Name Age Address Admitted MR

: Mrs. M : 20 yo : Namada : April, 10th 2013 at 21.00WITA : 510015

TIME 10/04/ 2013 (21.00)

SUBJECTIVE Patient referred from Narmada PHC with G1P0A0L0 40-41 w/T/H/IU head presentation, mother and fetal well active phase 1st stage of labor with severe preeclampsia . Patient confessed abdominal pain since 09.00 (10/04/2013), history water came out from her womb (+). Bloody slim (+), FM (+). Blur vision (-), epigastric pain (-), headache () No history of DM, HT, Asthma LMP : 26-06-2012 EDD : 03-04-2013 ANC history : 10x at PHC Last ANC : 13/03/2013 Result : BP : 100/70 mmHg, BW : 62,4 cm, 36 weeks, UFH : 29 cm, back on right side USG history : 2 x at Sp.OG Last USG 02/03/2013 Result : fetal S/L/ head presentation, 34-35 weeks, plasenta in fundus, EFW : 2,3 kg, EDD : 13-04-2013 Family planning history : Planning of family planning : Obstetrical history 1. This

OBJECTIVE General status GC : well Consciousness : composmentis BP : 160/110 mmHg PR : 88 bpm RR : 22 rpm T : 36,70C Local State Eye : pale (-/-), icteric (-/-) Cor : S1S2 single, regular, murmur (-), gallop (-) Pulmo : vesicular (+/+), ronchi (/-), wheezing (-/-) Abdomen : striae (+), scar (-) Extremity : edema (+/+), warm acral (+/+) Obstetrical State L1 : breech L2 : back on right side L3 : head L4 : 4/5 UFH : 33 cm EFW : 3410 gram UC : 3x10~35 FHR : 12-12-12 (144 bpm) VT: : 6 cm, eff 75%, amnion (+), head presentation, denom unclear, HII, unpalpable small part or umbilical cord.

ASSESTMENT G1P0A0L0 40-41 w/T/H/IU head presentation, active phase 1st stage of labor with severe preeclampsia

PLANNING Observe mother & fetal well being DM co to GP pro observe, GP co to SPV, advice manage severe preeklamsia like protap, continue MgSO4 drip

TIME

SUBJECTIVE Chronologist : 09.30 (26/03/12) S : patient Narmada PHC confessed abdominal pain. O : GC : well BP : 160/110 mmHg PR : 80 bpm RR : 20 tpm Temp : 37OC UFH : 35 cm, UC : 3x10~30 FHB : 12-12-12 (144 bpm) VT: : 6 cm, eff 75%, amnion (+), head presentation, denom unclear, HII, unpalpable small part or umbilical cord. A : Patient referred from Narmada PHC with G1P0A0L0 40-41 w/T/H/IU head presentation, mother and fetal well active phase 1st stage of labor with severe preeclampsia .

OBJECTIVE Lab Evaluation WBC : 15,83 x 103/L HB : 12,3 g/dl RBC : 4,60 x 106/L HCT : 37,4 103/L PLT : 280 x 103/L Protein : +4 Ureum : 23 mgl/dl Creatinin : 0,7mgl/dl SGOT : 18 mgl/dl SGPT : 9 mgl/dl HbSAg : (-)

ASSESTMENT

PLANNING

P: IVFD RL 28 tpm + MgSO4 inj. MgSO4 4 g Insert DC co to doctor advice : Refrred to NTB GH

TIME 01.00

SUBJECTIVE

OBJECTIVE UC : 3x10~35 FHR : 11-11-12 (136 bpm) VT: : 8 cm, eff 75%, amnion (+), head presentation, denom unclear, HII, unpalpable small part or umbilical cord.

ASSESTMENT G1P0A0L0 4041 w/T/H/IU head presentation, prolonged active phase 1st stage of labor with severe preeclampsia

PLANNING Dm co to GP pro amniotomy, GP acc to amniotomy

01.30 03.30 GC : well Consciousness : composmentis BP : 130/90 mmHg PR : 88 bpm RR : 22 rpm T : 36,70C UC : 3x10~35 FHR : 11-12-12 (140 bpm) VT: : complete, eff 100%, amnion (+), head presentation, denom unclear, HII, unpalpable small part or umbilical cord. 05.30 UC : 3x10~35 FHR : 12-12-12 (144 bpm) VT: : complete, eff 100%, amnion (+), head presentation, denom unclear, HIII, unpalpable small part or umbilical cord. Prolonged 2nd stage of labor 2nd stage of labor

Do amniotomy

DM co to GP pro VE, GP co SPV pro VE, SPV acc to VE

06.00

VE began

TIME 06.05

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING Baby was born female, BW 3250 gram, BL 48, AS 3-5 , anus(+), anomaly kongenital (-). Sign of post date : overgrown nails, a lot of hair in head, dry skin, yello discoloratin of skin Placenta was born, spontaneously, complete, bleeding + 100 cc

06.10

07.30

Mother convultion

BP : 180/110 mmHg PR : 20 bpm UC : (+) well UFH : 2 finger below umbilicus Active bleeding (-)

2 hour post partum

Obs, mother well being

UC not well

Masasse uterus

TIME

SUBJECTIVE

OBJECTIVE

ASESTMENT

PLANNING

27/03/ 2013 07.00

GC : well BP : 110/80 mmHg PR : 84 bpm RR : 20 bpm T : 36,6 C UC : (+) well UFH : 2 finger below umbilicus Active bleeding : (-)
Baby in NICU: PR :144 bpm RR : 46 bpm T : 36,40C