Name: Mrs. H JAge: 31 yoAdress: NarmadaAdmitted: May, 27th 2012 at 22.55

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING27/05/201222.55Patient referred from Narmada PHC with G1P0A0 38-39 weeks/T/H/IU inpartu latent phase 1st stage of labor with severe preeclampsia. Patient confessed abdominal pain that spread to frank since 17.00 (26/05/2012). Bloody slim (+). History rupture of membrane (-), FM (+).No history of nausea, vomiting, headache, visual disturbance and epigastric pain. No history of DM, HT, asthma.

LMP: 27/08/2011EDD: 04/06/2012

History of ANC: >4x at PHCLast ANC: 27/05/2012History of USG: -

History of family planning: -Next family planning: Injection 3 months

Obstetrical history:This

General status:GC: wellBP: 140/90 mmHgPR: 88 bpmRR: 24 T: 36,2Eye : palor (-), icteric (-)Thorax :Cor : S1S2 single reguler (murmur -), (gallop -)Pulmo : vesikuler (+/+), wheezing (-/-),Ronkhi (-/-).Abdomen : scar (-), striae (+), linea nigra (+)Extremity : edema (-/-), warm acral (+/+)

Obstetrical status:L1: breechL2: back on the right sideL3: headL4: 4/5UFH: 28 cm EFW: 2635 gUC: 2x10 ~ 30FHB: 12-12-13 (148 x/min)VT: 3 cm, eff 25%, amnion (+), head palpable HI, denominator unclear, impalpable small part / umbilical cord.

G1P0A0L0 39 weeks/S/L/IU latent phase 1st stage of labor with gestational hypertensionObs mother & fetal well beingDM co to SPV, advice:Obs progress of laborInfus RL without MgSO4

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNINGChronologist:At Polindes 21.00 (27/05/2012)S: Patient confessed abdominal pain that spread to frank.O:GC: wellBP: 160/110 mmHgPR: 80 bpmRR: 20 T: 36,5Head presentation, back on the right, 4/5UFH: 29 cm UC: +FHB: 12-12-11 (140 x/min)VT: 3 cm, eff 25%, amnion (+), head palpable HI, impalpable small part / umbilical cord.Proteinuria +2A:G1P0A0 38-39 weeks/T/H/IU inpartu latent phase 1st stage of labor with severe preeclampsia.P:Infus RLMgSo4 40% bolusReffered to Narmada PHCAt Narmada PHC 21.45 (27/05/2012)S: Patient confessed frank pain & lower abdominal pain since 17.00 (27/05/2012) with bloody slim (+). No history of nausea, vomiting, headache, visual disturbance and epigastric pain. FM (+).O:GC: moderateBP: 160/110 mmHgPR: 86 bpmRR: 20 T: 36,4Lab:HB: 11,9 g/dl RBC: 4,39 M/dl WBC: 12,62 K/dlPLT: 361 K/dlSGOT: 16 mg/dlSGPT: 12 mg/dlCreatinin: 0,6 mg/dlUreum: 13 mg/dlHbSAg: (-)Proteinuria: -

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNINGUFH: 28 cmUC: 2 x 10~ 35FHB: 12-12-11 (140 x/min)22.00VT: 3 cm, eff 25%, amnion (+), head palpable HI, denominator unclear, impalpable small part / umbilical cord.A:G1P0A0 38-39 weeks/T/H/IU inpartu latent phase 1st stage of labor with severe preeclampsia.P: co to GP:MgSO4 40% 28 tpmNifedipine 10 mg reffered to NTB GH28/05/201202.55Patient confessed abdominal painUC: 2x10 ~ 20FHB: 12-12-11 (140 x/min)VT: 3 cm, eff 25%, amnion (+), head palpable HI, denominator unclear, impalpable small part / umbilical cord.03.25Patient confessed abdominal pain came & relieved UC: 2x10 ~ 30FHB: 12-12-11 (140s x/min)VT: 8 cm, eff 75%, amnion (+), head palpable HI, denominator LOT, impalpable small part / umbilical cord.G2P0A1L0 A/S/L/IU with arrested active phase 1st stage of labor.Obs mother & fetal well beingDM co to SPV, pro SC; SPV acc SC at 07.30Prepare SC at 06.30Insert DCInj ampi 2 g IV

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING09.50SC beganFemale, W : 2900 gram, BL: 48 cm, AS 7-9Anus (+), Congenital anomali (-), Plasenta was born manually, completeBleeding 300 cc11.50GC: well Cons: CMBP: 110/70 HR: 84 bpmRR: 20 tpm T: 36 CUC: +UFH: at umbilicusAB: -2 hours post SCObserved mother and baby well beingSuggest mother to mobilization.29/05/201207.00GC: well Cons: CMBP: 110/80 HR : 82 bpm RR : 20 tpm T : 36,2 CUFH : 1 finger below umbilicusUC : +AB : -

Baby in NICU:PR:144RR: 46T: 36,41 day post SCObserved mother and baby well beingSuggest mother to mobilization, eat, and drink, medication.

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