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Time

subect

object

assesment

planning

20.00

Headhache (+), epigastric pain (+), blur vision (-). Abdominal pain (+) rare

General condition : well BP : 160/100 mmHg Pulse : 84x/mnt RR : 22x/mnt Temp : 37. 8 C UP : 60 cc/hr FHR : 148x/mnt UC : 2x/10-20

G1P0A0L0 A/S/L/IU with head presentation + negleted 2 nd stage of labor + eclampsia + history of watery vaginal discharge

-Evaluate mother and fetal well being -Obs. VS -Nifedipin 10 mg p.o

20.30

Headhache (+), epigastric pain (+), blur vision (-). Abdominal pain (+) rare

General condition : well BP : 160/100 mmHg Pulse : 88x/mnt RR : 20x/mnt Temp : 37. 8 C FHR : 168x/mnt UC : 2x/10-20
General condition : well BP : 160/100 mmHg Pulse : 80x/mnt RR : 22x/ mnt Temp : 37.5 C UP : 45 cc/hr FHR : 164x/mnt UC : 2x/10-20

G1P0A0L0 A/S/L/IU with head presentation + negleted 2 nd stage of labor + eclampsia + history of watery vaginal discharge+fetal tachicardia

-Evaluate mother and fetal well being -Obs. VS

21.00

Headhache (+), epigastric pain (+), blur vision (-). Abdominal pain (+) rare

G1P0A0L0 A/S/L/IU with head presentation + negleted 2 nd stage of labor + eclampsia + history of watery vaginal discharge+fetal tachicardia

-Evaluate mother and fetal well being -Obs. VS -Report to superviser for planning VE, -Advis : evaluate again and report again

22.00

Subjectiv complain (+)

General condition : well BP : 140/100 mmHg Pulse : 80x/mnt FHR : 150x/mnt UC : 2x/10-20

G1P0A0L0 A/S/L/IU with head presentation + negleted 2 nd stage of labor + eclampsia + history of watery vaginal discharge

-Evaluate was done but not improve so report to superviser again and propose SC Proposed agreed

Time 22.30

subect

object General condition : well BP : 150/100 mmHg Pulse : 80x/mn Tax : 37.4 C UC : 2x/10-20

assesment

planning -Prepare SC

G1P0A0L0 A/S/L/IU with head presentation + negleted 2 nd stage of labor + eclampsia + history of watery vaginal discharge

23.00

-SC begun at 23.10 wita

P1A0L1 with 3 rd stage of labor

Baby was born with head presentation and coiled placenta 2x : Male, 3200 gr, length 49 cm, AS 7-9, anus (+) Placenta complete, weight not measure, AM green thick, little amount.

00.30

General condition : well


BP : 150/100 mmHg RR : 20x/mnt UC : good Wound of operation : dry, bleeding (-), UFH : 2 fbu UP : 60 cc Pulse : 84x/mnt Tax: 37C

P1A0L1 with 4 th stage of labor

-Evaluate VS of mother -Evaluate Subjective complain -Evaluate wound operation -Evaluate UC -Educate mother to breast feeding
-Evaluate mother and fetal well being -Obs. VS

06.00

headhache (-), epigastric pain (+)

General condition : well


BP : 150/100 mmHg Pulse : 84x/mnt RR : 20x/mnt Tax: 37C UC : good Wound of operation : dry, bleeding (-), UFH : 2 fbu UP : 60 cc

1 day post SC

Time

subect
VT : CD 4 cm, eff 50 %, AM (+), head palpable, H2+, small organ and umbilical cord wasnt palpable History of obstetry: 1. this Lab : Proteinuria (+)3 Therapy in kr taliwang PHC : Infus RL Nifedipine 10 mg sublingual In VK : Blur vision (+), epigastric pain (-), headhache (+)

object Pelvic evaluate : Spina ischiadica not prominent Os coxigeus mobile Distansia tuberum >90 Hb : 15.0 gr% Leukosit : 11600 Hematorit : 36.9 trombosit :235000 HbSAg (-) Proteinuria : (+)2

assesment

planning

, 12.30 Subjectiv complain (+) General condition : well BP : 150/100 mmHg Pulse : 80x/mnt RR : 18x/ mnt Temp : 36,4 C UC : 3x/10-30 FHR : 140x/mnt
G1P0A0L1 P/S/L/IU with HEAD presentation +prolong active phase 1 stage labor+ PEB

-Evaluate mother and fetal well being -Obs. VS

Time 1430

subect Subjectiv complain (+)

object General condition : well BP : 140/110 mmHg Pulse : 84x/mnt Temp : 36,7 C UP : 70 cc/hr FHR : 128x/mnt UC : 3x/10-35
BP : 160/100 mmHg Pulse : 76x/mnt FHR : 130x/mnt UC : 3x/10-35 VT : CD 5 cm, eff 50 %, AM (+), head palpable, H2+, small organ and umbilical cord wasnt palpable

assesment G1P0A0L1 P/S/L/IU with HEAD presentation + prolong active phase 1 stage labor+ PEB

planning -Evaluate mother and fetal well being -Obs. VS

16.00

Subjectiv complain (+)

G1P0A0L1 P/S/L/IU with HEAD presentation + prolong active phase 1 stage labor+ PEB

-Report to supervisor -Proposed amniotomy, propose agree -Amniotic fluid : 30 cc, clear

16.30

Subjective complain (+)

General condition : well BP : 140/110 mmHg Pulse : 84x/mnt Temp : 36,7 C UC : 3x/10-35 FHR : 118x/mnt

G1P0A0L1 P/S/L/IU with HEAD presentation + prolong active phase 1 stage labor+ PEB

-Evaluate mother and fetal well being -Obs. VS -O2 5 lpm -Resusitasi RL : D5% 2:1 max drop -Left lateral position -CTG -Bolus MgSo4 2 gr IV

17.00

Convulsi 3 minute

G1P0A0L1 P/S/L/IU with HEAD presentation + prolong active phase 1 stage labor+ eclampsia

Time

subect

object

assesment

planning

17.45

Convulsi Abdominal pain +

BP : 150/70 mmHg Pulse : 84x/mnt Temp : 37 C UC : 4x/10 40 FHR : 128x/mnt


VT : CD complete, AM (-), head palpable, H3+, small organ and umbilical cord wasnt palpable

G1P0A0L1 P/S/L/IU with HEAD presentation 2 nd stage of labor+ eklampsia

Report to supervisor Proposed VE Propose agree

18.10

Abdominal pain >>

General condition : well BP : 140/100 mmHg Pulse : 88x/mnt UC 4x/10 40

P1A0L1 + 3 rd stage of labor

Baby was born with vacuum extraction, male, AS : 3-5 , W : 3500 gr, caput + baby sent to NICU -Placenta was born, completed, spontaneously episiotomi
-Evaluate mother -Obs. VS

20.10

Subjectiv complain (+)

General condition : well BP: 100/60 mmHg P: 88x /m RR:18x/m T : 36,9C UC : good UFH = 2 finger below umbilical

4 stage of labor

07.00

Subjectiv complain (+)

BP : 100/60 mmHg Pulse : 80x/mnt Rr : 16 x/mnt T: 37 Active bleeding (-) UC : good UFH : 2 fbu Wound of episiotomi : bleeding

1 day of VE

-Evaluate mother -Obs. VS

Time

subect

object

assesment

planning

17.45

Convulsi Abdominal pain +

BP : 150/70 mmHg Pulse : 84x/mnt Temp : 37 C UC : 4x/10 40 FHR : 128x/mnt


VT : CD complete, eff 100 %, AM (-), head palpable, H3+, small organ and umbilical cord wasnt palpable

G1P0A0L1 P/S/L/IU with HEAD presentation + eklampsia

Report to supervisor Proposed VE Propose agree

18.10

Abdominal pain >>

General condition : well BP : 140/100 mmHg Pulse : 88x/mnt UC 4x/10 40

Second stage of labor


Third stage of labor

Baby was born with vacuum extraction, male, AS : 3-5 , W : 3500 gr, caput + baby sent to NICU -Placenta was born, completed, spontaneously episiotomi
-Evaluate mother -Obs. VS

20.10

Subjectiv complain (+)

General condition : well BP: 100/60 mmHg P: 88x /m RR:18x/m T : 36,9C UC : good UFH = 2 finger below umbilical

4 stage of labor

07.00

Subjectiv complain (+)

General condition : well BP : 100/60 mmHg Pulse : 80x/mnt Rr : 16 x/mnt T: 37 Active bleeding (-)

1 day of VE

-Evaluate mother -Obs. VS

Time

subect Inspekulo in ER room : OUE CD (+), show tissue of placenta (+) VT : OUE CD (+), palpable tissue of placenta, CUAF b/c 14-16 APCD taa Therapy : Double line infus RL max drop. Insert catheter

object

assesment

planning

21.00

Abdominal pain >> Dizziness (+), weakness (+) Active bleeding (-)

General condition : moderate BP : 100/50 mmHg Pulse : 108x/mnt RR : 20x/mnt Tax : 37.8 C

Post partum day-13 with HPP secunder e.c rest placenta

Obs. VS Was infus 3000 cc

22.00

Dizziness (+), weakness (+), active bleeding (-)

General condition : weakness BP : 100/50 mmHg Pulse : 100/mnt RR : 22x/mnt Tax : 37.8 C

Post partum day-13 with HPP secunder e.c rest placenta

Obs. VS Report superviser : Uterotonika antibiotika

22.15

-Drip oxytocin 1 amp in 500 cc RL : 20 dpm -Ampicillin 1 gr IV -Obs. VS

Time

subect

object

assesment

planning

23.00

Dizziness (+), active bleeding (-), weakness (+)

General condition : moderate BP : 100/50 mmHg Pulse : 96x/mnt RR : 20x/mnt Tax : 37,5 C

Post partum day-13 with HPP secunder e.c rest placenta

Obs. VS

00.0006.00

Patient was sleep

07.00

Dizziness (+), active bleeding (-) weakness (+)

General condition : moderate BP : 100/60 mmHg Pulse : 92x/mnt RR : 18x/mnt Tax : 37 C

4 Post partum day-13

with HPP secunder e.c rest placenta

Obs. VS Pro USG

07.00

Subjectiv complain (+)

General condition : well BP : 100/60 mmHg Pulse : 80x/mnt Rr : 16 x/mnt T: 37 Active bleeding (-)

1 day of VE

-Evaluate mother -Obs. VS

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