Name

: Mrs. Salmiah

CTH

: 04 11 - 2008

Age

: 28 years

Pukul

: 06.35 pm

Address

: Gangga-West lombok
Subject

Wakt
u

06.3
5
pm

Patient

refered

by

Gangga

Community Health Center

with
G6P5A0H5
aterm/single/life/intra uterine with
transverse liy presentation.
cronologis :
Patients felt intermitten abdominal
pain and bloody shows since 08.00
am (04-11-2008), then she went to
Gangga
Community
Health
Center at 02.00 pm (04-11-2008).

She didnt feel rupture of amnion

membrane, and the fetal movement
was active. The examination in
Gangga
Community
Center found :

Health

General status : well

BP : 130/90 mmHg
Pulse = 80 x/mnt
RR: 24 x/mnt
Temp = 36C
Fetal heart rate = (+) 134 x/mnt
Uterine fundal length = 32 cm
VT : 2 cm, eff 25 %, amnion

fluid (+).

Object

Assesment

Planning

General status :
General condition: well, conciousness:
CM
Blood presure: 130/100
RR: 20 x/mnt
Pulse :88 x/mnt
T: 36,5 C
Eyes : an(-) ikt (-)
Cor -Pulmo : in normal range

- G6P5A0H5 atermm/
single/life/intra
uterine, footlink
presentation + stage 1
laten fase.

Observation
mother
and fetal well being.
Laboratory
examination : DL, UL,
HBsAg

Obstetric status :
L1 : head
L2 : right back
L3 :breech not entered pelvic inlet yet.
Uterine Fundal Length : 32 cm
Ac: 92
EFBW : 2944 g
His : (+), 2x/10~30
Fetal Heart Rate : 134 x/mnt
VT : 2 cm, eff 50 %, amniotic fluid
(+), footling precentation, descend HI.
ZA score : 4
Lab. result:
HBsAg (-)
Hb : 10
WB = 18.000
PLT = 232.000
HCT =4,23

informed Supervisor :
- advice : observation.

Wakt
u

Subject

Last menstrual period : Estimate of Delivery Date : History of family planning :

injection / 3 months
Family planning : spiral
ANC : routine in public health
center, 9x.
in pregnancys period the body
weight is not enough rise :
9/6-08 = 42 kg
14/7-08 = 43,5
14/8-08 = 44,3
2/9-08 = 45
Obstetric history: now
Obstetric History :
1. L, traditional attenden, 9 years.
2. L, traditional attenden, 8 years.
3. P, traditional attenden, 4,5 years.
4. P, traditional attenden, 3,5 years.
5. P, traditional attenden, 2 years.
6. now

Object

Assesment

Planning

General status :
General condition: well, conciousness:
CM
Blood presure: 130/100
RR: 20 x/mnt
Pulse :88 x/mnt
T: 36,5 C
Eyes : an(-) ikt (-)
Cor -Pulmo : in normal range

- G6P5A0H5 atermm/
single/life/intra
uterine, footlink
presentation + stage 1
laten fase.

Observation
mother
and fetal well being.
Laboratory
examination : DL, UL,
HBsAg

Obstetric status :
L1 : head
L2 : right back
L3 :breech not entered pelvic inlet yet.
Uterine Fundal Length : 32 cm
Ac: 92
EFBW : 2944 g
His : (+), 2x/10~30
Fetal Heart Rate : 134 x/mnt
VT : 2 cm, eff 50 %, amniotic fluid
(+), footling precentation, descend HI.
ZA score : 4
Lab. result:
HBsAg (-)
Hb : 10
WB = 18.000
PLT = 232.000
HCT =4,23

informed Supervisor :
- advice : observation.

Time

Subject

Object

Assesment

Planning

07.00
pm

Pulse = 96 x/mnt
His : 2x/10~20
FHR : 140x/mnt

- G6P5A0H5 atermm/
single/life/intra
uterine, footlink
presentation + stage 1.

Observation mother and fetal

well being.

08.00
pm

Pulse = 96 x/mnt
His : 2x/10~20
FHR : 140x/mnt

- G6P5A0H5 atermm/
single/life/intra
uterine, footlink
presentation + stage 1.

Observation mother and fetal

well being.

09.00
pm

Pulse = 96 x/mnt
His : 2x/10~20
FHR : 140x/mnt

- G6P5A0H5 atermm/
single/life/intra
uterine, footlink
presentation + stage 1.

Observation mother and

fetal well being.

09.30
pm

Pulse = 96 x/mnt
His : 2x/10~20
FHR : 140x/mnt

- G6P5A0H5 atermm/
single/life/intra
uterine, footlink
presentation + stage 1.

Observation mother and fetal

well being.

10.00
pm

Pulse = 96 x/mnt
His : 2x/10~20
FHR : 140x/mnt

- G6P5A0H5 atermm/
single/life/intra
uterine, footlink
presentation + stage 1.

Observation mother and fetal

well being.

10.30
pm

His : (+), 2x/10~30

FHR : 134 x/mnt
VT : 3 cm, eff 50 %,
amniotic fluid (+),
footling precentation,
descend HI.

- G6P5A0H5 atermm/
single/life/intra
uterine, footlink
presentation + stage 1.

Observation mother and fetal

well being.

Time

Subject

Object

Assesment

Planning

11.00 pm

Pulse = 96 x/mnt
His : 2x/10~20
FHR : 140x/mnt

- G6P5A0H5 atermm/
single/life/intra uterine, footlink
presentation + stage 1.

Observation mother and

fetal well being.

11.30 pm

Pulse = 96 x/mnt
His : 2x/10~20
FHR : 140x/mnt

- G6P5A0H5 atermm/
single/life/intra uterine, footlink
presentation + stage 1.

Observation mother and

fetal well being.

12.00 pm

Pulse = 96 x/mnt
His : 2x/10~20
FHR : 140x/mnt

- G6P5A0H5 atermm/
single/life/intra uterine, footlink
presentation + stage 1.

Observation mother and

fetal well being.

05/11/08
01.00 am

Pulse = 96 x/mnt
His : 2x/10~20
FHR : 140x/mnt

- G6P5A0H5 atermm/
single/life/intra uterine, footlink
presentation + stage 1.

Observation mother and

fetal well being.

01.30 am

Pulse = 96 x/mnt
His : 3x/10~20
FHR : 140x/mnt

- G6P5A0H5 atermm/
single/life/intra uterine, footlink
presentation + stage 1.

Observation mother and

fetal well being.

02.00 am

Pulse = 96 x/mnt
His : 3x/10~20
FHR : 140x/mnt

- G6P5A0H5 atermm/
single/life/intra uterine, footlink
presentation + stage 1.

Observation mother and

fetal well being.

Pulse = 96 x/mnt
His : 4x/10~40
FHR : 140x/mnt
VT : 6 cm, eff 75 %, amniotic fluid
(+), footling precentation, descend
HI.

- G6P5A0H5 atermm/
single/life/intra uterine, footlink
presentation + stage 1 active fase.

Observation mother and

fetal well being.

02.30

Time

Subject

Object

Assesment

Planning

03.00
pm

Pulse = 96 x/mnt
His : 4x/10~40
FHR : 140x/mnt

- G6P5A0H5 atermm/
single/life/intra uterine,
footlink presentation +
stage 1.

Observation mother and

fetal well being.

03.30
pm

Pulse = 96 x/mnt
His : 4x/10~40
FHR : 140x/mnt

- G6P5A0H5 atermm/
single/life/intra uterine,
footlink presentation +
stage 1.

Observation mother and

fetal well being.

04.00
pm

Pulse = 96 x/mnt
His : 4x/10~20
FHR : 140x/mnt
VT : completed, eff 100 %,
amniotic fluid (-) clear,
footling precentation, descend
HIII.

- G6P5A0H5 atermm/
single/life/intra uterine,
footlink presentation +
stage II.

Observation mother and

fetal well being.

04.15

His : 4x/10~40
FHR : 140x/mnt

- G6P5A0H5 atermm/
single/life/intra uterine,
footlink presentation +
stage II.

Baby was born with

spontan bracht,
female, 2500 g, body
length 47 cm, AS =
7-9.

04.20
am

Pulse = 96 x/mnt
His : 2x/10~20
FHR : 140x/mnt

- G6P5A0H5 atermm/
single/life/intra uterine,
footlink presentation +
stage III.

Placenta was born

completely, spontan,
weight = 500 g,
umbilical cord length
= 42 cm.

- G6P5A0H5 atermm/
single/life/intra uterine,

Observation mother and

fetal well being.

04.45
am

BP = 150/80
RR= 20 x/mnt

Waktu

Subject

Object

Assesment

Planning

05.00 am

BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Uterus contraction :
well, Fundal uterine
length = 2 finger below
umbilical
Bleeding = -

Fourth stages of labor

Observation maternal well

being
Observation for hemmorhage
sign

05.15am

BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Uterus contraction :
well, Fundal uterine
length = 2 finger below
umbilical
Bleeding = -

Fourth stages of labor

Observation maternal well

being
Observation for hemmorhage
sign

05.30 am

BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Uterus contraction :
well, Fundal uterine
length = 2 finger below
umbilical
Bleeding = -

Fourth stages of labor

Observation maternal well

being
Observation for hemmorhage
sign

06.00 am

BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Uterus contraction :
well, Fundal uterine
length = 2 finger below

Fourth stages of labor

Observation maternal well

being
Observation for hemmorhage
sign