Name : Mrs. R Age : 24 yo Adress : Bayan, KLU Admitted : October, 14th 2012 at 16.

10

TIME 14/10/ 2012 17.10

SUBJECTIVE Patient referred from Bayan PHC with G1P0A0L0 A/S/L/IU head presentation with prolonged active phase 1st stage of labor. Patient confessed abdominal pain spread to back since 06.00 wita (13/10/2012). History rupture of membrane (-), bloody slim (+), FM (+). No history of DM, HT, asthma. LMP : Forgot EDD : (-) History of ANC : > 4 Last ANC : 29/09/2012 History of USG : never History of family planning : (-) Next family planning : IUD Obstetrical History : I. This

OBJECTIVE General Status GC : well Consciusness : CM BP : 100/60 mmHg PR : 84 bpm RR : 22 bpm T : 37,8oC Eye : anemis (-/-), icteric (-/-) Cor : S1S2 single reguler, M (-), G () 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 : 28 cm EFW : 2635 g UC :2x/10 ~ 25 FHB : 12-12-11 VT : 6 cm, eff 75%, amnion (+), head palpable H I +, denominator unclear, impalpable small part / umbilical cord.

ASSESSMENT G1P0A0L0 A/S/L/IU with head presentation with prolonged active phase 1st stage of labor.

PLANNING Obs mother and fetal well being Check lab CBC, HbsAg DM Co SPV: Pro: Rehidrasi + Pro SC at 21.00 WITA

TIME

SUBJECTIVE Chronologist At Bayan PHC : 10.00 (14/10/2012) S : Patient refered abdominal pain since 06.00 (13/10/2012). History rupture of membrane (-) O: GC : well BP : 100/70 mmHg PR : 80 bpm RR : 18 bpm T : 36,5oC UFH: 31 cm back on the right side Head palpable, 2/5 UC : (+) 2x10 ~ 10 FHB : (+) 138 bpm VT : 6 cm, aff 50%, amnion (-) head palpable, LOA, H II, impalpable small part of fetal and umbilical cord A: G1P0A0L0 38-39 weeks /S/L/IU with latent phase 1st stage of labor . P: Obs mother and fetal well being - Refer patient to NTB GH

OBJECTIVE Pelvic Evaluation : Spina ischiadica not prominent Os coccigeous mobile Arcus pubis > 90o Lab Evaluation : Hb : 12,6 gr/dl HCT : 37,5% RBC : 4,11 M/uL PLT : 249 K/uL WBC : 25,60 K/uL HBsAg : (-)

ASSESSMENT

PLANNING

TIME 21.00

SUBJECTIVE Mother confessed abdominal pain (+++)

OBJECTIVE GC : well BP : 110/90 mmHg PR : 80 bpm RR : 20 bpm T : 36,7oC UC : 2x/10~25 FHB : 12-12-12 (148 bpm) VT : 8 cm, eff 75%, amnion (+), head palpable H I +, denominator unclear, impalpable small part / umbilical cord.

ASSESSMENT

PLANNING Skin test Ampicillin (Inject 2 gram Amicillin) Prepare to CS.

22.00

Sc began Amnion fluid: Meconeal Baby was born. Male. 3000 g. AS 7-9. Anus (+). Congenital anomaly (-). Placenta was born. Manually. Complete. 300 gram. Bleeding 300 cc

TIME 00.00

SUBJECTIVE

OBJECTIVE GC : well BP : 130/80 mmHg PR : 88 bpm RR : 20 bpm T : 37oC UC : (+) well UFH : 2 finger below umbilicus Active bleeding : (-)

ASSESSMENT 2 hours post partum

PLANNING Observed mother and baby well being. Suggest mother to mobilisation.

15/10/ 2012 07.00

Delivery wound pain

GC : well BP : 110/80 mmHg PR : 88 bpm RR : 20 bpm T : 36,40C UFH : 3 finger below umbilicus UC : (+) well Lochea rubra : (+) Baby rooming in : PR :144 bpm RR : 46 bpm T : 36,40C

One day post partum

Observed mother baby well being Suggest mother mobilisation, eat, drink, medication.

and to and