mr 17 - 10 - 2013 baru.pps

8/14/2019 MR 17 - 10 - 2013 baru.pps

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Name : Mrs. N.S. Age : 20 yo

Adress : Pemepek, Pringgarata, Central

LombokNo RM : 524575

Admitted : 15th Oktober 2013 at 20.02

WITA

8/14/2019 MR 17 - 10 - 2013 baru.pps


Time Subject Object Assessment Planning

15/10/13

20.02

Patient reffered from PKM

Pringgarata with G1P0A0L1 39-

40 weeks S/L/IU head

presentation + PROM. Patient

confessed water leaked out from

her womb since 16.30

(15/10/2013), abdominal pain(-).Blood slim (-), FM (+). History of

DM (-), HT (-), asthma (-).

LMP :08/01/2013

EDD :15/10/2013

History ANC : >4x, midwife, last

at 03/10/2013, result normal

History USG : -

History of family planning: -

Next family planning: inj. 3 month

Obstetric History:

1. This.

Chronologist: -

General status

GC : well

GCS: CM (E4V5M6)

BP : 120/70mmHg

PR: 92 tpm

RR: 22 tpm

T: 37,4°C

Local status

Eye : an (-/-), ict (-/-)

Pulmo: ves (+/+), rh (-/-), wh (-

/-)

Cor : S1S2 single regular M(-),

G(-)

Abd : striae gravidarum (+),

linea nigra (+), scar (-)Ext : edema (-/-)

Obstetric status

L1 : breech UFH: 31 cm

EFW : 3100gram

L2 : back on the left side

L3 : head

L4 : 4/5

UC : -

FHB : 12.12.12 (144x/min)

VT : Ø 1cm, eff. 10 %, Amnion

(-) clear, head palpable ↓HI,

denominator unclear,

impalpable small part of fetal &

umbilical cord.

PS: 5

G1P0A0L1 39-40

weeks S/L/IU head

presentation +

PROM

• Obs. Mother and fetal

well being.

• Obs. sign of labor

• Infuse RL 20 tpm

• Skin test, (-), inj.

Ampicillin 1 g/6 h IV

• DM co GP, GP coSPV pro CTG, and

then SPV advice:

Acc CTG, result

reactive

Pro USG

8/14/2019 MR 17 - 10 - 2013 baru.pps



Lab:

Hb = 11,1 g/dl

RBC = 4,41

WBC = 12,60

PLT = 258

HCT = 34,8%

HbSAg = (-)

16/10/13

04.30

water leaked out from her

womb

GC : well

GCS: CM (E4V5M6)

BP : 120/70mmHg

PR: 92 tpm

RR: 22 tpm

T: 37,4°C

UC : -

FHB : 12.12.12 (144x/min)

VT : Ø 1cm, eff. 10 %, Amnion (-) clear, head

palpable ↓HI, denominator

unclear, impalpable small part

of fetal & umbilical cord.

PROM -Obs. Mother and

fetal well being.

-CTG,

-Drip oxitocin 5 IU

06.00

06.30

07.00

07.30

UC: -

FHB: 12.12.13 (148x/minute)

UC: -

FHB: 12.12.12 (144x/minute)

UC: -

FHB: 12.11.12 (140x/minute)

UC: -

FHB: 13.12.12 (148x/minute

- 8 tpm

- 12 tpm

-16 tpm

-20 tpm

8/14/2019 MR 17 - 10 - 2013 baru.pps



08.00

08.30

09.00

09.30

10.00

Abdominal pain

UC:-

FHB: 12.12.13 (148x/minute)

UC: 2x/10’ ~ 30“

FHB: 12.12.12 (144x/minute)

UC: 3x/10’ ~ 30“

FHB: 12.11.12 (140x/minute)

VT : Ø 4cm, eff. 50 %, Amnion (-)

clear, head palpable ↓HI,

denominator unclear, impalpable

small part of fetal & umbilical cord.

UC: 3x/10’ ~ 35“

FHB: 13.12.12 (148x/minute)

UC: 3x/10’ ~ 35“

FHB: 12.12.13 (148x/minute)

1st Stage of labor

active phase

-24 tpm

-28 tpm

-32 tpm

-Obs. Progress of

labor with

partograph

-36 tpm

-40 tpm

12.00 Abdominal pain UC: 4x/10’ ~ 45“

FHB: 12.12.12 (144x/minute)

-Drip Oxytocin (2nd

flash):

-40 tpm

8/14/2019 MR 17 - 10 - 2013 baru.pps



12.30 Mother want to bearing down UC: 4x/10’ ~ 45“

FHB: 12.11.11.(142x/minute)


(-) clear, head palpable ↓HII,

denominator unclear, impalpable

small part of fetal & umbilical cord.

2nd stage of labor -Conduct delivery

13.15

13.20

Baby was born, male, AS

7-9, 3000 gram, 48 cm,

Anus (+), congenital

anomaly (-)

Placenta was born

spontaneus, complete,

500 gr,bleeding ± 150 cc

15.20 GC: well Cons: CM

BP: 110/70 HR: 80 bpm

RR: 20 tpm T: 36,5 C

UC: +

UFH: 2 finger below umbilicus

AB: -

Lochea : +

2 hours post

partum

• Obs. mother and baby

will being

• Suggest mother to

mobilisation, eat, and

drink.

8/14/2019 MR 17 - 10 - 2013 baru.pps


Name : Mrs. N

Age : 36 yo

Adress : Gunung sari , TengahNo RM : 524597

Admitted : 16th Oktober 2013 at 02.30

WITA

8/14/2019 MR 17 - 10 - 2013 baru.pps



15/10/13

02.30

Patient reffered from PKM

Pringgarata with G1P0A0L1 39-

40 weeks S/L/IU head

presentation + PROM. Patient

confessed water leaked out from

her womb since 16.30

(15/10/2013), abdominal pain(-).Blood slim (-), FM (+). History of

DM (-), HT (-), asthma (-).

LMP :08/01/2013

EDD :15/10/2013

History ANC : >4x, midwife, last

at 03/10/2013, result normal

History USG : -

History of family planning: -

Next family planning: inj. 3 month

Obstetric History:

1. Female,preterm,Hospital,mid

wife,2200 gr, 5 years

2. this

Chronologist: -

General status

GC : well

GCS: CM (E4V5M6)

BP : 120/70mmHg

PR: 92 tpm

RR: 22 tpm

T: 37,4°C

Local status

Eye : an (-/-), ict (-/-)

Pulmo: ves (+/+), rh (-/-), wh (-

/-)

Cor : S1S2 single regular M(-),

G(-)

Abd : striae gravidarum (+),

linea nigra (+), scar (-)Ext : edema (-/-)

Obstetric status

L1 : breech UFH: 31 cm

EFW : 3100gram

L2 : back on the left side

L3 : head

L4 : 4/5

UC : -FHB : 12.12.12 (144x/min)


(-) clear, head palpable ↓HI,

denominator unclear,

impalpable small part of fetal &

umbilical cord.

PS: 5

G1P0A0L1 39-40

weeks S/L/IU head

presentation +

PROM

• Obs. Mother and fetal

well being.

• Obs. sign of labor

• Infuse RL 20 tpm

• Skin test, (-), inj.

Ampicillin 1 g/6 h IV

• DM co GP, GP coSPV pro CTG, and

then SPV advice:

Acc CTG, result

reactive

Pro USG

8/14/2019 MR 17 - 10 - 2013 baru.pps



Lab:

Hb = 11,1 g/dl

RBC = 4,41

WBC = 12,60

PLT = 258

HCT = 34,8%

HbSAg = (-)

06.30 Abdominal pain GC : well

GCS: CM (E4V5M6)

BP : 120/80mmHg

PR: 86 tpm

RR: 18 tpm

T: 37,4°C

UC: 2x/10’ ~ 30

FHB : 12.11.11 (136x/min)

VT : Ø 5cm, eff. 50 %, Amnion (+) clear, head

palpable ↓HI, denominator



1st stage of labor

active phase

-Obs. Mother and

fetal well being.

-rehidration

-Obs. Progress of

labor with partograph

10.30 Water leak from her womb GC : well

GCS: CM (E4V5M6)BP : 120/80mmHg

PR: 86 tpm

RR: 18 tpm

T: 37,4°C

UC: 2x/10’ ~ 30

FHB : 12.11.11 (136x/min)

VT : Ø 5cm, eff. 50 %,

Amnion (+) clear, head

palpable ↓HI, denominatorunclear, impalpable small part

1st stage of labor

active phaseprolonged

• Obs. Mother and

fetal well being.• Obs. Progress of

labor with

partograph

8/14/2019 MR 17 - 10 - 2013 baru.pps



11.15 Mother want to bearing down GC : well

GCS: CM (E4V5M6)

BP : 120/80mmHg

PR: 86 tpm

RR: 18 tpm

T: 37,4°C

UC: 4x/10’ ~ 40”

FHB : 12.11.11 (136x/min)

VT : Ø 10cm, eff. 100 %,

Amnion (+) clear, head

palpable ↓HIII, denominator



2nd stage of labor -Conduct delivery

11.20 Baby was born, male,

AS 5-7, 2000 gram, 42cm, Anus (+),

congenital anomaly (-)

Placenta was born

spontaneus, complete,

500 gr,bleeding ± 100

cc

13.20 GC: well Cons: CM

BP: 110/70 HR: 80 bpm

RR: 20 tpm T: 36,5 C

UC: +

UFH: 2 finger below umbilicus

AB: -Lochea : +

2 hours post

partum

• Obs. mother and baby

will being

• Suggest mother to

mobilisation, eat, and

drink.

8/14/2019 MR 17 - 10 - 2013 baru.pps


Thank You

mr 17 - 10 - 2013 baru.pps

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