Name: Mrs.

E
Age: 26 yo
RM: 538866
Adress: Narmada
Admitted: May, 18th 2012 at 02.51

TIME

SUBJECTIVE

18/05/
2014
02.51

Patient referred from Narmada

PHC with G2P1A0L1 38-39 with
PROM > 12 jam. Patient confess
water leaked out from her vagina
since 13.00 WITA (17/05/14).
Abdominal pain (-) Bloody slim
(-),FM (+).
No history of DM, HT, asthma.
LMP: 20/08/2013
EDD: 27/05/2014
History of ANC: 5 x at Posyandu
Last ANC: Normal
History of USG: History of family planning:
Injection 3 months
Next family planning: IUD
Obstetrical history:
I.Female, 2600 gram, spontan,
aterm, midwife, live 6 yo
II.This

OBJECTIVE
General status:
GC: well
Cons: CM/E4V5M6
BP: 110/70 mmHg
PR: 88 bpm
RR: 20
T: 36,5
Eye : palor (-), icteric (-)
Thorax :
Cor : S1S2 single reguler (murmur
-), (gallop -)
Pulmo : vesikuler (+/+), wheezing
(-/-),
Ronkhi (-/-).
Abdomen : scar (-), striae (+), linea
nigra (+)
Extremity : edema (-/-), warm acral
(+/+)
Obstetrical status:
L1: breech
L2: back on the right side
L3: head
L4: 5/5
UFH: 33 cm
EFW: 3255 g
UC: FHB: 12-12-12 (144 x/min)
VT: 1 cm, eff 20%, amnion (-)
clear,

ASSESTMENT

PLANNING

G2P1A0L1 38-39
weeks S/L/IU
head presentation
with PROM > 12
hours

Obs mother & fetal

well being
Obs progress of labor
DM co to GP advice
induction with
misoprostol SPV
advice CS

TIME

SUBJECTIVE
Chronologist at pkm narmada:
01.30 (18/05/2014)
S:
Patient 9 month referred from midwife
confess abdominal pain since 13.00
WITA, (17/05/2014) fetal movement
(+)
LMP : 20-08 13
O:
GC: well
BP: 110/70 mmHg
PR: 80 bpms
RR: 16
T: 37
L1: breech
L2: back on the right side
L3: head
L4: 4/5
UFH: 32 cm
UC: FHB: 12-12-12 (144 x/min)
VT : 1 cm, eff 10%, amnion (-), head
palpable HI, unpalpable small part /
umbilical cord
A: G2P1A0L1 ,38-39 weeks , S/L/IU with
PROM > 12 hours
P: observation mother and fetal well being
refer to NTB GH

OBJECTIVE
Pelvic score :
Serviks dilatation : 1 ( 0)
Serviks length : 3 cm ( 0)
Station : H0 (0)
Consistency : mild (1)
Posistion : anterior (2)
Total ps : 3

Lab:
HB: 11,3 g/dl
RBC: 3,81 M/dl
HCT: 32,7 %
WBC: 12,43 K/dl
PLT: 207 K/dl
HbSAg: (-)

ASSESTMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

04.00

PLANNING
SC began
Baby was born :
Male, 3500 gram, BL :
51 cm, as: 7-9 anus (+),
anomali congenital (-)
Placenta was born
manually and complete

06.00

GC: well
GCS: E4V5M6
BP: 110/70 mmHg
PR: 88 bpm
RR: 22 rpm
T: 36,80 C
UC (+) well
UFH 2 finger bellow umbilical
Active bleeding (-)

2 hours post partum

Obs. Mother well being

Suggest mother to eat
and drink
Baby in NICU

TIME
07.00 (
18/05/
2014)

SUBJECTIVE

OBJECTIVE
GC: well
GCS: E4V5M6
BP: 120/80 mmHg
PR: 88 bpm
RR: 22 rpm
T: 36,80 C
UC (+) well
UFH 2 finger bellow umbilical
Active bleeding (-)
Lochea rubra (+)
Baby in NICU
GC : well
PR : 134 bpm
RR : 46 bpm
T : 36,5C

ASSESTMENT
One day post CS

PLANNING
Obs. Mother well being
Suggest mother to eat
and drink