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Identity
Wife Husband
Name : Ny. A Tn . R
Age : 25 years 29 year
Religion : Islam Islam
Education : SMP SMA
Work : IRT Employees
Tribes : Java / Indonesia Java / Indonesia
Address : Attack Attack
Tel : 085728xxx 085725xxx
5. Obstetric history
P1 A0 .Ah1
rn
Sexual patterns : During the postpartum the mother has not had
sexual intercourse with her husband, Complaint: no
10. History KB
She said she had never used any type of contraception
11. Medical history
- Mothers say they are not or have suffered from systemic diseases such as
hypertension, asthma, diabetes mellitus , tuberculosis, and HIV
- Mother said that her family was not having or had ever suffered from
systemic diseases such as hypertension, asthma, diabetes mellitus , tuberculosis,
and HIV
- Mom says that does not have twin breeds
h. Genetalia
Varices : no v
Oedem : there is no
Scar : Episiotomy scar stitched running suture
technique is mediolateral. Good stitching condition, slightly swollen, there
is sign infection.
Spending vaginal: Lokhea rubra
i. Anus
No hemorrhoids.
B. Baby Physical Examination
a) General situation :
good Awareness : compo smetis
b) Vital Signs
Temperature : 36.6 0 C
Respiratory : 46 times / minute
Pulse : 144 times / minute
c) Anthropometry
BB : 3100 grams LK : 33 cm
PB : 50 cm LILA : 10.5 cm
LD : 33 cm
d) Head : symmetrical, normal size, no abnormal bumps
e) Blackhead : flat, not sunken
f) Face : not pale, not yellow, and no scars
g) Eye : symmetrical, pink conjunctiva , sclera not jaundice
h) Nose : symmetrical, clean, no polyp
i) Mouth : clean, not pale, no trush
j) Neck : no swelling of the thyroid gland , lymph and no
widening
jugular vein .
k) Chest : symmetrical, no wheezing
l) Abdomen : when the baby is calm the stomach is palpable soft,
no bumps and scars
m) The umbilical cord : clean, no signs of infection
n) Genitalia : labia Mayora covers the labia minora , positive
urethral hole, vagina
holey.
o) Extremeity : symmetrical, active movement, total number of
fingers
p) Reflect
k. Supporting investigation
no investigation was performed.
i. Birth history
K L ACTION BLE K
ALA ONG EDING ET
I. 8 - 20cc n
II hours Episiotomes 100c orma
II 1 - c l
I hour 2nd 100c n
I 1 degreelaceration suturingtechnique ismediolate c orma
V 5 ral baste with thread cutgut 100c l
minut c n
es orma
2 l
hours n
orma
l
a 1 320c
moun 1 c
t hours
15
minut
es
ASSESMENT
Mrs. "Y " age 25 years P1 A0 Ah1 in the puzzle day to 2 normal with
wound pain on the perineal seams .
PLANNING
Date / time : 20 December 2011 / 14.15 WIB
1. Explain the results of the examination to the mother that the state of
mother and baby in normal circumstances
Evaluation : I understand the explanation given by the midwife and feel
happy and relieved
2. The midwife explained the importance of maintaining genetic hygiene and
advised the mother to clean the genetal apparatus with soap after either a BAK or a
bowel movement from the top to the anus
Evaluation : Mother understands the midwife's explanation and is able
to repeat the midwife's explanation as well the mother said she would try to
implement the suggestion
3. The midwife explains and advocates about the post- episiotomy sterilizing
perinium treatment with polish stitches using gauze that is betadine after genetalia
is washed with soapy water
Evaluation : I understand the explanation of the midwife and try to do
the suggestion
Mother understood with the advice given
4. Midwives advise mothers not to have sexual intercourse first during the
puerperium and explain the risk factors
Evaluation : Mother understands the midwife's explanation and is
willing not to have sexual intercourse with her husband during the puerperium
5. Tell the mother how to care for the umbilical cord with gauze that is given
warm water
Evaluation : I understand the advice and try to do it at home
6. Explain in the mother to maintain the fulfillment of nutrition patterns that
have been well done by eating foods that contain balanced nutrition that
is carbohydrates (rice, potatoes, bread), protein (tofu, tempeh, meat, fish, eggs),
vitamins (vegetables and fruits). And increase the consumption of foods containing
protein to accelerate wound healingepisiotomi
Evaluation: Mothers are willing to do a healthy and balanced nutrition
fulfillment pattern, especially protein consumption