Name

RM
Age
Address
Admitted

: Mrs. A
: 039841
: 27 years old
: Kayangan, KLU
: June 2nd 2012

TIME

SUBJECTIVE

02/0
6/20
12

Patient referred from

Kayangan PHC with
G2P1A0L1 S/L/IU, mother
& fetal well, with latent
phase 1st stage of labor
and breech presentation.
Patient confessed
abdominal pain that
spread to frank since
06.00 (02/06/12). Bloody
slim (+) since 06.00
(02/06/12). History
rupture of membrane (-),
FM (+).
No history of DM, HT,
asthma.

16.00

LMP : -/09/2011
EDD : -/06/2012
History of ANC : > 4x at
Posyandu
Last ANC : 24/05/2012
History of USG : 1x
(03/05/2012)
Result : S/L/IU, EFW 1488
gram, plasenta anterior
grade II, amnion (+),
EDD 12/07/2012.
History of family

OBJECTIVE
General Status :
GC : well
BP : 120/100 mmHg
PR : 78 bpm
RR : 20 bpm
Temp : 35,4oC
Eye : palor -/-, icteric -/Cor : S1S2 single reguler,
murmur (-), gallop (-).
Pulmo : vesikuler (+/+),
wheezing (-/-),
ronkhi (-/-).
Abdomen : scar (-), striae
(+), linea nigra (+).
Extremity : edema (-/-),
warm acral (+/+).
Obstetrical Status :
L1 : head
L2 : back on the left side
L3 : breech
L4 : UFH : 31 cm
AC : 87 cm
EFW : 2697 gram
UC : 2x10 ~ 25
FHB : 12-12-12 (144 bpm)

ASSESSMENT

PLANNING

G2P1A0L1 S/L/IU
with latent
phase 1st stage
of labor &
breech
presentation

Observation
mother & fetal
well being.
Observation
progress of
labor
Consult to GP,
advice :
observation.

TIME

SUBJECTIVE

02/0
6/20
12

Obstetrical History :
1.Male, aterm, spontan,
breech presentation,
2600 gram, midwife, age
5 years old, life.
2.This

12.00

OBJECTIVE
VT : 2 cm, effacement
25 %, amnion (+), breech
palpable HI, denom left
of anterior sacrum,
impalpable small
part/umbilical cord.
ZA score : 6
Multigravida (1)
Gestation age: < 37
weeks (2)
History of breech
presentation : 1x (1)
EFW : < 3176 g (2)
2 cm (0)
Station : < -3 (0)
Lab Examination :
HB : 11,0 g/dl
RBC : 3,84 x 106/L
WBC : 11,6 x 103/L
PLT : 359 x 103/L
HCT : 30,9 %
HbSAg : (-)

ASSESSMENT

PLANNING

TIME

SUBJECTIVE
Chronologist :
09.00
S : Patient came to
Kayangan PHC with
abdominal pain that
spread to frank since
06.00 (02/06/12).
Bloody slim (+) since
06.00 (02/06/12).
History rupture of
membrane (-), FM (+).
O:
GC : well
BP : 100/70 mmHg
PR : 80 bpm
RR : 20
Temp : 36,5oC
L1 : head
L2 : back on the left side
L3 : breech
L4 : UFH : 31 cm, AC : 89 cm
EFW : 2759 gram
FHB : 12-11-11 (136
bpm)
VT : 2 cm, effacement
25 %, amnion (+),
breech palpable,

OBJECTIVE

ASSESSMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

G2P1A0L1 S/L/IU
with latent phase 1st
stage of labor &
breech presentation

Observe
mother & fetal
well being
Skin test (-),
Inj. Ampicillin
1 g IV
Infuse D5
GP consult to
SPV, advice :
C-section at
22.00
CIE patient &

A : G2P1A0L1 S/L/IU,
mother & fetal well, with
latent phase 1st stage of
labor & breech
presentation.
P : Consult to GP was
advicing to :
Obs. mother & fetal well
being
Infuse RL (28 tpm)
Refer to NTB GH at
15.00
18.00

(-)

GC : well
BP : 110/80 mmHg
PR : 80 bpm
RR : 20 bpm
Temp : 36,7oC
UC : 2x10 ~ 25
FHB : 12-12-12 (144
bpm)

TIME
19.45

SUBJECTIVE
Patient confessed
water came out from
her womb

OBJECTIVE
GC : well
BP : 110/80 mmHg
PR : 80 bpm
RR : 20 bpm
Temp : 36,7oC
UC : 2x10 ~ 25
FHB : 12-11-11 (136
bpm)

ASSESTMENT

PLANNING

G2P1A0L1 S/L/IU
with latent
phase 1st stage
of labor, breech
presentation,
and history of
rupture
membrane.

Observe mother &

fetal well being.

VT : 3 cm,
effacement 25 %,
amnion (-), foot
palpable HI,
impalpable umbilical
cord.
23.00

C-section began
Baby was born :
Female, AS: 7-9,
BL: 46 cm, BW:
2300 gram.
(+),
Anus
congenital
anomaly
(-),
amnion (-).
Placenta was born
manually,
complete, bleeding
300 cc.
Placenta weight :

TIME
03/0
6/20
12

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

Patient confessed
wound pain.

GC : well
BP : 110/80 mmHg
PR : 72 bpm
RR : 24 bpm
T : 36,5oC
UFH : 2 finger below
umbilicus
UC : (+)
Active bleeding : (-)
Urine output : 280
cc/2 h
Operation wound good

2 hours post CS

mother
Observe
well being.
CIE mother to take
a rest.
Medication :
Infuse D5:RL = 3:1
Injection Ampicillin
1 gram IV
Inj. Ketorolax

Patient confessed
wound pain

GC : well
BP : 110/80 mmHg
PR : 72 bpm
RR : 24 bpm
T : 36,5oC
UFH : 2 finger below
umbilicus
UC : (+)
Active bleeding : (-)
Urine output : 280
cc/2 h
Operation wound good

One day post CS

Observed mother
and baby well
being
Suggest mother to
mobilisation, eat,
and drink,
medication.
Breast feeding

01.20

08.00