Name: Mrs.

RJ
Age: 24 yo
Address: Narmada
Admitted: April, 13th 2012 at 09.00

Time

Subject

13/05/
2012
09.00

Patient
referred
from
Narmada
PHC
with
G1P0A0L0
35-36
weeks/S/L/IU with arrested
active phase 1st stage of.
Labor.
Patient confessed abdominal
pain
(+)
since
08.00
(12/05/2012),
history
rupture of membrane (-). FM
(+)
History of DM (-), HT (-),
asthma (-).
LMP : 01/09/2011
EDD : 08/06/2012
History of ANC : >4x
Last ANC : 09/05/2012
History of USG : History of family planning : Next family planning : IUD
Obstetrical history :
I.This

Objective
General Condition :well
Consciousness : CM
BP : 120/80 mmHg
bpm
RR: 22 x/minute
36,0C

PR : 88
T :

Status Generalis:
Eye : anemic(-), 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, UFH: 31 cm
L2 : fetal back on left side
L3 : head
L4 : 4/5
EFW :3100 gr
UC: 1x10 30
FHR : (+), 12-12-12 (144 bpm)
VT : 7 cms, eff 50%, amnion
(+), head palpable, H I,
unpalpable small part of
fetal/umbilical cord
PE:
Sacrum convexity normal
Spina ischiadica not prominent

Assesment

Plannng

G1P0A0L0 35-36
weeks/S/L/IU with
arrested active
phase 1st stage
of. Labor.

Observation
mother and fetal
well being
DM co to SPV pro
acceleration. SPV
advice CS
Prepare CS (inj.
Ampicillinn 2 g,
DC)

Time

Subject
Chronologis:
12/05/2012
00.30
S: Patient came to Narmada PHC cenfessed
frenk pain
O:
General Condition :well
Consciousness : CM
BP : 120/80 mmHg
PR : 88 bpm
RR: 22 x/minute
T : 36,0C
Palpation:
L1 : breech, UFH: 31 cm
L2 : fetal back on left side
L3 : head
L4 : 3/5
EFW :3100 g
UC: 3x10 30
FHR : (+), 12-12-11 (140 bpm)
VT : 5 cms, eff 50%, amnion (+), head
palpable, H I, unpalpable small part of
fetal/umbilical cord
01.00
UC: 2x10 30
FHR : (+), 12-12-11 (140 bpm)
01.30
UC: 2x10 30
FHR : (+), 12-12-11 (140 bpm)
02.00
UC: 0x10 30
FHR : (+), 12-12-11 (140 bpm)
02.30
UC: 2x10 35
FHR : (+), 12-12-11 (140 bpm)

Objective
Lab :
HGB : 11,0
RBC : 3,8
HCT : 37,9
WBC : 13,6
PLT : 289
HbSAg : (-)

Assesment

Plannng

Time

Subject
03.00
UC: 2x10 40
FHR : (+), 12-12-11 (140 bpm)
04.00
UC: 2x10 20
FHR : (+), 12-12-11 (140 bpm)
VT : 8 cms, eff 50%, amnion (+), head
palpable, H I, unpalpable small part of
fetal/umbilical cord
04.30
UC: 2x10 45
FHR : (+), 12-12-11 (140 bpm)
05.00
UC: 2x10 40
FHR : (+), 12-12-11 (140 bpm)
05.30
UC: 2x10 40
FHR : (+), 12-12-11 (140 bpm)
06.00
UC: 2x10 45
FHR : (+), 12-12-11 (140 bpm)
VT : 8 cm, eff 50%, amnion (+), head
palpable, H I, unpalpable small part of
fetal/umbilical cord
IVFD: RL 20 dpm (2 flash)
07.00
UC: 2x10 50
FHR : (+), 12-12-11 (140 bpm)
IVFD D5%
08.00
UC: 2x10 45
FHR : (+), 12-12-11 (140 bpm)
VT : 8 cm, eff 50%, amnion (+), head
palpable, H I, unpalpable small part of
fetal/umbilical cord

Objective

Assesment

Plannng

Subject

Object

Assesment

11.00

Planning
C-section began
Baby was born,
Female., A-S : 7-9,
BL: 50 cm, BW :
3000 gr
Anus (+), congenital
anomaly
(-),
Amnion clear (+).
Placenta was born
manually,
complete,
bleeding 300 cc
Placenta weight :
400 gr
C-section Finished

13.00

Patient confessed her leg

cant moved

GC : well cons : E4V5M6

BP : 110/80 mmHg PR : 84
x/minute
RR : 20 x/minute
T : 36,7 C
UFH : at umbilicus
UC : (+)
Active bleeding (-)
Urine output: 400 cc/ 2 h
Operation wound good

2 hour Post Csection

Observe
mother
and baby well being
KIE mother to take a
rest

14/05/
12
07.00

Operation wound pain

GC : well cons : E4V5M6

BP : 120/70 mmHg PR : 88
x/minute
RR : 20 x/minute
T : 36,5 C
UFH : 1 finger below umbilicus
Uterine contraction: (+)
Active bleeding (-)
Urine output: 50 cc/h

1 day post Csection

Observe
mother
and baby well being
KIE
mother
to
Mobilisation,
eat,
drink
Rooming in