Name Age Address Time 25/04 /2012 22.

10

: Mrs. N : 29 years old : Sumbawa Subject Patient referred from Sumbawa Hospital with G1P0A0 39-40 wks S/L/IU with neglected second stage of labor. She confessed abdominal pain and history rupture of membrane since 00.00 am (24/04/2012) FM (+). Patient also complain fever and difficulty of breathing, History of DM (-), HT (-), asthma (-). LMP: forgot EDD: History of ANC: > 4x, midwife Last ANC: March 2012 USG : History of family planning : Next family planning : Obstetric History : 1. Abortus 2. this Object General Condition : weak Consciousness : CM BP : 150/90 mmHg PR : 120 x/minute RR: 24x/minute T : 38 C Status Generalis: Eye : an (-/-), icteric (-/-) Thorax : Cor : S1S2 single reguler (murmur -), (gallop -) Pulmo : vesikuler (+/+), wheezing (-/-), Ronkhi (-/-). Abdomen : scar (-), striae (+), linea nigra(+), bundle circle (-) Extremity : edema (-), warm acral (+) Obstetrical status L1: breech UFH :37 cm L2: back at right side L3: head L4: 3/5 EFW:4030 gram FHR: 15-15-15 UC : 3x10-30 VT : 7cm, effacement 80%, amnion(-), Caput (+),HII, edema vulva, unpalpable small part of fetal & umbilical cord

CTH

: April 25th 2012 At 22.10

Assesment G2P0A1 39-40 wks/S/L/IU with neglected second stage of labor + Fetal distres + PER +susp macrosomia

Planning -Obs. Mother and fetal well being -Laboratory check (DL, HBsAg) -Rescucitation intrauterine -coas consult to spv advice : prepare for SC -Injection Ampicilin 1 gr (iv) -DC inserted

Chronologist : 24/04/2012 19.00 Patient came to Sumbahawa hospital, with PROM & history of infertil 6 years go O: VT : - cm, portio thick, amnion +, HI 25/4/2012 01.00 am Induction Ms tab /6h /vagina VT : 1 cm, Portio thick, amnion +,HI His + seldom, DJJ + 03.00 Injection Ampicilin

PE: Spina ischiadica prominent Arcus pubis <90 Os coccygeus mobile Lab : HB : 9,2 RBC : 3,92 HCT 28,9 MCV: 73,7 MCH: 23,5 WBC: 32,69 PLT: 290 Protenuria : +1

07.00 Drip Oxytocin 0,5IU 2o tpm VT: : 3-4 cm, Portio thick, amnion-,HI
11.00 am : VT: : 4 cm, Portio thick,& oedeom, amnion,HI T: 37,8 C DJJL: 161 bpm 13.00 VT: : 4 cm, Portio oedeom, amnion-,HI, Caput DJJL: 153 bpm Drip stop 15.00 VT: : 4 cm, Portio oedeom, amnion-,HI, Caput DJJL: 181 bpm His + seldom Refer to NTB GH

Time

P
SC Began : Baby was born male, AS 6-8, 3200 gr, amnion meconeal , anus (+), congenital anomaly (-), Placenta was born manualy, complete, caput occipital sinistra bleeding 500 cc
Sign of post mature baby - SC finished

26/4/20 12 00.15 am

01.30

04.00 am

Operation wound pain

GC : well BP : 120/70 mmHg PR : 90 bpm RR : 22 t/m Temp : 38.0C UFH : 2 fingers below umbilicus UC : + Active bleeding : UO:

2 hours post SC

- Observation mother well being - Motivate mother to take a rest

Time

S
Operation wound pain

O
GC : well BP : 120/70 mmHg PR : 90 bpm RR : 22 t/m Temp : 38.0C UFH : 2 fingers below umbilicus UC : + Active bleeding : UO:
Baby in NICU

07.00