Post on 19-Dec-2015
description
Supervisor: dr. Juliawan, SpOGDM: Ery, Heri, Mamat, Asri
Case Resume :No. Case Total
Pathology Delivery 1
1. G1P0A0 39 - 40 weeks S/L/IU transverse lie with PROM < 12 hNormal Delivery -
G1P0A0 39 - 40 weeks S/L/IU transverse lie with PROM < 12 h
Name : Mrs. AAge : 35 years oldAddress : LingsarAdmitted : 20 – 02 – 2014 No. RM : 098647
G1P0A0 39 - 40 weeks S/L/IU transverse lie with PROM < 12 h
Time Subjective Objective Assesment Planning
11.00 WITA
At DR Teratai
- General condition : WellGCS : E4V5M6
BP : 120/80 mmHgPR : 80 x/mRR : 20 x/mTemp : 36,0 ◦C
UFH : 26 cm transverse lieEFW : - gramFHR: 12-12-12, reguler (144 bpm)UC : -VT : -
G1P0A0 39 – 40 weeks S/L/IU transverse lie with PROM < 12 h
DM co to GP pro SC, GP co to SPV for SC SPV : acc SC
CIE patient and family
Prepare for SC
11.40 WITA
- - SC began
12.10 WITA
- - Baby was born, male, 2700 gr, 49 cm, AS- 7-9, anus (+), anomaly congenital (-)
12.15 WITA
- - Placenta was born, manually and complete
Time Subjective
Objective Assesment Planning
14.10 WITA
- General condition : well BP: 110/80 PR : 88 x / mRR : 20x/mT: 36,8UFH: 2 finger below umbilicusUC: (+) wellActive bleeding (-)
P1A0H1 2 hours post partum
Obs. General Condition,Vital sign
Obs. Mother and baby well being
21/02/2014
07.00 WITA
- General condition : well BP: 120/80 PR : 80 x / mRR : 20x/mT: 36,8UFH: 2 finger below umbilicusUC: (+) wellActive bleeding (-)
Babies roomingPR: 148 bpmRR: 50 x/mTemp :36,6 ◦C
1st day post partum
Obs. Mother and baby well being
CIE: explanation about result of examination, drink n eat, breast feeding, and mobilization