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Name
: Mrs. I
RM
: 044809
Age
: 23 years old
TIME
SUBJECTIVE
OBJECTIVE
ASSESSME
NT
PLANNING
02/0
7/20
12
General Status :
GC : well
BP : 120/80 mmHg
PR : 84 bpm
RR : 20 bpm
T : 36,5oC
Eye : anemis (-/-), icteric
(-/-)
Cor : S1S2 single regular,
murmur (-), gallop (-).
Pulmo : vesicular (+/+),
wheezing (-/-), ronkhi (-/-).
Abdomen : scar (-), stria
gravidarum
(+),
linea
nigra (+).
Extremity : edema (-/-),
warm acral (+/+).
G1P0A0L0
40-41 weeks
S/L/IU latent
phase 1st
stage of
labor with
history of
rupture
membrane +
mild anemia
Observation
mother & fetal
well being.
Observation
progress of labor
01.3
0
LMP : 18/09/2011
EDD : 25/06/2012
History of ANC : > 4x at
Polindes
Last ANC : 26/06/2012
History of USG : 1x, result
normal
History of family planning
: (-)
Next family planning :
injection 3 months.
Obstetrical History :
I.This
Obstetrical Status :
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH : 34 cm
EFW : 3565 gram
UC : 2x/10 ~35
FHB : 11-12-12 (140 bpm)
VT : 2 cm, effacement
50%, amnion (-) clear,
head palpable HI+,
TIME
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLANNING
PE :
Spina
ischiadica
not
prominent
Os coccygeus mobile
Arcus pubis > 90o
Lab Examination :
Hb : 8,9 g/dl
RBC : 4,12 x 106/L
HCT : 30,1 %
WBC : 12,59 x 103/L
PLT : 288 x 103/L
HbSAg: (-)
05.3
0
Patient
confessed
abdominal pain
UC : 3x/10 ~35
FHB : 12-12-12 (144
bpm)
VT : 4 cm, effacement
50%, amnion (-), head
palpable
HI+,
denominator
unclear,
impalpable small part
and umbilical cord.
Observation
mother & fetal well
being.
Observation
progress of labor
with partograph
09.3
0
Patient
abdominal
frequently
UC : 4x/10 ~30
FHB : 12-11-12 (140
bpm)
VT : 8 cm, effacement
75%, amnion (-), head
palpable
HII,
denominator
LOA,
impalpable small part
Observation
mother & fetal well
being.
Observation
progress of labor
with partograph
confessed
pain more
TIME
SUBJECTIVE
OBJECTIVE
ASSESSMEN
T
PLANNING
11.3
0
Patient
confessed
abdominal pain
UC : 2x/10 ~25
FHB : 12-12-12 (144
bpm)
VT : 9 cm, effacement
90%, amnion (-), head
palpable HII+, caput
(+), impalpable small
part and umbilical cord.
Observation
mother & fetal
well being.
CTG reactive
DM co to GP, GP
advice
:
acceleration with
drip oxytocin.
12.3
0
UC : 4x/10 ~30
FHB : 12-11-11 (136
bpm)
VT : complete, amnion
(-), head palpable HII+,
caput (+), impalpable
small part and umbilical
cord.
2nd stage of
labor
Drip
oxytocin
began 8 tpm
Suggest mother to
eat and drink.
Suggest mother to
squatting down.
13.0
0
Patient
confessed
abdominal pain
UC : 4x/10 ~30
FHB : 12-11-12
bpm)
13.3
0
Patient
confessed
abdominal pain
UC : 4x/10 ~30
FHB : 12-12-12
bpm)
14.0
0
Patient
confessed
abdominal pain
UC : 4x/10 ~30
FHB : 12-11-11
(140
Drip oxytocin 12
tpm
(144
Drip oxytocin 16
tpm
(136
Drip oxytocin 20
tpm
TIME
SUBJECTIVE
OBJECTIVE
ASSESSMEN
T
VE began
VE succeed in 2 times
traction.
Perineum
episiotomy
(+)
Baby was born, male,
3500 gram, 50 cm, A-S
6-8, caput (+) on
occiput,
anus
(+),
anomaly congenital (-).
Placenta
was
born
spontaneous,
complete.
Bleeding 150 cc
Rupture
perineum
grade II
15.0
0
17.0
0
PLANNING
Patient confessed
delivery wound
GC : well
BP : 120/90 mmHg
PR: 80 bpm
RR : 20 bpm
T : 36.7C
UFH : 2 fingers below
the umbilicus
2 hours post
VE
TIME
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLANNING
03/0
7/20
12
Patient confessed
delivery wound
GC : well
BP : 110/70 mmHg
PR : 72 bpm
RR : 20 bpm
T : 36.2C
UFH : 2 fingers
below the umbilicus
Lochea rubra : (+)
Observe
mother
and
baby
well
being.
Suggest mother to
take a rest, eat, and
drink.
07.0
0
Baby in NICU :
GC : well
PR : 120 bpm
RR : 52 bpm
T : 36,4oC