Case Report

Name : Mrs. M
RM : 506720
Age : 39 years old
Address : Batu Layar
Admitted : February 01th 2013 (14.30)
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

01/03/13 Patient came to NTB GH referred from General Status : G4P3A0L3 36 - 37 Observation mother &
Meninting PHC with G4P3A0L3 36 - GC : Well weeks /S/L/IU head fetal well being.
14.30 37 weeks /S/L/IU head presentation GCS : Compos Mentis presentation with Check CBC, HbsAg,
with active phase 1st stage of labor + BP : 160/100 mmHg active phase 1st Observation proggres
hypertension in pregnancy + history of PR : 84 bpm stage of labor + of labor with partograf
DM. RR : 22 tpm hypertension in
Patient confessed history rupture of T : 36,8oC pregnancy + history
membrane (+) and intermiten of ROM
abdominal pain (+) since 13.00 Eye : anemis (-/-), icteric (-/-)
(01/03/13), bloody slime (+) FM (+). Cor : S1S2 single regular, murmur (-),
No history of HT, asthma. DM (+) for gallop (-).
3 years. Pulmo : vesicular (+/+), wheezing (-/-
), ronkhi (-/-).
LMP : 17-06-2012 Abdomen : scar (-), striae gravidarum
EDD : 24-03-2013 (+), linea nigra (+).
Extremity : edema (-/-), warm acral
History of ANC : >4x at PHC (+/+).
Last ANC : 27-02-2013
History of USG : - Obstetrical Status :
History of family planning : - L1 : breech
Next family planning : injection 3 L2 : back on the left side
month L3 : head
L4 : 4/5
Obstetrical History : UFH : 30 cm
I. Female, aterm, RSUD, midwife, EFW : 2940 gram
2700 g, dead at 7 months. UC : 3x10~40
II. Male, aterm, home, traditional FHB : 144 x/minute
birth attendance, 12 yo
III. Male, aterm, home, traditional VT : 4 cm, eff 50 %, amnion (-),
birth attendance, 9 yo head presentation, denominator UUK,
IV. This head palpable at HI, impalpable small
part and umbilical cord.
Time Subjective Objective Assessment Planning
Chronologist at Meninting PHC. Lab Examination :
(01/03/2013 at 13.30) HGB: 10,5 g/dl
Subjective RBC : 3,66 x 106/L
Patient came with her 4th pregnancy, HCT : 35,5 %
confessed history rupture of membrane (+) WBC : 6,7 x 103/L
and intermiten abdominal pain (+) since PLT : 151 x 103/L
13.00. HbSAg : (-)

Objective
BP : 150/100
HR : 88 x/mnt
T : 36,5
RR : 24 x/mnt
Head 2/5
UFH : 35 cm
EFW : 3720 g
UC : 3x10~40
FHB : (+) 140 x/mnt
VT : 4 cm, eff 50 %, amnion (-), head
presentation, denominator UUK, head
palpable at HII, impalpable small part and
umbilical cord
Lab 30/01/13
Hb 8,8
proteinuri (-)

Assessment
G4P3A0L3 36 - 37 weeks /S/L/IU head
presentation with active phase 1st stage of
labor + hypertension in pregnancy + history
of DM.

Planning
IVFD RL 28 dpm
Referred to Mataram GH
Time Subjective Objective Assessment Planning
18.30 Abdominal pain came often GC: well G4P3A0L3 36 - 37 Observation mother & fetal
BP: 150/100 mmHg weeks /S/L/IU head well being.
PR: 88 bpm presentation with Observation proggres of
RR: 22 tpm active phase 1st stage labor with partograf
T: 36 C of labor + DM co to GP. GP advice :
UC : 3x10~45 hypertension in nifedipin 10 mg
FHR : 148 x/mnt pregnancy + history
VT : 8 cm, eff 50 %, amnion (-), of ROM
head presentation, denominator UUK,
head palpable at HII, impalpable small
part and umbilical cord
18.45 Mother wants to bearing down UC : 4x10~45 2nd stage of labor Conduct mother to bearing
FHR : 136 x/mnt down
Teknus Perjol Vulka
Head seen at vulva 5 cm
18.55 Baby was born, male, BW
2600 g, BL 48 cm, anus (+),
congenital anomaly (-)
19.25 Placenta wasnt born yet after 30 Retencio placenta DM co to GP pro
minutes (after 2x oxytocin injection). hysterectomy. GP co to SPV,
Manual placenta FAILED. advice hysterectomy at
22.00.
UC (+) well CIE patient and family, then
UFH at umbilicus prepare for hysterectomy.
22.30 UC (+) well Retencio placenta At operating room, SPV tried
UFH at umbilicus manual placenta and success.

UC (+) well
UFH 1 finger below
umbilicus
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
02/03/ GC : well One day post Observed mother and baby
2013 BP : 110/70 mmHg partum well being
PR : 84 bpm Suggest mother to
07.00 RR : 20 bpm mobilisation, eat, and
T : 36,40C drink, medication.
UFH : 3 finger below umbilicus
UC : (+) well
Lochea rubra : (+)

Baby rooming in:

GC : well
PR : 140 bpm
RR : 40 bpm
T : 35,7OC
03/03/ GC : well 2 days post Observed mother and baby
2013 BP : 120/80 mmHg partum well being
PR : 80 bpm Suggest mother to
07.00 RR : 20 bpm mobilisation, eat, drink,
T : 36,50C and medication.
UFH : 3 finger below umbilicus
UC : (+) well
Lochea rubra : (+)

Baby rooming in :
GC : well
PR : 144 bpm
RR : 36 bpm
T : 35,9OC