THE NATURAL LEGAL MEDICINE CULTURE

ON EGYPT 29 YEARS P 2 A 0
IN PBM NABILA ZHAFIRAH

T dated / Hour Login : 12 December 2011 / 10.00 WIB

Midwife : Midwife Nabila
The place : PBM Nabila Zhafirah
I. ASSESSMENT
Date / time : December 12, 2017 / 14.10 WIB
A. Subjective Data
Patient identity Husband's name
Name : Ny. S Name : Mr. R
Age : 2 9 year Age : 30 year
Tribes : Java / Indonesia Tribes : Java / Indonesia
Religion : Islam Religion : Islam
Education : SMA Education : S1 Physiotherapy
Work : Private Work : Private
Address : Candirejo Rt 7 Kwangen, Gemolong

1. Reason Coming
Mom says she has given birth to her baby on date December 12,
2017 hours 12.10 WIB and currently the mother said her body was limp and her
stomach mules.

2. History pregnancy and delivery now

a. The : 2, A : 0, Life: 2
b. Pregnancy Age : 39 Sunday
c. Abnormalities during pregnancy: none
d. Date of delivery : December 12, 2017 Hour : 12.10 WIB
e. Type of labor : normal
f. The duration of labor : Kala I = 7 hour
Kala II = 15 minute
Kala III = 10 minute
Kala IV = 2 hours
g. Bleeding : Kala I : - cc
Kala II : 100 cc
Kala III : 150 cc
Kala IV : 75 cc
amount : 325 cc
h. Difficult in labor : there is no
i. Helper : Midwife
j. Congenital abnormalities : there is no
k. Child : live. Single
BB : 3.2 Kg
PB : 50 cm
3. Treat Join : yes
Reason : to make it easier for babies to get breastmilk and bring
mothers closer to their babies.
4. Menstrual History
a) Menarche : 14 years
b) Long :7 day
c) Color : Fresh Red
d) Cycle : 28 days
e) The number : 3 - 4x replace pads / day
f) Complaint : there is no
g) Amenorrhoea : there is no
5. Marital History
a. Age of marriage : 21 years
b. Married how many times : Mom says 1 time married
c. The length of marriage : Mom says 8 years married
d. Number of children : Mom says she has two children

6. Medical history
a. Health history now : Mom says her body is limp and her stomach mules after
childbirth
b. Past medical history : Mother says not suffering from decreased disease
(ashma, DM), infectious (TBC), chronic (heart) such as chest pounding (heart),
frequent eating, drinking, and urinating (DM), shortness of breath (Asthma), pressure
blood> 140/90 mmHg (Hypertension). Yellow Pain (Hepatitis), Seizures to Exit Foam
(Epilepsy) and whiteness Itching - Itching (PMS).
c. Family health history : Mother says in her family not suffering from decreased
disease (ashma, DM), infectious (TBC), chronic (heart) such as heart palpit (heart),
often eat, drink, and urinate (DM), shortness of breath (Asma) , blood pressure>
140/90 mmHg (Hypertension). Yellow Pain (Hepatitis), Seizures to Exit Foam
(Epilepsy) and whiteness Itching - Itching (PMS).
 7. Pregnancy History, Labor, Past Syphilis
Pregnant Comp Place of U K Type Peno Babies C
to- delivery of long Lact bleeding infection J
labor K
1 - BPS Ny. Ari 39mg Normal Midwife ari smoothly - - L

8. History KB
TYPE OLD WHEN DROP
USE DROP OUT
OUT REASONS
KB 3 7 2011 Want to
monthly years have a
injection second
child

 Planned family planning : Mother said there are plans for family planning.
 Type of Contraception : KB Injection 3 monthly
 When : After the baby is born
 Husband's response : Husband supports mother for family planning.
 The number of children you want : 2 persons

9. Daily Needs Patterns

NEEDS POST
# Dietary habit
Frequency 1 time
Portion 1 plate
Type of food Rice, side
Food dishes,
abstinence vegetables
Complaint There is no
Smoke There is no
Liquor No
Drinking No
herbal No
medicine
# Drink Pattern I time
Frequency Water
 Type There is no
Complaint

# Rest
Length of 1 hour
Sleep There is no
Complaint
# Personal
Hygiene Sibin
Bath Not yet
Shampooing Not yet
Tooth brush 1 time
Change There is no
dress
Complaint
Sexual life Not reviewed
Frequency Not reviewed
Complaint Not reviewed
# Elimination
BAK 2 times
Frequency Clear yellow
Color Typical
Smell There is no
Complaint Not yet
Frequency Not yet
CHAPTER Not yet
Color Not yet
Smell Not yet
Consistency
Complaint

10. Psychological Data

a. The mother's response to the birth of her baby
Mom says she is very happy with the birth of her baby and can be born safely and
the baby is healthy.
b. Husband / family response to the birth of her baby
Happy for the birth of her baby
c. Support provided by the husband / family
The husband provides mental support to the mother and provides for the needs of the
mother and baby and help with housekeeping later.
d. Plan to breastfeed her baby
Yes, as soon as the baby is born until old + 2 years.

11. Socio - Cultural Data

a. pet : mother does not have a pet like a cat or dog in his home
environment.
b. Environment : clean and comfortable.
c. Customs : Goal (BBL)
Selapanan (BBL)
d. Relationship between man: Mother's relationship with good society
e. Relationship with husband and family: good
f. Social activities : Mothers are active in activities in the village

12. Data Spiritual

mother able to run his worship properly diligent routine assessment, active mother 5
days prayer
13. Mother's Knowledge
a) About the puzzle period : the mother already knows little about the process
during the ifas period such as breastfeeding, breast care, newborn care, and others.
b) About feeding / baby feeding :
Benefits of breast milk : mother already know that in Breast
milk contained higher nutrients than formula milk.
Breast Care : mom says that mom already understand about breast care
Baby food : mom said that the baby should only get breast milk until the
age of 6 months without any additional food except vitamins and drugs.
c) About Baby care : mother said already know about way baby care
d) Mother's knowledge about gymnastics gymnastics : Mother said less know
e) About the KB tool : the mother already knows about the contraception.

B. Data Objective
1. Physical examination
a. General situation : Good Awareness : CM
b. Vital Sign : TD : 120/70 mmHg N: 82 x / min
 S : 37 0 C R: 22x / min
c. BB before pregnancy: 46 kg
BB right now : 59 kg
d. TB : 158 cm
e. LILA : 27 cm
2. Physical examination
a. Head and Neck
 Hair : black color, clean, good growth, no scalp lesion
 Face : no oedem, symmetrical
 Eye : conjunctiva not anemic, sclera not jaundice, no secretions
 Nose : clean, no polyp, symmetrical, no secret
 Mouth : clean, reddish color, siemtris
 Tooth : no teeth caries, no tartar
 Gum : reddish color, no oedem
 Lip : red color, there is moisture, symmetry, no lesions
 Ear : clean, no serumen
2. Neck : Thyroid gland : no swelling
Parotis Gland : no swelling
Form : symmetric
Mass : no mass
Stiffness : there is no
3. Chest
Auscultation of the heart : normal
Auscultation of the lung : normal
Form : symmetric
4. Breast
Enlargement : There is
Shape and size : Symmetrical
Color : Normal
Putting state : Stand out
Spending : There is
Type : Colostrum
Hyperpigmentation : Areola
Bumps : No bumps / masses
Pain : No pain
KGB Axila : no enlargement

5. Abdomen :
TFU : 2 fingers below the center
Contraction : Good
Consistency : Regular
6. Genetalia :
 Oedem : no oedem
 Varices : no varices
PPV :
 Loche Color : Red
 Type : Rubra
 The number : 1-2 times change pads / day, full 75 cc
 Smell : Typical Blood
Infection : There is no
Bartholini's gland : no oedem, mass or abnormal fluid.
7. Perineum and Anus :
 Stitch wound : there is no
 The state of injury : not infections
 Inflammation marks : no inflammation
 The vulvar state : normal
 Anus : not haemorroid
 Abnormalities : there is no
8. Extremities :
 On : Good
 Under : Good
 Oedem : there is no
 Varices : there is no
 Fingernails : redness
 Patellar reflexes :+/+
9. Medicines used :
Etamox 3 x 500 mg / day
Mefenamic acid 3 x 500 mg / day
10. Supporting investigation : no examination

II. DATA INTERPRETATION

Date / time : 12 December 2011 / 14.15 WIB
1. Diagnosis Midwifery
Mrs. S P2A 0 age 29 year 2 hours post partum with normal childbirth.
Subjective Basis: mom said had give birth baby 2 hours ago and now his body
is still limp as well his stomach feels mules.
Objective Ground : MY : Good Awareness: composmentis
VS :T : 120/70 mmHg R: 22 x / min
N: 82 x / min S: 37 0 C
TFU : 2 fingers below px
Uterine contractions : hard, uterine consistency: regular
PPV : Lochea Rubra, Color Red, Number 75 cc.
Breast Examination:
 Enlargement : There is
 Shape and size : Symmetrical
 Color : Normal
 Putting state : Stand out
 Spending : There is
 Type : Colostrum
 Hyperpigmentation : Areola
 Bumps : No bumps / masses
 Pain : No pain
2. Problem
There is no
III. POTENTIAL DIAGNOSIS AND ANTICIPATION
There is no
IV. ACTION SOON
There is no
V. PLANNING
Date / Time: 12 December 2011 / 14.20 WIB
1. Observation KU , VS, PPV. TFU, and uterine contractions.
2. Tell the mother about the cause of mules
3. Encourage mother to do early mobilization.
4. Tell mom about how to keep personal hygine.
5. Tell the mother how to breastfeed properly
6. Encourage the mother to breastfeed her baby as needed.
7. Encourage the mother to eat - a balanced diet.
8. Encourage the mother to take adequate rest.
9. Give therapy.

VI. IMPLEMENTATION
Date / Time: 12 December 2011 / 14.20 WIB
1) Observing KU , VS, PPV. TFU, and uterine contractions.
2) Tell the mother about the cause of mules: caused by the contraction of the uterus
to return to its original state before pregnancy.
3) Advise mother to do early mobilization such as starting to tilt, sit and
walk - the road.
4) Tell mom about how to keep personal hygine :
 Hygiene bath 2x a day.
 Moments after BAK / BAB wash the vulva to clean from front to back.
 Replace the pads when full or 2 - 3 times daily.
5) Tell mom how to breastfeed the right :
 The baby is placed in the arms of the mother's hand, the mother's palm holding
the butt and the baby's head facing the mother's breast, the baby's stomach clinging to
the mother's stomach.
 Head, ears and shoulders are a straight line.
 Apply a small amount of breast milk to the mother's nipple and areola.
 Breaststick the mother with the hand, then rngsang mouth baby to open by using
mother's nipple.
 Putputting mother's milk and some areola as soon as the baby opens its mouth.
 Watch the baby during breastfeeding to avoid choking.
 When the baby is satisfied the output of the nipple slowly by slowly pulling the
baby's chin or by inserting the little finger from the side of the baby's mouth.
 Apply a little breast milk to the nipple and areola and leave to dry.
6) Encourage mothers to breastfeed their babies as needed.
7) Encourage the mother to eat - a balanced nutritious meal.
8) Encourage the mother to take adequate rest.
9) Provide therapy :
Etamox 3 x 500 mg / day
Acid Mefnamate 3 x 500 mg / day

VII. EVALUATION
Date / Time: 12 December 2011 / 14.20 WIB
1. MY : Good Awareness: composmentis
VS :T : 120/70 mmHg R: 22 x / min
N: 82 x / min S: 37 0 C
TFU : 2 fingers below px
Uterine contractions : hard, uterine consistency: regular
PPV : Lochea Rubra, Color Red, Number 75 cc.
2. Mother already understand if the stomach is mules caused by the contraction of
the uterus to return to its original form.
3. Mother can already tilt, dudu and walk around.
4. Mother is willing to keep personal hygiene.
5. Mother already knows how to breastfeed properly.
6. Mother is willing to breastfeed her baby according to the wishes and needs of her
baby.
7. Mother is willing and will eat - a balanced nutritious meal.
8. Mom is willing to rest enough.
9. Therapy has been given to the mother.