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

: ..

Origin

: Self admitted

Time

: .

: ......................................................................................................................
I.

SUBJEKTIF ( Primary / Secondary)

1. Chief Complain :

2. Additional Complain
1.
2.
3.
4.
5.
3. Chronology of Complain/ Recent Illness

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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

No.

Age of Pregnancy

Type of Labor

Birth
Weight

Sex

Current Age

1
2
3
4
5
6
7
8
7. Previous Illnesses
No.
1
2
3
4
5
6
7
8

System Based Abnormal

Central Nervous System
Cardiovascular
Respiratory Tract
Gastrointestinal Tract
Urogenital Tract
Haematology
Immunology / Metabolic
etc ..

Explanation

8. History disease in family

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No.
1
2
3
4
5
6
7
8

System Based Abnormal

Central Nervous System
Cardiovascular
Respiratory Tract
Gastrointestinal Tract
Urogenital Tract
Haematology
Immunology / Metabolic
etc..

Explanation

9. Surgery History
No.
1
2
3
4

Genre Operation

Years

Explanation

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

Time

Age

Location

Problems

Management

12. Others Data ( others secondary data / information associated with obstetri and
gynecology)

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II.

OBJECTIVE
1.

GENERAL EXAMINATION

1. Vital Signs
General Condition

: ...

Consciousness

: ..

Blood Pressure

: ..................... mmHg

Pulse

: ..................... .time / mnt

Temperature

: ...................... 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

B. OBSTETRICAL EXAMINATION
1. Outer Examination
a. Inspection
..
..
..
..
..
b. Palpation
Uterine Fundal Height

: ................. cm

Abdominal Circumferrence : . cm
1. Leopold I :
........................
........................
........................
..
Leopold II :
...
...
...
...
Leopold III :
...
...
...
...
Leopold IV :
..
...
...
...
2. Head Palpation (perlimaan) : 5/5 , 4/5 , 3/5 , 2/5 , 1/5

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3. His

c.

Frequency

: .................. x / 10 minute

Length

: ............................................................................................ second

Strength

: strong / not strong

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

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iv.

Lowest part of fetus : head/ breech / foot breech/ foot / transversal

Station : Hodge I / II / III / IV

v.

denominator

: ................................................................

caput

: ................................................................

moulage

: ................................................................

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,

Linea terminalis

: ...

Impression

CV : cm

: tight / not tight

ii. Midpelvic

Sacrum

Pelvic wall

Spina ischiadica

Impression

: ...
: ...
: ...

: tight / not tight

iii. Pelvic outlet

Os. Coccygeus

: ...

Arkus pubis

: ...

Impression
Kesan panggul

: tight / not tight

:

Pelvis not tight

Relative tight pelvis

Absolute tight pelvis

b. Pelvic examination with babys head

Osborn examination

: + / - , head grope ...........................cm

Mueller Examination

:+/-

Muller Monro Kerr examination

:+/-

Feto pelvic proportion :

Proporsional

Mild CPD / suspect CPD

Heavy CPD

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c.

Pelvic Score examination / Bishop Score

Dilatation of servics ( cm )
Effecement
Station
consistension of services
Position of serviks

0
0

1
1-2

2
34

3
5-6

score

0 30 %
-3

40 50 %
-2

60 70 %
-1

80 %
+ 1 - +2

hard

medium

Soft

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
1.

WORKING DIAGNOSE

Mother

: ..................................................................................................................................
..................................................................................................................................

Fetus

: ..................................................................................................................................
..................................................................................................................................

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

: .....................................

C. PROBLEM LISTS
1. .

IV.

2.

....

3.

....

4.

....

5.

....

6.

....

PLANNING
1. Diagnostic Planning

2. Management planning

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)

Date

Time

Status RSU FKUKI/Ilmu Obstetrii/Obgyn RSU FK UKI/05.08

Follow up

Name
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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