Académique Documents
Professionnel Documents
Culture Documents
11/07/2012 (18.00)
S : Mother wants to bearing down
O : FHB : 136 bpm UC :
3x/10~45
VT : 10 cm, effacement 100%,
amnion (-) meconeal, mouth
palpable HIII+, impalpable
small part and umbilical cord.
A : G1P0A0L0 A/S/L/IU face
TIME SUBJECTIVE OBJECTIVE ASSESSME PLANNING
NT
Chronologist at Narmada
PHC :
11/07/2012 (18.20)
S : (-)
O : GC : well
BP : 120/70 mmHg PR : 80
bpm
RR : 22 bpm T : 36,5oC
FHB : 140 bpm UC :
3x/10~45
VT : 10 cm, amnion (-), mouth
palpable.
A : G1P0A0L0 A/S/L/IU face
presentation with 2nd stage of
labor.
P:
Observe mother & fetal well
being
Amoxicilin tablet at 18.10
(11/07/2012)
Refer to NTB GH
20.0 Mother wants to bearing down GC : well 2nd stage of Conduct mother
5 UC : 11-11-11 (132 labor to bearing down.
bpm) Baby was born
FHB : 4x/10 ~45 (20.10) :
Teknus perjol vulka Male, 3400 gram,
Fetus mouth 48 cm, AS 3-5.
TIME SUBJECTIVE OBJECTIVE ASSESSME PLANNING
NT
21.0 Patient confessed GC : weak HPP et Observe vital sign &
0 delivery wound BP : 110/70 mmHg causa bleeding.
PR : 92 bpm Atonia Uteri Suggest mother to
RR : 20 bpm + Suspect take a rest, eat, and
T : 36,7C Rest drink.
UC : (+) soft Placenta Massage fundus uteri
UFH : 2 fingers upper and exploration.
umbilicus Drip oxytocin 2 ampul
Active bleeding : (+) 20 tpm
Injection Metergin 1
ampul/IM
DM consult to SPV :
pro USG.
Advice : Observation
and USG tomorrow
morning.
22.0 Patient confessed GC : well 2 hours post Observe vital sign &
0 delivery wound BP : 120/80 PR : 80 partum bleeding.
bpm Suggest mother to
RR : 20 bpm T: take a rest, eat, and
36,4C drink.
UC : (+) well
UFH : 1 fingers below
umbilicus
Active bleeding : (-)
12/0 Patient confessed GC : well 1st day post Observe mother and
7/20 delivery wound BP : 100/60 PR : 92 partum baby well being.