TimeSOAP

20 Jan 201210.15Patient came to Polyclinic with G1P0A0L0 40-41 weeks S/L/IU with breech presentation + oligohydramnion + umbilical cord twisting.History of abdominal pain (-), history of ruptured membrane (-), bloody slime (-), bleeding (-), FM (+) weak

LMP: 09 04 2011EDD: 18 01 2012

History of ANC: > 4x, PHCLast ANC: 19/01/2012USG: 1x at RSUP NTB (19/01/2012)= Breech presentation, single, alive Umbilical cord twist on the neck Amnion , Placenta Gr.III at fundus uteri

History of family planning: (-)Next family planning: IUD

Chronology: (-)

Status generalis:GC : well GCS: E4V5M6BP : 120/70 mmHgPulse : 76 x/minT : 36,3CRR : 18 x/minEye: anemic (-/-), ict (-/-)Cor: S1S2 single, reg, M (-), G (-)Pul: Ves (+/+), Rh (-/-), Wh (-/-)Extremities: warm (+/+), edema (-/-)

Obstetric status:L1: headL2: fetal back on the left side L3: breechL4: 5/5UFH: 33 cm, AC: 96 cmEFW: 3168 grUFH: 24 cmUC: (-)FHB: (+) 12-12-12 (144 x/min)VT: (-)

Lab (20/01/2011 11.21) Hb : 13,1 RBC: 4,68 WBC : 12.000 HCT : 42.8% PLT : 310.000 BT: 2 55 ~ CT: 6 50 HbsAg : -

G1P0A0L0 40-41 weeks S/L/IU with breech presentation + oligohydramnion + umbilical cord twisting Observe maternal & fetal well being Observe GC & VS Suggest mother to consume nutritious foods Suggest mother to rest well DM co to GP pro SC,GP co to SPV, SPV: pro Elective SC at Jan 24, 2012

22 Jan 2012 07.30-GC: WellVital Signs:BP: 120/80 mmHgPR: 84 x/minRR: 20 x/minT: 36,9CUC: (-)FHR: (+), irregular, 104-156 x/min

G1P0A0L0 40-41 weeks S/L/IU with breech presentation + oligohydramnion + umbilical cord twisting + fetal distress Intrauterine rescucitation DM co to GP pro SC,GP co to SPV, SPV: pro SC at 9.30 (Jan 22, 2012)

08.20SC was begunBaby was born, male, 3750 grams, length : 50 cm, AS : 7-9, amnion: clear, anus (+), congenital anomaly (-)Placenta was born manually (+ 500 gr) - complete,Bleeding 250 cc

11.15-GC : wellBP : 100/60Pulse : 76x RR : 20x T : 35,5UC : (+) goodUFH : 1 finger umbilicusUO : 30 cc/hourActive bleeding : (-)

PR : 148 x/minT : 36CRR : 56x/min

2 hours post SC Observe maternal and fetal well being Suggest mother to eat and drink

22/02/201207.30GC : wellBP : 120/90Pulse : 96x RR : 18x T : 36,7UC : (+) goodUFH : 2 fingers umbilicusActive bleeding : (-)

BabyPR : 152 x/minT : 36.5CRR : 54x/min

1 day post SC Observe maternal and fetal well being Suggest mother to eat and drink