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Case Report
Name
: Mrs. UK
RM
: 555028
Age
: 36 years old
Address
TIME
SUBJECTIVE
OBJECTIVE
ASSESSMEN
T
PLANNING
10/2/
2015
General Status :
GC : well
BP : 110/80 mmHg
PR : 80 bpm
RR : 16 bpm
T : 36,5oC
Eye : anemis (-), icteric (-)
Cor : S1S2 single regular,
murmur (-), gallop (-).
Pulmo : vesiculer (+/+),
wheezing (-/-), ronkhi (-/-).
Abdomen : scar (-), striae
(+), linea nigra (+).
Extremity : edema (-/-),
warm acral (+/+).
G4P3A0L3
41-42 week
S/L/IU head
presentation
Observation
mother & fetal
well being.
DM co GP pro
CTG, advice :
ACC CTG
reactive,
termination with
oxytocin drip.
08.0
0
LMP : forget
EDD : History of ANC : > 4x at
PHC
Last ANC : 5/02/2015
Result: BP:120/80,
GW:39-40 week, FHB:+
(140x/m)
History of USG : 3x
Last USG : 09/02/2015
Result GW:41-42 week
History of family planning
: Oral contraception
Next family planning :
Injection 3 months
Obstetrical History :
I. Aterm/spontan/house/3
Obstetrical Status :
L1 : breech
L2 : back on the right side
L3 : head
L4 : 4/5
UFH : 34 cm
EFW : 3565 gram
UC : (-)
FHB : 12-12-13 (148 bpm)
VT : 1 cm, effacement
25%, amnion (+), head
palpable HI,
denominator unclear,
impalpable small part and
TIME
SUBJECTIVE
OBJECTIVE
Chronologist :
Risa GH (9-2-2015) 18.30
PS : 5
Cervix dilatation 1 cm : 1
Cervix length 1 cm : 2
Cervix consistency
moderate : 1
Cervix position posterior :
0
Station H I : 1
S :O:USG :
A : G4P3 41-42 weeks S/L
P : Pro termination and
refer to NTB GH
Lab Examination
(10/02/2015)
HB : 11,4 g/dl
RBC : 4,51 x 106/L
HCT : 36,4 %
WBC : 8,12 x 103/L
PLT : 355 x 103/L
HbSAg : (-)
ASSESSME
NT
PLANNING
10-2-2015 (09.30)
TIME
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLANNING
10.1
5
UC : 1x10-10
FHB : 11-11-11
(132 bpm)
DM co CTG to GP, GP
advice induction
ocxtocyn 5 IU in D5%
8 dpm
10.3
0
UC : 1x10-10
FHB : 12-12-11
(140 bpm)
11.0
0
UC : 2 x 10 ~ 25
FHB : 11-11-11
(132 bpm)
11.3
0
Abdominal pain
frequently
UC : 3 x 10 ~ 35
FHB : 12-11-11
(136 bpm)
VT : 2 cm, eff
50%, amnion (+),
head palpable HI,
denominator
unclear, impalpable
small part and
umbilical cord
12.0
0
Abdominal pain
frequently
UC : 3 x 10 ~ 40
FHB : 12-12-11
(140 bpm)
12.3
0
Abdominal pain
frequently
UC : 4 x 10 ~ 40
FHB : 11-11-11
(132 bpm)
G4P3A0L3 41-42
week S/L/IU head
presentation
Laten phase 1st
Stage of labor
-Drip oxytocin 16
tpm maintanance
-Observation mother
and fetal well being
-Observation
progress of labor
TIME
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLANNING
14.0
0
Abdominal pain
frequently
UC : 4 x 10 ~ 40
FHB : 11-12-11 (136
bpm)
14.3
0
Abdominal pain
frequently
UC : 4 x 10 ~ 40
FHB : 11-12-11 (136
bpm)
15.0
0
Abdominal More
frequently
UC : 4 x 10 ~ 45
FHB : 12-12-11 (140
bpm) VT : 6 cm, eff
75%, amnion (+),
head palpable HI,
denominator unclear,
impalpable small part
and umbilical cord
15.3
0
UC : 4 x 10 ~ 45
FHB : 12-12-11 (140
bpm) VT : 10 cm, eff
100%, amnion (-),
head palpable, HIII,
small part of fetus /
umbilical cord
TIM
E
SUBJECTIVE
OBJECTIVE
15.
40
Abdominal pain
frequently
UC : 4 x 10 ~ 45
FHB : 11-12-11 (136
bpm)
Baby shown on vulva,
with diameter 5 cm.
pressure of anus,
opening vulva
ASSESSMENT
nd
stage of labor
15.
50
PLANNING
Conduct of Labor
18.
00
GC: well
GCS: E4V5M6
BP: 110/70 mmHg
PR: 88 bpm
RR: 22 rpm
T: 37,10 C
UC (+) well
2 hours post
partum
4
3
4
4
4
4
23
4
4
4
4
4
24
Kurva Lubchenco
THANK YOU
TIME
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLANNING