Name: Mrs.

N I
Age: 20 yo
Adress: Narmada
Admitted: May, 15th 2012 at 09.40

TIME

SUBJECTIVE

15/05/
2012
09.40

Patient referred from

Poskesdes Sumbang
Narmada with G1P0A0 37-38
weeks S/L/IU head
presentation with inpartu
active phase 1st stage of
labor and severe
preeclampsia. Abdominal
pain (+). Bloody slim (-).
History rupture of membrane
(-), FM (+).
No history of nausea,
vomiting, headache, visual
disturbance and epigastric
pain.
No history of DM, HT,
asthma.
LMP: 27/08/2011
EDD: 04/06/2012
History of ANC: >4x at
Posyandu
Last ANC: 8/05/2012
170/110mmHg
History of USG: History of family planning:Next family planning:
Injection 3 months
Obstetrical history:
I.Abortus, 1 month.
II.Ini

OBJECTIVE
General status:
GC: well
BP: 130/90 mmHg
PR: 85 bpm
RR: 21
T: 36,5
Eye : palor (-), icteric (-)
Thorax :
Cor : S1S2 single reguler
(murmur -), (gallop -)
Pulmo : vesikuler (+/+),
wheezing (-/-),
Ronkhi (-/-).
Abdomen : scar (-), striae (+),
linea nigra (+)
Extremity : edema (-/-), warm
acral (+/+)
Obstetrical status:
L1: breech
L2: back on the left side
L3: head
L4: 4/5
UFH: 28 cm
EFW: 2635 g
UC: 2x10 ~ 25
FHB: 12-13-13 (152 x/min)
VT: 4 cm, eff 50%, amnion
(+), head palpable HII,
denominator LOA, unpalpable
small part / umbilical cord.

ASSESTMENT

PLANNING

G2P0A1L0 3738 weeks S/L/IU

head
presentation
with active
phase 1st stage
of labor and
severe
preeclampsia.

Obs mother & fetal

well being
Obs progress of
labor
Continue drip
MgSO4

TIME

SUBJECTIVE
Chronologist:
07.00 (15/05/2012)
S:
Patient confessed frank pain and
want to bearing down.
O:
GC: well
BP: 190/140 mmHg
PR: 82 bpms
RR: 20
T: 37
UC: 2x10 ~ 20
FHB: 11-11-11 (132 x/min)
VT: 4 cm, eff 50%, amnion (+),
head palpable HII, denominator
LOA, unpalpable small part /
umbilical cord.
Proteinuria: +3
A:
G1P0A0 37-38 weeks S/L/IU head
presentation with inpartu active
phase 1st stage of labor and
severe preeclampsias
P:
09.00
MgSO4 bolus 4 g
Drip MgSO4 6 g
Nifedipine tab 10 mg
Referred to NTB GH

OBJECTIVE
Lab:
HB: 12,7 g/dl
RBC: 5.06 M/dl
HCT: 41,6 %
WBC: 13,4 K/dl
PLT: 299 K/dl
SGOT : 22
SGPT : 16
Creatinin : 0,5
Ureum : 20
HbSAg: (-)
Proteinuria: +3

ASSESTMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

13.40

Patient confessed
abdominal pain ++

GC: well
BP: 180/120 mmHg
PR: 80 bpm
RR: 20
T: 36,5
UC: 2x10 ~ 30
FHB: 12-11-11 (136 x/min)
VT: 4 cm, eff 50%, amnion
(+), head palpable HII,
denominator LOA, unpalpable
small part / umbilical cord.

G2P0A1L0 37-38
weeks S/L/IU with
Arrasted active
phase 1st stage of
labor and severe
preeclampsia.

Obs mother & fetal

well being
CTG
DM co SPV, advice:
- Amniotomy
- Inj Ampiciline 1 gr IV
- Continue nifedipine
oral 1 tab/8 hours
(17.00)
-Amniotomy done
-10cc laudy

16.25

Abdominal pain +++

Patient want to bearing
down

GC: well
BP: 180/120 mmHg
PR: 80 bpm
RR: 20
T: 36,5
UC: 4x10 ~ 45
FHB: 12-12-12 (144 x/min)

G2P0A1L0 37-38
weeks S/L/IU with
2nd stage of labor
and severe
preeclampsia.

Conduct mother to
bearing down

Doranteknusperjolvulka
16.30

16.40

Baby was born, male,

AS 7-9, 2500 gram,
48 cm, Anus (+),
congenital anomaly
(-)
Placenta was born
spontaneous,
complete, bleeding
150cc

TIME
17.30

16/05/
2012
07.00

SUBJECTIVE
Patient confessed delivery
wound pain

OBJECTIVE

ASSESTMENT

PLANNING

GC: well
Cons: CM
BP: 170/130
HR: 80 bpm
RR: 20 tpm
T: 36,5 C
UC: +
UFH: 2 finger below
umbilicus
AB: -

2 hours post
partum

Observed mother and

baby well being
Suggest mother to
mobilisation, eat, and
drink, medication.

GC: well
Cons: CM
BP: 160/130
HR : 82
bpm
RR : 20 tpm
T:
36,2 C
UFH : 2 finger below
umbilicus
UC : +
AB : -

1 day post
partum

Observed mother and

baby well being
Suggest mother to
mobilisation, eat, and
drink, medication.

Baby rooming in:

PR:144
RR: 46
T: 36,4