MR 13 of June 2014

Name : Mrs. S
RM : 111987
Age : 21 years old
Address : Batulayar
Admitted : 12 June 2014

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
12/06/
2014
12.30
Patient referred from Meninting
PHC with G1P0A0L0 41-42 weeks
S/L/IU head presentation. Patient
confessed pregnant > 9 month with
no abdominal pain, history of water
came out from her vagina (-), bloody
slim (-), FM (+).
No history of DM, HT, asthma.

LMP : 22/08/2013
EDD: 29/05/2014

History of ANC : 11 x
Last ANC : 10/06/2014; Result: BP :
120/80 mmHg; PR : 80 bpm; RR : 20
bpm
T : 36,5
O
C

History of USG : 12/06/2014
S/L/IU, placenta at fundus gr III;
EFW: 2817

History of family planning: -
Next family planning : injection 3
month

Obstetrical History :
I. This

General Status :
GC : well
BP : 120/80 mmHg
PR : 80 bpm
RR : 20 bpm
T : 36,5
O
C
Eye : anemis (-), icteric (-)
Cor : S1S2 single regular, murmur (-),
gallop (-).
Pulmo : vesicular (+/+), wheezing (-/-),
ronkhi (-/-).
Abdomen : scar (-), striae gravidarum
(+), linea nigra (+).
Extremity : edema (-/-), warm acral
(+/+).

Obstetrical Status :
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH : 31 cm
EFW : 3100 gram
UC : -
FHB : 13-12-13 (152 bpm)
VT : 1 cm, effacement 10%, amnion
(+), head palpable HI, denominator
unclear, impalpable small part and
umbilical cord.
G1P0A0L0 42 weeks
S/L/IU head
presentation
Observation mother &
fetal well being.
DM consult to GP pro
CTG and induction, GP
advice:induction

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
Chronology:
At meninting PHC (12/06/14 at 10.00)
Patient confessed pregnant 9 weeks
with no any complaint. HPHT 22-08-
2013
O: general status: well; BP 120/80; PR:
88 x/m; T: 36
O
C;


Obstetric


L1: breech
L2: back on the left side
L3: head
L4: 4/5


His: (-)
FHB: 136x/minute)

A: G1P0A0H0 41-42 weeks S/L/IU

P: confirmation of pregnancy with USG
Pelvic Evaluation :
Spina ischiadica not prominent
Os coccygeus mobile
Arcus pubis > 90
o

Pelvic Score : 5
Cervix dilatation 1 cm : 1
Cervix length 2 cm : 1
Station H1 : 1
Cervix consistency moderate :
1
Cervix position mid : 1
Lab Evaluation
HB : 10,8 g/dl, RBC : 5,10 M/dl
WBC : 11,28 K/dl, PLT : 351
K/dl, HbSAg : (-)

16.30 UC : -
FHB : 12-12-12 (144 bpm)
Flash I
Drip oxytocin 5 IU in
D5% 500 cc
began at 8 tpm
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
17.00 Abdominal pain came and
relieved
UC : 2 x 10 ~ 25
FHB : 12-11-12 (140 bpm)
VT : 3 cm, effacement 25%,
amnion (+) , head palpable HI,
denominator unclear, impalpable
small part and umbilical cord.
Latent phase 1
st
stage of
labor
Drip oxytocin 12 tpm

17.30 Abdominal pain came and
relieved
UC : 3x 10 ~ 25
FHB : 12-12-12 (144 bpm)
Drip oxytocin 16 tpm
18.00 Abdominal pain came and
relieved, bloody slim (+), water
leaked out from vagina
UC : 4 x 10 ~ 40
FHB : 12-12-12 (144 bpm)
VT : 6 cm, effacement 50%,
amnion (-) clear, head palpable
HI, denominator unclear,
impalpable small part and
umbilical cord.
Active phase 1
st
stage of
labor
Drip oxytocin 20 tpm
18.30 Abdominal pain came and
relieved
UC : 4 x 10 ~ 40
FHB : 12-12-12 (144 bpm)
Drip oxytocin 20 tpm
19.00 Abdominal pain came and
relieved
UC : 4 x 10 ~ 40
FHB : 12-12-12 (144 bpm)
Drip oxytocin 20 tpm
19.30 Abdominal pain came and
relieved
UC : 4 x 10 ~ 40
FHB : 12-12-12 (144 bpm)
Drip oxytocin 20 tpm
20.00 Abdominal pain came and
relieved
In inspection there is head of
baby on vulva 3 cm, anus
pressure, vulva opening,
perineum bulging
2
nd
stage of labor Conduct of labor, perineum
rigidperformed
episiotomy
20.05 Baby was born, male, AS
7-9, 2500 gram, 49 cm,
Anus (+), congenital
anomaly (-)
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
Rupture of perineum
grade IIperformed
hecting perineum
Placenta was born
spontaneous, completed,
bleeding 150cc
22.05 Delivery wound pain GC : well, BP : 110/80 mmHg
PR : 88 bpm , RR : 24 bpm
T : 36,5 C
UC : (+) well
UFH : 2 finger belowumbilicus
Active bleeding : (-)
2 hours post partum Observed mother and
baby well being.
Suggest mother to
mobilization.
13-06-14
07.00
Delivery wound pain GC : well, BP : `110/80 mmHg
PR : 88 bpm, RR : 24 bpm
T : 36,4
0
C
UFH : 2 finger below umbilicus
UC : (+) well
Lochea rubra : (+)
Baby Rooming in:
GC : Well
PR :144 bpm
RR : 46 bpm
T : 36,7
0
C
2 day post partum Observed mother and
baby well being
Suggest mother to
mobilization, eat, and
drink,
Suggest mother to
breast feeding