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MEDICAL REPORT PREGNANCY

KELOMPOK 5

(Evie, Fina, Maesyaroh, N Muftihatun, Rusida, Yuliana)

ILKES
PROGRAM D4 KEBIDANAN
UNIVERSITAS NASIONAL
VARNEY OBSTETRIC CARE MANAGEMENT IN
PREGNANT WOMEN
1. Anamnesa

Mrs. "M" 26 years, Islamic religion, Sunda tribe, high school education, working as

a housewife, has been married for 7 years with husband Tn. "R" age 37 years, Islam religion,

Sundanese tribe, high school education, working as a driver, they reside in Kembang Nambo

Seeng, RT/RW 001/005, Cijoropasir Urban Village, Rangkasbitung.

Midwifery care for pregnant women ANC, dated 24 November 2015 at 17.00 WIB

in BPS Hj. Apipah

a. Data collection

The third routine pregnancy examination, the mother said pregnant second child had

given birth once, and had never had a miscarriage. Menstrual history of the mother said

first menstruation at the age of 13 years, 28 days cycle, 2-3 times change of pads,

duration of 7 days, the nature of blood dilute and no lumps and mother feel pain during

menstruation and menstruation regularly.

b. History of Obtetrics and Gynecology, Babies and Lactation

The first child is 6 years old. 9 months of pregnancy, delivery of mother in BPS

assisted by midwife, spontaneous childbirth type no complication in mother and baby

Female, baby weight 3300 gr, baby long 49 cm, Normal childbirth and lactation. This

pregnant mother said the first day of last menstruation is dated April 27th 2015, it can be

obtained maternal delivery estimate on February 4th 2016. Age 30 weeks of pregnancy 1

day.

Mother said the complaint at 0-5 months of gestation is nausea and vomiting. And

in the 2nd trimester exactly the age of 6 months pregnancy mother complained of

stiffness in the back and have been checked into the midwife in posyandu then get Fe and
Kalk therapy and often urinate at night. The first examination by the author on 26 year

old Ny "M" was conducted on Tuesday, November 24th 2015, at 17.00 WIB at BPS. Bd

Hj. Apipah Rangkasbitung, Lebak Banten.

At the time of the examination of the mother's anamnesa said that this is the second

pregnancy, had given birth once and never miscarried. Mother said pregnancy is now 7

months, First Day of Menstruation last April 27th 2015. Estimated delivery is February 4th

2016. Mother felt the movement of the first fetus 4 months of pregnancy, the movement

of the fetus is felt in the last 24 hours 15 times. Mother has no other perceived complaints

such as pregnancy alarms such as severe headaches, blurred vision, swelling of the face

and hands, excessive abdominal pain, fetal movement and birth bleeding and other

complaints. Mother has been immunized tetanus toxoid (TT), TT1 in primary school

mother and TT2 first pregnant, mother not consume drugs.

Mother used 3 months of injectable contraception for 2 years and had used pill

contraceptives for 4 years and the perceived complaints were irregular mother's period

such as blood spots, Mother had never experienced systemic diseases like heart, kidney,

Asthma, Diabetes Militus, hemophilia, sick soul etc. Mother admitted there is no history

of surgery, mother also does not have twin offspring.

c. Biopsychosociospiritual history

Changes in everyday diet there are changes, in the first trimester the mother

experienced a decrease in diet but then the second trimester increased again, the mother

ate 1-2 x a day with a moderate serving of one plate with a medium size, the type of food

consumed by mothers with fish, eggs, fruits, mothers drank ± 12 glasses per day, mother

chapter 1 times with consistency soft and there is no blood or pus in the feces and usual

urinate ± 8 times per day. Mother breaks enough, that is with 10 hours of sleep a night

and nap 1 hour per day. Maternal sexuality is not disturbed by pregnancy, the mother says
having sexual intercourse once in two weeks, and no complaints are felt, the mothers used

to do daily housework such as sweeping, mopping, washing clothes and plates, making

enough mothers to exercise, mothers do not have a habit of consuming cigarettes or

liquor. Mother planned this pregnancy and mother was happy for her pregnancy then

family response to pregnancy was good. Mother married her husband at the age of 19

years and her 31 years husband. Mother's relationship with husband and family well. As

well as the surrounding community either, the mother carries out her duty as a Muslim by

performing prayers 5 times every day.

Lack of knowledge of mother about pregnancy, such as: mother do not know about

sexsualy infection and HIV/AIDS and mother not yet preparing for delivery to risk

including cost, blood donor and birth attendant in case of complication. Mother knows

about breast care and post partum contraception and mother knows about exclusive breast

milk. Mother has prepared labor that is delivery equipment and vehicle.

d. Physical examination

From physical examination, the result is general condition of mother is,

composmentis awareness, stable emotional state, body weight 45 kg, body weight before

pregnant 38 kg, upper arm circle 22 cm, from examination of vital signs obtained as

follows tension 110/70 mmHg, Respiratory 20 x/minute, temperature 36,7ºC, pulse 80

x/minute, head clean, face no swelling or oedema. On conjunctival eye examination is not

pale, sclera not jaundiced, normal pupil, that is positive light reflex, no strabismus, clean

nose, clean ears, no mouth stomatitis, there are caries, no holes. There is no swelling of

the tyroid gland and lymph nodes.

On examination of chest obtained results, symmetrical chest shape, clean mamae

circumstances and no striae, areola mamae hyperpigmentation and prominent nipple, not

yet out of colostrum.


Abdominal examination showed no surgical wound, abdominal enlargement

according to gestational age, no edema and acites in the maternal abdomen, no linea nigra

and no livida striae, on obstetric examination obtained Leopold I result of finely rounded,

not bouncy, Leopold II on the left side of the mother's abdomen palpable elongate

prisoner and on the right palpable small parts of the fetus (left back), Leopold III bottom

is palpable round, hard, bouncy and not yet entered the up pelvis (head). Leopold IV not

performed, high fundus uteri 27 cm, weight fetus estimation (27-13) x 155 = 1988 grams,

Positive fetal heart rate, with regular frequency of 138 x/minute and maximum punctum

heard in lower left center of mother's.

The limb state of symmetrical arm shape, symmetrical foot shape, no hand and

finger edema or on the tibia or legs. There were no varicose veins in the legs, patellar

reflexes on right and left positive legs, backs seen physiological hyperlordosis, no tap

pain at waist examination Costro Vertebrata Angle Tendeness (CVAT).

Anogenital examination results, no varicose veins in the vulva, no injuries, no

redness, no pain, no edema. On examination the anus is not hemorrhoids.

In addition, there are also investigation of the investigation include examination of

blood levels of blood or blood hemoglobin examination with results 11,9 grams%, blood

type O, then done urine examination and urine reduction with negative results. Ultrasound

examination (ultrasound) on October 9th 2015: single fetal image, head presentation, fetal

heart rate (+ D), fetal movement (+), invisible gender, adequate amniotic fluid, placenta

in fundus.

e. Interpretation

Diagnosis: G2P1A0 pregnant 30 weeks 1 day with low chronicle energy, single live fetus

intra uterine presentation head


Subjective:

 The mother said it was her second pregnancy had given birth once and had never had
a miscarriage
 HPHT dated April 27th 2015
 Mother feels the movement of the first fetus at 4 months of pregnancy
 Mother still feel the movement of the fetus and felt in the last 24 hours about> 20
times
 Mother said not to know about sexsualy infection HIV/AIDS
Objective:

 Labor Estimates: February 4th 2016

 examination of vital signs obtained as follows tension 110/70 mmHg, Respiratory 20

x/minute, temperature 36,7ºC, pulse 80 x/minute

 upper arm circle: 22 cm

 Chest examination: Hyperpigmentation areola mammae (+), No Colostrum: Right (-)

left (-) Enlargement of stomach according to gestational age.

 Abdominal Palpation:

- Leopold I: the fundous part of the soft round soft mother is not bouncy

- Leopold II: Left side Left mother's abdomen palpable prisoner elongated like a

board, and the right side of the mother's abdomen palpable small parts

- Leopold III: the underside of the mother's stomach are palpable hard round

bouncy and not yet entered the up pelvis

- Leopold IV: Not done

 high fundus uteri 27 cm, weight fetus estimation (27-13) x 155 = 1988 grams,

 Heart rate: (+), 138x / min, regularly, maximum punctum 1 place to the lower left of

the mother center

 Hemoglobin: 11.9 gr%, Protein and urine reduction: (-)

Problem 1: Chronic energy shortage


Problem 2: Lack of mother preparation lack

Problem 3: Lack of mother knowledge about health

Basic 1: upper arm circle examination results: 22 cm (less than normal upper arm circle

size 23.5 cm)

Basic 2: The mother's colostrum has not come out right and left (-)

Basic 3: Mothers do not know about infection sexsualy and HIV/AIDS

f. Identify Diagnosis and Potential Problems:

Anemia, IUGR, and low baby weight

g. Identify the Need for Immediate Action or Collaboration

There is no

h. Planning

The care plans created by the authors on this visit are to describe the procedures for

pregnancy screening, do informed consent, notify the mother of the examination, notify

the mother of pregnant women's nutritional needs, notify the mother about breast care, tell

the mother about infection sexualy and HIV/AIDS, give mother Fe tablets and kalk, give

milk to pregnant women, tell the mother to make a return visit 2 weeks later or if there is

a complaint

i. Implementation

Implementation of the author's plan of care is to explain the procedure of pregnancy

examination that is on the examination of pregnancy will be done from head to toe

including breast and mother's genitals and also urine examination and maternal blood.

Mother will be taken a little blood, by stabbing the middle finger of the mother with a

needle in biomed and urine will also be checked, do informed consent and mother

approve and sign it, inform the mother of the examination that the general condition of

mother and fetus well, tension: 110/70 mmHg, gestational age 7 months over 2 weeks,
normal fetal heart rate, hemoglobulin 11,9 gr%, negative urine protein, and negative urine

reduction, telling mother about nutrition and nutrition needs of pregnant mother that is eat

regularly 3x a day with a portion enough to eat foods containing carbohydrates such as

rice, bread, protein-containing foods such as eggs, fish, tofu, tempeh, and vitamins such

as green vegetables, as well as to increase the needs of mothers can consume chocolate,

tea sweet and milk, tell mom about breast care that is for lactation preparation of mother

because at this moment mother colostrum have not come out, tell mother about ta In case

of any of the above signs immediately contact the nearest health worker, notify the

mother of the sexsualy infection and the pregnant woman's head, the fetal eye, the

swelling of the face and hands, the fetal movement is not felt, the heartache and vaginal

bleeding. HIV/AIDS. Sexsually infection is a sexually transmitted disease that is

dangerous, its characteristics are pain when the urinate, feels hot when the urinate, pus

out, smell of whiteness. HIV/ AIDS is a decline in the immune system. HIV/AIDS can be

transmitted through blood, syringes, breast milk and sexual intercourse, giving the mother

a tablet of Fe and a kalk. Fe 1 x 1 60 mg tablets daily as a booster of blood and calcium

tablet 1 x 1 500 mg daily as the formation of baby's bones and teeth, teaches how to take

medication fe tablets taken at night before bed using water/orange juice 1 times a day

because it can cause nausea and feces to black, calcium tablets taken 1 times daily after

breakfast using water and taking medication should not be accompanied by tea, coffee or

milk because it can inhibit the absorption of drugs, give milk to pregnant women, and tell

the mother how to drink the milk in drink 2 times per day and should not be accompanied

at the time of taking the medicine, telling the mother to make a return visit 2 weeks later

or on December 16th 2015 or if there is a complaint.


j. Evaluation

Informed consent signed by the mother, the results of the examination have been

told to the mother that the general state of the mother experiencing Chronic Energy

Deficiency and good fetus. Mother understands and can repeat what the midwife

explained. I want to do what the midwife advises. Therapi drug adder Fe and calc has

been given to mothers and mothers willing to take medicine. I am willing to make a

second visit two weeks later on December 16th 2015 or if there is a complaint.

DOCUMENTATION OF SOAP LEGAL ASSURANCE IN PREGNANT


WOMAN WITH CHRONIC ENERGY DISEASE

Name: Ny "M" Place: BPS Hj. Apipah

Age: 26 years

Day/Date/Hour Note Progress


Tuesday S - The mother said it was her second pregnancy had
th
November 24 given birth once and had never had a miscarriage
2015 - HPHT dated April 27th 2015
- Mother feels the movement of the first fetus at 4
17.00 pm months of pregnancy
- Mother still feel the movement of the fetus and felt in
the last 24 hours about> 20 times
- Mother said not to know about sexsualy infection
HIV/AIDS
- Labor Estimates: February 4th 2016
O
- examination of vital signs obtained as follows tension
110/70 mmHg, Respiratory 20 x/minute, temperature
36,7ºC, pulse 80 x/minute
- upper arm circle: 22 cm
- Chest examination: Hyperpigmentation areola
mammae (+), No Colostrum: Right (-) left (-)
Enlargement of stomach according to gestational age.
- Abdominal Palpation:
- Leopold I: the fundous part of the soft round soft
mother is not bouncy
- Leopold II: Left side Left mother's abdomen
palpable prisoner elongated like a board, and the
right side of the mother's abdomen palpable small
parts
- Leopold III: the underside of the mother's stomach
are palpable hard round bouncy and not yet entered
the up pelvis
- Leopold IV: Not done
- high fundus uteri 27 cm, weight fetus estimation (27-
13) x 155 = 1988 grams,
- Heart rate: (+), 138x / min, regularly, maximum
punctum 1 place to the lower left of the mother center
- Hemoglobin: 11.9 gr%, Protein and urine reduction:
A (-)
G2P1A0 pregnant 30 weeks 1 day with low chronicle
energy, single live fetus intra uterine presentation head.
Problem 1: Chronic energy shortage
Problem 2: Lack of mother preparation lack
Problem 3: Lack of mother knowledge about health
Diagnosis and Potential Problems: Anemia, IUGR, and
P low baby weight
- Explain the procedure of pregnancy examination that
is on the examination of pregnancy will be done from
head to toe including breast and mother's genitals and
also urine examination and maternal blood.
- Mother will be taken a little blood, by stabbing the
middle finger of the mother with a needle in biomed
and urine will also be checked.
- Do informed consent and mother approve and sign it.
- Inform the mother of the examination that the general
condition of mother and fetus well, tension: 110/70
mmHg, gestational age 7 months over 2 weeks,
normal fetal heart rate, hemoglobulin 11,9 gr%,
negative urine protein, and negative urine reduction,
- Telling mother about nutrition and nutrition needs of
pregnant mother that is eat regularly 3x a day with a
portion enough to eat foods containing carbohydrates
such as rice, bread, protein-containing foods such as
eggs, fish, tofu, tempeh and vitamins such as green
vegetables, as well as to increase the needs of mothers
can consume chocolate, tea sweet and milk.
- Tell mom about breast care that is for lactation
preparation of mother because at this moment mother
colostrum have not come out.
- Tell mother about ta In case of any of the above signs
immediately contact the nearest health worker, notify
the mother of the sexsualy infection and the pregnant
woman's head, the fetal eye, the swelling of the face
and hands, the fetal movement is not felt, the
heartache and vaginal bleeding.
- Tell mother about sexsually infectin and HIV/AIDS
on is a sexually transmitted disease that is dangerous,
its characteristics are pain when the urinate, feels hot
when the urinate, pus out, smell of whiteness. HIV/
AIDS is a decline in the immune system. HIV/AIDS
can be transmitted through blood, syringes, breast
milk and sexual intercourse.
- Giving the mother a tablet of Fe and a kalk. Fe 1 x 1
60 mg tablets daily as a booster of blood and calcium
tablet 1 x 1 500 mg daily as the formation of baby's
bones and teeth, teaches how to take medication fe
tablets taken at night before bed using water/orange
juice 1 times a day because it can cause nausea and
feces to black, calcium tablets taken 1 times daily
after breakfast using water and taking medication
should not be accompanied by tea, coffee or milk
because it can inhibit the absorption of drugs.
- Give milk to pregnant women, and tell the mother
how to drink the milk in drink 2 times per day and
should not be accompanied at the time of taking the
medicine.
- Telling the mother to make a return visit 2 weeks later
or on December 16th 2015 or if there is a complaint.

Informed consent signed by the mother, the


results of the examination have been notified to the
mother that is the general condition of mother and fetus
well, mother understand what has been explained and
willing to carry out the suggestion which have been
submitted and mother willing to come back on second
visit that is December 16th 2015 or if there complaint.
HIV/AIDS
Rangkasbitung, November 24th 2015
Inspector