Name: Mrs.

y
Age: 31 yo
RM: 090598
Adress: Cakra Mataram
Admitted: May, 31 2014
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
31/05/
2014
16.00
Patient from poliklinik NTB GH
with G1P0A0L0 40-41 weeks
S/L/IU with olighidroamnin,
abdominal pain (-), water leaked
out from her vagina (-) ,FM (+).

No history of DM, HT, asthma.

LMP: 16/08/2014
EDD: 22/05/2014

History of ANC: 8x at Poliklinik
NTB GH
Last ANC: TD 110/80, BW : 61
kg, UFH :34 cm, head
presentation, FHB (+), 40-41
weeks
History of USG: last USG
(31/05/2014) result :
Fetal S/L/IU, Flasenta in fundus,
Oligohidroamnion, EFW : 3880 gr

History of family planning: -
Next family planning: IUD

Obstetrical history:
I. This


General status:
GC: well
Cons: CM/E4V5M6
BP: 110/90 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: 4/5
UFH: 36 cm
EFW: 3875 gr
UC: -
FHB: 12-12-12 (144 x/min)
VT: -,

G1P0A0L0 40-41
weeks S/L/IU with
olighidroamnion
Obs mother & fetal
well being
DM co to GP pro
CTG and cervix
ripening with
misoprpstol, GP
advice :
CTG


TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING


Pelvic Score :
Cervix dilatation 0 (0)
Cervix length 3 (0)
Station -3 (0)
Concisteny of cervix Soft (2)
Position mid (1)
Total of Pelvic Score (3)

Pelvic examination
Promontorium impalpable
Spina ischiadica not
prominent
Arcus pubis > 90
Os coccygeus mobile


Lab:
HB: 11,9 g/dl
RBC: 3,91 M/dl
HCT: 31,7 %
WBC: 15,43 K/dl
PLT: 289K/dl
HbSAg: (-)
Proteinuria: -
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
16.30

Obs mother & fetal well
being
DM co to GP about
result of CTG, GP co to
spv advice :
Suggest mother to eat
and drink and ctg
again





18.00







DM co to GP about
result of CTG, GP co to
SPV advice :
CTG suspicous pro CS
at 08.00
Observation FHB
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
19.00


20.00


21.00


FHB: 12-11-12 (140 x/min)
UC : -

FHB: 12-11-11 (136 x/min)
UC : -

FHB: 12-12-12 (144x/min)
UC : -

Obs mother & fetal well
being

22.00


23.00


00.00


01.00


FHB: 12-11-11 (136 x/min)
UC : -

FHB: 12-12-12 (140 x/min)
UC : -

FHB: 12-11-11 (136 x/min)
UC : -

FHB: 11-11-11 (132 x/min)
UC : -



Obs mother & fetal well
being


02.00


03.00


04.00






FHB: 12-11-11 (136 x/min)
UC : -

FHB: 12-12-12 (144 x/min)
UC : -

FHB: 12-11-11 (136 x/min)
UC : -

Obs mother & fetal well
being

TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
05.00


06.00


07.00


FHB: 12-11-12 (140 x/min)
UC : -

FHB: 12-11-11 (136 x/min)
UC : -

FHB: 12-12-12 (144x/min)
UC : -

Obs mother & fetal well
being

08.00



FHB: 12-11-11 (136 x/min)
UC : -




Obs mother & fetal well
being



TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
08.30

SC began
Baby was born :
Male, 4100 gram, BL :
52 cm, as: 7-9 anus (+),
anomali congenital (-)

Placenta was born
manually and complete
Interoperative finding :
amnion fluid inadequate,
mekoneal,

10.30 GC: well
GCS: E4V5M6
BP: 140/80 mmHg
PR: 88 bpm
RR: 22 rpm
T: 36,8
0
C

UC (+) well
UFH 2 finger bellow umbilical
Active bleeding (-)

2 hours post CS Obs. Mother well being
Suggest mother to eat
and drink

Baby in NICU



TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
07.00
(02/05/
2014)
Delivery wound pain GC: Well
GCS : E4V5M6
BP : 120/70 mmHg
PR : 83 x / m
RR : 18x/m
Temp : 36.9C
UC : (+) well
Urine Output : 50 cc/ hours
UFH : 2 finger bellow umbilical
Lochea : (+) Rubra

baby in NICU
HR : 128 bpm
RR : 54 bpm
Temp : 36,70C

1 day post CS Observed mother well
being
Suggest mother to
mobilisation, eat, and
drink, medication.