Case 1

Name : Mrs. H
Age
: 18 yo
Address : Batu Layar
Admitted : 23rd June 2016

TIME

SUBJECTIVE

23/06/16
00.00

Patient referred from Meninting PHC with

G1P0A0L0 41-42 weeks, S/L/IU, head
presentation, mother and fetal in good
condition, with inpartu latent phase 1 st
stage of labor. Patient confessed bloody
slime from her womb (+) since 07.00
(22/6), abdominal pain spread to flank (+)
since 17.00 (22/6), water leaked out from
her womb (-), FM (+).
History of DM (-), HT (-), asthma (-) and
allergy (-).
LMP : 2-9-2015
EDD : 9-6-2016
GW : 42 weeks
History of ANC : 03x at PHC
last ANC 13/06/2016, BP 110/70 mmHg,
40-41 weeks, UFH 30 cm, head
presentation, FHB (+).
History of USG : 1x at Sp.OG
07/03/2016
:
fetal
S/L/IU,
head
presentation, BPD/AC/FL ~ 22-24 weeks,
EFW 660 gram, AFI enough clear, EDD
29/06/2016
History of family planning: Next family planning : injection 3 months
Obstetrical history
1. This

OBJECTIVE

ASSESSMENT

PLANNING

General status
GC : well
consciousness: CM
BP : 100/70 mmHg
PR: 72 bpm
RR: 16 bpm
T: 36,8C

G1P0A0L0 4142 weeks,

S/L/IU, head
presentation,
inpartu latent
phase 1st stage
of labor

DM planning:
Diagnostic planning
Check CBC, HbsAg
CTG
USG

Local status
Eye : an (-/-), ict (-/-)
Pulmo : ves (+/+), rh (-/-),
wh (-/-)
Cor : S1S2 single regular,
murmur (-), gallop (-)
Abd : striae gravidarum (+),
linea nigra (+), scar (-)
Ext : edema (-/-), warm
acral (+/+).
Obstetric status
L1 : breech
L2 : back on the right side
L3 : head
L4 : 4/5
UFH: 30 cm
EFW : 2945 gram
UC : 3x10 ~ 35
FHB : 12-12-11 (140 bpm)
VT : 3 cm, eff 25%,
amnion (+) head
presentation, H1,
denominator unclear, not
palpable small part &
umbilical cord

Therapy :
Observation progress
of labor
Observe mother &
fetal well being
Suggest mother to eat
and drink
Suggest mother to lay
to to the left side.
CIE : CIE mother and
family about planning

SUBJECTIVE

OBJECTIVE
Lab
HB 11,1 g%
RBC 4,45
HCT 34,4
WBC 13,01
PLT 254
HbSAg non reactive
PPT 13,6
APTT 28,7

ASSESSMENT

PLANNING

Time

Subjective

(22/06/2016)

Chronology at Meninting PHC:

22.30

S:
Patient confess abdominal pain
referred to flank since 19.00.
Bloody slime since 07.00
O:
GC : Well
Consciousness : CM
BP : 100/80 mmHg
PR: 82 bpm
RR: 20 tpm
Temp: 36,0 C
Obstetric status
L1 : breech
L2 : back on the right side
L3 : head
L4 : 4/5
UFH: 32 cm
FHB : 12-11-11 (136 bpm)
UC : 3x10 ~ 35
VT : 2 cm, eff 25%, amnion (+)
head presentation, denominator
unclear, H I, not palpable small
part & umbilical cord .
A:
G1P0A0L0 41-42 weeks /S/L/IU
head presentation, mother and
fetal in good condition, with inpartu
latent phase 1st stage of labor.
P:
IVFD RL flash I 28 dpm

Objective

Assessment

Planning

SUBJECTIVE
23.00

Water leaked out (-)

OBJECTIVE
General status
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 90 bpm
RR: 18 bpm0T: 36,6C
FHB (+) 12-12-12
UC : 3x10~35

06.00

Water leaked out (-)

ASSESSMENT

PLANNING
DM planning
Obs. progress of labor
Obs. Mother and
fetal well being
Suggest mother to
lie down the left side,
eat and drink

Time
21.00

Subject
Headache (-), nausea (-), vomiting
(-), urination (+), defecation (-)

Object
GC : Well
GCS : E4V5M6
BP : 100/70 mmHg
PR: 88 bpm
RR: 20 t/m
T: 36,0C

Assasstment

Planning

2 hours post partum

Obs. Mother well being

Obs vital sign, UC, bleeding
Suggest motherr to eat and
drink

1 day post partum

Obs. Mother well being

Obs vital sign, UC, bleeding
Suggest motherr to eat and
drink

UC : (+) well
UFH : 3 finger bellow umbilicus
Baby in rooming
HR : 144 x/minute
RR : 40 x/minute
T : 36.8oC
12/05/16
06.00

Headache (-), nausea (-), vomiting

(-), urination (+), defecation (-)

GC : Well
GCS : E4V5M6
BP : 120/80 mmHg
PR : 84 x/m
RR : 20x/m
Temp : 36,6C
UC : (+) well
UFH : 3 finger bellow umbilicus
Baby in rooming
HR : 146 x/minute
RR : 44 x/minute
T : 36.6oC

Case 2
Name : Mrs. I
Age
: 26 yo
Address : Gelogor, Lombok Barat
Admitted : 22nd June 2016

TIME

SUBJECTIVE

22/06/16
23.00

Patient referred from Sedau PHC with

G1P0A0L0 A/S/L/IU, head presentation,
mother and fetal in good condition, with
inpartu active phase 1st stage of labor +
PROM > 6 hours + Uterus Contraction not
adecuat. Patient confessed water leaked
out from her womb since 13.00 (22/6),
bloody slime (+) since 09.00 (21/6),
abdominal pain spread to flank (+), FM (+)
History of DM (-), HT (-), asthma (-) and
allergy (-).
History of medication: multivitamin
LMP : 26-9-2015
EDD : 3-7-2016
GW : 38-39 weeks
History of ANC : 09 x at PHC
last ANC 16/06/2016, BP 100/60 mmHg,
36 weeks, UFH 30 cm, head presentation,
FHB (+).
History of USG : 2x at Sp.OG and 1x at
GP
10/05/2016
:
fetal
S/L/IU,
head
presentation, 33-34 weeks, EFW 2300
gram, AFI enough, EDD 23/06/2016
History of family planning: Next family planning : injection 3 months
Obstetrical history
1. This

OBJECTIVE
General status
GC : well
consciousness: CM
BP : 130/90 mmHg
PR: 112 bpm
RR: 22 bpm
T: 37,5C
Local status
Eye : an (-/-), ict (-/-)
Pulmo : ves (+/+), rh (-/-),
wh (-/-)
Cor : S1S2 single regular,
murmur (-), gallop (-)
Abd : striae gravidarum (+),
linea nigra (+), scar (-)
Ext : edema (-/-), warm
acral (+/+).
Obstetric status
L1 : breech
L2 : back on the left side
L3 : head presentation
L4 : 4/5
UFH: 33 cm
EFW : 3410 gram
UC : 1x10 ~ 15
FHB : 12-12-13 (148 bpm)
Inspeculo: fluid (+) clear at
fornix post
VT : complete, amnion (-)
clear, head presentation,
H1, denominator unclear,
not palpable small part &
umbilical cord

ASSESSMENT

PLANNING

G1P0A0L0 3940 weeks,

S/L/IU, head
presentation,
2nd stage of
labor + history
of ROM

DM planning:
Diagnostic planning
Check CBC, HbsAg
Lakmus test
CTG
USG
Therapy :
Observation progress
of labor
Observe mother &
fetal well being
Suggest mother to eat
and drink
Suggest mother to lay
to to the left side.
CIE : CIE mother and
family about planning
DM co to GP co to
SPV, advice:
-rehidration if failed
acceleration with
oxytocin and vacuum
if failed C-section
-antibiotic ampicilin 1 gr
iv

SUBJECTIVE

OBJECTIVE
Lab
HB 11,1 g%
RBC 4,45
HCT 34,4
WBC 13,01
PLT 254
HbSAg non reactive
PPT 13,6
APTT 28,7

ASSESSMENT

PLANNING

Time

Subjective

(22/06/2016)

Chronology at Meninting PHC:

22.30

S:
Patient confess abdominal pain
referred to flank since 19.00.
Bloody slime since 07.00
O:
GC : Well
Consciousness : CM
BP : 100/80 mmHg
PR: 82 bpm
RR: 20 tpm
Temp: 36,0 C
Obstetric status
L1 : breech
L2 : back on the right side
L3 : head
L4 : 4/5
UFH: 32 cm
FHB : 12-11-11 (136 bpm)
UC : 3x10 ~ 35
VT : 2 cm, eff 25%, amnion (+)
head presentation, denominator
unclear, H I, not palpable small
part & umbilical cord .
A:
G1P0A0L0 41-42 weeks /S/L/IU
head presentation, mother and
fetal in good condition, with inpartu
latent phase 1st stage of labor.
P:
IVFD RL flash I 28 dpm

Objective

Assessment

Planning

SUBJECTIVE
00.00

Water leaked out (+),

abdominal pain (+)

OBJECTIVE
General status
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 90 bpm
RR: 18 bpm
T: 37,5C

ASSESSMENT
G1P0A0L0 39-40
weeks S/L/IU head
presentation 2nd
stage of labor with
fnertia uteri

DM planning
Obs. progress of labor
Obs. Mother and
fetal well being
Suggest mother to
lie down the left side,
eat and drink
DM co to GP co to
SPV, advice:
-rehidration if failed
acceleration with
oxytocin and vacuum
if failed C-section
-antibiotic ampicilin 1 gr
iv
-

G1P0A0L0 39-40
weeks S/L/IU head
presentation 2nd stage
of labor with fetal
distress and susp CPD
+ inertia uteri

DM co to GP co to SPV
advice:
C-section

FHB (+) 12-12-12

UC : 1x10~15
VT : complete, amnion (-)
clear, head presentation, H1,
denominator unclear, not
palpable small part &
umbilical cord

01.00

Water leaked out (+),

abdominal pain (+)

02.00

Patient moved to OK

FHB (+) 8-8-8 (96x/mnt)

UC : 1x10~15
VT : complete, amnion (-)
meconeal, head presentation
molage +2, HII, denominator
unclear, not palpable small
part & umbilical cord

PLANNING

Baby was born 02.28

Male 3200. AS 6 8,
molage (+2) Anus (+),
Congenital anomaly (-)
Plasenta was born at
02.30, complete, UFH 2
finger below umbilicus