Name

: Ny. H

age

: 18 years

Address

: Pringgarata

Admitted

: 08 12 09
: 10.15

Time

Subject

Object

Assesment

Planning

10.15

Patient referred from Bagu PHC

with G1P0A0 with PE.
LMP : forgot

General status :
General condition: good
Conciousness: CM
BP: 140/100 mmHg
RR: 24 x/mnt
PR: 80 x/mnt
T: 37 C
Eyes : an(-), ikt (-)
Cor -Pulmo : in normal range
Extremitas : oedem in lower
extremitas

G2P0A1H0 A/S/L/IU
head presentation
with PER

Obs. Mother and fetal

well being
Check lab : UL, DL,
HBs Ag
Obs inpartu sign
Advice mother to left
lateral position.
Report to supervisor ,
advice: observation
Observation viytal sign
every 1 hour

Chronologis :
Patient came to Bagu PHC at 09.15
(08/12/09)
confess
abdominal
pain
(+).
Hipertention (-), DM (-),
asma (-).
examination in PHC:
General condition : good
Conciousness: CM
BP : 140/100 mmHg
RR : 20 x/mnt
Edem : +
UFH : 38 cm
FHR : 138 bpm
VT: CD 2 cm, eff 30%, ket (+) head
presentation
ANC : >8 x at Polindes , last about
2 weeks ago.
Obstetric status:
1.
Abortus, 4 month
2.
This pregnant
History of contraception:Planning contraception:-

Obstetric status :
L1 : breech
L2 : left back
L3 : head
L4 : wasnt pelvic inlet, 5/5
UFH 38 cm
EFW : 4030 g
UC : 2 x 10 ~ 20
FHR : 152 bpm
VT : 1 cm, eff 10 %, AM
(+), head palpable, descend
HI,
denominator
unclear,
unpalpable small organ and
umbilical cord.

Time

Subject

Object
Lab examination :
Hb : 12,5 gr%
Leukosit : 5,86 %N
Trombosit : 171 K/ul
HCT : 37,9%
HbsAg : Proteinuri : +2
Pelvic score :

Assesment

Planning

Time

Subject

Object

Assesment

Planning

11.15

General condition: well

BP: 140/100 mmHg
RR: 24 x/mnt
PR: 80 x/mnt
T: 37 C
FHB: 12-12-12
UC : 2 x 10 ~ 20

Observation
hour again

vital

sign

12.15

General condition: well

BP: 140/100 mmHg
RR: 24 x/mnt
PR: 80 x/mnt
T: 37 C
FHB: 12-12-12
UC : 2 x 10 ~ 20

Observation
hour again

vital

sign

13.15

General condition: well

BP: 140/100 mmHg
RR: 24 x/mnt
PR: 80 x/mnt
T: 37 C
FHB: 12-12-12
UC : 2 x 10 ~ 20

Observation
hour again

vital

sign

21.30

Dizziness (+)
Abdominal discomfort (+)

General condition: weak

Conciousness: E2V3M5
BP: 170/120 mmHg
RR: 20 x/mnt
PR: 74 x/mnt
T: 36,8 C
FHB: 11-11-12
UC : 2 x 10 ~ 20

G2P0A1H0
A/S/L/IU
head
presentation
with PEB

Manage protap PEB:

Inject 4g IV MgSO4 (bolus)
Drip MgSO4 6g, 28 tpm

Time
02.00
(091209)

Subject

Object

Assesment

SC begun

Planning
Baby was born male, weight
4800g, length 50 cm, AS 7-9
Placenta was born complete, 1
minute after baby was born

04.00

BP : 160/90 mmHg
PR : 84 x/mnt
RR : 20 x/mnt
T : 36C
UC : good
UFH : 2 cm below umbilical
Wound of operation: good
Baby:
HR: 140 bpm
RR: 36 bpm
T: 36,6 C

2 hours post SC

Obs. Mother and baby well

being
Obs vital sign

07.00

BP : 160/90 mmHg
PR : 84 x/mnt
RR : 20 x/mnt
T : 36C
UC : good
UFH : 2 cm below umbilical
Wound of operation: good
Baby:
HR: 146 bpm
RR: 36 bpm
T: 36,7 C

1 day post SC

Obs. Mother and baby well

being
Motivated
mother
to
breastfeeding