Name: Mrs.

SPS
Age: 18 yo
Address: Pembuwun, Narmada
Admitted: June, 26th 2012 at 21.50

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

26/06/
2012
21.30

Patient referred from Selat

polindes with G1P0A0L0 4142 weeks S/L/IU head
presentation, with
prolonged 2st stage of
labor. Patient confessed
abdominal pain that spread
to frank since 13.00
(26/06/2012). History
rupture of membrane (+)
since 19.00 (26/06/2012).
Bloody slim (+), FM (+). No
history of DM, HT, asthma.

General status:
GC: well
BP: 140/90 mmHg
PR: 88 bpm
RR: 20 T: 36,2
Eye : palor (-), icteric (-)
Thorax :
Cor : S1S2 single reguler (murmur
-), (gallop -)
Pulmo : vesikuler (+/+), wheezing
(-/-),
Ronkhi (-/-).
Abdomen : scar (-), striae (+),
linea nigra (+)
Extremity : edema (-/-), warm
acral (+/+)

G1P0A0L0 41-42
weeks S/L/IU with
neglected 2st
stage of labor
with mild
preeclampsia

Obs mother &

fetal well being
Resucitation
Intrautrine
DM co to SPV pro
SC; SPV acc SC
Prepare SC:
- Insert DC
- Ceftriakson test
(-), inj ceftriakson
2 g IV

LMP: 06/09/2011
EDD: 13/06/2012
History of ANC: >4x at PHC
Last ANC: 20/06/2012
result normal
History of USG: History of family planning:Next family planning: Obstetrical history:
I.This

Obstetrical status:
L1: breech
UFH:
34 cm
L2: back on the right side EFW:
3565 g
L3: head
L4: 2/5
UC: 4x10 ~ 30
FHB: 9-9-9 (108 x/min)
VT: 10 cm, amnion (-) cloudy,
eff 100%, head palpable, caput
(+), molage (+), denom unclear,
HII, impalpable small part /
umbilical cord.

TIME

SUBJECTIVE
Chronologist: 13.00 (26/06/2012)
S: Patient came to selat polindes
confessed abdominal pain that
spread to frank since morning
O:
GC: well
BP: 120/80 mmHg
PR: 80 bpm
RR: 20
T: 36,5 C
head presentation, back on the right
side, 3/5
UFH: 34 cm
FHB: (+) 136 x/min
UC: 3x10 ~ 25
VT: 4 cm, eff 50% amnion (+),
head palpable HI, impalpable
small part / umbilical cord.
A: P: 17.00
S: abdominal pain that spread to
frank
O:
GC: well
BP: 120/80 mmHg
PR: 84 bpm
RR: 20
T: 36,5 C
FHB: (+) 144 x/min
UC: 4x10 ~ 30
VT: 8 cm, eff 75% , amnion (+),
head palpable HII, impalpable
small part / umbilical cord.

OBJECTIVE
Lab:
HB: 11,2 g/dl
RBC: 4,32 M/dl
HCT: 35,7 %
WBC: 25,99 K/dl
PLT: 285 K/dl
HbSAg: (-)
Proteinuria: +3

ASSESTMENT

PLANNING

TIME

SUBJECTIVE
19.00
S: abdominal pain that spread to
frank more often
O:
GC: well
BP: 120/80 mmHg
PR: 88 bpm
RR: 20
T: 36,5 C
FHB: (+) 136 x/min
UC: 4x10 ~ 40
VT: 10 cm, eff 100%, amnion (-)
clear, head palpable HII,
impalpable small part / umbilical
cord.
A: P: Infus RL : D5% = 2 : 1
Reffered to NTB GH

OBJECTIVE

ASSESTMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

00.05

PLANNING
SC began
Male, W : 3500 gram,
A-S 7-9, amnion
cloudy, anus (+)
Congenital anomali :
(-),
Plasenta was born
manually, complete
Bleeding 200 cc

02.05

Patient confessed chill

GC: well
Cons: CM
BP: 120/80
HR: 84 bpm
RR: 22 tpm
T: 36,5 C
UC: +
UFH: 1 fingers below
umbilicus
AB: UO: 200 cc

2 hours post SC

Observed mother
and baby well being
Suggest mother to
mobilization.

27/06/
2012
07.00

Patient confessed wound

pain

GC: well
Cons: CM
BP: 120/80
HR : 88 bpm
RR : 20 tpm
T : 37,4 C
UFH : 1 finger above
umbilicus
UC : +
AB : UO: 600 cc

1 day post SC

Observed mother
and baby well being
Suggest mother to
mobilization, eat,
and drink,
medication.

Baby in NICU:
PR: 148
RR: 43
T: 36,4