No.

MR

Bagian / SMF Obstetri Ginekologi

Fakultas Kedokteran / Rumah Sakit Umum FK UKI
Jl. Mayjen Sutoyo No. 2, Cawang, Jakarta 13630, Indonesia
Tel. ( 021 ) 8092317 ext. 205 / 108

OBSTETRIC STATUS

IDENTITY
PATIENT HUSBAND/ PARENT / FAMILY
Name : ……………………….......... Name : ………………………………...........
Age : ……………………….......... Age : ………………………………...........
Education : …………………………..... Education : ………………………………...........
Occupation : …………………………..... Occupation : ………………………………...........
Religion : …………………………..... Religion : ………………………………...........
Tribe : …………………………..... Tribe : ………………………………...........
Address : …………………………..... Address : ………………………………...........
…………………………..... ………………………………..........
…………………………..... ………………………………..........
......................................... .....................................................

Date of Admition : ……………………………………….. Time : …………………….

Origin : Self admitted
: ......................................................................................................................

I. SUBJECTIVE ( Primary / Secondary)

1. Chief Complain :
………………………………………………………………………………………………………………

2. Additional Complain
1. …………………………………………………………………………………………………………
2. …………………………………………………………………………………………………………
3. …………………………………………………………………………………………………………
4. …………………………………………………………………………………………………………
5. …………………………………………………………………………………………………………

3. Chronology of Complain/ Recent Illness

………………………………………………………………………………………………………………
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Status RSU FKUKI/Ilmu Obstetri/Ginekologi RSU FK UKI/05.08 Page 1 of 13

 ………………………………………………………………………………………………………………
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4. Menstruation History
First Period : …………………………………..............………. years old
Cycle: Regular : ………………………………...............…….. days/ month
Length : ……………………………………...............………… days
Amount : ……………….....… changes / ……………..........…… cc
st
1 Day of Last Period : ……………………………………................………………
Length : …………………………………...............…………… days
Amount : ………………....... changes / ……………….............. cc
Estimated Date of Labor : .......................................................................................
Period Pain ( desmenorrhea ) : ………………………………………………...............…….

5. Marital History
a. Marital Status : Married / Not Married / Widow
: 1 / 2 / 3 / 4 / 5 time
b. Last Marriage : ……………………..................................…month / years

6. Pregnancy, Labor, Parturition History

Birth
No. Age of Pregnancy Type of Labor Sex Current Age
Weight
1
2
3
4
5
6
7
8

7. Previous Illnesses

No. System Based Abnormal Explanation

1 Central Nervous System
2 Cardiovascular
3 Respiratory Tract
4 Gastrointestinal Tract
5 Urogenital Tract
6 Haematology
7 Immunology / Metabolic
8 etc …………………………..

8. History Disease in Family

Status RSU FKUKI/Ilmu Obstetri/Ginekologi RSU FK UKI/05.08 Page 2 of 13
 No. System Based Abnormal Explanation
1 Central Nervous System
2 Cardiovascular
3 Respiratory Tract
4 Gastrointestinal Tract
5 Urogenital Tract
6 Haematology
7 Immunology / Metabolic
8 etc……………………………..

9. Surgery History

No. Genre Operation Years Explanation

1
2
3
4

10. Family Planning Method

Genre Years
Not use KB
Hormonal ( tablet, inject , susuk )
IUD ( lipe loops, cooper T, … )
Condom
Natural ( calendar, interuptus )
Kontap
Etc ……………………………….

11. Antenatal History

Pregnancy check up : : ………………………………… from : …………………............................
Complaint, abnormal, and problems :

ANC Pregnancy
Location Problems Management
Time Age

12. Others Data ( others secondary data / information associated with obstetric and
gynecology)
………………………………………………………………………………………………………………
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Status RSU FKUKI/Ilmu Obstetri/Ginekologi RSU FK UKI/05.08 Page 3 of 13

II. OBJECTIVE
A. GENERAL EXAMINATION
1. Vital Signs
General Condition : ……………………………………………………………………..…….
Consciousness : ……….. …………………………………………………………………
Blood Pressure : ……………………………………….....................…………… mmHg
Pulse : ……………………………………………....................…. .time / mnt
Temperature : ……………………………………….....................………………. º C
Respiratory Rate :…….. ……………………………………....................……...time/ mnt
Height : ………………………....................…………………………………cm
Weight : …………………………....................……………………………… kg

2. Head :
Eyes :
i. Conjunctivae : ……………………………………………………..................
…………
ii. Sclera :
………………………………………………………..................………
Teeth : ……………………………………………………………………………………….………
Ear Nose and Throat :
………………………………………………………………………………………….……
……………………………………………………………………………………………….
…………………………………………………………………………………………….…

3. Neck : ………………………………………………………………………………………..……..
………………………………………………………………………………………………

4. Thorax :
a. Breasts : …………………………………………………………………………..…………
………………………………………………………………………..……………
……………………………………………….…………………….………………
……………………………………………………………………………………..
b. Heart : …………………………………………………………………………….……….
………………………………………………………..……………………………
…………………………………..…………………………………………………
c. Lungs : ………………………………………..……………………………………………
……………………………………………..………………………………………
……………………………………..………………………………………………

5. Abdomen :
a. Inspection : ……………......................................................................................
........................................................................................................
b. Palpation : ........................................................................................................
........................................................................................................
c. Percussion : ........................................................................................................
........................................................................................................
d. Auscultation : ........................................................................................................
........................................................................................................
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 6. Extremities :
a. Superior : …………………………………………………………………………………
………………………………………………………………………………….
………………………………………………………………………………….
b. Inferior : …………………………………………………………………………………
…………………………………………………………………………………
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B. OBSTETRICAL EXAMINATION
1. Outer Examination
a. Inspection
……………………………………………………………………………………………………..
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……………………………………………………………………………………………………..

b. Palpation
Uterine Fundal Height : ………………………………………...............………….. cm
Abdominal Circumferrence : ………………………………………………………….… cm

1. Leopold I :
……………………………………………………………………………........................…
……………………………………………………………………………........................…
……………………………………………………………………………........................…
………………………………………………………………………………………………..

Leopold II :
……………………………………………………………………………………………...…
……………………………………………………………………………………………...…
……………………………………………………………………………………………...…
………………………………………………………………………………………………...

Leopold III :
………………………………………………………..……………………………………….
………………………………………………………………..……………………………….
…………………………………………………………………..…………………………….
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Leopold IV :
……………………………………………………………………………………..…………
……………………………………………………………………………………...…………
……………………………………………………………………………………...…………
……………………………………………………………………………………...…………

2. Head Palpation (perlimaan) : 5/5 , 4/5 , 3/5 , 2/5 , 1/5

3. His
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 Frequency : …………………………..................…………………… x / 10 minute
Length : ............................................................................................ second
Strength : strong / not strong

c. Auscultation
Fetal Heart Sound ( DJJ )
i. Frequency : ......................................................................................................
ii. Rhythm : regular / not regular

2. Inner Examination
a. Inspeculo (by indication ) : .........................................................................................)
i. Fluor :+/-
If positive :
Color : Clear white / thin white /
Clotty white / yellowish

ii. Fluxus : + / - (active flow : + / -)

………………………………………………………………….
...........................................................................................

iii. Vulva / urethra / vagina :

………………………………………………………………….
………………………………………………………………….
...........................................................................................

iv. Portio : size :

……………………………………………....
……………………………………………….
Color : ……………………………………………….

b. Vaginal / Vaginal Toucher ( by indication : …………………….....................…….)

i. Vulva / vagina :
……………………………………………..............................
...........................................................................................

ii. Portio :
 Axis :
…………………………………………………...……
 Consistency :
…………………………………........................……
 Effacement : ........................................
......................................
 Opening : ....................................................
..........................

iii. Amnion Liquid : intact / not intact

If not intact, kind of fluid: clear/ mekonium / blure
iv. Lowest part of fetus : head/ breech / foot breech/ foot / transversal
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 Station : Hodge I / II / III / IV
denominator : ................................................................
caput : ................................................................
moulage : ................................................................

v. Estimated Fetal Weight (TBJ)

: ...........................................................................gr

3. Additional examination / classify

a. Pelvic examination/ pelvimetri clinic (done / not done ) :
i. Pelvic inlet
 Promontorium : to grope / cannot grope
 Conjugata Diagonal : ………. .………cm, CV : ……………………cm
 Linea terminalis : ………………………………………………………...
Impression : tight / not tight

ii. Midpelvic
 Sacrum : ………………………………………………………...
 Pelvic wall : ………………………………………………………...
 Spina ischiadica : ………………………………………………………...
Impression : tight / not tight

iii. Pelvic outlet

 Os. Coccygeus : ……………………………………………...…………
 Pubic Arch : ………………………………………………...………
Impression : tight / not tight

Kesan panggul :
 Pelvis not tight
 Relative tight pelvis
 Absolute tight pelvis

b. Pelvic examination with baby’s head

Osborn examination : + / - , head grope ……...........................……cm
Mueller Examination :+/-
Muller Monro Kerr examination :+/-

Feto pelvic proportion :

 Proportional
 Mild CPD / suspect CPD
 Heavy CPD

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 c. Pelvic Score Examination / Bishop Score

0 1 2 3 Score
Dilatation of cervix ( cm ) 0 1-2 3–4 5-6
Effacement 0 – 30 % 40 – 50 % 60 – 70 % 80 %
Station -3 -2 -1 + 1 - +2
Consistension of cervix Hard Medium Soft -
Position of cervix Posterior Medial Anterior -
Total

4. Laboratory Examination and Next examination

…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
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Note :
0 – 3 = low risk
3 – 5 = borderline
> 5 = high risk

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III. ASSESMENT
A. WORKING DIAGNOSE
Mother : ..................................................................................................................................
..................................................................................................................................
Fetus : ..................................................................................................................................
..................................................................................................................................

B. PROGNOSES
Pregnancy : …………………………………………………………………...................................…..
Labor : …………………………………………………………………...................................…..

C. PROBLEM LISTS
1. ………………………………………………………………………………….………………………
2. ……………………………………………………………………………………...………………….
3. …………………………………………………………………………………………...…………….
4. ………………………………………………………………………………………………...……….
5. ………………………………………………………………………………………………………....
6. ……………………………………………………………………………………………………...….

IV. PLANNING
1. Diagnostic Planning
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
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2. Management planning
………………………………………………………………………………………………………………
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3. Education Planning
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………

Co assistant Name : ………………………………………….

Dokter Jaga / Dokter Konsulen Obgin
Jakarta, ........................................................

( ....................................................................)

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--------------------ww

FOLLOW UP OF LABOUR

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 (STAGE I, II, III, IV)

Name
Date Time Follow up
Signature

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Post partum condition of mothers:
General condition : ..................................................................................................................................
Consciousness : ..................................................................................................................................
Blood pressure : ....................................................................................................................... mmHg
Pulse : ...................................................................................................................x / minute
Respiratory rate : ...................................................................................................................x / minute
Temperature : ............................................................................................................................ ° C

Bleeding :
Stage I : ........................................................................................................................................... cc
Stage II : ........................................................................................................................................... cc
Stage III: .......................................................................................................................................... cc
StageIV: ........................................................................................................................................... cc
Total : ........................................................................................................................................... cc

Baby :
Gender : Male / Female, Life/ Death
Apgar Score : ....................................................................................................................
Length : ............................................................................................................... cm
Weight : ................................................................................................................. gr
Anal :+/-
Major congenital disorder :+/-
Others : .....................................................................................................................

Placenta :
Size : ................................. x ........................................... x ......................................... cm
Umbilical cord length : ............................................................................................................................ cm
Insertio : sentralis / marginalis / parasentralis
Weight : .............................................................................................................................. gr
Disorders : ..................................................................................................................................

Co assistant Name : .........................................................................................................................................

Dokter Jaga / Dokter Konsulen Obgin :
Jakarta, ...........................................................

(.......................................................................)

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