Name Age Address

Time 18.10

:Mrs. N : 20 years old : Lingsar

Subject Patient refeered from Lingsar PHC with G1P0A0H0 A/S/L/IU with protracted active phase 1st stage of la or Chronologist! 1"#10#$00% 11&00 mother came to Polindes and confessed a dominal pain since 0'&00 (1"/0%/0%)* water+ vaginal discharge (#)* lood slim (#)* fetal movement (,)* histor+ of H- and ./ (#)& 01amination in polindes! General condition! good 2P! 110/30 mmHg P!451/mnt -!'"*'6C 77!$01/mnt U8H!$4 cm 089! $"': g 8H7! 1551/mnt ;-! < 3 cm* eff 30=* A/ (,)* head palpa le descends HI* >npalpa le fetal small organ and >m ilical -herap+! ? servation mother and fetal well eing 1'&00 Amniotic mem ran r>pt>red ;-! < % cm* eff %0=* A/ (#)* clear* head palpa le descends HI* >npalpa le fetal small organ and >m ilical -! '3*:6C -herap+! ?ral anti iotic Amo1icillin and Paracetamol 15&00 ;-! < complete* eff 100=* A/ (#)* head palpa le descends HII* >npalpa le fetal small organ and >m ilical 1:&00 7ehidration with 7L 1"&00 /other reffered to Lingsar PHC Object General stat>s ! General condition! good Concio>sness! C/ 2P! 1$0/40 mmHg 77! $5 1 /mnt P>lse ! %$ 1/mnt -! '3*56C 0+es ! an(#/#) i@t (#) Cor #P>lmo ! in normal range ? stetric stat>s ! L1 ! reech UH8 ! ''cm L$ ! left ac@ L' ! head L5 !was in pelvic inlet '/: 089 ! '510 g UC ! '1 106 50A 8H2 ! 1:41/mnt ;- !< complete* eff 100=* A/ (#)* head palpa le descend HII* cap>t (,)* mo>lage (,$)* denom transverse sagitalis s>t>re* >npalpa le small organ and >m ilical cord Pelvic eval>ation! Spina ischiadica not prominent Arc>s p> is B %0 ?s co1ige>s not mo ile Laboratory result: H2sAg (#) H2 C 11 gr= 92 C 1"&300 PL- C $"1&000 HC- C '5*$

Admitted

:16-10-2009 : 18.10

Assesment G1P0A0H0 A/S/L/IU prolonged $nd stage of la or e&c fail>re of descending head

Planning ? servation of mother and fetal condition La oratori>m e1amination! .L* H2sAg Left lateral position Cons>lt to s>pervisor at 14&$0* proposed for SC* advice! o serve for $ ho>rs and give motivation to sD>ating position and eat and drin@

Time

Subject 1"&$0 /other came in Lingsar PHC 1"&'0 2P! 110/30 mmHg 77! $51/mnt P! 441/mnt - rectal! '4*'6C ;- !< complete* eff 100=* A/ (#)* head palpa le descends HIII* >npalpa le fetal small organ and >m ilical 8H7! 15" 1/mnt UC! $#'1106 5:A U8H! $" cm 089! $'$: g -herap+! Ampicillin inE& 1g/I; 1"&:0 /other reffered to GH Mataram LMP: forgot EDD: AN : !"#$ in mid%ife History of family &lanning: Plan of family &lanning: '(st. History: 1. )*is

Object

Assesment

Planning

18." 0

A(dominal &ain !!

+ : ,-10. "0/ 0H1 : 123#4mnt

15."0

A(dominal &ain !!

+ : ,-10. "0/ 0H1 : 1,8#4mnt

20.10

A(dominal &ain !!

+ : ,-10. "0/ 0H1 : 120#4mnt 6) : < complete* eff 100=* A/ (#)* head palpa le descend HII* cap>t (,)* mo>lage (,$)* denom transverse sagitalis s>t>re* >npalpa le small organ and >m ilical cord

G1P0A0H0 A/S/L/IU prolonged $nd stage of la or

1e&ort to s7&er8isor at 20.20$ &ro&osed: 9 $ ad8i:e: &ro&osed agree Pre&ared to 9 -D -;nf7s 1L -;n<.am&i:illin 1 g4;6

21.22

=eg7n

21."0

9e:ond stage of la(or

2a + was orn female* weight ''00g* length :$ cm* AS 3#%& an>s (,)* n>chal cord (#)

21."2

)*ird stage of la(or

Placenta was orn complete*weight :00 g* length :0 cm Hemorrage ! $00cc

Time 13#10# $00% 00&00

Subject

Object General stat>s ! well 2P ! 1$0/30 mmHg P7 ! 40 1/mnt 77 ! $0 1/mnt UC ! good U8H ! $ cm elow >m ilical

Assesment 8o>rth stage of la or

Planning ? s& /other and a + well eing

0"&00

General stat>s ! well 2P ! 1$0/40 mmHg P7 ! 45 1/mnt 77 ! $0 1/mnt UC ! good U8H ! $ cm elow >m ilical 2a +! H7 ! 1$0 1/mnt 77! "01/mnt -! '"*4 FC

1st da+ post SC

/other and a + rawat ga >ng ? servation mother and a + well eing 0d>cated mother to ASI