Ny.

H
34 yo
Seteluk, Western of Sumbawa
Islam
G1P0A0L0 A/S/L/IU with neglected
2nd stage of labor.
 Time Subject Object Assessment Planning
05/06/12 Patient referred from PKM Seteluk General status G1P0A0L0 40-41 -Obs. Mother and fetal
20.20 G1P0 A0H0 42 wk with inpartu GC : well weeks S/L/IU with well being.
WITA active phase 1st stage of labor. Patient GCS: E4V5M6 neglected 2nd stage of -RL infusion
confessed abdominal pain since BP : 120/70 mmHg labor. -Skin test, (-), Inj. AB:
18.00 (2/06/2012). History rupture of PR: 100 tpm - Ampicilin 1 g/6 hour
membrane (+) since 05.00 RR: 24 tpm IV
(05/06/2012), bloody show (+), FM T: 37.4C - Gentamicin 80 mg/12
(+). History of DM (-), HT (-), hours
asthma (-). Local status - Metronidazole rectal
Eye : an (-/-), ic (-/-) suposituria 1 g/12 hours
LMP : 25/08/2012 Pulmo: ves (+/+), rh (-/-), wh (-/-) -DM consult to SPV pro
EDD : 1/06/2012 Cor : S1S2 single regular M(-), VE.
G(-) - SPV advice:
History ANC : 6x , midwife. Abd : striae gravidarum (+), linea - acc VE.
Last ANC: 15/05/2012, result normal nigra (+), scar (-) - Recucitation IU
History of USG : - Ext : edema (-/-).

History of family planning:- Obstetric status

Next family planning: Hormonal L1 : breech UFH: 34 cm
injection every 3 month. L2 : back on the left side
L3 : head
Obstetric History: L4 : 2/5
1. This UC : 3x/10 ~ 35
FHB : 12.13.12 (152x/minute)
Chronology: EFW : 3410 gram
S: VT: complete, amnion (-)
07.00 (5/06/2012) meconeal, head palpable, H III,
Patient referred from PKM Poto impalpable small part of fetal &
Tano, confessed abdominal pain placenta.
since 03.00 (5/06/2012). Pelvic evaluation
Sacrum : convexity normal
Spina ischiadica not prominent
Os coccigeous mobile
Pubic arch > 900
Promontorium impalpable
Time Subject Object Assessment Planning
O: Lab:
BP 120/80 mmHg, P 80 ppm, RR 20 Hb: 12,0
rpm, T 36.5 C. RBC: 4,34
VT: 8 cm, eff 80%, amnion (-) Plt: 264.000
cloudy, head palpable, H III, WBC: 19.850
impalpable small part of fetal &
placenta.
UC: 2x10~20.
FHB: 140 bpm.

11.00
S: -
O:
BP 120/80 mmHg, P 80 ppm, RR
20 rpm, T 37.6 C.
VT: 8 cm, eff 80%, amnion (-)
cloudy, head palpable, H III,
impalpable small part of fetal &
placenta.
UC: 2x10~20.
FHB: 144 bpm.

15.00
S: -
O:
BP 120/80 mmHg, P 80 ppm, RR
20 rpm, T 37.6 C.
VT: 10 cm, eff 100%, amnion (-)
cloudy, head palpable, H III,
impalpable small part of fetal &
placenta.
UC: 2x10~25.
FHB: 148 bpm.
 Time Subject Object Assessment Planning
20.45 Abdominal pain (+), nausea and GC : well G1P0A0L0 A/S/L/IU VE began
vomiting (+) UC : 3x10 ~ 35 head presentation
FHB (+) 12.12.12 (144 bpm). neglected 2nd stage of
labor.

21.15 Abdominal pain (+), nausea and GC : well G1P0A0L0 A/S/L/IU VE 1 times traction,
vomiting (+) UC : 3x10 ~ 35 head presentation Baby was born, male,
FHB (+) 12.13.12 (148 bpm). neglected 2nd stage of 3400 gram/53 cm, A-S 3-
labor. 5, caput (+) on occiput,
anus (+), anomaly
congenital
Placenta born
spontaneous, complete,
perineum episiotomy (+)
Bleeding 200cc

23.20 Patien confess abdominal pain General status 2 hour post partum, Continue observation
GC : well and medication
GCS: E4V5M6 Suggest mother to take a
BP : 120/70 mmHg rest
PR: 100 tpm
RR: 24 tpm
T: 36.7C
FH: 2 fingers below the umbilicus

6/06/12 - General status 1st day post partum Continue observation

07.00 GC : well and medication
GCS: E4V5M6 Suggest mother to take a
BP : 120/80 mmHg rest
PR: 88 tpm
RR: 20 tpm
T: 36.5C
FH: 2 fingers below the umbilicus
Time Subject Object Assessment Planning
Baby in NICU
PR: 146 bpm
RR: 52x/mnit
T: 36oC
Baby use D10 infusion