MIDWIFERY CARE OF MRS. “A” 24 Y.

O G1 P0000 36 WEEKS GESTATIONAL AGES

CEPAL PRESENTATION U LEFT BACK POSITION SINGLE LIVING FETUS
INTRA UTERINE WITH MILD ANEMIA

IN SUB UNIT OF PUBLIC HEALTH CENTRE OF WEST DENPASAR

Members Of Group :

1. Ni Made Dwi Ari Murtini P07124017001

2. Ni Ketut Sri Wahyuni P07124017002
3. Putu Cindy Anitya P07124017005
4. Putu Meidiana Karmilasari P07124017007
5. Ida Ayu Putu Manik Sulistyawati P07124017008
6. I Dewa Agung Ayu Intan Krisnadevi P07124017013
7. Komang Arselin Kesariana P07124017015
8. Ni Luh Anik P07124017016
9. Ni Nyoman Ayu Trisna Sari P07124017021
10. Ni Luh Ari Safitri P07124017028

MINISTRY OF HEALTH OF R.I

POLITECNIC OF HEALTH OF DENPASAR
MIDWIFERY DEPARTEMENT
2019
 Mrs. "A" came to the Dauh Puri Public Health Center in West Denpasar with complaints
of dizziness, fatigue, dizzy eyes and drowsiness. Mother said complaints that were felt to
interfere with daily activities including rest. Mother said this was the first pregnancy and never
had a miscarriage.

1. Data Assessment

Day / Date: Monday, 9 April 2018

Hours: 10:00 AM

NO. RM: 12345

Visit: Repeat

Companion: Husband

Data Source: Patient

A. Subjective Data
1. Identity

Wife husband

Name : Mrs. A Mr. N

Age : 24 years 25 years

Ethnic / :
NationJavanese Indonesian Javanese Indonesian

Religion : Islamic Islamic

Education : High school High school

Occupation : House wife Private workers

Home address : Jl. Nangka Selatan No 56, Denpasar

2. Reasons come

Mothers want to do routine pregnancy checks and laboratory examinations

3. Main Complaints

Mother said that mothers complain often feel dizzy, easily drowsy, and often get tired
when hava her daily activities since a week ago

4. Pregnancy History Now

1. Menstrual history

Menarche : 14 years

Cycle : 28 Days

Duration : + 7 days

Number : 3 x Change pads/day

Blood Properties : Dilute

Menstrual complaints: Never

2. Pregnancy history now

HPHT : 31 July 2018 TP: 7 May 2019

Pregnancy to : I (first)

Start sensing the fetal movement : 16 weeks gestation

3. This pregnancy history

During this pregnant mother checked as much as 4 x in midwives get a given

suplement; Antacid, B compleks, Vitamin B6 drunk 3 x 1/day, SF 1 × 1, Vit C,
B compleks, B12, B6 drunk 3 x 1/day, calcium drunk 3 x 1/day.

5. Social history

a. Marital Status : Yes

Age of marriage : 22 years

The Age of Marriage : + 2 years

Number of marriage : I (first)

6. Pregnancy history, childbirth and pos childbirth : No Complaints that are felt:

a. Trimester 1 : Nausea, dizziness

b. Trimester 2 : No

c. Trimester 3 : Dizziness, fatigue, leg cramps, back pain

7. Health history

a. Maternal health history

Mothers have never suffered from chronic and infectious diseases such as cough,
asthma, hypertension, diabetes and others.

b. Family Health History

From the family nobody suffered chronic and infectious diseases such as cough,
asthma, high blood, diabetes and others.

8. Kontraceptions History

Mothers have never used contraceptives since getting married.

9. Bio Psychological Data and Spiritual

a. Nutritional patterns

a) Types of food : rice, side dishes, green vegetables, fruits. Serves: 1

Platter of rice, vegetable bowl and a slice of fish. Frequency: 2 x a day.
b) Abstentions : None
c) Drinking pattern : 12 cups/day , type : White water, milk, juice
b. Hygiene pattern
a) Bathing frequency : 2 x a day
b) Tooth Rub Frequency : 3 x Daily
c) Frequency of change of clothing : 2 x a day
d) Shampooing : 2 x a week
e) Caring for Breasts : 2 x a day
f) Hand Wash : 6-7 x a day
c. Pattern activity

Mothers do not do daily activities as housewives like washing and cleaning the house
because often feel lethargic, giddy and quickly tired.
d. Elimination pattern

Pass Bowel

Frequency : 1 x a day

Color : blackish

Problem : None

Pass Urine

Frequency : 4 – 5xday

Color : Yellow

Smell : Ammoniac

Problem : None

e. Sleep patterns and breaks

Afternoon nap : 2 hours/day (13.00 – 15.00 Wita)

Night sleep : + 8 hours/day (22.00 – 05.00 Wita)

Problem : Fast tired and sleepy

f. Fetal movement has been perceived 10-20x/24 hours

g. Smoking, drinking-liquor, illegal drugs: never

h. Plan for the maternity place

Venue: Private Midwife Clinic

Assistant: Midwives

i. Sexual intercourse: no complaints.

j. Psychological Data

Mothers, husbands and other families feel worried about the situation now and support
this pregnancy and are expecting the presence of its first child, while the usual decision-
making in the family is husband. Mother and husband have prepared the preparation
needs of childbirth.
 k. Spiritual Data

Mothers perform prayers 5 times regularly according to religious teachings and

actively follow the event of study.

l. Socio-cultural Data

Nothing.

m. Knowledge of Mothers:

Mothers are not aware of any signs of danger when pregnant but are aware of physical
changes during pregnancy, maintaining nutritional patterns and resting patterns.

B. Objective Data

1. Physical examination

General examination

General circumstances : Good Consciousness: Compos mentis

Vital Signs

Blodd pressure : 90/70 mmHg

Temperature : 37oC

HR : 80 x/minute

RR : 24 x/min

Weight before pregnancy : 45 Kg while pregnancy : 53 Kg

Height : 155 cm

Upper Armband : 24cm

2. Physical examination

A. Inspection

Hair : Straight hair, black, no loss, and no dandruff

Advance : No Odema, no cloasma gravidarum

 Eyes : Symmetrical, Conjujngtiva looks pale/anemia, skelera not
ikterum

Mouth : Lips look pale, no fluid or dirt is visible.

Neck : No swelling of the lymph glands, no enlargement of the goiter

glands, no jugation of the jugularis veins.

Breast : Symmetrical both, prominent Mammae papillae, Brown

mammae areola, no abnormal bumps.

Abdominal : The stomach is enlarged according to the age of pregnancy 36

weeks no scar surgery.

Extremities : On both legs and hands are not varicose veins and do not look
pale.

B. Palpasi

Head or face : there is no an Abnormal lump

Neck :there is no enlargement of the thyroid gland and jugular vein

widening.

Breast : there is no an abnormal lump, and no discharge/colostrum and no

pain.

Abdominal

-Leopold I :Fundus’s height 2 finger under the umbilical, palpable flabby

rounded (28 cm) with a butt on the top of the fundus.

-Leopold II : The left part of the mother's stomach is hard, flat, and elongated,
and the right part of the mother's stomach is a small part of the
fetus’s body (extremities)

-Leopold III : At the bottom of the hard-bouncy part (presentation) head at the
bottom.

-Leopold IV : At the lower side of the fetus forms convergent

Interpretation of Fetus’s Weigh: 3720 grams

Genetalia : Normal, no varicose veins and no swelling , no discharge

Extremities : On the hands and feet are not palpable swelling

 C. Auskultasi

Chest : Normal Heartbeat (80 x/min).

Abdominal : Fetus’s Heartbeat (+) Frequency 132 x/min, the fetus’s HR is

regular and strong on the left, there is a noisy bowel.

D. Lower Extremities

Leg shape : normal

Patella reflection : Right/Left (+/+)

Skin : Normal

Varicose veins : None

Odema : None

3. Supporting Examination (date: 22-01-2018)

Laboratory

Hb : 9.0 gr%
VDRL : NR
Urine proteins : (-)
HBsAg : NR
Urine reduction : (-)
VCT : NR
Blood type :A

Ultrasound : Not done

II. ASSESMENT

Mrs. “A” 24 Y.O G1 P0000 36 Weeks Gestational Ages Cepal Presentation U Left Back
Position Single Living Fetus Intra Uterine With Mild Anemia
III. PLANNING

1. Establishing good relations and mutual trust between midwives and mothers, namely to
be friendly, polite, and listened to all complaints from mothers. There is a good
relationship between mothers and believers.
2. Tell the results of the tests that have been done are Blood pressure: 90/60 mmhg, HR: 80
x/min, RR: 24 x/min, S: 37oc, Weight: 53 kg, and gestational ages are 36 week, Fundus
heigh 2 fingers below PX , Fetus’s HR (+) 132 x/min. Mothers already know the results
of the examinations that have been notified.
3. Explaining to the mother the main causes of anemia are :
a. Less consume the nutritious foods, especially iron nutrition
b. Presence of interference in the absorption of iron in the intestines
c. Needs of nutrition is increase while pregnant
d. Loss of iron due to bleeding
4. Explaining to the mother the influence of anemia to mother and fetus
a. To the mother
a) Bleeding
b) Easy infection
c) Abandoned childbirth (old)
d) Retensio placenta
b. To the fetus
a) Miscarriage
b) Fetal death in the womb
c) Low Birth Weight
d) Premature
e) Easy infection
f) IUGR
g) IUFD
5. Explaining how to drink a iron tablet correctly, that is drunk with water or orange juice to
help its absorption. Don’t suggest to drink with tea or coffee because it will interfere the
absorption. Drunk at night before bedtime to reduce nausea feeling. Taken 2 times daily
for 1 month and 1 tablet every day in the following month. The mother already
understands and promises to drink the iron tablets properly.
6. Explain the side effects of consuming iron tablets is the feces into black but it is normal,
feels nausea after consuming then preferably consumed before bedtime at night. Mothers
already understand about the side effects of the iron tablets.
7. Provide vitamins to reduce nausea that is Vit. B6 is drunk 1x a day, vitamins to reduce
fatigue and appetite B complex 3x a day. Mothers are already getting the appropriate
vitamins.