Case I

Name : Mrs. Y
RM : 590644
Age : 26 years old
Address : Sedau, Narmada
Admitted : March 31st 2017
Time Subject Object Assessment Planning
31/03/ Patient referred from Sedau PHC General status G2P1A0H1 39- DM Planning:
2017 with G2P1A0H1 39-40 weeks GC : well 410 weeks Diagnostic:
14.50 S/L/IU head presentation,mother GCS: CM (E4V5M6) S/L/IU head CBC, HbsAg
and fetal in good condition, with BP : 110/70mmHg presentation CTG
inpartu latent phase of labor + PR: 88 tpm with inpartu
PROM. Patient confessed RR: 20 tpm active phase of Observation:
abdominal pain spread to the flank T: 36,8C labor Obs. Mother and fetal
since 05.00 (31-03-2017 ). Bloody well being.
slime (+), water leak out from her Local status Obs. Progress of labor
womb (+) since 06.30 (31-3-2017) Eye : an (-/-), ict (-/-) with WHO partograph
FM (+). Pulmo: ves (+/+), rh (-/-), wh (-
/-)
History of DM (-), HT (-), asthma (- Cor : S1S2 single regular M(-), CIE patient to eat and
). G(-) drink
Family history DM (-), HT (-), Abd : striae gravidarum (+), Inform patient about the
asthma (-). linea nigra (+), scar (-), BU (+) diagnostic planning
N
LMP : 22-05-2016 Ext : edema (-/-), warm (+/+)
EDD : 29-02-2017 DM co to GP, GP co to
GW : 39-40 weeks Obstetric status SPV, advice :
L1 : breech Obs. Progress of labor
History of ANC: 7x at PHC L2 : back on the right side with WHO partograph
last ANC:06-03-2017 L3 : head
Result L4 : 4/5
BP: 110/70, UFH: 28 cm
GW: 37 weeks, EFW : 2635 gr
UFH: 29 cm, head presentation UC : 3X10-30
FHB : 12.13.13 (156 x/min)
History of USG : 1x at PHC VT : 4 cm, eff.50 %, Amnion
Last USG (1-12-2016) (-), HI, head palpable,
Result : denominator ROA, impalpable
Fetal S/L/IU breech presentation 22-23 small part of fetal & umbilical
weeks, EFW 517 gr, EDD 2-4-2017, cord.
placenta fundus
History of family planning : (+) pill Lab: (31/3/2017)
 Time Subject Object Assessment Planning
Chronologist at Sedau PHC

10.00 S/ Patient came with abdominal pain

O/ GC : well
GCS: CM (E4V5M6)
BP : 100/70mmHg
PR: 84 bpm
RR: 20 bpm
T : 37 C

Obstetric status
UFH: 29 cm
UC : 2X10-20
FHB : 12.11.12 (140 x/min)
VT : 2 cm, eff. 25 %, Amnion (-) HI,
head palpable, denominator unclear,
impalpable small part of fetal & umbilical
cord.

A/ G2P1A0H1 39-40 weeks S/L/IU head

presentation,mother and fetal in good
condition, with inpartu latent phase of labor

P/
CIE patient the result of examination
Atopy skin test at 10. 15 result (-)
Ampicillin injection 1 gr at 10.30 via IV line
Obs mother and fetal well being
 Time Subject Object Assessment Planning
Chronologist at Sedau PHC

13.00 S/ Abdominal pain increase

O/ GC : well
GCS: CM (E4V5M6)
BP : 100/70mmHg
PR: 80 bpm
RR: 20 bpm
T: 37 C

Obstetric status
UFH: 29 cm
UC : 2X10-20
FHB : 12.11.12 (140 x/min)
VT : 2 cm, eff. 25 %, Amnion (-) HI,
head palpable, denominator unclear,
impalpable small part of fetal & umbilical
cord.

A/ G2P1A0H1 39-40 weeks S/L/IU head

presentation,mother and fetal in good
condition, with inpartu latent phase of labor
+ PROM

P/
CIE patient the result of examination
Referred to NTB GH
Time Subject Object Assessment Planning
15.30 Abdominal pain (++) Inspection: 2nd stage of labor - Conduct mother to
Mother want to bear down Sign of labor (+) crowning, bearing down
pressure on anus, opening of
vulva, bulging of perineum The baby was born
(15.30), spontan, female,
AS 7-9, BW: 3040 gr, BL:48
cm, anal (+), congenital
anomaly (-)

15.35 3rd stage of labor Placenta was born

spontan, complete,
bleeding : 200 cc,
rupture perineum gr. II
hecting
17.35 Abdominal pain (-) General status 2 hour post partum Obs. Mother and baby
Active bleeding (-) GC : well well being
consciousness: CM Amox tab 3x1
BP : 130/80 mmHg Mef acid tab 3x1
PR: 88 bpm Move to maternity care
RR: 20 bpm unit
T: 36,8C
UC : well
UFH : 2 finger below umbilicus
Active bleeding (-)
06.00 No complaint GC : well 1 day post partum Obs. Mother and baby
GCS: CM (E4V5M6) well being
BP : 110/70mmHg Suggest mother to eat
PR: 84 tpm and drink
RR: 18 tpm Amox tab 3x1
T: 36,8C Mef acid tab 3x1

UC : well Mobilization
UFH : 2 finger below
umbilicus
CTG