Name: Mrs.

L
Age: 20 yo
RM: 048300

TIME

SUBJECTIVE

23/07/
2012
04.05

Patient referred from

Narmada PHC with
G2P1A0H1 36 weeks S/L/IU
head presentation with HDK
and history of CS. Patient
confess Abdominal pain that
spread to the frank since
12.30 (22/07/12). Bloody
slim (+) since 19.00
(22/07/12). History rupture of
membrane (+) at 18.30
(22/07/12), FM (+).
No history of DM, HT,
asthma.
LMP: 16/11/2011
EDD: 23/08/2012
History of ANC: >4x at
Posyandu
Last ANC: 20/07/2012,
result
150/90mmHg
History of USG: History of family planning:
Injection 3 monthsNext
family planning: Injection 3
months
Obstetrical history:
I.Male, BW: 3200, 9 month,
CS at RSUP NTB, live 15 yo
II.Ini

OBJECTIVE
General status:
GC: well
Cons: CM/E4V5M6
BP: 130/100 mmHg
PR: 88 bpm
RR: 20
T: 36,5
Eye : palor (-), 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
L2: back on the right side
L3: head
L4: 4/5
UFH: 26 cm
EFW: 2325 g
UC: 3x10 ~ 30
FHB: 12-12-12 (144 x/min)
VT: 3 cm, eff 25%, amnion (-)
dry, head palpable HI,
denominator unclear,
unpalpable small part /
umbilical cord.

ASSESTMENT

PLANNING

G2P1A0L1 36
weeks S/L/IU
head
presentation
with laten phase
1st stage of
labor with
history rupture
of membrane,
gestational
hypertention
and history of
CS

Obs mother & fetal

well being
Cek DL HbSAg
Obs progress of
labor
Skin test ampi (-)
inj.ampi 1 gr/iv

TIME

SUBJECTIVE
Chronologist:
02.30 (23/07/2012)
S:
Patient 9 month confess Abdominal
pain that spread to the frank
since 12.30 (22/07/12). Bloody
slim (+) since 19.00 (22/07/12).
History rupture of membrane (+)
at 18.30 (22/07/12) and want to
bearing down.
LMP: 16/11/2011
EDD: 23/08/2012
Obstetrical history:
I. Male, CS at RSUP NTB, 15 years
ago
II. Ini
O:
GC: well
BP: 160/120 mmHg
PR: 92 bpms
RR: 18
T: 36,7
Eye : palor (-), icteric (-)
Cor : S1S2 single reguler (murmur -),
(gallop -)
Pulmo : vesikuler (+/+), wheezing
(-/-),
Ronkhi (-/-).
L1: breech
L2: back on the right side
L3: head
L4: 4/5
UFH: 28 cm
EFW: 2635 g
UC: 2x10 ~ 30
FHB: 12-12-12 (144 x/min)

OBJECTIVE
Lab:
HB: 12,4 g/dl
RBC: 4.84 M/dl
HCT: 39,3 %
WBC: 12,43 K/dl
PLT: 247 K/dl
HbSAg: (-)
Proteinuria: -

ASSESTMENT

PLANNING

TIME

SUBJECTIVE
VT: 1 cm, eff 25%, amnion (+),
head palpable HI, unpalpable small
part / umbilical cord.
A:
G2P0A0L1 36 weeks S/L/IU head
presentation with HDK and history of
CS
P:
Nifedipine 10 mg (03.00, 23/07/12)
Reffered to RSUP NTB

OBJECTIVE

ASSESTMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

08.05

Patient confessed
abdominal pain ++

GC: well
BP: 130/100 mmHg
PR: 80 bpm
RR: 20
T: 36,5
UC: 3x10 ~ 30
FHB: 12-11-11 (136 x/min)
VT: 5 cm, eff 50%, amnion
(-), head palpable HI,
denominator LOA, unpalpable
small part / umbilical cord.

G2P1A0L1 36
weeks S/L/IU head
presentation with
aktive phase 1st
stage of labor
with history
rupture of
membrane,
gestational
hypertention and
history of CS

Obs mother & fetal

well being
Obs progress of
labor
CTG result reactive

12.05

Abdominal pain ++

GC: well
BP: 130/100 mmHg
PR: 80 bpm
RR: 20
T: 36,5
UC: 3x10 ~ 40
FHB: 12-12-12 (144 x/min)
VT: 5 cm, eff 50%, amnion
(-), head palpable HI,
denominator LOA, unpalpable
small part / umbilical cord.

G2P1A0L1 36
weeks S/L/IU head
presentation with
arrested aktive
phase 1st stage of
labor with history
rupture of
membrane, and
gestational
hypertention
history of CS

Obs mother & fetal

well being
Obs progress of
labor
Suggest mother to
eat and drink
DM co to SPV, pro
observation progress
of labor SPV ACC
observation and
evaluation in 2 hours

14.00

Abdominal pain ++

GC: well
BP: 130/100 mmHg
PR: 80 bpm
RR: 20
T: 36,5
UC: 3x10 ~ 40
FHB: 12-12-11(140 x/min)
VT: 7cm, eff 75%, amnion
(-), head palpable HII,
denominator LOA, unpalpable

G2P1A0L1 36
weeks S/L/IU head
presentation with
aktive phase 1st
stage of labor
with history
rupture of
membrane, HDK
and history of CS

Obs mother & fetal

well being
Obs progress of
labor
CTG
Suggest mother to
eat and drink
DM co to SPV, pro
observation progress

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

17.00

Patient confessed
abdominal pain ++

GC: well
BP: 160/100 mmHg
PR: 80 bpm
RR: 20
T: 36,5
UC: 3x10 ~ 30
FHB: 12-11-11 (136 x/min)
VT: 7 cm, eff 50%, amnion
(-), head palpable HII,
denominator LOA, unpalpable
small part / umbilical cord.

G2P1A0L1 36
weeks S/L/IU head
presentation with
arrested aktive
phase 1st stage of
labor with history
rupture of
membrane,
gestational
hypertention and
history of CS

Obs mother & fetal

well being
Obs progress of
labor
DM co to SPV
advice: IU
resucitation then
accelaration with
oxy drip 12 tpm

19.00

Abdominal pain ++

UC: 3x10 ~ 30
FHB: 12-12-11 (140 x/min)
.

G2P1A0L1 36
weeks S/L/IU head
presentation with
arrested aktive
phase 1st stage of
labor with history
rupture of
membrane,
gestational
hypertention and
history of CS

Accelaration with oxy

drip began 8 tpm

19.30

Abdominal pain ++

UC: 3x10 ~ 40
FHB: 12-12-13 (148 x/min)

G2P1A0L1 36
weeks S/L/IU head
presentation with
arrested aktive
phase 1st stage of
labor with history
rupture of
membrane,
gestational
hypertention and
history of CS

oxy drip 12 tpm

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

20.00

Abdominal pain

UC: 4x/10 ~ 40
DJJ: 12-12-12 (144)

G2P1A0L1 36
weeks S/L/IU head
presentation with
arrested aktive
phase 1st stage of
labor with history
rupture of
membrane,
gestational
hypertention and
history of CS

Dryp oxy 12 tpm

20.30

Abdominal pain

UC: 4/10 ~ 40
DJJ: 12-12-13 (148)

G2P1A0L1 36
weeks S/L/IU head
presentation with
arrested aktive
phase 1st stage of
labor with history
rupture of
membrane,
gestational
hypertention and
history of CS

Dryp oxy 12 tpm

21.00

Abdominal pain

UC: 4x/10 ~ 40
DJJ: 12-12-13 (148)

G2P1A0L1 36
weeks S/L/IU head
presentation with
arrested aktive
phase 1st stage of
labor with history
rupture of
membrane,
gestational
hypertention and
history of CS

Dryp oxy 12 tpm

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

21.30

Abdominal pain

UC: 4x/10 ~ 40
DJJ: 13-12-13 (152)
VT: complete, amnion (-),
head palpable HIII,
denominator LOA, unpalpable
small part / umbilical cord.

G2P1A0L1 36
weeks S/L/IU head
presentation with
2st stage of labor
with history
rupture of
membrane,
gestational
hypertention and
history of CS

-Dryp oxy 12 tpm

-CTG result reactive

22.00

Abdominal pain
Mother want to bearing
down

GC: well
BP: 130/100 mmHg
PR: 80 bpm
RR: 20
T: 36,5
UC: 4x10 ~ 45
FHB: 12-12-12 (144 x/min)

G2P1A0L1 36
weeks S/L/IU head
presentation with
2st stage of labor
with history
rupture of
membrane,
gestational
hypertention and
history of CS

Baby was born, male,

AS 7-9, 2600 gram,
48 cm, Anus (+),
congenital anomaly
(-)
Placenta was born
spontaneous,
complete, bleeding
200cc

Doranteknusperjolvulka

TIME
00.00

24/07/
2012
07.00

SUBJECTIVE
Patient confessed delivery
wound pain

OBJECTIVE

ASSESTMENT

PLANNING

GC: well
Cons: CM
BP: 130/100
HR: 80 bpm
RR: 20 tpm
T: 36,5 C
UC: + well
UFH: 2 finger below
umbilicus
Lokhea rubra : +

2 hours post
partum

Observed mother and

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

GC: well
Cons:
CM
BP: 160/100
HR : 82
bpm
RR : 20 tpm
T
: 36,2 C
UFH : 2 finger below
umbilicus
UC : + well

1 day post
partum

Observed mother and

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

Baby rooming in:

PR:144
RR: 46
T: 36,4