contoh laporan jaga obstetri
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LAPORAN OBSTETRI PATOLOGI
1. G2P1A0 32 years old fullterm pre!a!"y f#rst stae of la$or % ol#o&ydram!#o! % 'a#led of O(yto"#! )r#ps
*esarea! Se"t#o! % I+) #!sert#o! ,-
G2P1A0 32 years old admitted on January 13 th2016 at 02.30 am, referred by Obstetrician with dianose G2P1A0fullterm of !renancy not in labour yet, "ntrauterine fetal sinleton ali#e ce!halic !resentation $ oliohydramnion.Planned for O%&.
#story/
&he mother didn't felt labor !ain
&here was no bloody show
&here was no water dischare
(he felt the baby's mo#ement
&here was no history of cardiac, !ulmonary, li#er, renal, hy!ertension and diabetic diseases
A)% * + times at Obstetrician
-P * -ay , 201/ % * ebruary , 2016
-arriae * Once for 10 years %ontrace!tion * 1 monthly contrace!ti#e inection, last ta4en 1 years ao
P1 * 2005, (!ontaneus #erte deli#ery at (haron clinic, 78 3300 r, 7 9: cm, ali#e
Ge!eral e(am#!at#o!s/General %ondition * ood, conscious7lood !ressure * 120;50 mm %%onuncti#e * anemic ?@ (clera * icteric ?@
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At 0:.9/ am 0+.00 am B% * rarely
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"ntrauterine fetal sinleton ali#e ce!halic !resentation $ oliohydramnion
a!aeme!t /
%esarean (ection
%ounselin, informed consent
%ounselin contrace!tion"B contrace!ti#e
7lood was !re!ared Obser#ation of #ital sin, B%,
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Perut * "ns!e4si * datar Pal!asi * teraba massa !adat setini 2 ari atas simfisis !ubis, !ermu4aan
4asar, )&?@Per4usi * 8 ?@Aus4ultasi * 7B ?$ )ormal
Status G#!e9olo#s /
"ns!e4si * lu4sus ?@, fluor ?@, #ul#a tida4 ada 4elainan"ns!e4ulo * lu4sus ?@, fluor ?@, #aina tida4 ada 4elainan, Punca4 #aina ?@P * lu4sus ?@, fluor ?@, #ul#a;#aina tida4 ada 4elainan, tida4 teraba !ortio%ut * @A;P bilateral * @%a#um oulasi &ida4 menonol
La$orator#um /
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Abdomen * "* datar P* Pal!asi* teraba massa !adat setini 2 ari atas simfisis !ubis, !ermu4aan 4asar,
)&?@P* 8 ?@A* 7B?$ )ormal
tremitas * hanat, edema ?@A * P3A1 90 tahun Post
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A * P3A1 90 tahun Post
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Jam 1/.00& * +0;60 mm