Name

:
Age
:
Adress
:
Admitted
02.49
Med.Record

Mrs. HT
22 years old
Marong, Selaparang
: December, 16th 2012 at
: 500240

TIME

SUBJECTIVE

22/12/
13
21.40

Patient referred from Sigerongan

PHC with G2P0A1L0 38-39
weeks S/L/IU head presentation
with PROM >12 hours +
Olygohidramnion.
Patient
confessed water came out from
her
womb
since
09.00
(22/12/2012), water came out
wiith a little amount, clear.
Abdominal pain that spread to
waist (+). Fetal movement (+).
No history of DM, HT, asthma.
LMP : 09/04/2012
EDD : 06/01/2013
History of ANC : 10x in posyandu
Last ANC : 21/12/2012
History of USG : never
History of family planning : (-)
Next family planning : Injection 3
months.
Obstetrical History :
I. This
Chronologist:
-

OBJECTIVE
General Status
GC : well
Consciusness : CM
BP : 120/70 mmHg
PR : 80 bpm
RR : 20 bpm
T : 36,5oC
Eye : anemis (-/-), icteric (-/-)
Cor : S1S2 single reguler, M (-), G (-)
Pulmo : vesikuler (+/+), wheezing
(-/-), ronkhi (-/-).
Abdomen : scar (-), striae (+), linea
nigra (+).
Extremity : edema (-/-), warm acral
(+/+)
Obstetrical Status
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH : 26 cm
EFW : 1675 g
UC :2x/10 ~ 25
FHB : 11-11-11 (132 bpm)
VT : 2 cm, eff 25%, amnion (+),
head palpable H I , denominator
unclear, impalpable small part /
umbilical cord.

ASSESSMENT

PLANNING

G1P0A0H0 37-38
weeks S/L/IU
head presentation
with latent phase
1st stage of labor +
mild anemia

Observe mother and

fetal well being.
Observe progress of
labor.
Check Lab: CBC,
HbsAg
Consult to GP: GP
advice observation
Transfer to VK Teratai

TIME

SUBJECTIVE

OBJECTIVE
Pelvic Evaluation :
Spina ischiadica not prominent
Os coccigeous mobile
Pubic arch > 900
Lab Evaluation
Hb : 9,7 g/dl
RBC : 4,3 M/dl
HCT : 39,9 %
WBC : 10,9 K/dl
PLT : 241 K/dl
HbSAg : (-)

ASSESSMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

03.30

GC : well
BP: 110/70 mmHg
HR: 84 x/minute
RR: 20 x/minute
T: 36,4 C
UC :2x/10 ~ 30
FHB : 140 bpm

G1P0A0H0 37-38
weeks S/L/IU head
presentation with
latent phase 1st stage
of labor + mild anemia

Observe mother and

fetal well being.
Observe progress of
labor
Evaluation 4 hours
later or if there is
indication

07.15

GC : well
UC :2x/10 ~ 30
FHB : 140 bpm
VT : 3 cm, eff 50%, amnion (+),
head palpable H I , denominator
unclear, impalpable small part /
umbilical cord.

G1P0A0H0 37-38
weeks S/L/IU head
presentation with
latent phase 1st stage
of labor + mild anemia

Observe mother and

fetal well being.
Observe progress of
labor

11.30

GC : well
UC :2x/10 ~ 30
FHB : 140 bpm
VT : 3 cm, eff 50%, amnion (+),
head palpable H I , denominator
unclear, impalpable small part /
umbilical cord.

G1P0A0H0 37-38
weeks S/L/IU head
presentation with
prolonged latent phase
1st stage of labor +
mild anemia

Observe mother and

fetal well being.
Observe progress of
labor
CTG
Consult SPV: advice
acceleration and CIE
Patient and Family

13.00

UC :2x/10 ~ 30
FHB : 144 bpm

Set Acceleration with

Oxytocindrip start from
8 dpm

13.30

UC :2x/10 ~ 30
FHB : 152 bpm

12 dpm

14.00

UC :2x/10 ~ 30
FHB : 144 bpm

16 dpm

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

14.30

UC :3x/10 ~ 30
FHB : 144 bpm

20 dpm

15.00

UC :3x/10 ~ 30
FHB : 156 bpm

24 dpm

15.30

UC :4x/10 ~ 30
FHB : 144 bpm

28 dpm

16.00

UC :4x/10 ~ 45
FHB : 152 bpm

28 dpm

16.30

Mothers want to bearing down

UC :4x/10 ~ 45
FHB : 152 bpm
Rupture of Membrane
VT: complete, amnion (-), head
palpable H II , denominator ROA,
impalpable small part / umbilical
cord.

2nd stage of labour

Conduct mother to
bearing down

Teknus-Perjol-Vulka
16.50

Baby was born (16.50)

Female, AS: 7-9, BL:
43 cm, BW: 2000
gram.
Placenta was born
Sontaneusly (17.00)
complete, bleeding
300
cc.
Placenta
weight : 500 gram
Anus (+), congenital
anomaly (-), amnion
(-).
Episiotomy : ruptur

TIME
19.00

17/12/
2012
07.00

SUBJECTIVE
Patient confessed wound pain.

OBJECTIVE

ASSESTMENT

PLANNING

GC : well
BP : 110/80 mmHg
PR : 72 bpm
RR : 20 bpm
T : 36,5oC
UFH : 1 finger below umbilicus
UC : (+)
Active bleeding : (-)

2 hours post post

partum

Observe mother well

being.
CIE mother to take a
rest.
Transfer to Melati room

GC : well
BP : 110/80 mmHg
PR : 80 bpm
RR : 20 bpm
T : 36,5oC
UFH : 1 finger below umbilicus
UC : (+)
Active bleeding : (-)

One day post post

partum

Observed mother and

baby well being
Check CBC
Suggest mother to
mobilisation, eat, and
drink, medication.