Identity

Name : Mrs. KI
Age : 16 years Old
Address : Narmada
Admitted on: December, 17th 2012
(16.00 wita)
Medical record : 070734

TIME

SUBJECTIVE

16/12/
2012
16.00

Patient
referred
from
Narmada
PHC
with
G1P0A0L0
A/S/L/IU
head
presentation prolonged 2nd
stage of labour
Patient say that she had
pregnant for 9 month, and
last menstrual periode was
at first week of march.
Abdominal pain that spread
to waist (+). Since 23.00
15/12/2012. Histrory water
leaked from her womb (+)
since
12.00
16/12/2012.
Bloody slim (+), FM (+).
No history of DM, HT,
asthma.
LMP : Forget
EDD :History of ANC : 7 x at
Posyandu
Result : Normal
History of USG : Never
History of family planning : Next
family
planning
:
Injection every 3 month
Obstetrical History :
I. This

OBJECTIVE
General Status
GC : well
Consciousness : CM
BP : 140/100 mmHg
PR : 92 tpm
RR : 20 bpm
T : 36,9 oC
Eye : anemis (-/-), icteric (-/-)
Cor : S1S2 single reguler, M (-), G
(-)
Pulmo : vesikuler (+/+),
wheezing (-/-), ronkhi (-/-).
Abdomen : scar (-), striae
gravidarum (+), linea nigra (+).
Extremity : edema (-/-), warm
acral (+/+)
Obstetrical Status
L1 : breech
L2 : back on the right side
L3 : head
L4 : 4/5
UFH : 36 cm
EFW : 3875 g
UC : 4x10~30
FHB : 10-10-11 (124 bpm)
VT : complete, amnion (-),
head palpable H II, caput (+),
denominator LOA, impalpable
small part / umbilical cord.

ASSESSMENT
G1P0A0L0
A/S/L/IU head
presentation
prolonged 2nd
stage of labour
+ anemia +
mild
preeclampsia

PLANNING
Observation
progress of labour
Rehydration with
RL:D5 2:1
GP consult to SPV,
SPV adv:
Prepare for SC
Insert DC
Inj Ampicillin 2
gr/iv
Shave pubic hair
KIE the family

TIME

SUBJECTIVE
Chronologist at Narmada PHC:
12.00 (16/12/2012)
S :
Patien came from midwifery
clinic
O : Genera Status : Mother and fetal
well
Consciousness : Composmentis
BP : 120/80 mmHg
PR : 80 bpm
RR : 20 bpm
T : 36,9 C
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH : 36 cm
UC : 4x10~40
FHB : 11-12-11 (136 bpm)
VT : 10 cm, eff 100%, amnion
(-) , head palpable HIII , denom
LOA, unpalpable small part /
umbilical cord.
A

:
G1P0A0H0
A/S/L/IU
head
presentation, 2nd stage of labour
susp big baby

P : IVFD RL 2nd flash

OBJECTIVE
Pelvic Evaluation :
Spina
ischiadica
prominent
Os coccigeous mobile
Pubic arch < 90
Lab Evaluation
HB : 8,8 g/dl
RBC : 3,55 x106 /l
HCT : 27,2 %
WBC : 15,26 x 103 /l
PLT : 335 x103/l
HbSAg : (-)
Proteinuria (++)

ASSESSMENT
not

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

17.30

19.30

PLANNING
CS began
Baby was born
(17.40), Female,
BW:3500 g/50 cm,
anus (+), AS: 7-9
Placenta was born
manually,
complete,
bleeding 500 cc

Patient confessed can not move her

leg

GC: well
BP: 130/80
RR: 20 tpm
UC: +
UFH: 2 finger
umbilicus
Urine output:

Cons: CM
HR: 80 bpm
T: 37,0 C

2 hours post
SC

Observed mother
and baby well
being
Suggest mother to
mobilisation.

1 day post SC

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

below
100 cc

Baby in NICU
PR: 110
RR: 50
T: 36,9
17/12/
2012
07.00

GC: well
BP: 130/80
HR: 72 bpm
RR: 16 tpm
T: 36,6 C
UC: +
UFH: 2 finger below
umbilicus
Urine output: 600 cc