Name : Mrs.

N
Age
: 21 yo
Adress : Bayan, KLU
Admitted: October, 11st 2012

TIME

SUBJECTIVE

OBJECTIVE

11/10/
2012
15.45

Patient referred from Bayan

PHC with G2P0A1L0 A/S/L/IU
with prolapse umbilical cord +
susp. breech presentation +
HROM + fetal distress.
Patient confessed abdominal
pain since 11.00 (11/10/12) and
rupture of membrane since
11.40 (11/10/12). Bloody slim
(+), FM (+).
No history of DM, HT, asthma.
LMP : forgot
EDD : History of ANC : > 4x at
Polindes
Last ANC : last month

GC : well
Consciusness : CM
BP : 120/80 mmHg
PR : 100 bpm
RR : 24 bpm
T : 37,2oC
Eye : anemis (-/-), icteric (-/-)
Cor : S1S2 single reguler, M (-), G (-)
Pulmo : vesikuler (+/+), wheezing (-/-),
ronkhi (-/-).
Abdomen : scar (-), striae (+), linea
nigra (+).
Extremity : edema (-/-), warm acral (+/
+)
Obstetrical Status

History of USG : History of family planning : Next family planning : Obstetrical History :
I.Abortus at 3 months
pregnancy
II.This

General Status

of

L1 : empty
L2 :
O
L3 : empty
L4 : UFH : 22 cm
EFW : UC : 3x/10 ~ 40
FHB : 13-13-13 (156 bpm)
VT : 6 cm, eff 75%, amnion (-) clear,
head palpable HI, palpable small part
(fingers) and umbilical cord.

ASSESSMENT

PLANNING

G2P0A1L0
A/S/L/IU
transverse lie +
active phase 1st
stage of labor+
history rupture of
membrane+
prolapse
umbilical cord

Observe mother and

fetal well being.
DM co to SPV pro CS,
advice : Acc CS at
17.00 Wita
CIE patient and family
Insert DC
Skin test (-), inj.
Ampicillin 2 g/IV.

TIME

SUBJECTIVE

OBJECTIVE

Chronologist at Bayan PHC:

Lab Evaluation

(11/10/2012)

HB : 12,9 g/dl
HCT : 41,1 %
WBC : 13,7 K/dl
PLT : 268 K/dl
HbSAg : (-)
BT: 145
CT: 600

12.40 wita
S : patient confessed rupture of
membrane and abdominal pain.
O : GC : well
BP : 120/70 mmHg
PR : 84 bpm
RR : 24 bpm
T : 36,5oC
Obstetrical status:
UFH : 28 cm
EFW: 2635 g
FHB : 160 bpm
His: 3x10~30
VT : 3 cm, amnion (-), palpable small
part and umbilical cord.
A

: G2P0A1L0 A/S/L/IU prolapse

umbilical cord + susp. breech
presentation + HROM + fetal distress.

P:
Infuse RL
Intra uterine resusitation
Inj. Ampicilin 1 gram
Referred to NTB GH

ASSESSMENT

PLANNING

TIME
16.30

SUBJECTIVE
Intermittent
abdominal pain

OBJECTIVE
BP : 120/80 mmHg
PR : 80 bpm
RR : 24 bpm
T : 37,2oC

ASSESSMENT

PLANNING
Transfer patient to operation room

FHB : 10-10-11 (124 bpm)

17.20

C-section began :
Baby was born, male, BW 2900
gram, AS 3-5, meconeal amnion
Anus (+), congenital anomaly (-),
Placenta was born manually,
complete, bleeding + 500 cc.

TIME

SUBJECTIVE

19.30

Patient confessed her leg

cant moved and
operation wound pain

12/10/
2012

Operation wound pain

07.00

OBJECTIVE

ASSESSMENT

PLANNING

GC : well
BP : 100/60 mmHg
PR : 80 bpm
RR : 24 bpm
T : 36,0oC
UFH : 1 finger below umbilicus
UC : (+) well
UO : 30 cc/hours

2 hours post CS

Observe mother well being

CIE mother to take a rest,
eat, and drink.

GC : well
BP : 110/80 mmHg
PR : 96 bpm
RR : 24 bpm
T : 36,5oC
UFH : 2 finger below umbilicus
UC : (+) well
Lochea rubra : (+)
Operation wound good

1 day post CS

Observe mother well being

CIE mother to mobilisation,
eat and drink

Baby in NICU :
PR : 148 bpm
RR : 42 bpm
T : 36,8OC