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Name : Mrs. S

Age : 27 yo

Address : Pemenang Came To Hospital : 25thjuly 2!"

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Time Subject Object Assesment Planning

25/07/

201416.30

Patient reffered from KLU GH withG2P0A1L0 A/S/L/IU head

presentation with neglected secondstage of laor! Patien confessedadominal pain spread to ac" since1#!00 wita $2%/0&/201%'( water

lea"ed o)t from her wom since20!00 $2%/0&/201%'( lood* slim $+'(,- $+'!

.o histor* of H( -( and asthma!

L-P 1310320145 2230&3201%

Histor* of A.6 7 %8 at midwife

Last A.6 2230&3201%9es)lt :P 120/&0USG ne;er

Histor* of famil* planning 3.e8t famil* planning in-?:P 1%0/@0 H9 @@ pm 4&(0 6 99 20 pmGeneral Stat)s 5*e an $3/3' ( ict $3/3'

hora8 6 S1S2 single reg)ler( m)rm)r $3'(gallop $3'!P ;es +/+ ( wh $3/3'! 9h $3/3'Adomen scar $3' ( striae $+'58tremit* edema 3 3 3 3=stetrical stat)s L1 reech U,H 44cm

L2 ac" on the right side

L4 headL% 4/5,B 4%10 gU6 2810CD4,H9 11311312$14?' pm> E # cm( amnion $3' m)dd*( head

palpale( cap)t $+'( molase $+'( edemaporsio $+'( FH1l( )npalpale small partof fetal/)milical cord!

La HG: 10(9:6 4(#?H6 41(1WBC ! 20"20PL 414H:SAg +

G2P0A1L0 %03%1wee"s S/L/IU withneglected acti;e phase

3=s mother and fetalwell eing

36I5 patient and famil*3- pro oser;ation for

;aginal deli;er*( -co to GP( GP co to

SP>( ad;=s! Progress of laor 1

ho)r( if no progress(prepare S6

Prepare 6S at 1#!00 wita Antiiotic

ceftria8one 1 g/I>$1@!00'

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Time Subject Object Assesment Planning

C#$%n%l%gist25/07/20140%!00S Patient came to midwife regionalwith # month pregnanc*! Patient

confess adominal pain since 1@!40$2%/0&/201%'( water lea"ed o)t fromher wom $3'( lood* slim $3'( ,-$+'!

= G6 wellG6S 5%>-?:P 110/&0 H9 @2 pm

4&(& 6 99 20 pm5,B 42 gU,H 42 cmU6 2810D40,H9 11312311 pm> E 4cm( eff 2( amnion $+'(head palpale( FHI( denom )nclear()npalpale small part offetal/)milical cord!

A G2P0A1L0( A/S/L/IU laten phase

P 3=s progress of laor

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Time Subject Object Assesment Planning

0@!00

S -other wants to earing down

= G6 wea"

G6S 5%>-?:P 120/&0 H9 @2 pm 4?(? 6 99 22 pmU6 4810D40,H9 11312312 pm> E @cm( eff &( amnion $3'(head palpale( FHII( denom 9=A)npalpale small part offetal/)milical cord!

A G2P0A1L0( A/S/L/IU acti;ephase

P 39eh*dration39efer to Pemenang PH6

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Time Subject Object Assesment Planning

10!00 $In Pemenang PH6'

S -other wants to earing down

= G6 wea"

G6S 5%>-?:P 120/@0 H9 @2 pm 4?(? 6 99 22 pmU6 4810D40,H9 11312312 pm> E &cm( eff &( amnion $3'(head palpale( FHII( porsio edema$+'( cap)t $+'( denom 9=A)npalpale small part of

fetal/)milical cord!

A G2P0A1L0( 4#3%0 wee"s S/L/IUneglected acti;e phase

P 36ontin)e 9eh*dration3In< Ampi 1gr39efer to KLU GH

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Time Subject Object Assesment Planning

12!00 $In Pemenang PH6'

S -other wants to earing down

= G6 wea"

G6S 5%>-?:P 120/@0 H9 @% pm 4?( 6 99 2% pmU6 4810D40,H9 11310311 pm> E complete( eff 100( amnion$3'( head palpale( FHII( porsioedema $+'( cap)t $+'( denom 9=A)npalpale small part of

fetal/)milical cord!

A G2P0A1L0( 4#3%0 wee"s S/L/IUneglected 2ndstage

P 36ontin)e 9eh*dration3=2 % Lpm39efer to .: GH

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Time subject %bject assessment &lanning

4/0'/201221.15

S6 egan

:a* was orn(female( A3S &3#!:B 40g( :L %

cm( meconeal $3'(Anomali $3'

Placenta was ornspontaneo)s(complete!

:leeding 400cc

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Time Subject Object Assesment Planning

23.15 # G6 well G6S 5%>-?:P 120/#0 mmHg H9 @0 pm99 20 pm 4?!&U,H UmilicalU6 $+'Lochea r)ra $+'

U= 200cc

G6 well cons 5%>-?:P 120/#0 mmHg H9 @@ 8/min)te99 20 8/min)te

4?(?C6U,H 2finger elow )milic)sU6 $+'U= %0 cc/H

:a* in roomH9 1%%8/min)te99 %? 8/min)te 4?(o6

2 ho)r post 6S

1stda*Post S6

=ser;e mother welleingKI5 mother to ta"e a rest

=ser;e mother and a*well eingKI5 mother to ta"e a rest

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