Name Age Adress Lombok No RM Admitted WITA

: Mrs. N.S. : 20 yo : Pemepek, Pringgarata, Central

: 524575 : 15th Oktober 2013 at 20.02

Time 15/10/13 20.02

Subject Patient reffered from PKM Pringgarata with G1P0A0L1 3940 weeks S/L/IU head presentation + PROM. Patient confessed water leaked out from her womb since 16.30 (15/10/2013), abdominal pain(-). Blood slim (-), FM (+). History of DM (-), HT (-), asthma (-). LMP :08/01/2013 EDD :15/10/2013 History ANC : >4x, midwife, last at 03/10/2013, result normal History USG : History of family planning: Next family planning: inj. 3 month

Object General status GC : well GCS: CM (E4V5M6) BP : 120/70mmHg PR: 92 tpm RR: 22 tpm T: 37,4C Local status Eye : an (-/-), ict (-/-) Pulmo: ves (+/+), rh (-/-), wh (/-) Cor : S1S2 single regular M(-), G(-) Abd : striae gravidarum (+), linea nigra (+), scar (-) Ext : edema (-/-) Obstetric status L1 : breech UFH: 31 cm EFW : 3100gram L2 : back on the left side L3 : head L4 : 4/5 UC : FHB : 12.12.12 (144x/min) VT : 1cm, eff. 10 %, Amnion (-) clear, head palpable HI, denominator unclear, impalpable small part of fetal & umbilical cord. PS: 5

Assessment G1P0A0L1 39-40 weeks S/L/IU head presentation + PROM

Planning Obs. Mother and fetal well being. Obs. sign of labor Infuse RL 20 tpm Skin test, (-), inj. Ampicillin 1 g/6 h IV DM co GP, GP co SPV pro CTG, and then SPV advice: Acc CTG, result reactive Pro USG

Obstetric History: 1. This. Chronologist: -

Time

Subject

Object Lab: Hb = 11,1 g/dl RBC = 4,41 WBC = 12,60 PLT = 258 HCT = 34,8% HbSAg = (-)

Assessment

Planning

16/10/13 04.30

water leaked out from her womb

GC : well GCS: CM (E4V5M6) BP : 120/70mmHg PR: 92 tpm RR: 22 tpm T: 37,4C UC : FHB : 12.12.12 (144x/min) VT : 1cm, eff. 10 %, Amnion (-) clear, head palpable HI, denominator unclear, impalpable small part of fetal & umbilical cord.

PROM

-Obs. Mother and fetal well being. -CTG, -Drip oxitocin 5 IU

06.00

UC: FHB: 12.12.13 (148x/minute) UC: FHB: 12.12.12 (144x/minute) UC: FHB: 12.11.12 (140x/minute) UC: FHB: 13.12.12 (148x/minute

- 8 tpm

06.30

- 12 tpm

07.00

-16 tpm

07.30

-20 tpm

Time

Subject

Object

Assessment

Planning

08.00

UC:FHB: 12.12.13 (148x/minute)

UC: 2x/10 ~ 30 FHB: 12.12.12 (144x/minute) Abdominal pain UC: 3x/10 ~ 30 FHB: 12.11.12 (140x/minute) VT : 4cm, eff. 50 %, Amnion (-) clear, head palpable HI, denominator unclear, impalpable small part of fetal & umbilical cord. UC: 3x/10 ~ 35 FHB: 13.12.12 (148x/minute) 1st Stage of labor active phase

-24 tpm

08.30

-28 tpm

09.00

-32 tpm -Obs. Progress of labor with partograph

09.30

-36 tpm
10.00 UC: 3x/10 ~ 35 FHB: 12.12.13 (148x/minute) -40 tpm

12.00

Abdominal pain

UC: 4x/10 ~ 45 FHB: 12.12.12 (144x/minute)

-Drip Oxytocin (2nd flash): -40 tpm

Time
12.30

Subject
Mother want to bearing down

Object
UC: 4x/10 ~ 45 FHB: 12.11.11.(142x/minute) VT : 10cm, eff. 100 %, Amnion (-) clear, head palpable HII, denominator unclear, impalpable small part of fetal & umbilical cord.

Assessment
2nd stage of labor

Planning
-Conduct delivery

13.15

Baby was born, male, AS 7-9, 3000 gram, 48 cm, Anus (+), congenital anomaly (-)

13.20

Placenta was born spontaneus, complete, 500 gr,bleeding 150 cc

GC: well Cons: CM BP: 110/70 HR: 80 bpm RR: 20 tpm T: 36,5 C UC: + UFH: 2 finger below umbilicus AB: Lochea : + 2 hours post partum Obs. mother and baby will being Suggest mother to mobilisation, eat, and drink.

15.20

Name Age Adress No RM Admitted WITA

: Mrs. N : 36 yo : Gunung sari , Tengah : 524597 : 16th Oktober 2013 at 02.30

Time 15/10/13 02.30

Subject Patient reffered from PKM Pringgarata with G1P0A0L1 3940 weeks S/L/IU head presentation + PROM. Patient confessed water leaked out from her womb since 16.30 (15/10/2013), abdominal pain(-). Blood slim (-), FM (+). History of DM (-), HT (-), asthma (-). LMP :08/01/2013 EDD :15/10/2013 History ANC : >4x, midwife, last at 03/10/2013, result normal History USG : History of family planning: Next family planning: inj. 3 month

Object General status GC : well GCS: CM (E4V5M6) BP : 120/70mmHg PR: 92 tpm RR: 22 tpm T: 37,4C Local status Eye : an (-/-), ict (-/-) Pulmo: ves (+/+), rh (-/-), wh (/-) Cor : S1S2 single regular M(-), G(-) Abd : striae gravidarum (+), linea nigra (+), scar (-) Ext : edema (-/-) Obstetric status L1 : breech UFH: 31 cm EFW : 3100gram L2 : back on the left side L3 : head L4 : 4/5 UC : FHB : 12.12.12 (144x/min) VT : 1cm, eff. 10 %, Amnion (-) clear, head palpable HI, denominator unclear, impalpable small part of fetal & umbilical cord. PS: 5

Assessment G1P0A0L1 39-40 weeks S/L/IU head presentation + PROM

Planning Obs. Mother and fetal well being. Obs. sign of labor Infuse RL 20 tpm Skin test, (-), inj. Ampicillin 1 g/6 h IV DM co GP, GP co SPV pro CTG, and then SPV advice: Acc CTG, result reactive Pro USG

Obstetric History: 1. Female,preterm,Hospital,mid wife,2200 gr, 5 years 2. this

Chronologist: -

Time

Subject

Object Lab: Hb = 11,1 g/dl RBC = 4,41 WBC = 12,60 PLT = 258 HCT = 34,8% HbSAg = (-)

Assessment

Planning

06.30

Abdominal pain

GC : well GCS: CM (E4V5M6) BP : 120/80mmHg PR: 86 tpm RR: 18 tpm T: 37,4C UC: 2x/10 ~ 30 FHB : 12.11.11 (136x/min) VT : 5cm, eff. 50 %, Amnion (+) clear, head palpable HI, denominator unclear, impalpable small part of fetal & umbilical cord.

1st stage of labor active phase

-Obs. Mother and fetal well being. -rehidration -Obs. Progress of labor with partograph

10.30

Water leak from her womb

GC : well GCS: CM (E4V5M6) BP : 120/80mmHg PR: 86 tpm RR: 18 tpm T: 37,4C UC: 2x/10 ~ 30 FHB : 12.11.11 (136x/min) VT : 5cm, eff. 50 %, Amnion (+) clear, head palpable HI, denominator unclear, impalpable small part

1st stage of labor active phase prolonged

Obs. Mother and fetal well being. Obs. Progress of labor with partograph

Time 11.15

Subject Mother want to bearing down

Object GC : well GCS: CM (E4V5M6) BP : 120/80mmHg PR: 86 tpm RR: 18 tpm T: 37,4C UC: 4x/10 ~ 40 FHB : 12.11.11 (136x/min) VT : 10cm, eff. 100 %, Amnion (+) clear, head palpable HIII, denominator unclear, impalpable small part of fetal & umbilical cord.

Assessment 2nd stage of labor

Planning -Conduct delivery

11.20

Baby was born, male, AS 5-7, 2000 gram, 42 cm, Anus (+), congenital anomaly (-) Placenta was born spontaneus, complete, 500 gr,bleeding 100 cc

13.20

GC: well Cons: CM BP: 110/70 HR: 80 bpm RR: 20 tpm T: 36,5 C UC: + UFH: 2 finger below umbilicus AB: Lochea : +

2 hours post partum

Obs. mother and baby will being Suggest mother to mobilisation, eat, and drink.

Thank You