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Name: Mrs.

RH
Age: 21 yo
Adress: Gunung Sari
No RM: 02038269
Admitted: 18
th
April 2012 at 01.45 WITA
Time Subjective Objective Assestment Planning
18/04/2012
01.45 WITA
Patient referred from Gunung
Sari PHC with G1P0A0L0 38
wks/S/L/IU head presentation,
mother and fetal in well
condition, with PROM more than
12 hours.
Patient confessed water came
out from her womb at 01.00
(17/04/12), clear odorless, 3
cloth wet. Confessed abdominal
pain since 06.00 (17/04/12).
Bloody slim (-). FM (+). Dizziness
(-), History of DM (-), HT (-),
Asthma (-).
LMP : 20-07-2011
EDD : 027-04-2012
History of ANC : > 4x, at PHC
Last ANC : 17/04/2012
History of family planning : -
Next family planning : injection
for 3 month
History of USG: -
Obstetrical history :
I.This
General status :
GC : well GCS : E4V5M6
BP : 140/90 mmHg
RR : 22x/mnt
Pulse : 92 x/mnt
T : 36,4 C
Eyes : an (-/-) ikt (-/-)
Cor : S1S2 single regular, M (-), G (-)
Pulmo : vesiculer (+/+), rh (-/-), wh (-/-)
Abd : scar (-), striae (+)
Extremity edema (-/-)

Obstetric status :
L1 : head UFH: 30 cm
L2 : back on left side
L3 : breech L4 : 4/5
EFW : 2480 g
FHB: 11-11-12 (140 x/min)
UC : -
VT : 1 cm, eff 10%, amn (-) clear, head
palpable, H I, denom unclear, unpalpable
small part or umbilical cord
PE:
Sacrum convexity normal
Spina ischiadica not prominent
Os coccygeus mobile
Arcus pubis > 90
PS:
cerviks dilatation 1 cm: 1
Cerviks length 4 cm: 0
cerviks consistency soft: 1
Cerviks position mid: 1
Station H I: 1
Total: 4

G1P0A0L0 38
wks/S/L/IU head
presentation
with PROM > 12
hours +
Gestational
hipertension
observation mother
& fetal well being
DM co to SPV: pro
vaginal labor with drip
oxytocin; cont inj
ampicillin/8 hour/iv.
SPV advice: CTG. If
reactive pro labor
induction with
oxytocin drip and
moved patient to VK-
teratai

KEMANA KONSULX
MALAM???????
Time Subjektive Objective Assessment Planning
Chronologist :
17/04/12 : 21.30
S : patient confessed 9 mo of pregnancy and lower
abdominal pain since 13.00 (17/04/12) continued
by rupture of membran at 16.00, clear. Bloody slim
(-).
LMP: 20-7-2011 EDD: 27-4-2012
O:
GC : well
BP : 130/90 mmHg
RR : 20x/mnt PR : 80x/mnt
T : 37 C
UFH : 30 cm; breech at fundus, head presentation
4/5, back on rleft side. EFW:3255
FHR : 12-12-12
UC : infrequently

A : G1P0A0L0 38 wks/S/L/IU head presentation,
mother and fetal in well condition with PROM
more than 12 hours

P: tell mother and family examination result
Inj ampicillin 1 gr iv (20.15)
Refer patient

22.40
S: -
O: VT : 1 cm, eff 25%, amn (+), head palpable,
denom unclear, H1, unpalpable small part or
umbilical cord
A: G1P0A0L0 38 wks/S/L/IU head presentation,
mother and fetal in well condition with PROM
more than 12 hours
P: referred to NTB GH
Lab exam
HGB : 12,2
RBC: 4,56
Hct: 37,3
WBC : 14,33
PLT : 312
HBsAg : -
Protein urine:
Time Subjektive Objective Assestment Planning
07.30




General status :
GC : well
BP : 120/80 mmHg
RR : 20x/mnt
Pulse : 88 x/mnt
T : 36,8 C

Obstetric status
UC: -
FHB: 12-12-12

NST reactive
G1P0A0L0 38
wks/S/L/IU head
presentation with
PROM > 12 hours
Co to SPV, SPV adv:
Start Drip Oxytocin
09.30 - UC: -
FHB: 12-12-12
Start drip oxytocin at
8dpm
10.00-11.00 Abdominal pain UC: 1 x 10 10
FHB: 11-12-11
Oxy drip: 12 dpm -
20dpm
11.30-12.00 Abdominal pain UC: 2 x 10 30
FHB: 11-12-11
Oxy drip: 24 dpm 28
dpm
12.30 Abdominal pain UC: 3 x 10 30
FHB: 11-12-12
Oxy drip: 32dpm
13.00-13.30 Abdominal pain UC: 3 x 10 35
FHB: 12-13-13
Oxy drip: 36-40 dpm
14.00-14.30 Abdominal pain UC: 3 x 10 40
FHB: 12-13-13
Oxy drip: 40 dpm
(maintenance)
Time Subjektive Objective Assestment Planning
14.30 Abdominal pain (+++)
Bloody slim (++)
UC: 3 x 10 40
FHB: 12-13-13

VT: 6 cm, eff 70%, amn (-) clear,
head palpable, H II, denom LOA,
unpalpable small part or umbilical
cord
G1P0A0L0 38
wks/S/L/IU head
presentation with
active phase 1
st
stage
of Labor
Obs. Mother and fetal
well being
Obs. Progress of Labor
CIE patient to eat and
drink
15.00-15.30 Abdominal pain (+++) UC: 4 x 10 40
FHB: 12-12-12
Oxy drip: 40 dpm
15.30 Mother want to bearing down GC: well

UC: 3 x 10 40
FHB: 12-12-11
VT: complete, amn (-) clear, head
palpable, H II+, denom LOA,
unpalpable small part or umbilical
cord
G1P0A0L0 38
wks/S/L/IU head
presentation with 2
nd

stage of Labor
Obs. Mother and fetal
well being
Obs. Progress of Labor
CIE patient to squat
15.45 Abdominal pain (+++)
Mother want to bearing down

UC: 4 x 10 45
FHB: 12-12-13

Anal pressure, perineum prominent,
Vulva open

Conduct mother to
bearing down
15.55




16.05
Baby was born female,
AS 7-9, 2750gram,
49cm, Anus (+),
congenital anomaly (-)

Placenta was born
spontaneus, complete,
bleeding 150cc

Time Subjektive Objective Assestment Planning
16.10 - UC: (+) weak
Inspeksi: rupture perineum and
vaginal mucous
4
th
stage of Labor
with rupture
perineum Grd. II
- Drip oxytocin 20 IU
in 500cc of RL
- Heacting rupture
18.00 - GC: well
BP: 120/80 mmHg
PR: 80x/mnt
RR: 20x/mnt
T: 36.8
TFU: 2 fingers below umbilicus
UC: (+) good
AB: (-)

4
th
stage of Labor - Cont. drip oxytocin
until 6 hours post
partum
- Obs. Mother and
baby well being
- CIE patient to breast
milk
- Amoxicillin tab
500mg/8hours
- Asam meefenamat
tab 500mg/8hours
- SF 1tab/12hours
19/03/2012
07.00
GC: well
BP: 120/80 mmHg
PR: 80x/mnt
RR: 20x/mnt
T: 36.5
TFU: 3 fingers below umbilicus
UC: (+) good
AB: (-)

Baby was rooming in
PR: 144x/mnt
RR: 38x/mnt
T: 36.5

1 day post partum - Obs. Mother and
baby well being
- CIE patient to
mobilisation
- Amoxicillin tab
500mg/8hours
- Asam meefenamat
tab 500mg/8hours
- SF 1tab/12hours