Name : Rahmi Andrita Yuda

Class : III B/ DIV Kebidanan

Nim : 154310655

MIDWIFERY CARE FOR PREGNANT WOMEN Ms “D” G1P0A0H0

With GESTASIONAL AGE 10 WEEKS In RSUD SOLOK
On MAY 4th 2018

SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

Date / Hours : On May 4th
2018 at 09.00 a.m
1. She said this was her first
pregnancy and her pregnancy
entered 2 months
2. She was complains of nausea
in the morning for the past 2
weeks.
1. General Circumstances : Well
2. Awareness : Composmentis
3. Clinical data such as vital signs :
 B.P : 100/80 mm/hg
 Pulse : 80 x/i
 Respiration : 24 x/i
 Temp : 36,50 C
 Weight : 50 kg
 Height : 155 cm
Diagnosis : Ms “D” G1P0A0H0
10 Weeks Gestation With
Nausea, maternal and fetal
condition are good.
Problems :
Nausea, often fatigue and dizzy.
The Needs of :
1. Notify mother and family
about mother and fetal’s
condition and the results of the
examination
Evaluation :
Maternal and fetal condition are
good with vital signs;
 B.P : 100/80 mm/hg
 Pulse : 80 x/i
3. She said that She is very active
but has noted more fatigue at
the end of the day and she
often dizzy.
4. She said She has not felt fetal
movement as of this time.
4. Physical Examination :
 Head : there is no
abnormalities
 Face : Pale, no edema
 Eyes : pale conjungtiva,
the sclera is not
jaundiced.
 Ear : there is no
abnormalities
 Nose : there is no polip,
and another
abnormalities
1. Information about  Respiration : 24 x/i
maternal and fetal  Temp : 36,50 C
conditon.
2. Information about how 2. Gives the mother, information
to cope the nausea and that nausea and vomiting in TM
the vommiting. 1 is a natural thing. Also Tell
3. Information about the mother how to cope the
balanced nutrision nausea and vommiting by eating
4. Information about take a a little bit of food but often, eat
rest pattern the cereal or biscuit, then avoid
5. Continue taking prenatal eating oily foods and smelly
vitamins sting , and on waking up do not

 Mouth : there is no stand up but sit down first.

caries or stomatitis Evaluation : mother understand

 Neck : no swollen gland about the informatian that was

 Breast : symmetrice, given.

prominent nipples,
colostrum has not come 3. Tell the mother to consume

out yet. balanced nutrition of pregnant

women. And encourage mothers
 Abdomen : there is no
to eat little by little but often.
striae and linea
Palpate Leopold :
 Leopold I : not checked yet Evaluation : Mother understand
Leopold II : not checked yet about the informatian that was
Leopold III : not checked yet given.
Leopold IV : not checked yet
4. Suggest the mother to get
m enough take a rest, and reducing
the heavy activity.
Mc Donald : not checked yet
Evaluation : Mother understand
Fetal Heart Rate : not checked
about the informatian that was
yet
given.
 Ekstremitas : there is no
abnormalities
5. Tell to the mother to
5. Laboratory results :
Continue taking prenatal
Haemoglobin : 10,2 gr%/dl
vitamins like vitamin C, Fe, and
kalk.
Evaluation : Mother understand
about the informatian that was
given. And mother will continue
to consume that vitamin.

6. advised to the mother to

another one-month visit .
Evaluation : mother understand
and promise to visit then control
her condition.