Case 1

Name : Mrs. F
Age : 35 years old
Address : Puncang Lendang, Batu
Layar
Admitted : 10th July 2016
RM : 580528

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

10/07/
2016
08.47

Patient referred from Meninting

PHC with P3A0L3 with Retentio
Placenta. Patient has given birth in
Meninting
PHC
at
07.45
spontaneously. The placenta didnt
born after 30 minutes Then, the
midwife did manual placenta but
failed. Now, patient confessed
weakness (+) and dizzines (+).

General status:
GC: Moderate
GCS: E3V4M6
BP: 90/50 mmHg
PR: 120 bpm
RR: 24 x/min
T: 36,70C
Eye : anemis (+/+), icteric (-/-)
Thorax :
Cor : S1S2 single reguler,
murmur (-), gallop (-)
Pulmo : vesikuler (+/+),
wheezing (-/-), Ronkhi (-/-).
Abdomen : scar (-), striae
gravidarum (+), linea nigra (+)
Extremity : edema (-/-), warm
acral (-/-)

P3A0L3 with HPP

e.c.
Retentio
placenta
+
hipovolemic shock +
moderate anemia

No history of DM, HT, and asthma

History of Familiy Disease: HT (-)
Allergy (-)
LMP:
EDD:
History of USG: History of family planning: Injection
3 months
Next family planning: Injection 3
months
Obstetrical history:
I. 9
months/Spontaneous/midwife/P
HC/female/11 yo/life
II. 9
months/Spontaneous/midwife/P
HC/Female/5 yo/life
III. 9
months/spontaneous/midwife/P
HC/male/1 day/life

Obstetrical status:
UFH: as high as umbilicus
UC: poor
Genitalia inspection: umbilical
cord in vulva, active bleeding
(+), ruptur perineum grade II.

PLANNING
DM planning:
Diagnostic planning
Check CBC, RFT,
HbsAg, PTT, APTT
Therapy
Double line IVFD RL,
loading 4 flash
Oxigen Nasal Canule
4 lpm
Manual Placenta
Pro transfusion 2 kolf,
1 kolf/day
Observation Vital Sign
and bleeding
DM co GP, GP advice:
Manual Placenta

Time

Subject

Object
Lab:
HB: 8,1
RBC: 3,12
HCT: 25,3
WBC: 16,47
PLT: 358
HbsAg: (-)
PPT: 15,7
APTT:33,3

Assessment

Planning

Case 2

Name : Mrs. S
Age : 35 years old
RM : 57-71-48
Address : Selong, Lombok Timur
Admitted : 10th July 2016

Time
20th
April
2016
23.00

Subject
Patient referred from Sedau PHC
with G1P0A0L0 40-41 weeks
S/L/IU head presentation with
prolonged second stage of labor.
Patient confessed abdominal
pain (+) since 17.00
(19/04/2016), bloody slime (+)
since 06.00 (20/04/2016), water
leaked from her womb (+) since
08.00 (20/04/2016), FM (+).
History of DM (-), HT (-), asthma
(-), allergy (-).
LMP : 08 / 07 / 2015
EDD : 15 / 04 / 2016
GW : 40-41 week
History ANC : 6x at PHC
Last ANC: 11-02-2016,
Result GW 30 weeks, BP :
120/70 mmHg, BW: 55 kg, head
presentation, UFH: 21cm, FHB
(+) 130x, edema (-). Lab
(07/03/2016): Hb 11,0 gr%.
History of USG : History of family planning: Next family planning: Obstetric history:
1. This

Object
General status
GC : well
Consciousness: CM
BP : 120/80 mmHg
PR: 88 tpm
RR: 20 tpm
T: 36,6C
Local status
Eye : anemic -/-, icteric -/Cor : S1S2 single regular,
murmur (-), gallop (-).
Pulmo : vesicular (+/+),
wheezing (-/-),
rhonchi (-/-).
Abdomen : scar (-), striae (+),
linea nigra (+).
Extremity : edema (-/-), warm
acral (+/+).
Obstetric status
L1 : breech
L2 : back on right side
L3 : head
L4 : 3/5
UFH : 31 cm
EFW : 3100 gr
FHB: 12-12-12
UC : 1 x 10 ~ 10
VT : complete, eff 100%,
amnion (-), head presentation,
caput (+) HII, small part or
umbilical cord unpalpable.

Assessment
G1P0A0L0 40-41
weeks S/L/IU head
presentation with
neglected second
stage of labor.

Planning
DM Planning:
Diagnostic:
CBC
CTG
Therapy:
Ceftriaxone inj. 2 gr.
Termination per
abdominal
DM co to GP, GP co to
SPV, SPV advice:
Termination per
abdominal

Time

Subject

Object
Lab (20/04/2016):
HB: 10,3
RBC: 4,13
HCT: 32,5
WBC: 15,80
PLT: 278
HbsAg: (-)

Assessment

Planning

Time
10/07/
2016
12.30

Subject
Chronology at Gunung Sari PHC
S:
Patient pregnant 9 month confessed lower abdominal pain referred
to flank since 22.00 (9-7-2016). Bloody slime (+) since 23.00 (9-72016). Fetal Movement (+).
LMP: 13-10-2015
EDD: 20-07-2016
O:
General status
GC : well
Consciousness: CM
BP : 110/70 mmHg,
PR : 82 ppm,
RR : 20 rpm,
T : 36,2 C.
L1 : breech
L2 : back on right side
L3 : head
L4 : 4/5
UFH : 34 cm
UC: 3x10~30
FHB: (+) 138 bpm
VT: 2 cm eff 25%, amnion (+), head palpable, HI, denominator
unclear, small part or umbilical cord unpalpable.
A:
G2P1A0L1 38-39 weeks S/L/IU head presentation, mother and fetal
in good condition with inpartu latent phase first stage of labor.
P:
-

CIE about the patient condition.

Suggest mother to eat and drink.
Suggest mother to laying to the left side
Obs. Sign of labor 4 hours again (16.30)

Object

Assessment

Planning

Time
10/07/
2016
16.30

Subject
Chronology at Gunung Sari PHC
S:
Patient confessed lower abdominal pain referred to flank (+), Fetal
Movement (+).
O:
General status
GC : well
BP : 110/70 mmHg,
PR : 82 ppm,
RR : 19 rpm,
T : 36,5 C.
UC: 3x10~30
FHB: (+) 137 bpm
VT: 4 cm eff 30%, amnion (+), head palpable, HI, denominator
ROA, small part or umbilical cord unpalpable.
A:
G2P1A0L1 38-39 weeks S/L/IU head presentation, mother and fetal
in good condition with inpartu active phase first stage of labor.
P:
-

CIE about the patient condition.

Suggest mother to eat and drink.
Suggest mother to laying to the left side
Obs. 4 hours again (20.30)

Object

Assessment

Planning

Time
10/07/
2016

Subject
Chronology at Gunung Sari PHC
S:
Patient confessed lower abdominal pain referred to flank (+)

20.30
O:
General status
GC : well
BP : 100/70 mmHg,
PR : 84 ppm,
RR : 19 tpm,
T : 36,5 C.
UC: 3x10~35
FHB: (+) 140 bpm
VT: 4 cm eff 50%, amnion (+), head palpable, HII, denominator
ROA, small part or umbilical cord unpalpable.
A:
G2P1A0L1 38-39 weeks S/L/IU head presentation, mother and fetal
in good condition with inpartu arrested active phase first stage of
labor.
P:
- CIE about the patient condition.
- Midwife co to GP, GP advice: IVFD PZ 28 tpm
- Reffered to NTB GH

Object

Assessment

Planning

Time
21.15

Subject
Abdominal pain (+)

Object
General status
GC : well
Consciousness: CM
BP : 120/80 mmHg
PR: 88 tpm
RR: 20 tpm
T: 36,7C
FHB: 12-12-12
UC : 3 x 10 ~ 30

Assessment
G1P0A0L0 40-41
weeks S/L/IU head
presentation with
neglected second
stage of labor.

01.50

Planning
C-section start at
operating room NTB
GH

Baby was born female,

3000 gr, AS 7-9, BL 47
cm, HC 34 cm, anus
(+), congenital anomaly
(-)
Placenta was born
complete at 02.00
Baby moved to NICU

04.00

No complaint

General status
GC : well
Consciousness: CM
BP : 120/70 mmHg
PR: 84 tpm
RR: 20 tpm
T: 36,6C
UC: well
UFH: 1 fingers below umbilicus
Active bleeding (-)
Baby in NICU
HR: 140 x/min
RR: 35 x/min
T: 36,3 C

2 hours post Csection

- Obs. mother and baby

well being

Time
06.00

Subject
No complaint

Object

Assessment

Planning

General status
GC : well
Consciousness: CM
BP : 120/80 mmHg
PR: 88 tpm
RR: 20 tpm
T: 36,7C
UC : well
UFH: 1 fingers below umbilicus
Active bleeding (-)

1st day post C-section

- Obs.mother and baby

well being

Baby in NICU
HR: 140 x/min
RR: 38 x/min
T: 36,5 C