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Name
Age
Address
Admitted
RM
Diagnose
: Mrs. M
: 28 yo
: Taman Sari, Gunung
Sari,
Lombok Barat
:December, 01st 2014
: 550835
: G2P1A0L1 A/S/L/IU
head
presentation
with history of CSection 13 years ago
and CPD.
Time
December
01st 2014
03.30 wita
Subjective
Objective
kg,
General status
GC : well
GCS : E4V5M6
BP : 120/90 mmHg
PR : 84 bpm
RR : 22 tpm
T : 36,9 0C
Eye : anemis (-/-), ikteric (-/-)
Cor : S1S2 single, M (-), G (-)
Pulmo : BVes (+/+), Whz (-/-),
Rh (-/-)
Abdomen : striae gravidarum
(+), linea nigra (+), scar (+)
Extremity :
Upper : oedem (-/-), warm
(+/+)
Lower :oedem (-/-),warm
(+/+)
Obstetrical Status
L1 : breech L2 : back at left
side
L3 : head
L4 : 4/5
UFH : 31 cm EFW : 3100 gr
UC : + His: 3x/10~30
FHB : 12-12-11 (140 bpm)
VT : 3 cm, eff : 25%, amnion
(+), head presentation, denom
unclear, HI, impapable small
part of fetus/ umbillical cord
Assessme
nt
Planning
G2P1A0L1
A/S/L/IU
head
presentatio
n latent
phase 1st
stage of
labor with
history of
C-Section
15 years
ago
Diagnostic:
Laboratoriu
m test
Obs.
Mother and
fetal well
being
Obs.
Progress of
labor
CIE family
Time
Subjective
Objective
PS : 6
Cervix Dilatation : 2
Cervix length : 1
Cervix position : 1
Station : 1
Cervix Consistency : 1
PE :
Spina ischiadica: not prominent
Os coxygeus : mobile
Arcus pubis : >90o
Lab result :
HB : 11,7 g/dL
HCT : 35,6 %
WBC : 15,78x 103/uL
PLT : 283 x 103/uL
BT : 210
CT : 620
HbsAg : (-)
Proteinuria : -
Assessm
ent
Planning
Time
Subjective
:
:
:
:
breech
back on the right side
head
4/5
UFH: 35 cm
FHB : 11-11-12 (136 bpm)
UC : 3x/10-35
VT : 3 cm, eff 50%, amnion (+),
head palpable, HI, impalpable
small part of fetus or umbilical cord.
A/ G2P1A0L1 40-41 wks L/IU head
presentation postterm with history
of C-Section 15 years ago
P/-
Objective
Assessme
nt
Planning
Time
Subjective
Objective
Assessment
Planning
December, 01st
2014
GC : Well
BP : 130/80 mmHg
PR : 80 bpm
RR : 22 tpm
T : 36,0 0C
UC : +
His:
3x/10~35
FHB : 12-11-11 (136 bpm)
VT : 5 cm, eff : 50%,
amnion (-) clear, head
presentation, denom
unclear, HI, impapable
small part of fetus/
umbillical cord,
active phase
labor
04.30
08.30 wita
GC : Well
BP : 120/80 mmHg
PR : 84 bpm
RR : 22 tpm
T : 36,0 0C
UC : +
His:
4x/10~40
FHB : 12-12-13 (148 bpm)
VT : 10 cm, eff : 100%,
amnion (-) clear, head
presentation, denom
unclear, HII impalpable
small part of fetus/
umbillical cord
09.00 wita
CS began
Baby was born, female,
BW 3300 gr, BL 49 cm,
Time
Subjective
11.00 wita
02/12/2014
07.00 wita
Objective
Assessmen
t
Planning
2 hours Post
CS
1 day post
partum
THANK YOU