Identity

Name : Mrs. MK
Age : 27 Years Old
Address : Gunung Sari
Admitted on: December, 28th 2012
(05.00 Wita)
Med. Record : 500810

TIME

SUBJECTIVE

28/12/
2012
05.00

Patient referred from private

midwife clinic with G2P1A0L1
42-43 wk S/L/IU with inpartu
active phase 1st stage of
labour with serotinus.
Abdominal pain that spread
to
waist
since
02.00
28/12/2012. History water
leaked from her womb (+) at
02.30 28/12/2012. Bloody
slim (+), Fetal Movement
(+).
No history of DM, HT,
asthma.
LMP : 10-03-2012
EDD : 17-12-2012
History of ANC : 13x at
Posyandu
Last ANC : 10/12/2012
History of USG : never
History of family planning :
Injection 3 months
Next
family
planning
:
Injection 3 months.
Obstetrical History :
I. Aterm, Female, Midwife,
2500g, 9 YO
II. This

OBJECTIVE
General Status
GC : well
Consciusness : Composmentis
BP : 120/90 mmHg
PR : 80 bpm
RR : 20 tpm
T : 37,0 C
Eye : anemis (-/-), icteric (-/-)
Cor : S1S2 single reguler, M (-),
G (-)
Pulmo : vesikuler (+/+),
wheezing (-/-), ronkhi (-/-).
Abdomen : scar (-), striae
gravidarum (+), linea nigra (+).
Extremity : edema (-/-), warm
acral (+/+)
Obstetrical Status
L1
L2
L3
L4

:
:
:
:

breech
back on the left side
head
4/5

UFH : 30 cm
EFW : 2790 g
UC :3x10~40
FHB : 13-14-13 (160 bpm)
VT : 4 cm, eff 50%, amnion
(-), clear head palpable H I,
denominator unclear,
impalpable small part /
umbilical cord.

ASSESSMENT
G2P1A0L1 4243 weeks S/L/IU
with inpartu
active phase 1st
stage of labour
+ HROM

PLANNING
Observe mother
and fetal well
being.
Check CBC and
HBsAG
DM pro GP to
observation
progress of labour
with partograf, GP
acc observation
progress of labour
with partograf.

TIME

SUBJECTIVE

OBJECTIVE
Lab Evaluation
HB : 11,3 g/dl
RBC : 4,63 x106/l
HCT : 35,0 %
WBC : 10,74 x103/l
PLT : 153 x103/l
HbSAg : (-)

ASSESSMENT

PLANNING

TIME

SUBJECTIVE
Chronologist at midwife clinic :
04.00(28/12/2012)
S : Patient came confessed have 9
month pregnancy and abdominal
pain that spread to waist since
02.00 Wita and water came out
from her womb since 03.00
O : GC : well
BP : 110/70 mmHg
PR : 84 bpm
RR : 20 tpm
T : 36,3 oC
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH : 32 cm
EFW : 3100 g
FHB : (160 bpm)
LMP : 10/03/2012
EDD : 17/12/2012
VT : 5 cm, eff 50%, amnion (-),
head palpable H1
A : G2P1A0H1 42-43 wk S/L/IU head
presentation with inpartu active
phase 1st stage of labour + serotinus
P : Referred to NTB GH

OBJECTIVE

ASSESSMENT

PLANNING

TIME
09.00

SUBJECTIVE
Patient confessed abdominal pain

OBJECTIVE
GC : Well
Consciousness :
Composmentis
BP: 120/90
PR : 80 tpm
T : 37,0C
RR : 20 tpm
UC: 3x10~35
FHR: 12-13-12 (148 bpm)
VT : 6 cm, eff 75%,
amnion (-) clear, head
palpable HI, denom
LOA, impalpable small
part of fetus or umbilical
cord

ASSESTMENT

PLANNING

G2P1A0L1 4243 Wk S/L/IU

with prolonged
active phase
1st stage of
labour

Observation mother
and fetal well
being
Observation
progress of labour
DM pro GP to
observation
progress of labour,
GP co to SPV, SPV
advice
acceleration if CTG
reactive

10.00

Patient confessed abdominal pain

UC: 3x10~35
FHR: 12-12-12 (144 bpm)

Set IVFD D5 with 5

IU of Oxytosin 8
dpm

10.30

Patient confessed abdominal pain

UC: 3x10~35
FHR: 12-12-12 (144 bpm)

12 dpm

11.00

Patient confessed abdominal pain

UC: 3x10~35
FHR: 12-11-12 (140 bpm)

16 dpm

11.30

Patient confessed abdominal pain

UC: 3x10~35
FHR: 12-11-12 (140 bpm)

20 dpm

12.00

Patient confessed abdominal pain

UC: 3x10~35
FHR: 13-12-13(152 bpm)

24 dpm

12.30

Patient confessed abdominal pain

UC: 3x10~35
FHR: 12-12-12 (144 bpm)

28 dpm

TIME
13.00

SUBJECTIVE
Patient confessed abdominal pain

OBJECTIVE
GC : Well
Consciousness :
Composmentis
BP: 110/80
PR : 82tpm
T : 37,0C
RR : 20 tpm

ASSESTMENT

PLANNING

G2P1A0L1 4243 Wk S/L/IU

with prolonged
active phase
1st stage of
labour

Observation mother
and fetal well
being
Observation
progress of labour
32 dpm

UC: 3x10~40
FHR: 12-11-12 (140bpm)
VT : 9 cm, eff 90%,
amnion (-) clear, head
palpable HII, caput (+),
denom LOA, impalpable
small part of fetus or
umbilical cord
13.30

Patient confessed abdominal pain

UC: 4x10~40
FHR: 180 bpm

G2P1A0L1 4243 Wk S/L/IU

with prolonged
active phase
1st stage of
labour + Fetal
Distress

Stop oxytocin drip

Intrauterine
Resuscitation:
Set O2
Set RL:D5% : 2:1
(fast drop)

14.00

Patient confessed abdominal pain

UC: 4x10~40
FHR: 13-13-14(160 bpm)

G2P1A0L1 4243 Wk S/L/IU

with arrested
active phase
1st stage of
labour

Observation mother
and fetal wellbeing
DM pro SC to GP,
GP consult SPV
(15.00): SPV
advice
Rehydration and
inj Antibiotic.

VT : 9 cm, eff 90%,

amnion (-) clear, head
palpable HII, caput (+),
denom LOA, impalpable
small part of fetus or

TIME
16.00

SUBJECTIVE
Patient confessed abdominal pain

OBJECTIVE
GC : Well
Consciousness :
Composmentis
BP: 110/70
PR : 82tpm
T : 37,0C
RR : 19 tpm

ASSESTMENT

PLANNING

G2P1A0L1 4243 Wk S/L/IU

with 2nd stage
of labour

Observation mother
and fetal well
being
Observation
progress of labour

G2P1A0L1 4243 Wk S/L/IU

with prolonged
2nd stage of
labour

DM pro SC to GP,
GP consult SPV:
SPV advice SC
now.

UC: 4x10~30
FHR: 12-11-12 (140bpm)
VT : complete, amnion
(-) clear, head palpable
HII, caput (+), denom
LOA, impalpable small
part of fetus or umbilical
cord
17.00

Patient confessed abdominal pain

UC: 4x10~30
FHR: 12-11-12 (140bpm)
VT : complete, amnion
(-) clear, head palpable
HII, caput (+), denom
LOA, impalpable small
part of fetus or umbilical
cord

19.45

Pre Op
CIE Patient &
Family
Set DC
Inj Ampicillin 1
gr/IV
Shave pubic hair
CS began
Baby was born
(19.47), Female,
BW:3250 g/53 cm,
anus (+), AS: 7-9,

TIME
21.45

SUBJECTIVE
Patient confessed can not move her
leg

OBJECTIVE
GC: well
BP: 110/70
RR: 24 tpm
UC: +
UFH: 1 finger
umbilicus
Urine output:

Cons: CM
HR: 84 bpm
T: 36,5 C

ASSESTMENT

PLANNING

2 hours post
SC

Observed mother
and baby well
being
Observe vital sign,
sign of bleeding,
urine output.

1 day post SC

Observed mother
and baby well
being
Suggest mother to
mobilisation, eat,
and drink,
medication.

below
200 cc

Baby in NICU
PR: 135 bpm
RR: 52 tpm
T: 36,9 C
29/12/
2012
07.00

GC: well
BP: 110/80
HR: 80 bpm
RR: 20 tpm
T: 36,5 C
UC: +
UFH: 2 finger below
umbilicus
Urine output: 800 cc
Baby in NICU
PR: 126 bpm
RR: 50 tpm
T: 36,7 C