OBSTETRIC EMERGENCY ROOM REPORT

DUTY ON : XXXXX
1. SUP, 30 yo
N ASSESS PROBLEM ICD PLAN OF
DATA BASED
0 MENT LIST X CARE
1. Anamnesis (ICD IX 89.03) :
Complained labor pain (+) since 08.00 pm
(16/01/2018), watery vaginal discharge (-), fetal
movement (+) good.

LMP : 19/04/2017
EDD : 26/01/2018
PNC : O&G

Obstetric history :
1. ♂, 2800 gr, SVD, 4 yo
2. Current pregnancy

Married : 1x ~ 5 year
 OBSTETRIC EMERGENCY ROOM REPORT
DUTY ON : xxxxx
yyyyy
PLAN
N ASSESS PROBLEM ICD
DATA BASED OF
0 MENT LIST X
CARE
2 Physical Examination (ICD IX 89.03) :
Weight/Height : 68/158 (BMI : 27.24)
Present state :
BP : 120/80 RR : 20
P : 80 T.ax: 36.5
General state :
Eyes : Anemic (-)
Thorax : Cor : S1S2 single, regular, murmur (-)
Pulmo: Vesicular +/+, rhonchi-/-, wheezing -/-
Abdomen : ~ Obstetric state
Extremities: Warm +/+
+/+
Obstetric state :
Abdomen:
Fundal Height 3 fingers below proc. Xyphoideus (30 cm)
Uterine contraction (+)
FHB (+) 148 bpm

Leopold examination:
L I : palpable soft rounded part, seemed buttock
L II : palpable flat part, extending on left side, seemed back on
left maternal side
L III : palpable hard rounded part, seemed head presentation
L IV: Convergent, seemed lower fetal part had not entered
pelvic inlet
 OBSTETRIC EMERGENCY ROOM REPORT
DUTY ON : xxxxx
yyyyy
PLAN
N ASSESS PROBLEM ICD
DATA BASED OF
0 MENT LIST X
CARE
Inspeculo v/v : cervical dilatation (+), fluxus (-), fluor (-)
VT (MRK) : Cervical dilatation 1 cm, effacement 25%
10.30 pm Soft – Medial, Fetal membrane (+)
Head palpable, unclear denominator, ↓HI
Unpalp small part/ umbilical cord
Pelvic examination ~ normal
 OBSTETRIC EMERGENCY ROOM REPORT
DUTY ON : xxxxx
yyyyy
N ASSESS ICD
DATA BASED PROBLEM LIST PLAN OF CARE
0 MENT IX
3 USG TAS (ICD IX 88.78) : G2P1001 38 weeks 1. Term Intervention :
Fetus Single/Life, Head 6 day, Single/Life, pregnancy 1. Expectative
presentation, FHB(+), FM(+) 1st stage of labor vaginal delivery
with 1st
BPD 9.08~37W3D AVE 36W1D stage of
HC 32.77~36W0D EFW 2857 g EFW : 2857 g Target :
AC 31.76~36W0D EDD 12/02/18 labor 1. Well born baby
and mother in
FL 6.92~35W2D good condition
Placenta fundus corpus anterior
grade III Instruction :
AF : 1.67 cm (SDP) Pdx : -
Therapy :
- Expectative
4 Laboratory Result vaginal delivery
(ICD IX 99.07)
WBC 12.42 Monitoring :
HGB 12.03 Complaint, vital sign,
HCT 39.76 FHB, Sign of Inpartu
PLT 188.10
BT/ CT: 2’00”/9’00”
 OBSTETRIC EMERGENCY ROOM REPORT
DUTY ON :

N ASSESS PROBLEM ICD

DATA BASED PLAN OF CARE
0 MENT LIST IX
At. 08.00 pm G1P0000 40 Instructions:
Evaluation after adequate uterine weeks 0 days, 1st - Expectative
contraction: stage of labor vaginal delivery
Abdomen: (ROM) - Amoxicillin 500mg
Uterine contraction 3-4x/10 ~ 30-35” @ 8 hours (io)
FHB (+) 142 bpm EFW: 3177g
Monitoring: manage ~
partograph WHO
VT (LYD) 08.00 pm
Cervical dilatation 4 cm, effacements
50%, Fetal Membrane (-)
Head Palpalble, Left Occiput
Transverse, ↓ H I
Unpalpable small part/umb cord
 OBSTETRIC EMERGENCY ROOM REPORT
DUTY ON :

N ASSESS PROBLEM ICD

DATA BASED PLAN OF CARE
0 MENT LIST IX
At. 11.40 pm 2nd stage of labor Instruction:
Patient urge to bear Lead to bear down
down ↓
Evaluation: At. 11.45 pm Spontaneously
Abdomen: uterine born baby ♂, 3250 g, AS: 8-9
contraction 4-5x/10 ~ Episiotomy (+)
45-50” FHB (+) 148
bpm

VT (LYD) 11.40 pm
Cervical dilatation
complete, Fetal
Membrane (-)
Head Palpalble,
Occiput Anterior, ↓ H
III +

3rd stage of labor Active management of 3rd

stage of labor
↓
At. 11.50 pm
Born placenta complete
perineal hecting (+)