Identity

Name : Mrs. NDY

Age : 26 years Old
Address : Sandubaya , Mataram
Admitted on: December, 13th 2012
(12.00 wita)
Medical record : 070283

TIME

SUBJECTIVE

OBJECTIVE

13/12/
2012
12.00

Patient
referred
from
Sandubaya
Polindes
with
G2P1A0H1
39-40
weeks
S/L/IU head presentation with
PROM > 12 hours
Abdominal pain that spread
to waist (-). Histrory water
leaked from her womb (+)
since 23.00 wita 12/12/12.
Bloody slim (-), FM (+).
No history of DM, HT,
asthma.
LMP : 13/03/2012
EDD : 20/12/2012
History of ANC : >4x at
Posyandu
History of USG : 1 x at SpOG
Result :
History of family planning :
injection every 3 month (4
years)
Next
family
planning
:
Injection every 3 month
Obstetrical History :
I. Aterm, 2800 gr,
Midwife, Life 5 YO.
II. This

Male,

General Status
GC : well
Consciousness : CM
BP : 130/90 mmHg
PR : 72tpm
RR : 20 bpm
T : 36,9 oC
Eye : anemis (-/-), icteric (-/-)
Cor : S1S2 single reguler, M (-), G
(-)
Pulmo : vesikuler (+/+),
wheezing (-/-), ronkhi (-/-).
Abdomen : scar (-), striae
gravidarum (+), linea nigra (+).
Extremity : edema (-/-), warm
acral (+/+)
Obstetrical Status
L1 : breech
L2 : back on the right side
L3 : head
L4 : 4/5
UFH : 32 cm
EFW : 3255 g
UC :FHB : 12-12-12 (144 bpm)
VT : 3 cm, eff 25%, amnion
(-), head palpable H I,
denominator unclear,
impalpable small part /
umbilical cord.

ASSESSMENT

PLANNING

G1P0A0H0 3940 weeks S/L/IU

head
presentation
with PROM> 12
hours + mild
preeclampsia

Observe mother
and fetal well
being.
Inj Ampiccillin
GP consult to SPV:
induction with
oxytosin drip
Observation
proggress of labour
CTG

TIME

SUBJECTIVE
Chronologist at Sandubaya Polindes :
12.30 (13/12/2012)
S :
G2P1A0H1 pregnant 39-40
weeks with history water leaked
from patient womb (+) since
23.00 wita 12/12/12. Bloody slim
(-), FM (+).
O : BP : 110/80 mmHg
PR : 84 bpm
RR : 20 bpm
T : 36,5oC
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH : 31 cm
UC : (-)
FHB : 12-13-13 (152 bpm)
VT : 1 cm, eff 10%, amnion (-) ,
head palpable HI , denom
unclear, unpalpable small part /
umbilical cord.
A : G2P1A0H1 41 weeks S/L/IU head
presentation with PROM > 12 hours
P:

Inj. Ampi 1 gr/iv

OBJECTIVE
Pelvic Score : 6
Cervix dilatation 1 cm : 1
Cervix length 1 cm : 2
Cervix consistency
moderate : 1
Cervix position mid : 1
Station H I : 1
Lab Evaluation
HB : 11,4g/dl
RBC : 4,56 M/dl
HCT : 32,9 %
WBC : 23,1 K/dl
PLT : 331 K/dl
HbSAg : (-)
Proteinuria (+)

ASSESSMENT

PLANNING

TIME

SUBJECTIVE

14.30

OBJECTIVE

ASSESTMENT

UC : (-)
FHR (11-11-12)

PLANNING
Set IVFD D5 with 5
IU of Oxytosin
start at 8 dpm

VT : 3 cm, eff 25%,

amnion (-), head palpable
H I, denominator
unclear, impalpable small
part / umbilical cord.
15.00

UC: (1x10~20)
FHR: 12-12-12

12 dpm

15.30

UC: (2x10~30)
FHR: 12-11-12

16 dpm

16.00

UC: (3x10~30)
FHR: 12-12-11

20 dpm

16.30

UC: (3x10~35)
FHR: 12-11-12

24 dpm

16.40

Patient want to bearing down

UC: (3x10~35)
FHR: 12-12-12
VT : Complete, amnion
(-), head palpable H III,
denominator unclear,
impalpable small part /
umbilical cord.
Teknus Vulka Perjol

G1P0A0H0 3940 weeks

S/L/IU with II
stage of labour
+ mild
preeclampsia

Conduct mother to
bearing down

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

17.00

19.00

PLANNING
Baby was born
spontaneously,
Male, BW:3200
g/52 cm, anus (+),
AS: 7-9
Placenta was born
spontaneously,
complete,
bleeding 500 cc

GC: well
Cons : CM
BP: 110/80
HR: 84 bpm
RR: 24 tpm
T: 36,5 C
UC: +
UFH: 2 finger below
umbilicus

2 hours post
partum

Observed mother
and baby well
being
Suggest mother to
mobilisation.

1 day post
partum

Observed mother
and baby well
being
Suggest mother to
mobilisation, eat,
and drink,

Baby rooming in with

mother
PR: 120
RR: 50
T: 36,7
14/12/
2012
07.00

GC: well
BP: 120/80
HR: 80 bpm
RR: 20 tpm
T: 36,5 C
UC: +
UFH: 2 finger below
umbilicus
Urine output: 100 cc