Name: Mrs.

M
Age: 31 yo
RM: 538859
Adress: Lingsar
Admitted: May, 17th 2012 at 22.50

TIME

SUBJECTIVE

17/05/
2014
22.50

Patient referred from Sigerongan

PHC with G4P3A0L2 40 weeks
S/L/ head presentation with
arrested active phase first stage
of labor. Patient confess
Abdominal pain since 03.00
WITA (17/05/14). Bloody slim
and water leaked out from her
vagina since 14.30 WITA
(17/05/14),FM (+).
No history of DM, HT, asthma.
LMP: 12/08/2013
EDD: 19/05/2014
History of ANC: >4x at Posyandu
Last ANC: Normal
History of USG: History of family planning:
Injection 3 monthsNext family
planning: IUD
Obstetrical history:
I.Female, 3200 gram, spontan,
aterm, midwife, live 14 yo
II.Male , 3100 gram, spontan,
aterm, midwife, live 12 yo
III.IUFD
IV.This

OBJECTIVE
General status:
GC: well
Cons: CM/E4V5M6
BP: 110/70 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: 35 cm
EFW: 3720 g
UC: 3x10 ~ 30
FHB: 12-12-12 (144 x/min)
VT: 8 cm, eff 80%, amnion (-)
clear, head palpable HI, Caput +,
denominator unclear, unpalpable
small part / umbilical cord.

ASSESTMENT
G4P3A0L2 with
S/L/IU with
arrested active
phase first stage
of labor

PLANNING
Obs mother & fetal
well being
Obs progress of labor
DM co to GP advice
observation for one
hour , GP co to SPV
advice :
recutitation
Observation for one
hour
accelelaration if
there isnt progress

TIME

SUBJECTIVE
Chronologist at pkm sigerongan:
14.30 (17/05/2014)
S:
Patient 9 month confess Abdominal pain
since 03.00 WITA (17/05/2014) fetal
movement (+)
O:
GC: well
BP: 110/70 mmHg
PR: 80 bpms
RR: 16
T: 37
L1: breech
L2: back on the right side
L3: head
L4: 4/5
UFH: 34 cm
UC: 3x10 ~ 40
FHB: 12-12-12 (144 x/min)
VT : 4 cm, eff 25%, amnion (-), head
palpable HII, unpalpable small part /
umbilical cord
A: G4P3A0H2 A/T/L/IU Head presntation
with active phase first stage of labor
P: observation mother and fetal well being

OBJECTIVE
Lab:
HB: 10,7 g/dl
RBC: 3,91 M/dl
HCT: 31,7 %
WBC: 17,43 K/dl
PLT: 247 K/dl
HbSAg: (-)
Proteinuria: -

ASSESTMENT

PLANNING

TIME

SUBJECTIVE
18.30 :
S: Patient confessed abdominal pain
O: GC: well
BP: 110/70 mmHg
PR: 80 bpms
RR: 16
T: 37
UC: 4x10 ~ 40
VT : 8 cm, eff 25%, amnion (-), head
palpable HII, unpalpable small part /
umbilical cord
A: G4P3A0H2 A/T/L/IU Head presntation
with active phase first stage of labor
P: observation mother and fetal well being

OBJECTIVE

ASSESTMENT

PLANNING

TIME

SUBJECTIVE
20 :30
S: Patient confessed abdominal pain
O: GC: well
BP: 110/70 mmHg
PR: 80 bpms
RR: 16
T: 37
UC: 4x10 ~ 40
VT : 8 cm, eff 25%, amnion (-), head
palpable HII, unpalpable small part /
umbilical cord
A: G4P3A0H2 A/T/L/IU Head presntation
with arrested active phase first stage of
labor
P: observation mother and fetal well being

OBJECTIVE

ASSESTMENT

PLANNING

TIME

SUBJECTIVE
21 :30
S: Patient confessed abdominal pain
O: GC: well
BP: 110/70 mmHg
PR: 80 bpms
RR: 16
T: 37
UC: 4x10 ~ 40
VT : 8 cm, eff 25%, amnion (-), head
palpable HII, unpalpable small part /
umbilical cord
A: G4P3A0H2 A/T/L/IU Head presntation
with arrested active phase first stage of
labor
P: observation mother and fetal well being
IVFD RL
Prepare for reffered to NTB GH

OBJECTIVE

ASSESTMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

23.30

Abdominal pain

GC: well
BP: 120/70 mmHg
PR: 80 bpm
RR: 20
T: 36,5
UC: 3x10 ~ 25
FHB: 12-11-11 (136 x/min)
UC : 3x10~25

G4P3A0L2 with
S/L/IU with arrested
active phase first
stage of labor

Obs mother & fetal well

being
Obs progress of labor

00.00

Abdominal pain

GC: well
BP: 130/100 mmHg
PR: 80 bpm
RR: 20
T: 36,5
UC: 3x10 ~ 30
FHB: 12-12-12 (144 x/min)
VT: complete, amnion (-) clear,
head palpable HI, caput +,
denominator unclear, unpalpable
small part / umbilical cord.

Second stage of
labor

Obs mother & fetal well

being
Obs progress of labor
Suggest mother to eat
and drink

00.30

Abdominal pain

GC: well
BP: 110/70 mmHg
PR: 80 bpm
RR: 20
T: 36,5
UC: 2x10 ~ 25
FHB: 12-12-11(140 x/min)

Second stage of
labor

Obs mother & fetal well

being
Obs progress of labor
Suggest mother to eat
and drink

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

01.00

Abdominal pain +

GC: well
BP: 110/70 mmHg
PR: 80 bpm
RR: 20
T: 36,5
UC: 2x10 ~ 35
FHB: 12-11-11 (136 x/min)
VT: complete, amnion (-),
head palpable HI,caput (+),
denominator unclear,
unpalpable small part /
umbilical cord.

Arrested second
stage of labor

DM co to GP advice
CS, SPV advice
observation for one
hour

01..30

Abdominal pain +

UC: 2x10 ~ 30
FHB: 12-12-11 (140 x/min)
.

Arrested second
stage of labor

Obs mother & fetal

well being
Obs progress of
labor

02.00

Abdominal pain +

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

Arrested second
stage of labor

DM co to GP advice
CS, SPV advice SC

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

03.00

PLANNING
SC began
Baby was born :
Male, 4000 gram, BL :
50 cm, as: 7-9 anus (+),
anomali congenital (-)
Placenta was born
manually and complete

05.00

GC: well
GCS: E4V5M6
BP: 110/70 mmHg
PR: 88 bpm
RR: 22 rpm
T: 36,80 C
UC (+) well
UFH 2 finger bellow umbilical
Active bleeding (-)

2 hours post partum

Obs. Mother well being

Suggest mother to eat
and drink
Baby in NICU

TIME
07.00 (
18/05/
2014)

SUBJECTIVE

OBJECTIVE
GC: well
GCS: E4V5M6
BP: 120/80 mmHg
PR: 88 bpm
RR: 22 rpm
T: 36,80 C
UC (+) well
UFH 2 finger bellow umbilical
Active bleeding (-)
Lochea rubra (+)
Baby in NICU
GC : well
PR : 132 bpm
RR : 44 bpm
T : 36,2C

ASSESTMENT
One day post CS

PLANNING
Obs. Mother well being
Suggest mother to eat
and drink