mr jaga sabtu 17 mei 2014

Name: Mrs. MAge: 31 yoRM: 538859Adress: LingsarAdmitted: May, 17th 2012 at 22.50

Name: Mrs. MAge: 31 yoRM: 538859Adress: LingsarAdmitted: May, 17th 2012 at 22.50

TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

17/05/201422.50

Patient referred from Sigerongan PHC with G4P3A0L2 40 weeks S/L/ head presentation with arrested active phase first stage of labor. Patient confess Abdominal pain since 03.00 WITA (17/05/14). Bloody slim and water leaked out from her vagina since 14.30 WITA (17/05/14),FM (+).No history of DM, HT, asthma.

LMP: 12/08/2013EDD: 19/05/2014

History of ANC: >4x at PosyanduLast ANC: NormalHistory of USG: -

History of family planning: Injection 3 monthsNext family planning: IUD

Obstetrical history:I.Female, 3200 gram, spontan, aterm, midwife, live 14 yoII.Male , 3100 gram, spontan, aterm, midwife, live 12 yoIII.IUFDIV.This

General status:GC: wellCons: CM/E4V5M6BP: 110/70 mmHgPR: 88 bpmRR: 20 T: 36,5Eye : palor (-), icteric (-)Thorax :Cor : S1S2 single reguler (murmur -), (gallop -)Pulmo : vesikuler (+/+), wheezing (-/-),Ronkhi (-/-).Abdomen : scar (-), striae (+), linea nigra (+)Extremity : edema (-/-), warm acral (+/+)

Obstetrical status:L1: breechL2: back on the right sideL3: headL4: 4/5UFH: 35 cm EFW: 3720 gUC: 3x10’ ~ 30’’FHB: 12-12-12 (144 x/min)VT: Ø 8 cm, eff 80%, amnion (-) clear, head palpable ↓HI, Caput +, denominator unclear, unpalpable small part / umbilical cord.

G4P3A0L2 with S/L/IU with arrested active phase first stage of labor

• Obs mother & fetal well being

• Obs progress of labor• DM co to GP advice

observation for one hour , GP co to SPV advice :

• recutitation• Observation for one

hour• accelelaration if

there isn’t progress


Chronologist at pkm sigerongan:14.30 (17/05/2014)S:Patient 9 month confess Abdominal pain

since 03.00 WITA (17/05/2014) fetal movement (+)

O:GC: wellBP: 110/70 mmHgPR: 80 bpmsRR: 16 T: 37

L1: breechL2: back on the right sideL3: headL4: 4/5UFH: 34 cm UC: 3x10’ ~ 40’’FHB: 12-12-12 (144 x/min)VT : Ø 4 cm, eff 25%, amnion (-), head

palpable ↓HII, unpalpable small part / umbilical cord

A: G4P3A0H2 A/T/L/IU Head presntation with active phase first stage of labor

P: observation mother and fetal well being

Lab:HB: 10,7 g/dl RBC: 3,91 M/dl HCT: 31,7 %WBC: 17,43 K/dlPLT: 247 K/dlHbSAg: (-)Proteinuria: -


18.30 :

S: Patient confessed abdominal pain

O: GC: wellBP: 110/70 mmHgPR: 80 bpmsRR: 16 T: 37 UC: 4x10’ ~ 40’’

VT : Ø 8 cm, eff 25%, amnion (-), head palpable ↓HII, unpalpable small part / umbilical cord

A: G4P3A0H2 A/T/L/IU Head presntation with active phase first stage of labor



20 :30




A: G4P3A0H2 A/T/L/IU Head presntation with arrested active phase first stage of labor



21 :30




A: G4P3A0H2 A/T/L/IU Head presntation with arrested active phase first stage of labor

P: observation mother and fetal well being IVFD RL Prepare for reffered to NTB GH


23.30 Abdominal pain GC: wellBP: 120/70 mmHgPR: 80 bpmRR: 20 T: 36,5UC: 3x10’ ~ 25’’FHB: 12-11-11 (136 x/min)UC : 3x10’~25”

G4P3A0L2 with S/L/IU with arrested active phase first stage of labor


• Obs progress of labor

00.00 Abdominal pain GC: wellBP: 130/100 mmHgPR: 80 bpmRR: 20 T: 36,5UC: 3x10’ ~ 30’’FHB: 12-12-12 (144 x/min)VT: Ø complete, amnion (-) clear, head palpable ↓HI, caput +, denominator unclear, unpalpable small part / umbilical cord.

Second stage of labor


• Obs progress of labor• Suggest mother to eat

and drink

00.30 Abdominal pain GC: wellBP: 110/70 mmHgPR: 80 bpmRR: 20 T: 36,5UC: 2x10’ ~ 25’’FHB: 12-12-11(140 x/min)

Second stage of labor


• Obs progress of labor• Suggest mother to eat

and drink


01.00 Abdominal pain + GC: wellBP: 110/70 mmHgPR: 80 bpmRR: 20 T: 36,5UC: 2x10’ ~ 35’’FHB: 12-11-11 (136 x/min)VT: Ø complete, amnion (-), head palpable ↓HI,caput (+), denominator unclear, unpalpable small part / umbilical cord.

Arrested second stage of labor

DM co to GP advice CS, SPV advice observation for one hour

01..30 Abdominal pain + UC: 2x10’ ~ 30’’FHB: 12-12-11 (140 x/min).



• Obs progress of labor

02.00 Abdominal pain + UC: 3x10’ ~ 40’’FHB: 12-12-13 (148 x/min)


DM co to GP advice CS, SPV advice SC


03.00 SC beganBaby was born :Male, 4000 gram, BL : 50 cm, as: 7-9 anus (+), anomali congenital (-)

Placenta was born manually and complete

05.00 GC: wellGCS: E4V5M6BP: 110/70 mmHgPR: 88 bpmRR: 22 rpm T: 36,80 C

UC (+) wellUFH 2 finger bellow umbilicalActive bleeding (-)

2 hours post partum •Obs. Mother well being•Suggest mother to eat and drink

Baby in NICU


07.00 ( 18/05/2014)

GC: wellGCS: E4V5M6BP: 120/80 mmHgPR: 88 bpmRR: 22 rpm T: 36,80 C

UC (+) wellUFH 2 finger bellow umbilicalActive bleeding (-)Lochea rubra (+)

Baby in NICUGC : wellPR : 132 bpmRR : 44 bpmT : 36,2ºC

One day post CS •Obs. Mother well being•Suggest mother to eat and drink

mr jaga sabtu 17 mei 2014

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