Obs 3/12/2018 (06.00) S/ Keluhan (-), Gerakan janin (+) O/ Kes: Compos mentis TD : 130/90 mmHg N 92x/m T : 36.6C RR 18x/m His (-) Djj 141x/menit TFU = 27 cm.
A/ G3P2A0 AH 1 UK 35-36 minggu T/H + PEB (membaik) + TBJ 2170 gr p/ • Observasi tanda – tanda inpartu • Dnp Mgs04 6gr dalam RL 500cc • Dexametason 2x6mg /IM • Nifedipin 3x10mg • Balance cairan
Nb 06.00 :Infus RL drip mgS04 40%/6gr
Obs 3/12/2018 (10.00) S/ Keluhan (-), Gerakan janin (+) O/ Kes: Compos mentis KU: CM (E4V5N6) TD : 140/90 mmHg N 88x/m T : 36.6C RR 20x/m His (-) Djj 138x/menit
A/ G3P2A0 AH 1 UK 35-36 minggu T/H + PEB (membaik) + TBJ 2170 gr p/ • Observasi tanda – tanda inpartu • Observasi keadaan umum • Terapi lanjut
Nb 09.00 :aff DC
Obs 3/12/2018 (12.30) S/ Keluhan (-), Gerakan janin (+) O/ Kes: Compos mentis KU: CM (E4V5N6) TD : 150/80 mmHg N 88x/m T : 36.6C RR 20x/m His (-) Djj 138x/menit
A/ G3P2A0 AH 1 UK 35-36 minggu T/H + PEB (membaik) + TBJ 2170 gr p/ • Int. RL 12 tpm • Livron 1x1 tab • Cek hasil labolatorium SGOT/SGPT, Ur,Cr.
Obs 3/12/2018 (14.20) S/ Keluhan (-), Gerakan janin (+) O/ Kes: Compos mentis KU: CM (E4V5N6) TD : 140/90 mmHg N 88x/m T : 36.6C RR 20x/m His (-) Djj 143x/menit
A/ G3P2A0 AH 1 UK 35-36 minggu T/H + PEB (membaik) + TBJ 2170 gr p/ • Int. RL 12 tpm • Livron 1x1 tab (14.30) • Tunggu hasil labolatorium • Nifedipin bila 50 ≥ 160/110