Name: Mrs.

H J
Age: 31 yo
Adress: Narmada
Admitted: May, 27th 2012 at 22.55

TIME

SUBJECTIVE

27/05/
2012
22.55

Patient referred from Narmada

PHC with G1P0A0 38-39
weeks/T/H/IU inpartu latent
phase 1st stage of labor with
severe preeclampsia. Patient
confessed abdominal pain
that spread to frank since
17.00 (26/05/2012). Bloody
slim (+). History rupture of
membrane (-), FM (+).
No history of nausea,
vomiting, headache, visual
disturbance and epigastric
pain.
No history of DM, HT, asthma.
LMP: 27/08/2011
EDD: 04/06/2012
History of ANC: >4x at PHC
Last ANC: 27/05/2012
History of USG: History of family planning: Next family planning: Injection
3 months
Obstetrical history:
I.This

OBJECTIVE
General status:
GC: well
BP: 140/90 mmHg
PR: 88 bpm
RR: 24
T: 36,2
Eye : palor (-), icteric (-)
Thorax :
Cor : S1S2 single reguler
(murmur -), (gallop -)
Pulmo : vesikuler (+/+),
wheezing (-/-),
Ronkhi (-/-).
Abdomen : scar (-), striae (+),
linea nigra (+)
Extremity : edema (-/-), warm
acral (+/+)
Obstetrical status:
L1: breech
L2: back on the right side
L3: head
L4: 4/5
UFH: 28 cm
EFW: 2635 g
UC: 2x10 ~ 30
FHB: 12-12-13 (148 x/min)
VT: 3 cm, eff 25%, amnion
(+), head palpable HI,
denominator unclear,
impalpable small part /
umbilical cord.

ASSESTMENT

PLANNING

G1P0A0L0 39
weeks/S/L/IU
latent phase 1st
stage of labor
with gestational
hypertension

Obs mother & fetal

well being
DM co to SPV,
advice:
- Obs progress of
labor
- Infus RL without
MgSO4

TIME

SUBJECTIVE
Chronologist:
At Polindes 21.00 (27/05/2012)
S: Patient confessed abdominal pain
that spread to frank.
O:
GC: well
BP: 160/110 mmHg
PR: 80 bpm
RR: 20
T: 36,5
Head presentation, back on the right,
4/5
UFH: 29 cm
UC: +
FHB: 12-12-11 (140 x/min)
VT: 3 cm, eff 25%, amnion (+), head
palpable HI, impalpable small part /
umbilical cord.
Proteinuria +2
A:
G1P0A0 38-39 weeks/T/H/IU inpartu
latent phase 1st stage of labor with
severe preeclampsia.
P:
Infus RL
MgSo4 40% bolus
Reffered to Narmada PHC
At Narmada PHC 21.45
(27/05/2012)
S: Patient confessed frank pain & lower
abdominal pain since 17.00
(27/05/2012) with bloody slim (+).
No history of nausea, vomiting,
headache, visual disturbance and
epigastric pain. FM (+).
O:
GC: moderate

OBJECTIVE
Lab:
HB: 11,9 g/dl
RBC: 4,39 M/dl
WBC: 12,62 K/dl
PLT: 361 K/dl
SGOT: 16 mg/dl
SGPT: 12 mg/dl
Creatinin: 0,6 mg/dl
Ureum: 13 mg/dl
HbSAg: (-)
Proteinuria: -

ASSESTMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMEN
T

PLANNING

UFH: 28 cm
UC: 2 x 10~ 35
FHB: 12-12-11 (140 x/min)
22.00
VT: 3 cm, eff 25%, amnion (+), head
palpable HI, denominator unclear,
impalpable small part / umbilical cord.
A:
G1P0A0 38-39 weeks/T/H/IU inpartu latent
phase 1st stage of labor with severe
preeclampsia.
P:
co to GP:
-MgSO4 40% 28 tpm
-Nifedipine 10 mg
reffered to NTB GH
28/05/
2012
02.55

Patient confessed abdominal pain

UC: 2x10 ~ 20
FHB: 12-12-11 (140
x/min)
VT: 3 cm, eff 25%,
amnion (+), head
palpable HI,
denominator unclear,
impalpable small part /
umbilical cord.

03.25

Patient confessed abdominal pain came &

relieved

UC: 2x10 ~ 30
FHB: 12-12-11 (140s
x/min)
VT: 8 cm, eff 75%,
amnion (+), head
palpable HI,
denominator LOT,
impalpable small part /

G2P0A1L0
A/S/L/IU with
arrested
active phase
1st stage of
labor.

Obs mother
& fetal well
being
DM co to
SPV, pro SC;
SPV acc SC
at 07.30
Prepare SC

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

09.50

PLANNING
SC began
Female, W : 2900
gram, BL: 48 cm, AS
7-9
Anus (+), Congenital
anomali (-),
Plasenta was born
manually, complete
Bleeding 300 cc

11.50

GC: well
Cons: CM
BP: 110/70
HR: 84 bpm
RR: 20 tpm
T: 36 C
UC: +
UFH: at umbilicus
AB: -

2 hours post SC

Observed mother
and baby well being
Suggest mother to
mobilization.

29/05/
2012
07.00

GC: well
Cons: CM
BP: 110/80
HR : 82
bpm
RR : 20 tpm
T:
36,2 C
UFH : 1 finger below
umbilicus
UC : +
AB : -

1 day post SC

Observed mother
and baby well being
Suggest mother to
mobilization, eat,
and drink,
medication.

Baby in NICU:
PR:144
RR: 46
T: 36,4