Name

: Mrs. Subri

Age

: 35 years

Address

: labuapi

Wakt
u

Subject

08.2
5
pm

Patient with G1P0A0 40 -41 weeks

came alone to mataram general
hospital at 08.25 pm ( 3-12-2008)

31208

cronologis :
Patient came with Back discomfort
and watery Vaginal discharge at
04.00 pm

Last menstrual period : 25-02-08

EDD ; 2-12-08
History of family planning : (-)
Family planning : (-)
ANC : routine in public health
center, > 4x.
Obstetric history:
1. Now.

CTH

: 3 12 2008
: 20.25pm

Object
General status :
General condition: well,
Conciousness: CM
BP: 120/90 mmHg
RR: 24 x/mnt
Pulse :84 x/mnt
T: 36,5C
Eyes : an(-) ikt (-)
Cor -Pulmo : within normal limit
Obstetric status :
L1 : head
L2 : right back
L3 : breech
L4 : desend 4/5
UFH : 32 cm
EFW : 3255 g
UC : 1-2x-10-25
FHR : 150 x/mnt
VT : 1 cm.efff 25 %, amniotic
membran (+), the small part of fetal and
umbilical cord unpalpable.
Lab. result:
HBsAg (-)
HB = 11,8
WB = 12.700
TRB = 287.000
HMT = 36,3

Assesment

Planning

G1P0AH0 40-41 mggu

single/life+
observation inpartu

Observation
mother
and fetal well being.
Laboratory
examination : DL,
HBsAg

Wakt
u

Subject

01.0
0am

Mother felt abdominal pain and

watery vaginal discharge

Object

General status :
General condition: well,
Conciousness: CM
BP: 120/90 mmHg
RR: 24 x/mnt
Pulse :84 x/mnt
T: 36,5C
Eyes : an(-) ikt (-)
Cor -Pulmo : within normal limit

Assesment

Planning

G1P0A0 40-41 weeks

+ observasi inpartu

Obsevation mother and

fetal

G1P0A0 40-41 weeks

+ observasi inpartu

Obsevation mother and

fetal

Obstetric status :
L1 : head
L2 : right back
L3 : breech
L4 : desend 4/5
UFH : 32 cm
EFW : 3255 g
UC : 1-2X-10-25
FHR : 150 x/mnt

07.3
0
am

Mother felt abdominal pain

General status :
General condition: well,
Conciousness: CM
UC: 2X-10-25
FHR : 144X/MNT
VT : 2 cm.efff 30 %, amniotic
membran (+), descend H1, the small
part of fetal and umbilical cord
unpalpable.

Wakt
u

11.0
0am

Subject

Mother felt more abdominal pain

And patient Move to nifas ward

Object

General status :
General condition: well,
Conciousness: CM
UC :1-2x-10-25
FHR : 130x/mnt

Assesment

Planning

G1P0A0 40-41 weeks

+ observation inpartu

Obsevation mother and

fetal
Observation progression
of labor

G1P0A0 40-41 weeks

+ inpartu active phase
of first stage of labor

Obsevation mother and

fetal
Observation 4 hour later

VT : 2cm. efff 20 %, amniotic

membran (+), descend H1, the small
part of fetal and umbilical cord
unpalpable

4/12
/08
3.30
pm

Mother felt abdominal pain

(patient back to VK)

UC : 2x-10-35
FHR : 140x/mnt
VT : 4cm. Efff 20 %, amniotic
membran (+), descend H1, the small
part of fetal and umbilical cord
unpalpable.

Wakt
u

7.30
pm

Subject

Mother felt more abdominal pain

Object

General status :
General condition: well,
Conciousness: CM
UC : 1-2x-10-2
FHR : 130x/mnt
VT : 4 cm. efff 30 %, amniotic
membran (+), descend H1, the small
part of fetal and umbilical cord
unpalpable

Assesment

Planning

G1P0A0 40-41 weeks

+ inpartu prolonged
active phase of first
stage of labor

Obsevation mother and

fetal
Observation progression
of labor
Reported
to
supervisor : proposed
drip oxy
Advice : agreed

UC :1-2x10-25
FHR : 145x/mnt

Drip oxy 8 drops/mnt

UC : 1-2x10-25
FHR : 145x/mnt

Drip oxy 12 drops/mnt

9.00

UC : 1-2x10-25
FHR : 140x/mnt

Drip oxy 16 drops/mnt

9.30

UC : 1-2x10-25
FHR : 140x/mnt

Drip oxy 20 drops/mnt

UC : 1-2x10-25
FHR : 140x/mnt

Drip oxy 24 drops/mnt

UC : 1-2x-10-25
FHR : 140x/mnt

Drip oxy 28 drops/mnt

8.00
pm
8.30

10.0
0
10.3
0

Wakt
u

11.0
0
pm
11.3
0

00.0
0 AM
00.3
0

Subject

Object

Assesment

Planning

UC :1-2x10-25
FHR : 145x/mnt

Drip oxy 32 drops/mnt

UC : 1-2x10-25
FHR : 145x/mnt

Drip oxy 36 drops/mnt

UC : 2x-10-35
FHR : 140x/mnt

Drip oxy 40 drops/mnt

UC : 2x10-35
FHR : 140x/mnt

Drip oxy 40 drops/mnt

Wakt
u

Subject

1.30
am

Mother felt more abdominal pain

2.30
am

Mother felt more abdominal pain

4.30
am

Object

Assesment

Obsevation mother and

fetal
Observation 3 hours
later

UC : 4x10-35
FHR : 145x/mnt
VT : 7 cm. Efff 75 %, amniotic
membran (+), descend H1, the small part
of fetal and umbilical cord unpalpable
UC : 4x10-35
FHR : 145x/mnt
VT : complete. Efff 100 %, amniotic
membran (-), amniotic fluid (+) clear,
descend HIII, the small part of fetal and
umbilical cord unpalpable
UC : 4x10-35
FHR : 140x/mnt
VT : complete. Efff 100 %, amniotic
membran (-), amniotic fluid (+) clear,
descend HIII, the small part of fetal and
umbilical cord unpalpable

Planning

G1P0A0 + second
stage of labor

Lead mother to bearing

down

G1P0A0 + prolonged
second stage of labor

Reported
to
supervisor : proposed :
EV
Advice : agreed

S
5.O0
am

Mother want to bearing down

UC : 4x10-35
FHR : 135x/mnt
VT : complete. Efff 100 %, amniotic
membran (-), amniotic fluid (+)clear,
descend HIII, the small part of fetal and
umbilical cord unpalpable

G1P0A0 40-41 weeks

+ inpartu second stage
of labor
S

Baby was born, EV,

male, 3500, A-S: 7-9,
was
born
Placenta
complete, at: 5.15 am

5.15

General condition: well,

Consciousness: CM,BP : 110/80,
PR: 88 x/mt, RR : 24 x/mt
Uterine Contraction: good
FH: 2 fingers under umbilicus

- observation mother
well being
- Observation for
hemorrhage sign

5.30

General condition: well,

Consciousness: CM,BP : 120/80,
PR: 80 x/mt, RR : 22 x/mt
Uterine Contraction: good
FH: 2 fingers under umbilicus

observation mother
well being
Observation
for
hemorrhage sign

5.45

General condition: well,

Consciousness: CM,BP : 120/75,
PR: 76 x/mt, RR : 24 x/mt
Uterine Contraction: good
FH: 2 fingers under umbilicus

observation
mother
well being
Observation
for
hemorrhage sign

06.00

General condition: well,

Consciousness: CM,BP : 120/80,
PR: 82 x/mt, RR : 20 x/mt
Uterine Contraction: good
FH: 3 fingers under umbilicus
Lochia = +

observation
mother
well being
Observation
for
hemorrhage sign

06.30
am

General condition: well,

Consciousness: CM,BP : 110/80,
PR: 88 x/mt, RR : 24 x/mt
Uterine Contraction: good
FH: 2 fingers under umbilicus

- observation mother
well being
- Observation for
hemorrhage sign

7.00 am

General condition: well,

Consciousness: CM,BP : 120/80,
PR: 80 x/mt, RR : 22 x/mt
Uterine Contraction: good
FH: 2 fingers under umbilicus

observation mother
well being
Observation
for
hemorrhage sign

5.45

General condition: well,

Consciousness: CM,BP : 120/75,
PR: 76 x/mt, RR : 24 x/mt
Uterine Contraction: good
FH: 2 fingers under umbilicus

observation
mother
well being
Observation
for
hemorrhage sign

06.00

General condition: well,

Consciousness: CM,BP : 120/80,
PR: 82 x/mt, RR : 20 x/mt
Uterine Contraction: good
FH: 3 fingers under umbilicus

Mother and baby will

being good