Name/adress

: Mrs. Faizah/Sekarbela

Age
Time

30 years old
Subject

16.3
0

Patient came to Mataram GH

referred by Tanjung Karang PHC
with G1P0A0 39-40 W/S/L/IU
head presentation with PROM >
12 hours
LMP:21/02/2009
EDD:28/11/2009
Chronologist :
Patient came to Tanjung Karang
PHC at 13.45 (02/12/09) confess
abdominal pain (+), bloody show
(+), watery vaginal discharge (+)
since 03.00 (02/12/2009)
Examination in PHC:
BP: 120/70 mmHg
PR: 84 bpm
T: 36,8 C
UFH : 30 cm
FHR: 136 bpm
UC: 2x10-25
VT : CD 3 cm, eff 30%, AM (-),
head
palpable,
denominator
unclear, descend HI, unpapable
small organ and umbilical cord.
Therapy
-Inject ampicillin I g/iv
-RL flas 1

Admitt
ed to
Hospit
al
Object

Examinaton at VK IRD :
General condition: good
GCS : E4V5M6
BP :120/60 mmHg
PR : 88 bpm
RR : 20 tmp
Temp : 37 C
An -/-, ict -/Cor & pulmo : in normal
range
Abd : normal range
Ext : oedema Obstetric status :
L1 : extremitas
L2 : fetal head on left side
L3 : shoulder
L4 : wasnt pelvic inlet (5/5)
UFH : 26 cm
EFW : FHR : 12-11-12
UC : 1x10-10
VT :CD 1 cm, eff 10 % AM (-),
clear,
shoulder
palpable,
denominator
unclear,
descend HI, small part and
umbilical
cord
wasnt
palpable.

2 Desember 2009

Assesment 16.30 witaPlanning

G1P0A0L0 4041/S/L/IU
tranverse
position phase
laten stage 1st
with PROM >
12 hours

Obs. Mother and fetal

wellbeing
Report to supervisor:
propose SC
Advice: SC at 19.00
Preparing to SC

Time

Subject
L1
L2
L3
L4

=
=
=
=

breech
fetal back on right side
head
was not pelvic inlet, 5/5

ANC 6 x at PHC, last 2 weeks ago

Obstetric history
1. This pregnant

Object

Assesment

Planning

Lab. Examination :
Hb : 11,1 gr%
Leko : 15.800 mm3
Trombo : 258.000 mm3
Hct : 33,4 gr%
HBsAg : -

Contraception history: Contraception planing: inject 3

month
19.0
0

SC begun

21.0
0

Confess foot feel like

06.0
0

Baby was born male,

2900 gram, AS 7-9,
amniotic fluid clear
Placenta was born 1
minute letter.
Reffered baby to NICU
-General condition: good
-BP : 110/80 mmHg
-PR : 88 x/mnt
-RR : 20 x/mnt
-T : 36,8 C
-UFH : 1 finger under
umbilicus
-UC : good
-Lokea (+)
-Wound of operation is good

2 hour post SC

Obs. Mother and baby

well being
Motivated to breast
feeding

-General condition: good

-BP : 120/80 mmHg
-PR : 84 x/mnt
-RR : 18 x/mnt
-T : 36,6 C
:2
finger
under
-UFH

1 day post SC

Obs. Mother and baby

well being
Motivated to breast
feeding