Name Age Address Admitted MR

: Mrs. M : 24 yo : Cakranegara : April, 03th 2013 at 09.40 WITA : 529421

TIME 03/04/ 2013 (09.41)

SUBJECTIVE Patient referred from Cakranegara PHC with G2P1A0L1 39 weeks S/L/IU head presentation, mother & fetal well with active phase 1st stage of labour with edema porsio and suspect big baby Patient confessed abdominal pain since 19.00 (02-04-2013), water came out from the womb since 07.00 (03-04-2013), Bloody slim (+), and FM (+). History of HT (-), DM (-). And asma (-). LMP : 01/07/2012 EDD : 08/04/2013 ANC history : 10x at PHC Last ANC : 28/03/2013 Result : BP : 90/70 mmHg, BW : 65 kg, 38-39 weeks, UFH : 30 cm USG history : Family planning history : Plan of family planning : Obstetrical history 1. Aterm, male, 2800 g, spt, midwife, 4 yo 2. This

OBJECTIVE GC : well Consciousness : composmentis BP : 120/90 mmHg PR : 76 bpm RR : 20 rpm T : 36,50C Local State Eye : pale (-/-), icteric (-/-) Cor : S1S2 single, regular, murmur (), gallop (-) Pulmo : vesicular (+/+), ronchi (-/-), wheezing (-/-) Abdomen : striae albicans (+), scar (-) Extremity : edema (-/-), warm acral (+/+) Obstetrical State L1 : breech L2 : back on the right side L3 : head L4 : 3/5 UFH : 35 cm EFW : 3720 gram UC : 3x10~35 FHR : 13-13-13 (156 bpm) VT : 7 cm, amnion (-), head presentation, caput (+), edema porsio, denom unclear, HII, unpalpable small part or umbilical cord.

ASSESTMENT G2P1A0L1 39-40 weeks S/L/IU head presentation neglected active phase 1st stage of labor

PLANNING Observe mother & fetal well being Inj. ceftriaxone GP co to SPV pro termination SPV advise observe progress of labour until 11.00 am, if not progress prepare to CS

TIME

SUBJECTIVE
Chronologist at Cakranegara PHC S/ Patient confessed abdominal pain since 19.00 (02-04-2013), water came out from the womb since 07.00 (03-04-2013), Bloody slim (+), and FM (+). HPHT :1-07-2012 HTTP: 8-04-2013 O/ GC: well Conciousness: CM BP: 110/80 mmHg PR: 84 bpm RR: 20 rpm T: 36,6 L1: breech L2: back in the left side L3: head L4: 4/5 TFU: 37 cm EFW:4030 g UC: 3x10~30 DJJ: 11-11-12 VT: 7 cm, amnion (-), head presentation, edema porsio, denom unclear, HII +, unpalpable small part or umbilical cord. A/ G2P1A0L1 39 weeks S/L/IU head presentation, mother & fetal well with active phase 1st stage of labour with edema porsio and suspect big baby

OBJECTIVE
Lab HB: 11,7 g/dL RBC: 4,02 x 106/uL HCT: 37,8 % WBC : 14,1 x 103/uL PLT: 240 x 103/uL HbSAg: (-)

ASSESTMENT

PLANNING

TIME

SUBJECTIVE P/ Infus RL Injection ampicilin Refer to NTB GH

OBJECTIVE

ASSESTMENT

PLANNING

11.00

UC : 3x10~35 FHR : 13-13-13 (156 bpm) VT : 7 cm, amnion (-), head presentation, caput (+), edema porsio, denom unclear, HII, unpalpable small part or umbilical cord.

GP co to SPV advice CS

12.00 12.07

CS began Baby was born female, BW 3500, BL 47, AS 7-9, amnion meconeal, anus(+), anomaly kongenital (-). Placenta was born, manually, complete, bleeding + 100 cc, GC : well Consciousness : composmentis BP : 110/80 mmHg PR : 80 bpm RR : 20 rpm T : 36,60C UC: (+) UFH : 2 fingers below umbilicus AB : (-) GC : well Consciousness : composmentis BP : 120/80mmHg 2 hours post CS Obs, mother well being Suggest mother to eat, drink and mobilitation

12.12

16.12

04/03/ 2013 07.00

1 day post CS

Obs, mother well being Suggest mother to eat, drink and mobilitation