You are on page 1of 5

MIDWIFERY CARE IN PREGNANCY NORMAL TO THE NY.

A UK 32-33 WEEK IN PUSKESMAS


BELIMBING PADANG

OCTOBER 31 Th, 2018 AT: 16.00 WIB

S O A P
1. General Examination Diagnosis: G1P0A0, 32-33 1. Explain the condition of the mother and
October 31Th, 2017, on BB: 50 kg TB: 152 cm TD: weeks gestational age, fetal fetus are currently-TD: 110/80 mmhg,

16.00 wib 110/80 mmhg Lila: 26 cm tunngal life insimanation Pulse: 80x/minute, RR: 23x/min.
Temperature: 36.7 ' c layout of the elongated Temperature: 36.7 ' c, DJJ: 144x/min
Pulse/minute x 80: RR: 23 head of presentation. EV: I understand his condition and the
x/minute me Good fetus is currently in good shape
Mother says pregnant first
Awareness: Compos mentis Problem: no
child, gestational age 8
2. Encourage the mother to let the mother
months pregnancy checked,
2. Examination of Head to toe The needs of the meristirahat and reduce the heavy activity
come to
Head:  Counseling about EV: the mother is willing to set the pattern
the shape of the head: nutrition of breaks and activities
symmetrical pregnant women
cleanliness: clean  Guidance about 3. provide information regarding the
color of hair: Black Eyes: patterns of rest and fulfillment of the adekuat nutrients such as
eyelid: not odema activity sayur2an, consumption of fruits and side
conjunctiva: An amenis dishes.
sklera: An ikterik EV: I understand about the nutritional
Ears: needs of the adekuat
ear forms: Symmetrical left
and right 4. explain the importance of pregnant
mothers in gymnastics is to loosen the
hygiene: no secretions muscles and is useful when the birthing
Mouth: EV: I understand the importance of
dental caries: none pregnant gymnastics

Neck: 5. explain in the mother about the dangers


There is no enlargement of the of pregnancy such as eye pain, head of the
thyroid gland and lymphatic great low vision, bleeding, abdominal pain
calendar nganggat excellent, feet and hands
good swallow reflex swelling, reduced fetal movement.
EV: I understand the danger signs of
Chest: pregnancy
chest shape: symmetrical, no
abnormalities 6. describe the mother signs of labor
breasts: no pain and bumps, EV: I understand the signs of labor
symmetrical left and right
the normal enlargement 6. recommends that mothers do the
nippel: stand out repeated visits if there are complaints or
heart: heart sounds normal one months
(lub-dup) not sound mur-mur EV: the mother is willing to do repeated
lungs: pulmonary sounds visits
normal, no wheezing and rochi

The back and the waist:


Londorsis and there is no
lower back pain
Abdomen: enlargement in
accordance with the gestational
age, no bump sign
abnormalities and no
contractions
leopoid 1: TFU mid central PX
(30 cm)
BLM is no contraction, on top
of the rounded part of the
fundus palpable, tender and
bouncy refuses (buttocks).
leopoid II:
the left part of the abdomen of
the mother: palpable hard
elongated arrestees (back)
the right part of the stomach of
the mother: the smallest part of
the fetus is palpated
(ektremnitas fetus)

leopoid III: the lower part of


the abdomen is palpated
mother part round, hard and
bouncy (head)
leopoid IV: Convergent
DJJ: 144x/min
TBJ: (30-12) x155 = 2790
grams

Ekstermitas: odema: no
tension: no
redness: no
varicose veins: no
reflex panatella: positive
Genetalia: Normal
3. laboratory Examination
HB: 11.2%
urine protein: negative
urine glucose: negative

You might also like