Name

: Mrs. W

RM

: 039827

Age

: 26 years old

Address

: Narmada, Lombok Barat

Hospital Admission : June 2nd 2012

TIM
E

SUBJECT

02/
06/
201
2

Patient referred from

Narmada PHC with
G1P0A0L0 43-44 weeks
S/L/IU, head presentation
with latent phase 1st stage
of labor and PROM > 12
hours. Patient confessed
fluid leak out from her
womb since 20.30
(01/06/2012), bloody slim
(+), FM (+).
No history of DM, HT,
asthma.

13.0
0

LMP : 01/08/2011
EDD : 08/05/2012
History ANC : > 4x at clinic
Last ANC : forgot
USG : 2x
History of family planning :
Next family planning :
injection 3 months
History of Obstetric :
1. This

OBJECT
General Status
GC : well
BP : 120/80 mmHg
PR : 86 bpm
RR : 22 bpm
Temp : 36,6oC
Eye : palor -/-, icteric
-/Cor : S1S2 single
reguler, murmur (-),
gallop (-).
Pulmo : vesikuler (+/
+), wheezing (-/-),
ronkhi (-/-).
Abdomen : scar (-),
striae (+), linea nigra
(+).
Extremity : edema (-/-),
warm acral (+/+).
Obstetric Status
L1 : breech
L2 : back on the right
side
L3 : head
L4 : 4/5
UFH : 33 cm
UC : 2x10 ~ 30

ASSESSMENT

PLANNING

G1P0A0L0 4344 weeks,

S/L/IU, head
presentation
with latent
phase 1st stage
of labor and
PROM > 12
hours.

Observation
mother & fetal
well being.
Ampicillin inj. 1
gr IV at
Narmada PHC.
Consult to GP :
observation
labor
progression with
partograf.

TIME

SUBJECT
Chronologist :
06.00
S : Patient came to
Narmada PHC, confessed
fluid leak out from her
womb since 20.30
(01/06/2012)
O:
GC : well
BP : 120/70 mmHg
PR : 80 bpm
RR : 16 bpm
Temp: 37,8oC
UFH : 37 cm , EBW : 4030
gr
L1 : breech
L2 : back on the right
side
L3 : head
L4 : 4/5
UC : (-)
FHB : 12.12.11 (140 bpm)
VT : 2 cm, eff 25%,
amnion (-), head palpable
in H1, denominator
unclear, impalpable fetal
small part and umbilical

OBJECT
VT : 2 cm,
effacement 20%,
amnion(-), head
palpable at HI,
denominator
unclear, impalpable
small part of fetal &
umbilical cord.
Lab Examination :
HGB : 10,1 g/dl
RBC : 4,57 x 106/ L
WBC : 8,0 x 103/ L
PLT : 176 x 103/ L
HCT : 34,9 %
HBsAg : (-)

ASSESSMENT

PLANNING

TIME

SUBJECT
A : G1P0A0 43-44 weeks
S/L/IU head
presentation with laten
phase 1st stage of labor
and PROM > 12 hours.
P : Consult to GP was
advicing to :
Obs. mother & fetal
well being
Ampicillin inj. 1 gr IV
Infuse RL
Paracetamol 500 gr
PO
Made reference to
NTB GH
12.30 : Refer to NTB GH

OBJECT

ASSESSMENT

PLANNING

TIME
17.0
0

SUBJECTIVE
(-)

OBJECTIVE
GC : well
BP : 120/70 mmHg
PR : 76 bpm
RR : 20 bpm
T : 36,4oC
UC : 3x10 ~ 25
FHB : 12.13.12 (148
bpm)
VT : 3 cm,
effacement 30%,
amnion (-), head
palpable at HI,
denominator unclear,
impalpable small part
of fetal & umbilical
cord.

ASSESSMENT

PLANNING

G1P0A0L0 4344 weeks,

S/L/IU, head
presentation
with latent
phase 1st stage
of labor and
PROM > 12
hours.

Educate mother
to sideway to the
right.
Educate mother
to eat and drink.
Observation
mother & fetal
well being.

TIME
21.0
0

SUBJECTIVE

OBJECTIVE

(-)

GC : well
BP : 110/70 mmHg
PR : 84 bpm
RR : 20 bpm
T : 36,4oC
UC : 2x10 ~ 15
FHB : 12.12.12 (144 bpm)
VT : 3 cm, effacement
50%, amnion(-), head
palpable at HI,
denominator unclear,
impalpable small part of
fetal & umbilical cord.

ASSESSMENT
G1P0A0L0 43-44
weeks, S/L/IU, head
presentation with
arrested latent phase
1st stage of labor
(dystocia 3 cm) and
PROM > 12 hours.

PLANNING
Observation
mother & fetal well
being.
Consult to GP,
advice :
Rehydration RL :
D5 = 1:2
CTG; if reactive,
conservative,
but if
pathologic,
termination
CTG result :
tachycardia
GP consult to SPV,
advice: C-section
CIE patient &
family
Preparation of Csection :
Infuse D5
Ampicillin inj. 1
gr IV (skin test -)
Transmit patient
to the operation
room.

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

03/0
6/20
12

C-section began
Baby was born :
Male, AS: 7-9,
BL: 54 cm, BW:
4500 gram.
Anus
(+),
congenital
anomaly
(-),
amnion (-).
Placenta was born
manually,
complete, bleeding
300 cc.
Placenta weight :
600 gram
C-section finished

00.0
0

02.2
0

PLANNING

Patient
confessed her
leg cant
moved and
operation
wound pain

GC : well
BP : 120/70 mmHg
PR : 72 bpm
RR : 24 bpm
T : 37,3oC
UFH : 2 finger below
umbilicus
UC : (+)
Active bleeding : (-)
Urine output : 400 cc/2

2 hours post CS

mother
Observe
well being
CIE mother to take
a rest

TIME

SUBJECTI
VE

OBJECTIVE

ASSESSMENT

PLANNING

08.00

Operation
wound pain

GC : well
BP : 120/70 mmHg
PR : 72 bpm
RR : 24 bpm
T : 37,3oC
UFH : 2 finger below
umbilicus
UC : (+)
Active bleeding : (-)
Urine output : 30
cc/hours Operation wound
good

1 day post C-section

Observe
mother
well being
CIE
mother
to
mobilisation, eat,
drink.
Breast feeding

04/06/1
2
08.00

Operation
wound pain

GC : well
BP : 100/70 mmHg
PR : 80 bpm
RR : 20 bpm
T : 36,1oC
UFH : 2 finger below
umbilicus
UC : (+)
Active bleeding : (-)
Urine output : 30
cc/hours Operation wound
good

2 day post C-section

Observe
mother
well being
CIE
mother
to
mobilisation, eat,
drink.
Breast feeding