MIDWIFERY STUDY PROGRAM

MITRA RIA HUSADA

Komplek Yayasan Karya Bhakti RIA Pembangunan
Jl. Karya Bhakti No.3 Cibubur – Jakarta Timur Telp (021) 873 0818, 8775 4573 Fax. 8730818

MEDICAL REPORT

Register Number : 186.2014

Date/Time : January 14, 2015
Place : Sukatani Public Health Center

Biodata Wife Husband

Name : Mrs. W Mr. A

Age : 25 years 27 years
Tribe/Nation : Java/Indonesia Minahasa/Indonesia
Religion : Islam Islam
Last Education : S1 S1
Profession : Housewife Army
Address : Masjid Nurul Falah Street RT 01/06
Phone : 08558867311 089510792782

SUBJECTIVE DATA
1. Current Visit  First Visit  Repeat Visit(*)
Main Complaint
Check pregnant, frequent urination at night

2. Mariage History
Get married once. First married age 24 years. With husband now 1 year old.

3. Menstrual History
Menarche age 12 years. Cycle 28 Day. Regular. Long 7 Day.
Typical blood : Watery. Stench. Flour albus: Yes. Dismenorea : Yes.
Much 45 cc
The first day of the last menstruation October 4, 2014. Estimated deliver July 11, 2015.
Gestational Age 14 Week.

4. History of this Pregnancy

a. ANC History
 ANC since gestational age 9 Week. ANC at Public Health Center
 Frequency : Trimester I 1 time
Trimester II 1 time
Trimester III ........ time
b. First fetal movement at 13 weeks of gestation, fetal movements in the last 24 hours 6 times.

c. Complaint
Frequent urination at night

d. Nutritional Patterns Eat Drink

 Frequency 3 times a day 5 times a day
 Kind rice, vegetable, side dish, fruit water, milk 1 glass a day
 Amount 3 times 1 plate 7-9 glass a day
 Complaint no complaints
Elimination Pattern Defecate Urination
  Frequency 1 times a day 6-8 times a day
 Color blackish yellow clear yellowish
 Smell typical of stool typical urine
 Consistency soft liquid
 Amount medium medium
Activity Pattern
 Daily Activities : washing, cleaning, cooking, reading book
 Rest/Sleep : sleep at 10 pm, wake up at 5 am
 Sexuality : Frequency before pregnancy 2 times a week, after frequency 1
times a week
Complaint: sometimes feel uncomfortable
e. Personal Hygiene
 Bathing Habits 2 times a day
 Habit of cleaning the genitals from front to back
 Habit of changing underwear 2 times a day
 Type of underwear used cotton
f. Imunization
TT 1 Date .......................................... TT 3 Date ..................................................
TT 2 Date .......................................... TT 4 Date ..................................................

5. Past labor and puerperal pregnancy history

G ... P ... A ... Pregnant ........ Week
Labor Childbirth
Pregn Date of Birth Gestation Type pf Complicatons Gender Birth
Complicatio
ant to al age labor Helper moth Baby Weigh Laktation
n
er t
1. This
pregnant

6. History of contraception
Numbe Type of Start wearing Stop/Change ways
r Contraception Date By Place Complaint Date By Place Reason
1. Never
yet

7. Medical history
a. Systemic disease that has been / is being suffered from
Nothing
b. Illness that has been / is being suffered by the family
Nothing
c. Hereditary history of twins
Nothing
d. Habits
 Smoke ... No one smokes
 Drinking herbs ... During pregnancy don’t take herbal medicine
 Alcohol ... No one has ever drank alcohol
 Abstinence from eating/drinking ... Nothing
 Dietary changes (cravings, decreased appetite, etc) ... Feels more eating
8. Psycho-Social-Spiritual state
a. This birth :  Desired(*)  Undesirable
b. Mother’s knowledge of pregnancy and the current state
Mother already understand because every counseling is given by the midwife
c. Acceptance of the mother to her current pregnancy
Mother accepted this pregnancy because it was planned
d. Family responses to pregnancy
Family and husband also accept this pregnancy
e. Obedience in worship
Mother worship on time

OBJECTIVE DATA
1. Physical examination
a. General circumstances : Good Awareness : Composmentis
b. Vital sign
 Blood Pressure : 120/80 mmHg
 Pulse : 87 X/Minutes
 Temperature : 36,5 °C
 Respiration : 20 X/Minutes
c. Height : 165 cm
 Weight : before pregnancy 55 kg, now weight : 60 kg
 LILA : 23,7 cm IMT : 20,2
d. Head and Neck
 Facial Edema : Nothing
 Cloasma gravidarum + / - : Nothing
 Eye : a. Conjungtiva : Pink, not pale
b. Sklera : White, not icteric
 Mouth : Clean, no stomatitis and dental caries
 Neck : No enlargement of the thyroid gland, lymph nodes and jugular veins
e. Breast
 Shape : symmetrical
 Areola mammae : hiperpigmentasi
 Nipple : stand out
 Colostrum : not yet out
f. Abdomen
 Shape : longitudinal
 Scar : nothing
 Striae gravidarum : striae livida
Leopold palpation
 Leopold I : Fundus palpable buttocks
Uterine Fundal Height : 3 fingers above the sympghysis ( 22 Cm)
 Leopold II : right, back
left, extremity
 Leopold III : head presentation hasn’t yet entered the pelvis
 Leopold IV :-
 Osborn test :-
 Estimated fetal weight : 2514 gr
 Auscultation : Punctum maximum lower right
Frequency : 125 X/minutes
g. Extremities
 Edema : nothing
 Varicose veins : nothing
  Patellar reflex : positif
 Nail : short, clean :
h. Genetalia outside
 Chadwick sign : yes
 Varicose veins : nothing
 Scar : nothing
 Bartholini’s Gland : no infection
 Spending : nothing
i. Anus (Hemoroid) : nothing

2. External pelvic examination (if needed)

 Dystantia spinarum : .......... cm
 Dystantia cristarum : .......... cm
 Boudeloque : .......... cm
 Hip circumference : .......... cm

3. Supporting investigation
a. Blood :
 Hb : 11,5 gr%
 Blood type :A+
b. Triple Elimination
 HBsAg :-
 HIV/AIDS :-
 Syphilis :-
c. Urine
 Protein : Negatif
 Glucose : Negatif
d. Ultrasound results :-

ASSESMENT
Mother : G1 P0 A0 pregnancy 14 week
Fetus : Single, Intra-Uterine life, Head Presentation

PLANNING
January 14, 2015 at 10.20
1. Deliver the results of the examination that the mother and fetus are in good health.
Evaluation: Mother feels happy knowing the condition of her pregnancy.
2. Inform the mother about the danger signs of pregnancy such as bleeding, severe abdominal
pain, severe dizziness accompanied by pain, and so on and tell the mother to have it checked
immediately if you experience the above.
Evaluation: The mother understands the danger signs in pregnancy and will check if she
experiences them.
3. Providing IEC regarding nutritious food for pregnant women and beneficial for the fetus.
Evaluation: Mother already understands and increases the variety of her diet.
4. Encourage mothers and husbands to read and study the MCH handbook provided so that the
mother's knowledge about pregnancy increases.
Evaluation: Mother will often read the MCH booklet at home.
5. Provide vitamins in the form of folic acid for the intelligence of the baby and Fe tablets to meet
the daily iron needs of the mother to prevent anemia with the rule of 1 time a day with water.
Evaluation: Mother will take vitamins and Fe tablets according to the drinking rules.
6. Notify the mother for pregnancy control in 1 month or if she feels any complaints or problems.
Evaluation: Mother knows when to return to the midwife for control.
7. Encourage mothers to reduce drinking at night and drink more during the day and remind
mothers to pee before bed.
Evaluation : Mother already understands well

((TTD and name of midwife who took action))

(Wahyu Kusuma Dewi, S.Tr. Keb)