Professional Documents
Culture Documents
22 OCTOBER 2009
Name
Age
: 21 years old
Wakt
u
Subject
23.3
0
(28/
10/0
9)
admite
d
: Oct, 28 th 2009
: 18.00pm
Object
General status :
General condition: good
Conciousness: CM
BP: 110/70
RR: 16x/mnt
Pulse :88 x/mnt
T: 36,2C
Eyes : an(-) ikt (-)
Cor -Pulmo : within normal limit
Obstetric status :
L1 : head
L2 : L3 : breech
L4 : desend 4/5
UFH: 33 cm
AC:98 cm
EFW : 3234 g
UC : 1-x10-20
Fetal Heart Rate : 136 bpm
VT : 1 cm, eff 25 %, AM (+),
HI,
and
Assesment
Planning
G2P1A0 40W/S/L/IU
with breech
presentation
Wakt
u
Subject
Object
Assesment
Planning
Lab. result:
HBsAg (-)
HB = 13,8
WB =20.200
TRB = 371.000
Hct = 28.0
07.0
0
Abdominal pain -
FHR:148 bpm
UC:-
Obs.inpartu sign
12.0
0
Abdominal pain -
FHR:144 bpm
UC:-
08.0
0(29
/10/
09)
Abdominal pain -
FHR:150 bpm
UC: -
Obs.inpartu sign
08.0
0(30
/10/
09)
Abdominal pain -
FHR:140 bpm
UC: -
Obs.inpartu sign
14.0
0
Abdominal pain -
FHR:140 bpm
UC: -
Obs.inpartu sign
20.1
5
FHR:152 bpm
UC: 3x10-35
VT : 5 cm, eff 40 %, AM (+), palpable
breech descend HI, unpalpable small organ and
umbilical cord
G2P1A0 H1
40W/S/L/IU
active phase
first stage of
labor
Obs.inpartu sign
Move to VK
20.3
0
FHR:152 bpm
UC: 3x10-35
VT : 4 cm, eff 40 %, AM (+), breech
palpable descend HI, unpalpable small organ
and umbilical cord
ZA score:5
G2P1A0 H1
40W/S/L/IU
active phase
first stage of
labor
Report
to
supervisoradvice:obser
vation
Wakt
u
Subject
Object
Assesment
Planning
00.2
0
FHR:144 bpm
UC: 3x10 40
VT : 4 cm, eff 25 %, AM (+), breech
palpable descend HI, unpalpable small
organ and umbilical cord
00.5
0
FHR:144 bpm
UC: 3x10 40
Observation
01.2
0
FHR:144 bpm
UC: 3x10 45
Observation
01.5
0
FHR:144 bpm
UC: 3x10 40
Observation
02.2
0
FHR:144 bpm
UC: 3x10 40
Observation
02.3
0
FHR:144 bpm
UC: 3x10 40
Observation
02.4
0
02.5
5
G2P1A0 H1
40W/S/L/IU
prolong active
phase first stage
of labor
Report to supervisor: SC
tomorrow
Observation mother and
baby wellbeing
Satge 2 of labor
Satge 3 of labor
Placenta was
minuts letter
born
04.5
5
2 hour post
partum
- observation mother
well being
- Observation for
hemorrhage sign
1 day post
partum
motivied mother to
breast feeding.
Wakt
u
Subject
Object
Assesment
Planning
Inspection: HIII
22.0
0
22.1
5
Report to supervisor:
prorpose
Vacum
ekstraction:agree
Stage 2 of labor
Stage 3 of labor
Placenta was
minuts letter
born
00.1
5
2 hour post
partum
- observation mother
well being
- Observation for
hemorrhage sign
06.0
0
1 day post
partum
MOTHER AND
BABY WELL BEING
Name/adress
Age
Address
Time
23.30
Admitted
to
Hospital
: Mrs.linda/Kayangan
19 years old
Narmada
Subject
11 Oktober 2009
23.30 wita
Object
Examinaton at VK :
GCS : E4V5M6
BP :110/70 mmHg
PR : 96x/
RR : 18x/
Temp : 38 C
An -/-, ict -/Cor & pulmo : in normal range
Abd : normal range
Ext : oedema -/
Obstetric status :
L1 : breech
L2 : fetal back on the right side
L3 : head
L4 : was in pelvic inlet 4/5
UFH :34cm
EFW : 3410 gr
FHR : 148 bpm
UC :3x10-35
VT :vulva edema, CD complete, AM (-),
green,
head palpable, caput (+)
descend HIII, small part and umbilical
cord wasnt palpable.
Lab. Examination :
Hb : 11,9 gr%
Leko : 19.600 mm3
Trombo : 224.000 mm3
Hct : 36,2 gr%
HBsAg : -
Assesment
Planning
G1P0A0L0 A/S/L/IU
with neglected 2th
stage of labor.
Time
Subject
Object
Assesment
Planning
Satge 2 of labor
Satge 3 of labor
02.15
06.00