Case 1

Identity
Name
: Mrs. A
Age
:24 years old
RM
:56-95-39
Address
: ampenan
Admitted to hospital: November, 8th
2015

Time

Subjective

08/11/15

S: Patient referred from Gn Sari

PHC with G2P1A0L1 38-39 weeks
S/L/IU head presentation with
PROM <12 hours, mother and fetal
well being. Patien t confessed
abdominal pain and history of water
leaked for her womb since 06.00
(8-11-2015), FM (+).

15.25
wita

Marrieage : 4 years
LMP: 15/02/2015
EDD: 22/11/2015
GW: 38-39 Weeks
History of ANC: 3x at posyandu
Last ANC: 12/10/2015, result:: BP
110/70, GW 28-29 weeks, UFH 24
cm, FHB (+)
History of USG: 1x at Sp.OG
Last : 23/09/2015, result: fetus/
S/L/IU, 30-32 weeks, EFW: 1601 gr,
EDD: 22/11/2015, male
History of family planning: Next family planning: Obstetric history:
1. 9 months/ pkm/ spontan/ midwife/
3100/ male/ 4 years

Objective
General status:
GC: Well
GCS: CM
BP:120/80
PR: 88 bpm
RR: 22 bpm
T : 36,7 C
Local Status:
eye: an (-/-), ict (-/-)
Tho: pulmo: vesiculer +/+, rh
-/-,
wh -/cor: S1S2 Single reguler
Abd: striae gravidarum+, linea
nigra -, scar
Ext: warm +/+, edema -/Obs status:
LI:Breech
LII: Back on the right side
LIII: Head
LIV: 4/5
UFH:31 cm
EFW: 3100 gr
FHB:11-11-12
UC: 2x 10-25
VT: dilatation 2 cm, eff 25%,
amnion (-), head palpable, HI.

Assesment
G2P1A0L1 38-39
weeks S/L/IU head
presentation with
laten phase and
history of water
leaked

Planning
-DM Planning:
Diagnostic:
- CTG
Theraphy:
- IVFD
- Observation mother
and fetal well being
- Observation progress
of labor
- Suggest mother to
eat and drink, lay
down to the left side
- Ampicilin 1 gr
DM co to GP co to SPV,
advice:
-Observation mother
and fetal well being

Time

Subjective
Chronology at Gn. Sari PHC
(08/11/2015) 09.45 wita
S: patient 9th month pregnancy
refered from polindes confessed
abdominal pain spread to the flank
and since 06.00 , blody slim (-)
(08/11/2015) , history of water
leaked from her womb (+) 05.00
O:
GC: Well
BP 110/70 mmHg
PR 82 bpm
RR 20 bpm
T 36,5C
UC: FHB: 11-12-12
VT: dilatation 1 cm, eff 10%, amnion
-, head palpable, denom unclear, HI,
not palpable small part of fetal and
umbilical cord.
A: G2P1A0L1 38 weeks S/L/IU
head presentation with PROM,
mother and fetal well being.
P: Observation mother and fetal
well being

Objective
Lab
Hb11,3
RBC 4,23
WBC 11,28
PLT 351

Assesment

Planning

Time

Subjective
Chronology at Gn. Sari PHC
(08/11/2015) 12.00 wita
S:patient conffessed ther was still
water leaked from her womb
O:
GC: Well
BP 100/80 mmHg
PR 80 bpm
RR 20 bpm
UC: FHB: (+)
A: G2P1A0L1 38 weeks S/L/IU
head presentation with PROM,
mother and fetal well being.
P: Observation mother and fetal well
being, Suggest mother to eat and
drink, lay down to the left side

Objective
Lab
Hb10,08
RBC 3,49
WBC 16,17
PLT 385

Assesment

Planning

Time
17.15

Subjective
Patient confessed abdominal pain

Objective

Assesment

GC Well
BP 120/70
PR 80 bpm
RR 20 bpm
T 36,5 C
UC : 2x/10-25
DJJ 12-12-12
VT: dilatation 3 cm, eff 25%,
amnion -, head palpable,
denom unclear, HI, not
palpable small part of fetal and
umbilical cord.

G2P1A0L1 38-39
weeks S/L/IU head
presentation with
laten phase and
history of water
leaked

17.30

19.30

Planning
DM planning
Therapy:
- Observation mother
and fetal well being
- Observation progress
of labor
- Suggest mother to
eat and drink, lay
down to the left side
- Evaluate in 4 hours

- Inj ampicilin 1 gr iv

Patient confessed abdominal pain

more often

GC Well
BP 120/70
PR 82 bpm
RR 20 bpm
T 36,8 C
UC : 3x/10-40
DJJ 11-11-12
VT: dilatation 4cm, eff 25%,
amnion -, head palpable,
denom unclear, HI, not
palpable small part of fetal and
umbilical cord.

DM planning:
G2P1A0L1 38-39
weeks S/L/IU head
presentation with
avtive phase and
history of water
leaked

Therapy :
-Observation fetal and
mother
-Sugest mother to eat
and drink
-Sugest mother to lay
down to the left side
-Observation progres of
labor with partograph

Time
21.00

Subjective
Patient conffessed abdominal pain
more often

Objective
GC: well
BP:110/70
PR: 84
RR:22
T:36,8
UC:4X10-45
FHB: 12-12-121
VT: dilatation 10cm, EFF:
100%, Amn: (-) unclear , head
palpable, denom ROA ,HIII,
unpalpable small part of fetus,
umbilical cord

Assesment

Planning

G2P1A0L1 38-39
weeks S/L/IU head
presentation 2nd
stage of labor

-Lead mother to bearing

down
-Observation fetal and
mother
adjust mothers
position

21.15

Baby was born,

spontan, female, AS
7-9, BW:2800 gr,,
anomali congenital
(-),

21.20

- Placenta was born

spontaneously
- Perineum ruptur grade
2- hecting

Time

Subjective

23.20

Objective
GC: well
BP:110/70
PR: 84
RR:20
T:36,0
UFH: 2 finger bellow umbillical
UC: Well
Active bleeding: -

Assesment
2 hours post
partum

DM Planning:
-Observation vital sign
mother and fetal
-Observation uterus
contraction, vaginal
bleeding
-Suggest mother to
lactation
-Suggest mother to eat
and drink

1 day post partum

DM Planning:
-Observation vital sign
mother and fetal
-Observation uterus
contraction, vaginal
bleeding
-Suggest mother to
lactation
-Suggest mother to eat
and drink
-Suggest mother to
mobilitation

Baby:
PR 144 bpm
RR 48 bpm
T 36,4
07.00

Abdominal pain (+)

GC: well
BP:110/70
PR: 80
RR:19
T:36,3
UFH: 2 finger bellow umbillical
UC: Well
Active bleeding: Baby:
PR 146 bpm
RR 48 bpm
T 36,7

Planning