TIME

SUBJECTIVE

OBJECTIVE

19/12/
2012
09.40

Patient came to VK IRD GH NTB

reffered from Kayangan PHC
with G2P0A1L0 43 weeks/S/L/IU
head presentation with serotinus
+ Susp. CPD. Patient confessed
abdominal pain that spread to
waist since 05.00 (19/12/2012).
No histrory rupture of membrane.
Bloody slim (+), FM (+).
No history of DM, HT, asthma.
LMP : Forgot
EDD : History of ANC :
Posyandu
History of USG : never

>4x

at

History of family planning : (-)

Next family planning : Injection 3
months.
Obstetrical History :
I. Abortion
II. This

General Status
GC : well
Consciusness : CM
BP : 110/60 mmHg
PR : 84 bpm
RR : 20 bpm
T : 36,5oC
Eye : anemis (-/-), icteric (-/-)
Cor : S1S2 single reguler, M (-), G (-)
Pulmo : vesikuler (+/+), wheezing
(-/-), ronkhi (-/-).
Abdomen : scar (-), striae (+), linea
nigra (+).
Extremity : edema (-/-), warm acral
(+/+)
Obstetrical Status
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH : 31 cm
EFW : 3120 g
UC :3x/10 ~ 30
FHB : 11-11-12 (136 bpm)
VT : 6 cm, eff 50%, amnion (+),
head palpable H I , denominator
unclear, impalpable small part /
umbilical cord.

ASSESSMENT

PLANNING

G2P0A1L0
A/S/L/IU head
presentation with
active phase 1st
stage of labor.

Observe mother and

fetal well being.
Observe progress of
labor.
Check Lab: CBC,
HbsAg
CTG
GP consult SPV: SPV
advice :
Observation
Transfer to VK Teratai
Repeat CTG 2
hours later

TIME

SUBJECTIVE
Chronologist
At Kayangan PHC
S: Patient pregnant for 9 month
confessed abdominal pain spread to
waist since 02.00 (19/12/2012).
O: GC: well
BP : 110/60 mmHg
PR : 84 bpm
RR : 20 bpm
T : 36,5oC
UFH : 33 cm
EFW : 3410 g
UC :4x/10 ~ 45
FHB : 142 bpm
VT : 8 cm, eff 75%, amnion (+), head
palpable H I , denominator unclear,
impalpable small part / umbilical cord.
A: G2P0A1L0 43 weeks S/L/IU head
presentation with serotinus + susp. CPD
P:
IVFD RL 20 tpm
Injeksi Ampicillin/IV
Reffered to GH NTB

OBJECTIVE
Pelvic Evaluation :
Spina ischiadica not prominent
Os coccigeous mobile
Pubic arch > 900
Lab Evaluation
Hb : 13,5 g/dl
RBC : 4,4 M/dl
HCT : 43,8 %
WBC : 15,5 K/dl
PLT : 290 K/dl
HbSAg : (-)

ASSESSMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

11.15

GC : well
BP: 120/70 mmHg
HR: 88 x/minute
RR: 20 x/minute
T: 36,4 C
UC :3x/10 ~ 30
FHB : 11-12-12 (140 bpm)

Observe mother and fetal well

being.
Observe progress of labor with
partograf ( 4 hours later)

13.00

GC : well
BP: 120/70 mmHg
HR: 88 x/minute
RR: 20 x/minute
T: 36,4 C
UC :3x/10 ~ 30
FHB : 146 bpm
VT : 7 cm, eff 50%, amnion
(+), head palpable H I ,
denominator unclear, impalpable
small part / umbilical cord.

Advice SPV: Reevaluation

Consult SPV: advice continue
observation

14.00

14.30

Os confessed
rupture of
membrane

GC : well
BP: 120/70 mmHg
HR: 88 x/minute
RR: 20 x/minute
T: 36,4 C
UC :3x/10 ~ 40
FHB : 140 bpm
VT : 7 cm, eff 75%, amnion (-),
head palpable H I ,
denominator unclear, impalpable
small part / umbilical cord.

G2P0A1L0 A/S/L/IU head

presentation with prolonged
active phase 1st stage of
labor.

Observe mother and fetal well

being.
Observe progress of labor with
partograf
Suggest mother to ead and
drink
Consult SPV: advice
Intrauterine resuscitation
Acceleration with Oxytosin
drip
Observation 3 hours later
Set IVFD RL : D5% : 2:1 (fast
drop)
Set O2
Suggest mother to lie down on
the left side

TIME

SUBJECTIVE

OBJECTIVE

15.00

UC :2x/10 ~ 30
FHB : 144 bpm

17.00

VT : 7 cm, eff 50%, amnion (-),

oedem portio, head palpable H
I , caput (+) denominator unclear,
impalpable small part / umbilical
cord.

ASSESSMENT

Set Acceleration with

Oxytocindrip start from
8 dpm

17.30

19.00

19.20

PLANNING

Consult SPV: advice

SC at 22.00
CIE patient and family
Test Ampi
Inj Ampi 1 gr/IV
Mother want to bearing down

UC :4x/10 ~ 45
FHB : 144 bpm
VT : complete, amnion (-),
oedem portio, head palpable H
III , caput (+) denominator LOA,
impalpable small part / umbilical
cord.

2nd stage of labour

Conduct mother to
bearing down

Baby was born (19.20)

Female, AS: 7-9, BL:
48 cm, BW: 2900
gram.
Placenta was born
Spontaneusly (19.25)
complete, bleeding
150 cc.
Anus (+), congenital
anomaly (-), amnion
(-).
Episiotomy : ruptur
grade II hecting

TIME

SUBJECTIVE

21.20

Patient confessed wound pain

20/12/
2012
07.00

OBJECTIVE

ASSESSMENT

PLANNING

GC : well
BP : 110/80 mmHg
PR : 72 bpm
RR : 20 bpm
T : 36,5oC
UFH : 1 finger below umbilicus
UC : (+)
Active bleeding : (-)

2 hours post post

partum

Observe mother well

being.
CIE mother to take a
rest.
Transfer to Melati
room

GC : well
BP : 110/80 mmHg
PR : 80 bpm
RR : 20 bpm
T : 36,5oC
UFH : 1 finger below umbilicus
UC : (+)
Active bleeding : (-)

One day post post

partum

Observed mother and

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