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No. Register : 01XX

Login Date / hour : 20 December 2011 / 14:00 hrs

Room : R.Nifas
By : Midwife Baiq

Wife Husband
Name : Ny. A Tn . R
Age : 25 years 29 year
Religion : Islam Islam
Education : SMP SMA
Work : IRT Employees
Tribes : Java / Indonesia Java / Indonesia
Address : Attack Attack
Tel : 085728xxx 085725xxx

1. The reason for entering the childbirth room

Mom says she wants to check on her and her baby.
2. Main complaint
Mom says the stitches are painful.
3. Marital History
Marital status : The first marriage, Shah
Married since age : mother 22 years husband 24 years old
The length of marriage : 3 years
4. History Menstruation
HPHT : 11 March 2011
HPL : December 18, 2011
Menarche : 14 year
Long Menstruation : 7 days
Regular / not : Regular
Cycle : 28 days
The number : 3x replace pads on the first day and 2x
replace pads on the second day
Complaint : There is no

5. Obstetric history
P1 A0 .Ah1

6. History of pregnancy, labor, and childbirth

Labor Babies

Pre bo UK Type Helper T L BB Complic Lactatio Complic

gnant to- rn Labor he place /P Bo ations n ations


1 1 40 spontan mid C p 3 There smoo There

8/12 mgg eous wife PM 100 is no thly is no
/ grams

7. The history of this labor

Date of delivery : December 18, 2011, at 10:00 am
Place of delivery : RIZQY CPM
Type of labor : Spontaneous
Helper : Midwife
8. Newborn Baby Condition
Born on date : December 18, 2011, at 10:00 am
BB / PB born : 3100 gram / 50cm
Gender : women
Sleep patterns : 12 hours / day
 Nutrition patterns
Suckling frequency : 9 times / day
Duration : 20 minutes
Maternal and Infant Problems : there is no
 Pattern of elimination
BAK : 7-8 times / day
Consistency : liquid
Color : typical urine
Smell : typical urine
CHAPTER : 3 times / day
Consistency : soft
Color : typical feces
Smell : typical feces
9. Post partum history
Pattern of daily needs
 Nutrition
Serves a day : 1 portion runs out
Type : rice, vegetables, side dishes, fruit
Food abstinence : no dietary restrictions
The drinking pattern : 7-8 glasses / day
Type : Water, tea, milk
Complaint : There is no
 Elimination
a. BAK
Frequency : 6-7x / day amount : 1200 cc
Color : clear yellow Complaint : there is no
Frequency : 1x / day amount :-
Color : yellow Complaint : there is no
 Break
Siesta : ½-1 hour
Sleep at night : 5-6 hours No complaints
 Pattern Activity
Mobilization : have been able to walk, and take care of themselves and
learn to care for her baby
Work : taking care of themselves and the baby is still assisted by the
Sports / postnatal gymnastics: doing puerperal exercises as taught
midwife, ie kegle exercises every morning
Complaint : there is no
 Breastfeeding experience: the mother says she has no
experience breastfeeding
 Breastfeeding Habits
Position : lie down and sit down
Breast Care : cleaning the nipple before nursing
Problem : there is no
 Personal hygiene : bath 2 times / day
brush your teeth 2 times / day
shampoo 3 times / week
change underwear 2 times / days
change outfit 2 times / day

 Sexual patterns : During the postpartum the mother has not had
sexual intercourse with her husband, Complaint: no
10. History KB
She said she had never used any type of contraception
11. Medical history
- Mothers say they are not or have suffered from systemic diseases such as
hypertension, asthma, diabetes mellitus , tuberculosis, and HIV
- Mother said that her family was not having or had ever suffered from
systemic diseases such as hypertension, asthma, diabetes mellitus , tuberculosis,
and HIV
- Mom says that does not have twin breeds

12. Spiritual Psychosocial History

 mom says her husband and family always support him to care for his
baby and his relationship is good.
 She said she and her family understood the nature of the puerperium
 Mom says Decision makers in the family are husband and he
 Mother said obedient worship and often follow the study
 Mother says live with husband
 Mom says she has no pets at home
13. Habits that hurt health
Mother says no smoking habit, drinking alcoholic beverages, and no dietary
restrictions whatsoever.
1. Physical examination
A. Mother's Physical Examination
a. General
situation : good Awareness : compos mentis
b. Emotional status : stable
c. Vital signs :
Blood pressure : 120/80 mmHg
Pulse : 85 x per minute
Respiratory : 22x per minute
Temperature : 36.8 0 C
d. Anthropometry
BB : 65 kg PB : 160 cm
e. Head and Neck Examination
Hair : Clean Hair, no dandruff
Face : No oedema and no cloasma gravidarum
Eye : pink conjunctiva , white sclera
Mouth : clean, odorless, no stomatitis, no caries gear.
Neck : no enlargement of the tyroid , lymph nodes ,
and jugular veins .
Ears: Clean, no serumen
e. Breast Examination
Form : symmetric
Nipple : stand out
Areola : hyperpigmentation , clean
Breast milk : smoothly, no milk dam found
f. Abdomen
Enlargement : normal, TFU 2 fingers below the center
Bumps : there is no
Scar : there is no
g. Extremities
Oedem : no edema
Varices : no varicose veins
Reflect patella : left (+), right (+)
Nail : clean and short, if pressed pink

h. Genetalia
Varices : no v
Oedem : there is no
Scar : Episiotomy scar stitched running suture
technique is mediolateral. Good stitching condition, slightly swollen, there
is sign infection.
Spending vaginal: Lokhea rubra
i. Anus
No hemorrhoids.
B. Baby Physical Examination
a) General situation :
good Awareness : compo smetis
b) Vital Signs
Temperature : 36.6 0 C
Respiratory : 46 times / minute
Pulse : 144 times / minute

c) Anthropometry
BB : 3100 grams LK : 33 cm
PB : 50 cm LILA : 10.5 cm
LD : 33 cm
d) Head : symmetrical, normal size, no abnormal bumps
e) Blackhead : flat, not sunken
f) Face : not pale, not yellow, and no scars
g) Eye : symmetrical, pink conjunctiva , sclera not jaundice
h) Nose : symmetrical, clean, no polyp
i) Mouth : clean, not pale, no trush
j) Neck : no swelling of the thyroid gland , lymph and no
jugular vein .
k) Chest : symmetrical, no wheezing
l) Abdomen : when the baby is calm the stomach is palpable soft,
no bumps and scars
m) The umbilical cord : clean, no signs of infection
n) Genitalia : labia Mayora covers the labia minora , positive
urethral hole, vagina
o) Extremeity : symmetrical, active movement, total number of
p) Reflect

k. Supporting investigation
no investigation was performed.

i. Birth history

I. 8 - 20cc n
II hours Episiotomes 100c orma
II 1 - c l
I hour 2nd 100c n
I 1 degreelaceration suturingtechnique ismediolate c orma
V 5 ral baste with thread cutgut 100c l
minut c n
es orma
2 l
hours n
a 1 320c
moun 1 c
t hours

Mrs. "Y " age 25 years P1 A0 Ah1 in the puzzle day to 2 normal with
wound pain on the perineal seams .

Date / time : 20 December 2011 / 14.15 WIB

1. Explain the results of the examination to the mother that the state of
mother and baby in normal circumstances
Evaluation : I understand the explanation given by the midwife and feel
happy and relieved
2. The midwife explained the importance of maintaining genetic hygiene and
advised the mother to clean the genetal apparatus with soap after either a BAK or a
bowel movement from the top to the anus
Evaluation : Mother understands the midwife's explanation and is able
to repeat the midwife's explanation as well the mother said she would try to
implement the suggestion
3. The midwife explains and advocates about the post- episiotomy sterilizing
perinium treatment with polish stitches using gauze that is betadine after genetalia
is washed with soapy water
Evaluation : I understand the explanation of the midwife and try to do
the suggestion
Mother understood with the advice given
4. Midwives advise mothers not to have sexual intercourse first during the
puerperium and explain the risk factors
Evaluation : Mother understands the midwife's explanation and is
willing not to have sexual intercourse with her husband during the puerperium
5. Tell the mother how to care for the umbilical cord with gauze that is given
warm water
Evaluation : I understand the advice and try to do it at home
6. Explain in the mother to maintain the fulfillment of nutrition patterns that
have been well done by eating foods that contain balanced nutrition that
is carbohydrates (rice, potatoes, bread), protein (tofu, tempeh, meat, fish, eggs),
vitamins (vegetables and fruits). And increase the consumption of foods containing
protein to accelerate wound healingepisiotomi
Evaluation: Mothers are willing to do a healthy and balanced nutrition
fulfillment pattern, especially protein consumption