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Name: Mrs.

R
Age: 21 yo
Adress: Narmada
Admitted: May, 12th 2012 at 22.30

TIME

SUBJECTIVE

12/05/
2012
22.30

Patient referred from Sedau


PHC with G1P0A0L0 38
weeks S/L/IU head
presentation with prolonged
2nd stage of labor. Patient
confessed abdominal pain
that spread to frank since
02.00 (11/05/12). Bloody
slim (+) since 08.00
(12/05/12). History rupture of
membrane (-), FM (+).
No history of DM, HT,
asthma.
LMP: 18/08/2011
EDD: 25/05/2012
History of ANC: >4x at
Posyandu
Last ANC: 10/05/2012
History of USG: History of family planning:Next family planning:
injection 3 months
Obstetrical history:
1.This

OBJECTIVE
General status:
GC: well
BP: 120/70 mmHg
PR: 69 bpm
RR: 22
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: 3/5
UFH: 31 cm
EFW: 3100 g
UC: 3x10 ~ 40
FHB: 12-12-11 (140 x/min)
VT: complete, amnion (+),
head palpable HIII,
denominator LOA, caput (+),
molage grade III, unpalpable
small part / umbilical cord.
PE:
Arcus pubis > 90

ASSESTMENT

PLANNING

G1P0A0L0 3738 weeks S/L/IU


with neglected
2nd stage of
labor.

Obs mother & fetal


well being
CBC, HbSAg
Amniotomy
Continue
rehidration
Skin Test
Ceftriaxone (-),
Ceftriaxone inj 1 gr
IV
DM co GP pro VE:
acc VE
Prepare VE

TIME

SUBJECTIVE
Chronologist:
12.00 (12/05/12)
S: Patient came to Sedau PHC with
frank pain referred to lower part
of stomach, want to bearing.
Bloody slim (+).
O:
GC: well
BP: 120/80 mmHg
PR: 84 bpm
T: 36,5
TFU: 28 cm
Head presentation, back on the left
side, 4/5
UC: 3x10 ~ 30
FHB: 136 x/min
VT: 7 cm, eff 50%, amnion (+),
head palpable HI, LOA,
unpalpable small part / umbilical
cord.
A: G1P0A0L0 38 weeks S/H/IU head
presentation, mother & fetal well,
with active phase 1st stage of
labor.
P: Obs progress of labor, obs mother
& fetal well being
16.00 (12/05/12)
UC: 4x10 ~ 40
FHB: 136 x/min
VT: 8 cm, eff 80%, amnion (+),
head palpable HI, LOA,
unpalpable small part / umbilical
cord.
18.00 (12/05/12)
UC: 4x10 ~ 45
FHB: 140 x/min

OBJECTIVE
Lab:
HB: 12,6 g/dl
RBC: 4.98 M/dl
HCT: 38,0 %
WBC: 19,90 K/dl
PLT: 365 K/dl
HbSAg: (-)

ASSESTMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

20.00 (12/05/12)
S: Patient confessed abdominal pain
that more frequently
O:
GC: well
BP: 120/80 mmHg
PR: 80 bpm
T: 36,5
VT: 10 cm, eff 100%, amnion (+),
head palpable HII, LOA, unpalpable
small part / umbilical cord.
A: G1P0A0L0 38 weeks S/H/IU head
presentation, mother & fetal well,
with prolonged 2nd stage of labor.
P:
- Rehidration 2 RL & 1 D5
- Referred to NTB GH
23.45

VE began
Episiotomy done
Successed with 2
traction
Baby was born, male,
BW 3000 gr, BL 50
cm,
AS 6-8, amnion
meconeal
Anus (+), caput (+),
anomaly conginetal
(-).
Placenta was born
spontaneus,
complete, bleeding
100 cc

TIME

SUBJECTIVE

OBJECTIVE

13/05/
2012
01.45

Patient confessed chill

GC: well
Cons: CM
BP: 110/70
HR: 84 bpm
RR: 22 tpm
T: 36,5 C
UC: +
UFH: 1 finger below
umbilicus
AB: -

2 hours post VE

Observed mother and


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

14/05/
2012
07.00

Delivery wound pain

GC: well
Cons: CM
BP: 110/80
HR : 80
bpm
RR : 20 tpm
T:
36,4 C
UFH : 2 finger below
umbilicus
UC : +
AB : -

Two days post


VE

Observed mother and


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

Baby rooming in:


PR:144
RR: 46
T: 36,4

ASSESTMENT

PLANNING