ENGLISH ASSIGNMENT

“ MIDWIFERY DOCUMENTATION ”
DOSEN PENGAMPU : NI MADE DWI MAHAYATI, S.ST., M.KEB

OLEH :

NAMA : DESAK MADE DEVI PRASETYANINGSIH

NIM : P07124221099
KELAS : B AFILIASI

KEMENTERIAN KESEHATAN RI
POLITEKNIK KESEHATAN KEMENKES DENPASAR
JURUSAN KEBIDANAN
DENPASAR
2022
 CASE

Place of Service : Buleleng Public Health Center

Date given service : Saturday , 5th Februari 2022. At 09.00 am.

A. Subjective Data
Mother Husband
Name : Mrs. "KS" Name : Mr. "GA"
Age : 28 years old Age : 30 years old
People : Bali People : Bali
Religion : Hinduism Religion : Hinduism
Education : Senior High School Education : Bachelor Of Education
Job : Housewife Job : Teacher
Address : A. Yani Street number 29
Phone Number : 081230999xxx
Health Insurance : BPJS

Complaints/reasons for self-examination: The mother said she wanted to check

the pregnancy.
Menstrual history :
Menarch age 13 years, volume: 3-4 times change of sanitary pads/day, regular
cycle, diluted blood properties, complaints when menstruation is not present.
HPHT : 15-11-2021, TP : 22-08-2022
Marriage History: Married one times, 2 years old.
Previous Pregnancy and Childbirth History : -
Pregnancy history : -
Immunization Status : T5
Last Immunization Time : at child
Supplement drugs consumed during pregnancy:
1. Folic acid 1x1 tablets (30 tablets).
2. Vit B6 1x1 tablets, (10 tablets).
Inspection History :
1. Date : 15/1/2022, (Midwife Sumiadi, complaints of unwell and late
menstruation, gestational age 9 weeks, body weight: 60 kg, height : 159 cm,
blood pressure: 110/70 mmHg, upper arm circumference 25 cm, height of
uteri fundus: not yet palpable, oedema : (-), supplement: B6 (1x1 tablet) 20
tablets and Folavit (1x1 tablet) 20 tablets. It is recommended to have a blood
check at puskesmas.
2. Date : 29/01/2022, (dr. Rai SpOG), complaints of pain in simpisis, nausea
and vomiting twice a day, gestational age 11-12 weeks, Weight: 60,5 kg, TD:
110/70 mmHg, height of uteri fundus : not yet palpable, recommended for a
one-month re-visit.
History of contraceptive use : Mother says never contraceptives.
Biological needs :
1. Breathing : No complaints
2. Diet: 3 times /day, servings of one plate, composition: half a plate of rice, two
spoonfuls of Japanese vegetables/kale/chickpeas/moringa leaves, two
spoonfuls of chicken comb/sea fish, 2 pieces of omelette, no food abstinence.
3. Drinking pattern: 8 glasses per day
4. Elimination pattern: BAK 5-6 times/day, clear/yellowish, defecation 1-2
times/day yellowish/brownish flaccid properties.
5. Sexual intercourse: the mother says she rarely has sexual relations at this time
but can relate to the husband if the body condition feels good and healthy.
6. Light daily activities, Mother said currently doing household care activities,
such as sweeping, washing, cleaning the house. Mothers say it's rare to go out
of the house, except to go get a pregnancy check-up and buy basic daily
necessities. Mom says she always wears a mask when you're out of the
house.
7. Personal hygiene: Bathing 2 times/day, brushing teeth twice/day, shampooing
3 times/week, taking care of the breasts every bath with soap/not special,
 cleaning the genitals every time defecation, urinating and when bathing,
washing hands every time will be active and finished activities, change
underwear 3 times/day.
Psychological needs :
Mother's feelings towards pregnancy: happy, traumatized in life: mother says no,
consultation with psychological: mother says never.
Social Needs :
Mother's complaints when worshipping do not exist.
Behavior and lifestyle : the mother says there is no deviant behavior and affects
the health of the pregnancy.
History of disease :
1. There is no history of illness ever suffered by the mother.
2. There is no history of illness that is being suffered by the mother.
3. There is no history of declining family diseases.
4. There is no history of gynecological diseases.
Complaints that have been felt :
Mom says Trimester I feels nauseous
Mother's knowledge of pregnancy:
1. Mother says knowing about physical changes during pregnancy
2. Mothers say knowing about nutrients during pregnancy such as eating foods
high in protein and fiber, folic acid vitamins for fetal growth.
3. Mothers say knowing about the need for rest and good sleep patterns during
pregnancy.
4. Mother says knowing about monitoring baby's welfare
5. Mother says knowing about health care during pregnancy

Knowledge of the dangers of pregnancy :

Trimester I :
1. Mother says knowing about severe vomiting nausea early in pregnancy
 2. Mother says knowing about complaints of dizziness and severe headaches in
the I trimester
3. Mother said to know about the condition easily tired

Maternity Planning :
1. Place of delivery: Balimed Hospital
2. Childbirth Helper: Doctor Sp. OG.
3. Transportation to the place of delivery: Car
4. Maternity companion: Husband/Biological mother
5. Methods of overcoming pain: waist massage
6. Main decision makers in childbirth: Mother/Husband
7. Other decision makers if the main decision maker is unable to:
Husband/Family
8. Maternity fund: has not taken care of health insurance
9. Prospective donors: Husband
10. Referral hospital in case of emergency: Buleleng District General Hospital.
11. Caregiver of other children during maternity mother: -
12. Initiation of early breastfeeding: Mothers plan to initiate early breastfeeding
13. Postpartum contraceptives: Hormonal injection 3 months (Depo)
14. Other : None

B. Objective Data
General Inspection
General Circumstances : Good, Consciousness : Compos Mentis GCS : 15, E : 4
V : 5 M : 6.
Weight: 60 Kg, blood pressure: 120/70 mmHg, axillate temperature : 36.6 0C
pulse : 80x/min, respiration : 20x/min.
Posture : Normal
Weight at previous inspection :59,5 kg (18/01/2022)
Pain Assessment
Pain :0
Pain properties :0
Location :-
Pain intensity (0-10) : 0 Physical Examination
Head : Symmetrical
Hair : Clean
Face : Normal
Eyes : Pink conjunctiva, white sclera
Nose : Clean
Mouth : Pink lips
Ear : Clean
Neck :
Normal Lymph nodes, Normal Thyroid Gland, Normal Jugular Vein
Breast :
Symmetrical shape, nipple protruding, no expense, good hygiene
Chest : symmetrical shape
Stomach :
Inspection :-
Palpation :-
Leopold I :-
Leopold II :-
Leopold II :-
Leopold IV :-
Auscultation :-
Other conditions/abnormalities : None
Upper and lower extremities
Hand : Symmetrical, no oedema
Limbs : Symmetrical, no oedema
Patellar Reflex : positive/positive
Varicose veins : None
 Other conditions/abnormalities : none
Special Examination (Not performed)
Genetalia Eksterna
Mons Pubis :-
Labia Mayora :-
Labia Minora :-
Clitoris :-
Other conditions/disorders : -
Genetalia Interna
Vaginal inspection
Pervaginam expenditure : -
Vaginal abnormalities : -
Anus Inspection : -
Supporting Examination Results
Laboratory
Blood type :-
Hemoglobin level :-
Protein Uri :-
Uri Reduction :-
PPIA :-
Sphillis :-
Hb Sag :-

C. Analysis
G1P0A0 gestational age 11 weeks 5 days live intrauterine fetus.

Problem :
1. The mother does not yet know about the dangers of pregnancy I trimester.

D. Management
1. Informing the mother of the results of the examination within normal limits,
the mother understands and accepts the condition well.
2. Requesting the mother's consent for midwifery care, the mother is willing to
be given midwifery care.
3. Providing counseling, information and education about the dangers of
trimester I pregnancy, the mother understands and is able to mention the
dangers of trimester I pregnancy.
4. Providing counseling, information and education to mothers about first aid,
mothers understand and have planned childbirth.
5. Providing counseling, information and education to the mother about sexual
intercourse during pregnancy, the mother understands well.
6. Give the supplement, SF 1x1 mg (30 tablets), and vit C 1x 1(30 tablets), the
mother receives and takes the drug until exhausted.
7. Agreed to another month's re-visit, I understand and will return on April 5th,
2022.
8. Documenting the results of the examination, recorded in the form of SOAP
and recorded in the maternal health book of the child as well as the register of
clinic