Name

Age
Address
Admitted
RM

: Mrs. K
: 21 years old
: Pemenang
: 4th of March 2016
: 576319

TIME

SUBJECTIVE

04/04/201
6
22.30

Patient referred f rom KLU GH

with G1P0A0L0 S/L/IU, head
presentation, mother and fetal
not in good condition with
latent phase of labor +
umbilical cord prolapse + fetal
distress. Patient confessed
abdominal pain since 20.00
(03/04/2016).) water leaked out
from her womb since 13.00
(04/2016), bloody slime (+)
12.00 (04/04/2016), FM (+).
History of DM (-), HT (-),
asthma (-) and allergy (-).
LMP : 23/06/2015
EDD : 30/03/2016
GW : 40-41 weeks
History of ANC : 7x at posyandu
last ANC 10/03/2016 BP 100/60
mmHg, BW 51 kg, 37-38
weeks, UFH 28 cm, FHB (+)
History of USG : 1x at Sp.OG
Last USG 21/03/2016
BPD : 35-36 weeks
Placenta at fundus corpus
anterior/ gr III / amnion enough,
EDD 3048 gram
History of family planning: Next family planning : injection

OBJECTIVE
General status
GC : well
consciousness: CM
BP : 120/70 mmHg
PR: 76 bpm
RR: 24 bpm
T: 36,5 C
Local status
Eye : an (-/-), ict (-/-)
Pulmo : ves (+/+), rh (-/-), wh
(-/-)
Cor : S1S2 single regular, m
(-), g (-)
Abd : striae gravidarum (+),
linea nigra (+), scar (-)
Ext : edema (-/-), warm acral
(+/+).
Genitalia : umbilical cord
prolapse
Obstetric status
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH: 29cm
EFW : 2790 gr
UC : 4x10~40
FHB : 13-13-13 (156 bpm)
VT : 8 cm, eff 75%, amnion
(-) clear, HII, head palpable,
umbilical cord palpable.

ASSESSMENT

PLANNING

G1P0A0L0 40-41
weeks S/L/IU, head
presentation, with
active phase of labor
+ umbilical cord
prolapse

DM planning:
Diagnostic planning
Check CBC, HbsAg,
BT, CT
CTG
Therapy :
Obs. progress of
labor
Obs. Mother and
fetal well being
Suggest mother to
lie down the left side,
Inj Ampicillin 2 gr IV
Menahan kepala
Pro termination with
C-section
DM co GP, GP co to
SPV , SPV advice :
Pro termination with
c-section

SUBJECTIVE
Obstetrical history
I. This

OBJECTIVE
Lab :
HB 12,6
RBC 4,00
HCT 37,1
WBC 23,3
PLT 343
PPT 12,4
APTT 29,3

ASSESSMENT

PLANNING

SUBJECTIVE
14.30

Choronology at Sancong PHC

04/04/2016
S/ Patien 9 month pregnancy
confessed abdominal pain since
20.00 (03/4/2016), water leaked
out from her womb (+) since
13.00 (04/04/2016), bloody slim
(+), fetal movement (+)
O/GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 80 bpm
RR: 20 bpm
T: 36,7C
UFH : 30cm
EFW : 2945 gram
Breach on fundus, back on the
left side, 4/5
UC : 3 x10~20
FHB : 144 bpm
VT : 4cm, eff 50%, amnion
(+), head palpable, HII,
umbilical cord palpable
A/ G1P0A0H0 gw 41 weeks
S/L/IU head presentation
mother and fetal in good
condition with inpartu active
phase of labour
P/ Obs. progress of labor
Obs. Mother and fetal well
being

OBJECTIVE

ASSESSMENT

PLANNING

SUBJECTIVE
18.30

S/ patient confessed abdominal

pain more
O/GC : well
consciousness: CM
BP : 110/80 mmHg
PR: 80 bpm
RR: 20 bpm
T: 36,5C
UC : 4 x10~45
FHB : 145 bpm
VT : 5 cm, eff 50%, amnion
(+), head palpable, HII, denom
ROA, umbilical cord palpable
A/P/-

19.30

S/ patient confessed abdominal

pain more
VT : 6-7 cm, eff 70%, amnion
(+), head palpable, HII, denom
ROA, umbilical cord palpable
A/P/ IVFD RL 28 dpm
Referred to KLU GH

OBJECTIVE

ASSESSMENT

PLANNING

SUBJECTIVE
21.00

Choronology at KLU GH
04/04/2016
S/ Patien 9 month pregnancy
referred from Sancong PHC
with umbilical cord prolapse.
Patien confessed abdominal
pain since 20.00 (03/4/2016),
water leaked out from her womb
(+) since 13.00 (04/04/2016),
bloody slim (+) since 14.00, fetal
movement (+)
O/GC : well
consciousness: CM
BP : 100/70 mmHg
PR: 80 bpm
RR: 20 bpm
T: 37C
UFH : 29 cm
EFW : 2790 gram
Breach on fundus, back on the
left side, 4/5
UC : 3 x10~35
FHB : 162 bpm
VT : 5 cm, eff 50%, amnion
(-), head palpable, HII,
umbilical cord palpable
A/P/ O2 4 lpm
Inj Cefotaxim 1 gram
Referred to NTB GH

OBJECTIVE

ASSESSMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

23.00

PLANNING
C-section start
Baby was born at 23.15, male, 3500
gr, A-S 7-9, BL 52 cm, Anus (+),
congenital anomalies (-)
Placenta was born completely at
23.20

01.30

Pain on wound (+)

General status
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 88 bpm
RR: 20 bpm
T: 36,6C
UC : good
UFH : as high as umbilicus
Active bleeding (-)

2 hour post c-section

-Observation mother and baby well

being
- Suggest mother to eat and drink
-Suggest mother to mobilisate if can
-Obs. bleeding

1 day post c-section

-Observation mother and baby well

being
- Suggest mother to eat and drink
-Suggest mother to mobilisate if can
-Obs. bleeding

Baby in NICU
HR : 146x/minute
RR : 44x/minute
T : 36.4oC
06.00

Pain on wound (+)

General status
GC : well
consciousness: CM
BP : 120/80 mmHg
PR: 84 bpm
RR: 20 bpm
T: 36,7C
UC : good
UFH : as high as umbilicus
Active bleeding (-)
Baby in NICU
HR : 140x/minute
RR : 42x/minute
o

SUBJECTIVE
23.00

Mother wants to bearing down

OBJECTIVE
General status
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 88 bpm
RR: 20 bpm
T: 37,5C
FHB (+) 12-13-12
UC : 4x10~40

ASSESSMENT
2nd stage of labor

PLANNING
Conduct of labor
Baby was born by
manual aid at 22.35,
male, A-S 3-5, BW
3450 gr, BL 50 cm,
anus (+), congenital
anomalies (-)
Placenta was born
completely at 22.40,
bleeding 150 cc

00.20

No complain

General status
GC : well
consciousness: CM
BP : 110/80 mmHg
PR: 84 bpm
RR: 20 bpm
T: 36,6C
UC : good
UFH : 2 fingers below
umbilicus
Avtive bleeding (-)
Baby in NICU
HR : 146x/minute
RR : 44x/minute
T : 36.7oC

2 hours post partum

-Observation mother
and baby well being
- Suggest mother to eat
and drink
-Obs. bleeding
DM co to GP, GP co
SPV
SPV advice : give
antibiotic 1 gr/6 hours

SUBJECTIVE
06.00

No complain

OBJECTIVE

ASSESSMENT

General status
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 88 bpm
RR: 20 bpm
T: 36,5C
UC : good
UFH : 2 fingers below
umbilicus
Avtive bleeding (-)

1 day post partum

Baby in NICU
HR : 144x/minute
RR : 42x/minute
T : 36.7oC

PLANNING
-Observation
mother
and baby well being
- Suggest mother to eat
and drink
-Mobilisation
-Obs. bleeding