Case 1: GPA, ...

years old, gravid - weeks, not in labor/ in labor stage 1 latent phase/active phase, with alive single et!s, intra!terine, head/breech presentation "dentity Name Age Ethnic Religion Occu ation Education $ate o# Admission Ana#nesis o Chie Co#plain o $istory o Present "llness o $istory o Past "llness !istory o# hy ertension denied !istory o# dia%etes mellitus denied !istory o# allergy denied !istory o# asthma denied !istory o# trauma denied o Antenatal ,are AN, - times at mid"i#es/ u%lic health centre : Mrs. : ... years old : Javanese/Sundanese/Batak : Moslem : !ouse"i#e/em loyee : Elementary School/Junior !igh School/Senior !igh School : Octo%er ...th &'() * ukul %r +

o $istory o %enstr!al .atient menarche at - years old Menstrual cycle: Regularly//rregularly0 once a month #or - days0 she changed the dressing ... a day 1irst day last menstrual at --..th &'() o &bstetrics $istory 'o. (ate Gestational Age - "eeks )abor $istory S ontaneous vaginal delivery &. Physical -+a#ination o 4eneral condition o 5evel o# consciousness o 6ital Signs Blood ressure !eart rate Res iration rate 8em erature o Body 9eight o Body !eight General -+a#ination o Eyes : anemic con:unctiva ;/;0 icteric sclera ;/; : mm!g : 7/minutes : 7/minutes : o, : kg : cm : moderately/severely ill : com os mentis *e+ Male/ 1emale ,irth weight grams ,reast eeding 3

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o Mouth o 8hora7 !eart 5ung Mammae o A%domen /ns ection .al ation .ercussion o E7tremities

: "et oral mucous mem%rane

: regular (st and &nd heart sounds0 murmur ; 0 gallo ; : vesicular %reath sounds 3/30 rhonchi ;/;0 "hee<ing ;/; : areola hy er igmentation3/30ni le retraction;/;0 %reast milk;/; : conve70 linea nigra *3+0 striae gravidarum *3+ : su le0 ain on al ation *;+ : tym anic in all =uadrants : "arm on al ation0 edema ;/;0 ,R8 > & seconds0 hysiologic

Auscultation : %o"el sounds *3+0 ... 7 / minute re#le7es 3/3/3/30 athologic re#le7es ;/; &bstetric -+a#ination o 1irst day o# last eriode o 5a%or estimation o 1undal height o 1etal "eight estimation o 1etal heart rate o !is : - times contraction o 5eo old : 5eo old / 5eo old // 5eo old /// 5eo old /6 o .elvic E7amination : : head/%reech : %ack at the right/le#t side : head/%reech : ../? : ...th &'() : ...th &'() : - cm : - grams :-% m er (' minutes *-;-sec+0 mild/moderate/strong

o /ns eculo : "as not er#ormed o 6aginal toucher : vulva and vagina "ithin normal limit0 ortio "as thick/thin and rigid/tender0 cervical o ening - cm0 cervical e##acement -@0 amnion sac *;/3+0 head/%reech resentation0 hodge )aboratory -+a#ination o !emoglo%in o !ematocrit o 5eucocyte o 8rom%ocyte o Blood ty e o Bleeding time o ,lotting time o .lasma glucose C.G : NS8/,S8 -. /A0", ("%A*12"' Partograph 1ltrasonography /orking (iagnosis 4.A0 ... years old0 gravid -;- "eeks0 not in la%or/ in la%or stage ( latent hase/active hase0 "ith alive single #etus0 intrauterine0 head/%reech resentation0 "ith Planning : - g/d5 : ... @ : .../u5 : .''' /u5 : / Rh3 : - minutes : - minutes : - mg/d5

(iagnosis A ter Proced!re Mother : . A 0 - years old0 ost artus matures "ith s ontaneous vaginal delivery and ost hecting "ith indication o# e isiotomy mediolateral/caesarian section indicated %y Ba%y : Male/#emale0 term neonates0 gestational age -;- "eeks according to Ne" Ballard Score0 %irth "eight - grams0 %irth length - cm0 A gar score -/-0 "ith .reat#ent