Identity

Name : Mrs. RS
Age : 27 Years Old
Address : Lingsar, West Lombok
Admitted on: December, 26th 2012
(14.00 Wita)
Med. Record : 071735

TIME

SUBJECTIVE

26/12/
2012
14.00

Patient referred from NTB GH

Policlinic with G4P2A1H2 4243
wk
S/L/IU
head
presentation.
Abdominal pain (-). Histrory
water leaked from her womb
(-). Bloody slim (-), FM (+).
No history of DM, HT,
asthma.
LMP : 01-03-2012
EDD : 08-12-2012
History of ANC : >4x at
Polindes
Last ANC : 26/12/2012
History of USG : never
History of family planning :
Injection 3 months
Next
family
planning
:
Injection 3 months.
Obstetrical History :
I. Female, Aterm, BTA, 6 YO
II. Male, Aterm, 3000 g,
Midwife, 4,5 YO.
III.Abortion
IV.This

OBJECTIVE
General Status
GC : well
Consciusness : CM
BP : 120/80 mmHg
PR : 80 bpm
RR : 20 tpm
T : 36,8 oC
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 : 31 cm
EFW : 3100 g
UC :FHB : 12-12-13 (148 bpm)
VT : 1 cm, eff 10%, amnion
(+), head palpable H I,
denominator unclear,
impalpable small part /
umbilical cord.

ASSESSMENT
G4P2A1H2 4243 weeks S/L/IU
head
presentation

PLANNING
Observe mother
and fetal well
being.
Check CBC and
HBsAG
DM suggest to GP
to induction of
labour, GP consult
to SPV: SPV acc to
induction if CTG
Reactive
CTG

TIME

SUBJECTIVE

OBJECTIVE
PS : 5
Cervix dilatation 1 cm : 1
Cervix length 2 cm : 1
Cervix consistency
moderate : 1
Cervix position mid : 1
Station H I : 1
Lab Evaluation
HB : 9,0 g/dl
RBC : 3,94 x106/l
HCT : 29,7 %
WBC : 12,3 x103/l
PLT : 377 x103/l
HbSAg : (-)

ASSESSMENT

PLANNING

TIME

SUBJECTIVE
Chronologist at Narmada PHC :
22.15 (25/12/2012)
S : Patient came to Narmada PHC
confessed have 10 month
pregnancy
O : GC : well
BP : 120/80 mmHg
PR : 80 bpm
RR : 20 tpm
T : 36,8 oC
L1 : breech
L2 : back on the left side
L3 : head
L4 : 5/5
UFH : 32 cm
FHB : 11-12-11 (136 bpm)
LMP : 01/03/2012
EDD : 08/12/2012
Hb : 10 gr %
Protein Urine : (-)
A : G4P2A1H2 42-43 wk S/L/IU head
presentation
P : Referred to NTB GH

OBJECTIVE

ASSESSMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

15.00

UC: FHR: 12-12-12 (144 bpm)

Set IVFD D5 with 5

IU of Oxytosin

15.30

UC: FHR: 12-12-12 (144 bpm)

8 dpm

16.00

UC: FHR: 12-11-12 (140 bpm)

12 dpm

16.00

UC: FHR: 12-11-12 (140 bpm)

16 dpm

16.30

UC: FHR: 13-12-13(152 bpm)

20 dpm

17.00

UC: FHR: 12-12-12 (144 bpm)

24 dpm

17.30

UC: FHR: 12-12-13 (148 bpm)

28 dpm

18.00

UC: FHR: 12-13-13 (152 bpm)

32 dpm

18.30

UC: FHR: 12-13-13 (152 bpm)

36 dpm

19.00

UC: FHR: 12-13-12 (148 bpm)

40 dpm

19.30

UC: FHR: 12-12-12 (144 bpm)

40 dpm

20.00

UC: FHR: 12-11-11 (136 bpm)

40 dpm

20.30

UC: FHR: 12-12-12 (144 bpm)

40 dpm

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

21.00

UC: FHR: 12-12-11 (144 bpm)

Continue 2nd Flash

40 dpm

21.30

UC: FHR: 12-12-12 (144 bpm)

40 dpm

22.00

UC: FHR: 12-11-12 (140 bpm)

40 dpm

22.30

UC: FHR: 12-11-12 (144 bpm)

40 dpm

23.00

UC: FHR: 13-12-13 (152 bpm)

40 dpm

23.30

UC: FHR: 12-12-12 (144 bpm)

40 dpm

24.00

UC: FHR: 12-12-13 (148 bpm)

40 dpm

27/12/
2012
00.30

UC: FHR: 12-13-13 (152 bpm)

40 dpm

01.00

UC: FHR: 12-13-13 (152 bpm)

G4P2A1H2 4243 weeks

S/L/IU head
presentation
with drip
failure

DM suggest to SPV
to CS, SPV acc CS
in the morning

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

27/12/
2012
10.35

12.35

PLANNING
CS began
Baby was born
(10.40), Female,
BW:3300 g/50 cm,
anus (+), AS: 7-9
Placenta was born
manually,
complete,
bleeding 500
cc

Patient confessed can not move her

leg

GC: well
BP: 110/70
RR: 24 tpm
UC: +
UFH: 2 finger
umbilicus
Urine output:

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

2 hours post
SC

Observed mother
and baby well
being
Suggest mother to
mobilisation.

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
28/12/
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