• Name : Mrs.

M
• Age : 40 yo
• Address : Penimbung
• Admitted : May 08th, 2016
• MR : 577951
 TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

08/05/ Patient referred from Penimbung General status: G7P5A1L5 DM planing:

2016 PHC with G7P5A1L5 aterm S/L/IU GC: well aterm/S/L/IU head Diagnostic :
21.30 head presentation, mother and GCS: E4V5M6 presentation with • CBC, HbSAg, CTG
fetal in good condition with BP: 120/90 mmHg arrested active Therapy:
arrested active phase and HR: 84 bpm phase, and Obs mother and fetal
grandemultipara.Patient confessed RR: 20 x/min grande mulptipara Lying to the left side
water leaked from her womb T: 370C Obs. Progress labor with
since(-). Abdominal pain (+) since WHO partograph
16.30 (08/05/2016), bloody slime Eye : anemis (-/-), icteric (-/-) Acceleration with
(-), FM (+). Thorax : Amniotomy
Cor : S1S2 single reguler ,
No history of DM, HT, and asthma murmur( -), gallop • DM co Gp, Gp co to
History of family: DM (-), HT (-), (-) SPV, SPV advice: acc
asthma (-) Pulmo : vesikuler (+/+), wheezing amniotomy
(-/-), Ronkhi (-/-).
LMP: - Abdomen : scar (-), striae
EDD: - gravidarum(+), linea nigra (+)
GW: - Extremity : edema (-/-), warm
acral (+/+)
History of ANC: 5x at PHC
Last result (16/04/2016): BP: Obstetrical status:
110/80 mmHg, BW: 68 kg, GW 34 L1: breech
weeks, UFH 32 cm, head L2: back on left side
presentation, FHB (+) L3: head presentation
L4: 4/5
History of USG: 1x at OBGYN UFH: 37 cm
(26/04/2016) EFW: 4030 gram
Result: Fetal S/L/IU, head UC: 3 x 10’~35”
presentation, BPD/AC/FL: 30-32 FHB: 12-12-13 (148 bpm)
weeks, EFW: 1500 g, AFI : VT: Ø 5 cm, eff. 50 %, Amnion
enough, clear, placenta at fundus (+) clear, head palpable, denom
grade II, EDD: 11/06/2016 LOA,↓HI, palpable small part &
umbilical cord
History of family planning: injection
3 months
Next family planning: IUD
Time Subject Object Assesment Planning
Lab :
Obstetrical history : HGB : 11,2
1.Female/ 9 months/ 3700 gr/ RBC : 3,94
midwife/ Home / L/ 24 y.o HCT : 34,1
2. Female/ 9 months/ 3700 WBC : 10,92
gr/midwife/Home/L/ 21 y.o PLT : 315
3.Male/ 9 months/ 3800 gr/ HBSAg : reactive
midwife/ Home/L/ 16 y.o
4.Female/ 9 months/4000 gr/
midwife/Home/L/14 y.o
5.Female/ 9 months/ 3700 gr/
midwife/Home/L/8 y.o
6.Abortus/ 3 mo/curetage
7.This
Time Subject Object Assesment Planning
08/05/ Chronology at Penimbung PHC
2016 08/05/2016
S/ Patient 9 month pregnant, confessed
abdominal pain (+), bloody slime (-),
FM (+)

O/
General status
GC : well
GCS: CM (E4V5M6)
BP : 120/80mmHg PR: 80 x/m
T: 36,5°C

L1 Breech
L2 Back on the left side
L3 Head
L4 3/5
UFH: 36 cm
UC: 2 x 10’~20”
FHB: 136 X/mnt
VT:
• 16.12 WITA Ǿ 6-7cm, eff 15%,
head presentation, amnion (+), ↓H1,
denom unclear, unpalpable small part/
umbilical cord
• 18.12 WITA Ǿ 8 cm, eff 25%,
amnion (+), ↓H1, denom unclear ,
unpalpable small part/ umbilical cord
• 20.00 WITA Ǿ 8 cm, eff 25%,
amnion (+), ↓H1, denom unclear ,
unpalpable small part/ umbilical cord
Time Subject Object Assesment Planning
A/
16.12 WITA :G7P5A1L5 aterm
S/L/IU head presentation mother
and fetus in good condition with
inpartu second phase of labor
20.00 WITA: G7P5A1L5 aterm
S/L/IU head presentation mother
and fetus in good condition with
arrested second phase of labor

P/
IVFD RL
 Time Subjective Objective Assessment Planning
01.30 wita Abdominal pain (+++) UC : 3 x 10’~40” G7P5A1L5 DM planning
FHB 12-13-12 (132 bpm) aterm/S/L/IU head • obs progress of labor
VT: Ø 6cm , eff. 50 %, Amnion presentation with
(-) meconeal, head palpable, Arrested active
↓HI, unpalpable small part & phase
umbilical cord

05.30 Abdominal pain (+++) UC : 4 x 10’~40” G7P5A1L5 DM co to GP, GP co to SPV,

FHB 13-12-12 (148 bpm) aterm/S/L/IU head advice :
VT: Ø 9cm , eff. 90 %, Amnion presentation with • pro C-section this morning
(-)meconeal head palpable, ↓HII, Arrested active
unpalpable small part & umbilical phase
cord

06.30 Abdominal pain (+++) UC : 4 x 10’~40” •Patient move to ok cyto

FHB 13-12-13 (148 bpm)