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Name: Mrs. MAge: 23 yo

Adress: LingsarAdmitted: October, 17th 2012 at 00.40

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17/10/201200.40

Patient referred fromSegerongan PHC withG1P0A0L0 A/S/L/IU headpresentation, mother and fetalwell, with latent phase 1st stageof labor + Mild preeclampsia.

Patient confessed abdominalpain that spread to frank since16.00 (16/10/12). Historyrupture of membrane (-).Bloody slim (-), FM (+).No history of DM, HT, asthma.

LMP: forgotEDD: -

History of ANC: >4x at PHCLast ANC:History of USG: -

History of family planning:-Next family planning: injection3 months

Obstetrical history:1.This

General status:GC: wellBP: 120/80 mmHgPR: 88 bpmRR: 22 T: 37Eye : anemis (-), icteric (-)

Thorax :Cor : S1S2 single reguler (murmur-), (gallop -)Pulmo : vesikuler (+/+), wheezing(-/-),Ronkhi (-/-).Abdomen : scar (-), striae (+),linea nigra (+)Extremity : edema (-/-), warm

acral (+/+)

Obstetrical status:L1: breechL2: back on the right sideL3: headL4: 4/5UFH: 31 cmEFW: 3100 g

UC: 2x10 ~ 30FHB: 12-12-13 (148 x/min)VT: 3 cm, effacement 25%,amnion (+), head palpable HI+,denominator unclear, impalpablesmall part and umbilical cord.

G1P0A0L0 A/S/L/IUhead presentation,mother and fetalwell, with latentphase 1st stage oflabor + Mild

preeclampsia.

Obs mother & fetalwell being

Check CBC, HbSAg Obs. Progress oflabour

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Chronologist:At PHC (16/10/2012) 23.00S: Patient pregnant 9 months confessed

abdominal pain since 16.00 (16/10/2012)O:BP: 140/100 mmHgPR: 84 bpm

RR: 20 T: 36Head presentation, back on the right side, 4/5UFH: 33 cmL1: breechL2: back on the right sideL3: headL4: 3/5FHB: (+) 138 x/min

23.25VT: 3 cm, eff 50% amnion (+), head palpable

H I, impalpable small part / umbilical cord.

23.30Protein ureine +1

A:G1P0A0L1 A/S/L/IU head presentation, mother

and fetal well, with latent phase 1st stage oflabor + Mild preeclampsia.

P: Infus RL flash 1 Nifedipine 5 mg Reffered to Gangga PHC

Lab:HB: 11,4 g/dl

RBC: 4,10 M/dl

HCT: 35,4 %WBC: 10,49 K/dl

PLT: 183 K/dlHbSAg: (-)

UL:BJ : 1,030pH : 6,0Protein : +1Blood : +3

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05.00 UC: 3 x 10 ~ 25FHB: 12-12-12(144x/min)VT: 4 cm,effacement 50%,amnion (+), headpalpable HI+,denominator unclear,impalpable small partand umbilical cord.

G1P0A0L0 A/S/L/IUhead presentation,mother and fetalwell active phase1st stage of labor,

Obs. Progress of labour

09.00 UC: 3 x 10 ~ 25FHB: 12-12-11

VT: 4 cm,effacement 50%,amnion (+), headpalpable HI+,denominator unclear,impalpable small partand umbilical cord.

G1P0A0L0 A/S/L/IUwith arrested

active phase 1ststage of labor(dystocia 4 cm)

Obs mother & fetal wellbeing

Coo SPV:Amniotomy, if didnt haveprogress Pro akselerasi

09.15 Amniotomy : AmnionmeconealInj. Ampi 1 gr IV

10.00 UC: 3 x 10 ~ 40FHB: 12-12-12(144x/min)

VT: 6 cm,effacement 75%,amnion (-), head

Obs mother & fetal wellbeingEvaluation 4 hours again

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14.00 GC: wellUC: 4 x 10 ~ 40FHB: 140 bpmVT: complate, effacement50%, amnion (-), headpalpable HI I, denominatorunclear, impalpable smallpart and umbilical cord.

2nd stage of labor

16.40 GC: wellUC: 4 x 10 ~ 40FHB: 140 bpmVT: complate, effacement50%, amnion (-) meconeal,head palpable HI I Caput (+),

denominator unclear,impalpable small part andumbilical cord.

G1P0A0L0 A/S/L/IUneglected 2ndstage of labor

Observed until 21.30 if didnt have progress Pro SC

20.00 UC: 3 x 10 ~ 35FHB: 148 bpmVT: complate, effacement50%, amnion (-) meconeal,

head palpable HI I Caput (+),denominator unclear,impalpable small part andumbilical cord.

Prepare SC Set DC cateter Skin test Skin test Ampi (-) Inj.

Ampi 2 gram IV CIE patient and family.

23.00 CS beganBaby was born (23.10) :Male, BW 3100 gram AS

1-3, BL 51 cm.Anus (+), congenitalanomaly (-).

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01.0018/10/20

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Wound pain. GC : wellBP : 110/70

PR : 88 bpmRR : 20 bpm

T : 37,2oCUC : (+) wellUFH : at umbilicusUO : 80 cc/hoursAB : (-)Operation wounds good

2 hours post SC Observed mother and babywell being

Suggest mother tomobilization, eat and drink,and medication.

Breast feeding

07.00 Wound pain. GC : wellBP : 110/70PR : 88 bpmRR : 20 bpm

T : 37,2oCUC : (+) well

UFH : at umbilicusUO : 80 cc/hoursAB : (-)Operation wounds good

Baby in NICU :PR : 150RR : 45

T : 36,2oC

1 day post SC Observed mother and babywell being

Suggest mother tomobilization, eat and drink,and medication.

Breast feeding