Name : Mrs.

K
Age : 29 yo
Address : Tanjung
Came To Hospital : 3th July 2012

Time

Subject

Object

2/07/
2012
04.20

Patient reffered Tanjung GH with

G1P0A0L0
A/S/L/IU
head
presentation with arrested second
stage of labor. + mild preeclampsia +
leukosistosis.
Patien
confessed
abdominal pain spread to back since
03.00 wita (2/7/2012). Bloody slim
(-), history of ruptur of membran (+)
since 02.00 wita (2/7/2012), FM (+).
No history of HT, DM, and asthma.

GC : well
GCS : E4V5M6
BP : 140/90
HR: 103 bpm
T : 38,3 C
RR : 26 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 : 37cm
L2 : back on the right side

LMP : 28/9/2011
EDD : 5/7/2012
History of ANC : > 4x at midwife
Last ANC : 4-6-2012
USG : never
History of family planning : Next family planning : Obstetrical history :
1.This

L3 : head
L4 : 3/5
EFW : 4030 g
UC : 3x10~35
FHR : 11-12-14 (160) bpm
VT : 8cm, eff 75%, amnion (-), head
palpable, H1l, unpalpable small part of
fetal/umbilical cord.
Lab :
HGB : 9,2
RBC : 3,94
HCT : 28,6
WBC : 25,31
PLT : 352
HBSAg : +

Assesment
G1P0A0L0 A/S/L/IU
with neglected active
phase first stage of
labor

Planning
Obs mother and fetal
well being
Check lab CBC, HbsAg
Obs. Progress of labor
Co to SPV, advice :
- Recucitation IU

- Antibiotic
ceftriaxone
1 g/IV
(06.00)
- Prepare SC at 09.00
wita

Time

Subject
Chronologist
2/07/2012
01.50
S:
Patient came to Tanjung GH with 9
month pregnancy referred from BPS
with arrested second stage of labor,
os refered abdominal pain since
16.00 (1/07/2012) conduct mother
to bearing down 1 hour. BPS
Bloody slim (-), FM (+).
O:
GC : well
GCS : E4V5M6
BP : 130/80
HR: 80 bpm
T : 37,7 C
RR : 18 bpm
UFH : 34 cm
UC : 2x10~20
FHR : 12-13-13 bpm
VT : 10 cm, eff 100%, amnion (-),
head palpable,
H1, caput (+)
unpalpable
small
part
of
fetal/umbilical cord, oedem vulva,
rupture of muscle 1st degree.
A : G1P0A0H0 39-40 wk S/L/IU
head presentation with prolonged
second stage
P:
23.30
-Inj.ceftriaxone 1 g/IV at BPS
-Co to GP
-Rehidration RL : D5, 2:1
-O2 4 lpm
-Pct 3x1

Object

Assesment

Planning

Time

3/07/2
012
09.30

subject

object

assessment

planning

SC began
Baby was born,
female, A-S : 6-8.
BW : 3750g, BL : 54
cm, meconeal (+),
Anomali (-)
Placenta was born
spontaneous,
complete.
Bleeding 300cc

Time
12.00

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 :

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