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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 : Mrs.

Age : ... years old

Ethnic : Javanese/Sundanese/Batak

Religion : Moslem

Occuation : !ouse"i#e/emloyee

Education : Elementary School/Junior !igh School/Senior !igh School

$ate o# Admission : Octo%er ...th &'() *ukul %r+

Ana#nesis

o Chie Co#plain

o $istory o Present "llness

o $istory o Past "llness

!istory o# hyertension 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

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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. (ateGestational

Age

)abor

$istory*e+

irth

weight

reast

eeding

(. &''2 - "eeks

Sontaneous

vaginal

delivery

Male/

1emalegrams 3

&.

Physical +a#ination

o 4eneral condition : moderately/severely ill

o 5evel o# consciousness : comos mentis

o 6ital Signs

Blood ressure : mm!g

!eart rate : 7/minutes

Resiration rate : 7/minutes

8emerature : o ,

o Body 9eight : kg

o Body !eight : cm

General +a#ination

o Eyes : anemic conunctiva ;/;0 icteric sclera ;/;

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8/13/2019 Format Obs

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o nseculo : "as not er#ormed

o 6aginal toucher : vulva and vagina "ithin normal limit0 ortio "as thick/thin

and rigid/tender0 cervical oening - cm0 cervical e##acement -@0 amnion

sac *;/3+0 head/%reech resentation0 hodge -

)aboratory +a#ination

o !emoglo%in : - g/d5

o !ematocrit : ... @

o 5eucocyte : .../u5

o 8rom%ocyte : .''' /u5

o Blood tye : / Rh3

o Bleeding time : - minutes

o ,lotting time : - minutes

o lasma glucose : - mg/d5

CG: NS8/,S8 -.

A0" ("%A*2"'

Partograph

ltrasonography

orking (iagnosis

4A0 ... 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

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(iagnosis Ater Proced!re

Mother :

A 0 - years old0 ost artus matures "ith sontaneous vaginal delivery and ost

hecting "ith indication o# eisiotomy 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 Agar score -/-0 "ith -

reat#ent