhi (-/-).L1: breechL2: back on the right sideL3: headL4: 4/5UFH: 28 cm EFW: 2635 gUC: 2x10 ~ 30FHB: 12-12-12 (144 x/min)Lab:HB: 12,4 g/dl RBC: 4.84 M/dl HCT: 39,3 %WBC: 12,43 K/dlPLT: 247 K/dlHbSAg: (-)Proteinuria: -

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNINGVT: 1 cm, eff 25%, amnion (+), head palpable HI, unpalpable small part / umbilical cord.

A:G2P0A0L1 36 weeks S/L/IU head presentation with HDK and history of CS

P:Nifedipine 10 mg (03.00, 23/07/12)Reffered to RSUP NTB

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING08.05Patient confessed abdominal pain ++GC: wellBP: 130/100 mmHgPR: 80 bpmRR: 20 T: 36,5UC: 3x10 ~ 30FHB: 12-11-11 (136 x/min)VT: 5 cm, eff 50%, amnion (-), head palpable HI, denominator LOA, unpalpable small part / umbilical cord.G2P1A0L1 36 weeks S/L/IU head presentation with aktive phase 1st stage of labor with history rupture of membrane, gestational hypertention and history of CSObs mother & fetal well beingObs progress of laborCTG result reactive

12.05Abdominal pain ++GC: wellBP: 130/100 mmHgPR: 80 bpmRR: 20 T: 36,5UC: 3x10 ~ 40FHB: 12-12-12 (144 x/min)VT: 5 cm, eff 50%, amnion (-), head palpable HI, denominator LOA, unpalpable small part / umbilical cord.

G2P1A0L1 36 weeks S/L/IU head presentation with arrested aktive phase 1st stage of labor with history rupture of membrane, and gestational hypertention history of CSObs mother & fetal well beingObs progress of laborSuggest mother to eat and drinkDM co to SPV, pro observation progress of labor SPV ACC observation and evaluation in 2 hours

14.00

Abdominal pain ++GC: wellBP: 130/100 mmHgPR: 80 bpmRR: 20 T: 36,5UC: 3x10 ~ 40FHB: 12-12-11(140 x/min)VT: 7cm, eff 75%, amnion (-), head palpable HII, denominator LOA, unpalpable small part / umbilical cord.G2P1A0L1 36 weeks S/L/IU head presentation with aktive phase 1st stage of labor with history rupture of membrane, HDK and history of CSObs mother & fetal well beingObs progress of laborCTGSuggest mother to eat and drinkDM co to SPV, pro observation progress of labor SPV ACC observation

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING17.00Patient confessed abdominal pain ++GC: wellBP: 160/100 mmHgPR: 80 bpmRR: 20 T: 36,5UC: 3x10 ~ 30FHB: 12-11-11 (136 x/min)VT: 7 cm, eff 50%, amnion (-), head palpable HII, denominator LOA, unpalpable small part / umbilical cord.G2P1A0L1 36 weeks S/L/IU head presentation with arrested aktive phase 1st stage of labor with history rupture of membrane, gestational hypertention and history of CSObs mother & fetal well beingObs progress of laborDM co to SPV advice: IU resucitation then accelaration with oxy drip 12 tpm

19.00Abdominal pain ++UC: 3x10 ~ 30FHB: 12-12-11 (140 x/min).

G2P1A0L1 36 weeks S/L/IU head presentation with arrested aktive phase 1st stage of labor with history rupture of membrane, gestational hypertention and history of CSAccelaration with oxy drip began 8 tpm19.30Abdominal pain ++UC: 3x10 ~ 40FHB: 12-12-13 (148 x/min)G2P1A0L1 36 weeks S/L/IU head presentation with arrested aktive phase 1st stage of labor with history rupture of membrane, gestational hypertention and history of CSoxy drip 12 tpm

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING20.00Abdominal painUC: 4x/10 ~ 40DJJ: 12-12-12 (144)G2P1A0L1 36 weeks S/L/IU head presentation with arrested aktive phase 1st stage of labor with history rupture of membrane, gestational hypertention and history of CSDryp oxy 12 tpm

20.30Abdominal pain UC: 4/10 ~ 40DJJ: 12-12-13 (148)G2P1A0L1 36 weeks S/L/IU head presentation with arrested aktive phase 1st stage of labor with history rupture of membrane, gestational hypertention and history of CSDryp oxy 12 tpm

21.00Abdominal painUC: 4x/10 ~ 40DJJ: 12-12-13 (148)G2P1A0L1 36 weeks S/L/IU head presentation with arrested aktive phase 1st stage of labor with history rupture of membrane, gestational hypertention and history of CSDryp oxy 12 tpm

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING21.30Abdominal painUC: 4x/10 ~ 40DJJ: 13-12-13 (152)VT: complete, amnion (-), head palpable HIII, denominator LOA, unpalpable small part / umbilical cord.G2P1A0L1 36 weeks S/L/IU head presentation with 2st stage of labor with history rupture of membrane, gestational hypertention and history of CS-Dryp oxy 12 tpm-CTG result reactive

22.00Abdominal painMother want to bearing downGC: wellBP: 130/100 mmHgPR: 80 bpmRR: 20 T: 36,5UC: 4x10 ~ 45FHB: 12-12-12 (144 x/min)

DoranteknusperjolvulkaG2P1A0L1 36 weeks S/L/IU head presentation with 2st stage of labor with history rupture of membrane, gestational hypertention and history of CSBaby was born, male, AS 7-9, 2600 gram, 48 cm, Anus (+), congenital anomaly (-)Placenta was born spontaneous, complete, bleeding 200cc

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING00.00Patient confessed delivery wound painGC: well Cons: CMBP: 130/100 HR: 80 bpmRR: 20 tpm T: 36,5 CUC: + wellUFH: 2 finger below umbilicusLokhea rubra : +2 hours post partumObserved mother and baby well beingSuggest mother to mobilisation, eat, and drink, medication.24/07/201207.00GC: well Cons: CMBP: 160/100 HR : 82 bpm RR : 20 tpm T : 36,2 CUFH : 2 finger below umbilicusUC : + well

Baby rooming in:PR:144RR: 46T: 36,41 day post partumObserved mother and baby well beingSuggest mother to mobilisation, eat, and drink, medication.

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