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Name: Mrs. N.S.Age: 20 yo

Address: NarmadaAdmitted: october, 29 th 2012 at 10.30 wita

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TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

11/07/201210.45

Patient referred from Poli Hamilwith G2P1A0H1 A/S/L/IU headpresentation with PROM. Patientconfessed rupture of membranesince 06.00 (10/07/2012) clear.

Abdominal pain (-). Bloody slim (-

), FM (+).No history of DM, HT, asthma.

LMP: ForgotEDD: -

History of ANC: >4x

History of USG: -

History of family planning:injection 3 monthsNext family planning : Injection 3months

Obstetrical history:I. Female, aterm, spontaneous,

midwife, 2500 gram, 5 yo,alive.

II. This

General status:

GC: wellBP: 110/80 mmHgPR: 88 bpmRR: 24 T: 36,5General Satus:

Eye : anemis (-), icteric (-)Thorax :Cor : S1S2 single regular (murmur -), (gallop -)Pulmo : vesicular (+/+), wheezing (-/-),Ronchi (-/-).

Abdomen : scar (-), striae (+), lineanigra (+)Extremity : edema (-/-), warm acral(+/+)

Obstetrical status:

L1: breechL2: back on the right sideL3: headL4: 4/5UFH: 37 cmEFW: 4030 gUC: -FHB: 12-12-12 (144 x/min)VT: 2 cm, eff 25%, amnion (-)clear, head palpable HI, impalpablesmall part / umbilical cord.

G2P1A0L1 A/S/L/IU with

PROM > 12hours + Susp.

macrosomia

Obs mother & fetalwell being

skin test ampi (-) Inj. Ampicillin 1 gr /6 hourIV

Cek DL, HBsAg.

DM co GPpro induction with

oxytocin drip if CTGreactive, advice:acc induction with

drip oxytocin if CTGreactive

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TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

Chronology:-

PS: 5

Cervic dilatation 1 cm : 1Cervix length 1 cm : 2Cervix consistency moderate :1Cervix position posterior : 0Station H I : 1

PE: Promontorium impalpableSpina ischiadica not prominentOs coccygeus mobile

Arcus pubis >90

Lab:HB: 10,3 g/dlRBC: 4,53 M/dlWBC: 6,93 K/dlPLT: 69,7 K/dlHbSAg: (-)

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TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

11.00 - GC: wellBP: 120/80 mmHgPR: 88 bpmRR: 20 T: 36,5

CTG: reactiveUC: -FHR: 11-12-12 (140)

G2P1A0L1 A/S/L/IUwith PROM > 12hours + Susp.macrosomia

Drip oxy began 8 dpmflash I

11.30 - UC: -FHR: 11-11-10

Drip oxy 12 dpm

12.00 Abdominal pain came andrelieved UC: 2x/10 ~ 10 FHR: 11-11-12 Drip oxy 16 dpm

12.30 Abdominal pain came andrelieved

UC: 3x/10 ~ 10 FHR: 11-12-11

Drip oxy 20 dpm

13.00 Abdominal pain came and

relieved

UC: 3x/10 ~ 10

FHR: 11-12-12

Drip oxy 24 dpm

13.30 Abdominal pain came andrelieved

UC: 4x/10 ~ 10 FHR: 12-11-11

Drip oxy 28 dpm

14.00 Abdominal pain came andrelieved

UC: 4x/10 ~ 15 FHR: 12-12-12 (144)

Drip oxy 32 dpm

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TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

14.30 Abdominal pain came andrelieved

UC: 4x/10 ~ 20 FHR: 12-12-12 (144)

Drip oxy 36 dpm

15.00 Abdominal pain came andrelieved

UC: 4x/10 ~ 30 FHR: 12-12-12 (144)

Drip oxy 40 dpm

15.30 Abdominal pain came andrelieved

UC: 4x/10 ~ 30 FHR: 12-12-12 (144)

Drip oxy 40 dpm

16.00 Abdominal pain came andrelieved

UC: 4x/10 ~ 35 FHR: 12-12-12 (144)

Drip oxy 40 dpm

16.30 Abdominal pain came andrelieved UC: 4x/10 ~ 35 FHR: 12-11-12 (140)VT: 4 cm, eff 50%, amnionmembrane (- ) , head palpable HI ,denominator ROA, impalpablesmall part / umbilical cord

Drip oxy 40 dpm

17.00 Abdominal pain came andrelieved

UC: 4x/10 ~ 40 FHR: 12-12-12 (144)

Drip oxy 40 dpm

17.30 Abdominal pain came andrelieved

UC: 4x/10 ~ 40 FHR: 12-12-12 (144)

Drip oxy 40 dpm

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