OBSTETRIC STATUS

Mother’s Age : 28 th
Pregnancy : G1P0A0
Gestational Age : 32 mg
Complications during pregnancy :-
Complications of childbirth :-
Ruptures of the membranes : 2 weeks before operation, green
Type of Delivery` : Sectio Caesaria
Indication : - ruptures of the membran
- oligohidramnion
- fetal hipoksia
NEONATAL STATUS
Date of Baby Born : 06-07-2017
Gender : Boy
Weight : 1900 gr
Lenght : 49 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 2 2 2

teratur

Lemah Sedang Baik Tonus otot 2 2 2

Tidak ada Meringi Menangi Peka rangsang 1 2 2

s s
Biru / Putih tubuh Seluruh Warna 1 1 2
merah, merah
ekstrem
itas biru
NEW BALLARD SCORE
Kesan: total ballard score 41 weeks
DOWN SCORE

Kesan: tidak gawat nafas

 Gafik Lubchenko

12/28/2018

7
Conclussion : appropiate for date, preterm
PHYSICAL EXAMINATION
A. General Appearance
Heart rate : 144 x/menit
Respiratory Rate : 60 x/menit
 temperature : 36,8 ºC
General appearance : Crying Strongly, Active Motion
Skin : - Color : red
- Turgor : Normal
- Tonus : Normal
* Gesture : Flexion
* Reflexes : - Moro : (+) -glabela: (+)
- rooting: (+) - palmar : (+)
- plantar: (+)
- Tonus leher : (+)
* sound : Loud
B. HEAD

Shape : Normochepal
Sutura : Normal, moulage (-)
Fontanela : soft, open sinciput, horizontal
Eyes : Normal, sekret (-)
Nose : Normal, the breath of the nostrils(-)
Ear : Normal
Mouth : Normal
Caput succedaneum :-
Cephal hematom :-
C. Neck : tonus normal
D. Thorax :
- Heart : Bunyi jantung SI= tunggal, SII= split tak
konstan, bising Jantung (-)
- Lung : Vesikuler Sound (+) Normal
E. Stomach : Supel, turgor normal, fresh umbilical cord
F. Genitalia : Normal, testis sudah turun ke skrotum, penis
(+) 3 cm, miksi (+)
G. Anus : (+) Normal, mekonium (-)
H. Ekstremitas : Normal, jumlah jari di keempat ekstremitas
lengkap
I.Tulang punggung : Dalam batas normal
J. Anomali lain : Tidak ditemukan
ASSESMEN

Birth weight is sufficient, Preterm, appropiate for date ,

delivery with sectio caesaria on indication ruptures of the
membran, oligohydramnion, fatel hypoxia
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
Observation in the picu
TERIMAKSIH