Name : Mrs.

S
Age : 27 yo
Address : Pemenang
Came To Hospital : 25th july 2014

Time

Subject

Object

Assesment

Planning

25/07/
2014
16.30

Patient reffered from KLU GH with

G2P0A1L0
A/S/L/IU
head
presentation with neglected second
stage of labor. Patien confessed
abdominal pain spread to back since
19.00 wita (24/07/2014), water
leaked out from her womb since
20.00 (24/07/2014), bloody slim (+),
FM (+).
No history of HT, DM, and asthma.

GC : well
GCS : E4V5M6
BP : 140/80
HR: 88 bpm
T : 37,0 C
RR : 20 bpm
General Status :
Eye : an (-/-) , ict (-/-)
Thorax :
C : S1S2 single reguler, murmur (-),
gallop (-).
P : ves +/+ , wh (-/-). Rh (-/-)
Abdomen : scar (-) , striae (+)
Extremity : edema - - Obstetrical status :
L1 : breech
UFH : 33cm
L2 : back on the right side

G2P0A1L0 40-41
weeks S/L/IU with
neglected active phase

-Obs mother and fetal

well being
-CIE patient and family
-DM pro observation for
vaginal delivery, DM
co to GP, GP co to
SPV, adv:
Obs. Progress of labor 1
hour, if no progress,
prepare SC
Prepare CS at 19.00 wita
Antibiotic
ceftriaxone
1 g/IV
(18.00)

LMP : 15-10-2013
EDD : 22-07-2014
History of ANC : > 4x at midwife
Last ANC : 22-07-2014
Result: BP 120/70
USG : never
History of family planning : Next family planning : injection 3
month
Obstetrical history :
1.Abortus, 3 months
2.This

L3 : head
L4 : 3/5
EFW : 3410 g
UC : 2x10~35
FHR : 11-11-12(136) bpm
VT : 9 cm, amnion (-) muddy, head
palpable, caput (+), molase (+), edema
porsio (+), H1l, unpalpable small part
of fetal/umbilical cord.
Lab :
HGB : 10,5
RBC : 3,96
HCT : 31,1
WBC : 20,20
PLT : 313
HBSAg : +

Time

Subject
Chronologist
25/07/2014
04.00
S:
Patient came to midwife regional
with 9 month pregnancy. Patient
confess abdominal pain since 18.30
(24/07/2014), water leaked out from
her womb (-), bloody slim (-), FM
(+).
O:
GC : well
GCS : E4V5M6
BP : 110/70
HR: 82 bpm
T : 37,7 C
RR : 20 bpm
EFW : 3255 g
UFH : 32 cm
UC : 2x10~30
FHR : 11-12-11 bpm
VT : 3cm, eff 25%, amnion (+),
head palpable, HI, denom unclear,
unpalpable
small
part
of
fetal/umbilical cord.
A : G2P0A1L0, A/S/L/IU laten phase
P:
-Obs progress of labor

Object

Assesment

Planning

Time

Subject
08.00
S: Mother wants to bearing down
O:
GC : weak
GCS : E4V5M6
BP : 120/70
HR: 82 bpm
T : 36,6 C
RR : 22 bpm
UC : 3x10~30
FHR : 11-12-12 bpm
VT : 8cm, eff 75%, amnion (-),
head palpable, HII, denom ROA
unpalpable
small
part
of
fetal/umbilical cord.
A : G2P0A1L0, A/S/L/IU active
phase
P:
-Rehydration
-Refer to Pemenang PHC

Object

Assesment

Planning

Time

Subject
10.00 (In Pemenang PHC)
S: Mother wants to bearing down
O:
GC : weak
GCS : E4V5M6
BP : 120/80
HR: 82 bpm
T : 36,6 C
RR : 22 bpm
UC : 3x10~30
FHR : 11-12-12 bpm
VT : 7cm, eff 75%, amnion (-),
head palpable, HII, porsio edema
(+), caput (+), denom ROA
unpalpable
small
part
of
fetal/umbilical cord.
A : G2P0A1L0, 39-40 weeks S/L/IU
neglected active phase
P:
-Continue Rehydration
-Inj Ampi 1gr
-Refer to KLU GH

Object

Assesment

Planning

Time

Subject
12.00 (In Pemenang PHC)
S: Mother wants to bearing down
O:
GC : weak
GCS : E4V5M6
BP : 120/80
HR: 84 bpm
T : 36,5 C
RR : 24 bpm
UC : 3x10~30
FHR : 11-10-11 bpm
VT : complete, eff 100%, amnion
(-), head palpable, HII, porsio
edema (+), caput (+), denom ROA
unpalpable
small
part
of
fetal/umbilical cord.
A : G2P0A1L0, 39-40 weeks S/L/IU
neglected 2nd stage
P:
-Continue Rehydration
-O2 4 Lpm
-Refer to NTB GH

Object

Assesment

Planning

Time

3/09/2
012
21.15

subject

object

assessment

planning

SC began
Baby was born,
female, A-S : 7-9.
BW : 3550g, BL : 54
cm, meconeal (-),
Anomali (-)
Placenta was born
spontaneous,
complete.
Bleeding 300cc

Time
23.15

Subject
-

Object

Assesment

Planning

GC : well
GCS : E4V5M6
BP : 120/90 mmHg
HR : 80 bpm
RR : 20 bpm
T : 36.7
UFH : Umbilical
UC : (+)
Lochea rubra : (+)
UO :200cc

2 hour post CS

Observe mother well

being
KIE mother to take a rest

GC : well cons : E4V5M6

BP : 120/90 mmHg HR : 88 x/minute
RR : 20 x/minute
T : 36,6C
UFH : 2finger below umbilicus
UC: (+)
UO: 40 cc/H

1st dayPost SC

Observe mother and baby

well being
KIE mother to take a rest

Baby in room:
HR: 144x/minute
RR: 46 x/minute
T: 36,5oC