OBSTETRIC STATUS

Mother’s Age : 36 th
Pregnancy : G2P1A0
Gestational Age : 38 weeks
Complications during pregnancy : -
Complications of childbirth :-
Ruptures of the membranes :-
Type of Delivery` : Sectio Caesaria
Indication : - Trasverse lie
NEONATAL STATUS
Date of Baby Born : 13-12-2018
Gender : boy
Weight : 3610 gr
Lenght : 51 cm
Head circumference : 35 cm
 APGAR SCORE
0 1 2 APGAR SKOR 1’ 5’ 10’

Tidak ada <100 >100 Denyut jantung 2 2 2

Tidak ada Tidak Baik Pernapasan 1 2 2

teratur

Lemah Sedang Baik Tonus otot 2 2 2

Tidak ada Meringi Menangi Peka rangsang 2 2 2

s s
Biru / Putih tubuh Seluruh Warna 1 1 2
merah, merah
ekstrem
itas biru
NEW BALLARD SCORE
Kesan: total ballard score is 38  38 weeks
DOWN SCORE

Conclussion : not distress respiratory

 Gafik Lubchenko

12/15/2018

7
Conclussion : large for date, term
PHYSICAL EXAMINATION
A. General Appearance
Heart rate : 136 x/menit
Respiratory Rate : 36 x/menit
 temperature : 37,1 ºC
General appearance : Crying Strongly, Active Motion
Skin : - Color : red
- Turgor : Normal
- Tonus : Normal
* Gesture : Flexion
* Reflexes : - Moro : (+) - rooting: (+)
- palmar : (+) - plantar: (+)
- Tonus leher : (+)
B. HEAD

Shape : Normochepal
Sutura : Normal, moulage (-)
Fontanela : soft, open sinciput, horizontal
Eyes : Normal, sekret (-)
Nose : Normal, nostrils breath (-)
Ear : Normal
Mouth : Normal
Caput succedaneum :-
Cephal hematom :-
C. Neck : tonus normal
D. Thorax :
- Heart : hearth sound SI= reguler, SII= split constant,
hearth noisy (-)
- Lung : Vesikuler Sound (+) Normal
E. Stomach : Supel, turgor normal, fresh umbilical cord
F. Genitalia : Normal, the testes are down, miksi (+)
G. Anus : (+) Normal, mekonium (-)
H. Ekstremitas : Normal, fingers on four extremities are normal
I. Backbone : normal
J. Another anomaly : not found
ASSESMEN

normal body weight baby, Term, large for gestational age,

delivery with sectio caesaria on indication trasverse lie
MANAGEMENT PLAN
Early breastfeeding initiation
Vit K1 intramuscular injection, 1 mg dose in the anterolateral left
thigh
Hepatitis B vaccine intramuscular injection 0,5 ml in the
anterolateral right thigh, 1 hour after giving vit K injection
Rooming in
TERIMAKSIH