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%