Name : DONA MELIANA

Age : 28 years old

MR No. : 64 67 76
Date : June 12th, 2009

Anamnesis :
A 28 years old patient was admitted to the Delivery Room of Dr. M. Djamil
Central General Hospital on June 12th, 2009 at 12.00 am sent from polyclinic of Obstetry
and Gynecology of M. Djamil hospital centre with diagnosis G2P1A0H1 posterm
pregnancy 42 weeks.

Present Illness History :

 Feeling of pain from to region was absent.
 Bloody show from the vagina was absent.
 Fluid leakage from the vagina was absent.
 No massive vaginal bleeding.
 Amenorrhea since 10 months ago.
 First date of last menstrual period was August 17th , 2008 .
 Estimation date of delivery at May 24th , 2009
 Fetal movement was felt since 6 months ago
 No complain of nausea, vomitting and vaginal bleeding neither during early
pregnancy nor late pregnancy.
 Prenatal care to Puskesmas and polyclinic of Obstetry and Gynecology of M. Djamil
hospital centre regularly.
 Menstruation History : menarche at 14 years old, regular cycle, 1 x 28 days, which
last for 5 to 7 days each cycle with the amount of 2-3 times pad change/day without
menstrual pain.

Previous Illness History :

There wasn’t previous history of heart, lung, liver, kidney, DM and hypertension.

Family Illness History :

There wasn’t history of hereditary disease, contagious and physicological illness in the
family.

Marriage history : once in

History of pregnancy/abortion/delivery : 2/0/1
History of family planning : nothing
History of immunization : nothing

Physical Examination :
GA Cons BP PR RR T Weight Height
Mdt CMC 110/70 84 20 36,8 C 60 kg 154 cm
Eyes : Conjunctiva wasn’t anemic, Sclera wasn’t icteric
Neck : JVP 5-2 cmH2O, tyroid gland no enlargement
Chest : H/L normal
Abdoment : OR
Genitalia : OR
Extremity : Edema -/-, Physiological Reflex +/+, Pathological Reflex -/-

Obstetric Record :
Face : Chloasma gravidarum was positive
Breast : Both enlarge, areola/nipple hyperpigmentation, colostrum (+)
Abdoment :
I : Enlarge according to term pregnancy, median line hyperpigmentation, striae
gravidarum (+), cicatrix (-)
Pa : L1 : Uterine fundal was palpable 3 finger above symphisis pubic
A large nodular mass, soft was palpated
L2 : A hard and resistance structure was felt on the right side
Numerous small, irregular were felt on the left side
L3 : A hard mass was palpable and floating
L4 : The lowest part of the fetal body has not entered the inlet
Uterine Fundal Height : cm Estimated fetal body weight : gr
Uterine contraction : (-)
Pe : Tympani
Au : Peristaltic sound was normal Fetal Heart Sound : 140 x/minutes

Genitalia :I V/U normal

VT  1 jari
Portio thick, 1 ½ cm, posterior, soft
Amnionic sac was intact
Head palpable H I

Pelvic Inlet : Promontory was palpated (DC = 9 cm; VC = 7.5 cm)

Inominate line was palpated 2/3 – 2/3
Sacrum bone : concave
Pelvic side wall : straight
Ischiadic spine : no protruded
Coccygeus bone : moveable
Arc of pubic : > 90
Pelvic Outlet : Inter tuberous distance could be passed through by normal adult fist
(10,5 cm)
Impression : No contracted pelvic

Diagnose :
G1P0A0H0 gravid posterm 42 – 43 weeks + obs. Inpartu
Fetal alive, singleton, intra uterine, head presentation floating

Management :
Control GA, VS, FHS, delivery sign
Check routine blood labor
Plan : vaginal delivery

Laboratory :
Hb : 11.7 gr%
Leucocyte : 15,000/mm
Hematocrit : 36%
Trombocyte : 192,000/mm3

October 7th ,2007

At 06.00 am :
An/ Feeling of pain from waist to region which referred to the groin (+)
Fetal movement (+)
Physical Examination :
GA Cons BP PR RR T FHS Uterine Contraction
mdt CMC 110/70 82 20 af 152 5-6’/30”/medium

Genitalia :I V/U normal

VT  2-3 cm
Amnionic sac (+), clear
Head was palpable at HI-II
D/ G1P0A0H0 parturient posterm 1st take laten phase kala I
Fetal alive, singleton, intra uterine, head presentation at HI-II
M/ evaluate 4 hours again
Control GA, VS, FHS, Uterine Contraction
P/ Vaginal delivery

At 08.00 am :
An/ Feeling of pain from to region which referred to the groin (+)
Fetal movement (+)
Physical Examination :
GA Cons BP PR RR T FHS Uterine Contraction
mdt CMC 110/70 80 20 af 144 +/Seldom/

Genitalia :I V/U normal

VT  1 jari
Amnionic sac (+), clear
Portio thick, 1 ½ cm, posterior, soft
Head was palpable at HI-II
D/ G1P0A0H0 parturient posterm 1st take laten phase kala I
Fetal alive, singleton, intra uterine, head presentation at HI-II
M/ evaluate 4 hours again
Control GA, VS, FHS, Uterine Contraction
P/ Vaginal delivery
At 12.00 am :
An/ Feeling of pain from to region which referred to the groin (+)
Fetal movement (+)
Physical Examination :
GA Cons BP PR RR T FHS Uterine Contraction
mdt CMC 110/70 80 20 af 140 (-)

Genitalia :I V/U normal

VT  1 jari
Amnionic sac (+), clear
Portio thick, 1 ½ cm, posterior, soft
Head was palpable at HI-II
D/ G1P0A0H0 parturient posterm 1st take laten phase kala I
Fetal alive, singleton, intra uterine, head presentation at HI-II
M/ evaluate 4 hours again
Control GA, VS, FHS, Uterine Contraction
Move KR
USG and CTG
P/ Vaginal delivery

USG Presentation : Fetal alive, singleton, intra uterine, head presentation

Fetal movement activity was good
Biometri, BPV : 92 mm, FL : 75 mm, HL : 65 mm, AL : 32,9 mm
Estimation of fetal weight : 3100 gram
Placenta was plante on posterior corpus
Amnionic sac, AFI : 7,3 SDAV : 2,54

Impression : gravid aterm

Fetal alive
CTG presentation : baseline : 120 -130 dpm
variabaility : 5 – 10 dpm
akseleration : (+) positif
deceleration : (-) negatif
fetal movement : (+) positif
contraction : 4-5/25-30/medium

Impression : CTG reaktif

0ctober 8th , 2007

At 11.30 am :
An/ Feeling of pain from to region which referred to the groin (+)
Fetal movement (+)
Physical Examination :
GA Cons BP PR RR T FHS Uterine Contraction
mdt CMC 110/70 82 20 af 146 +/Seldom/

Genitalia :I V/U normal

VT  1 jari
Amnionic sac (+)
Portio thick, 1 ½ cm, posterior, soft
Head was palpable at HI-II
D/ G1P0A0H0 parturient posterm 1st take laten phase kala I
Fetal alive, singleton, intra uterine, head presentation at HI-II
M/ Control GA, VS, FHS, Uterine Contraction
P/ Vaginal delivery

At 15.30 :
An/ Feeling of pain from to region which referred to the groin (-)
Fetal movement (+)
Physical Examination :
GA Cons BP PR RR T FHS Uterine Contraction
mdt CMC 110/70 80 20 af 138 (-)

Genitalia :I V/U normal

VT  1 jari
Amnionic sac (+)
Portio thick, 1 ½ cm, posterior, soft
Head was palpable at HI-II
D/ G1P0A0H0 parturient posterm 1st take laten phase kala I
Fetal alive, singleton, intra uterine, head presentation at HI-II
M/ evaluate 4 hours again
Control GA, VS, FHS, Uterine Contraction
P/ Vaginal delivery

At 16.00 :
Begin induction laber with oxitocyn 5 UI in 500 cc RL, start with 10 gtt/minute,
increase 5 gtt/minute until optimal uterine contraction ( max: 60 gtt/minute )

At 20.15 :
An/ Feeling of pain from to region which referred to the groin (-)
Fetal movement (+)
Physical Examination :
GA Cons BP PR RR T FHS Uterine Contraction
mdt CMC 110/70 80 20 af 138 (-)

Genitalia :I V/U normal

VT  1 jari
 Amnionic sac (+)
Portio thick, 1 ½ cm, posterior, soft
Head was palpable at HI-II
D/ G1P0A0H0 parturient posterm 42 – 43 weeks + after drip induxin
Fetal alive, singleton, intra uterine, head presentation at HI-II
M/ evaluate 4 hours again
Control GA, VS, FHS, Uterine Contraction
CTG
P/ Vaginal delivery

At 06.30 :
An/ Feeling of pain from to region which referred to the groin
Fetal movement (+)
Physical Examination :
GA Cons BP PR RR T FHS Uterine Contraction
mdt CMC 110/70 84 20 af 142 5-6/25-30/medium

Genitalia :I V/U normal

VT  2-3 cm
Amnionic sac (+)
Head was palpable at HI-II
D/ G1P0A0H0 parturient posterm 1st take laten phase kala I
Fetal alive, singleton, intra uterine, head presentation at HI-II
M/ Control GA, VS, FHS, Uterine Contraction
P/ Vaginal delivery

At 10.30 :
Patient come in KB
CTG presentation : baseline : 120 -130 dpm
variabaility : 5 – 10 dpm
akseleration : (+) positif
deceleration : (-) negatif
fetal movement: (+) positif
contraction : 4-5/25-30/medium

Impression : CTG reaktif

October 9th , 2007

At 10.30 :
An/ Feeling of pain from to region which referred to the groin
Fetal movement (+)
Physical Examination :
GA Cons BP PR RR T FHS Uterine Contraction
mdt CMC 110/70 80 20 af 148 4-5/30/medium

Genitalia :I V/U normal

VT  1 jari
Amnionic sac (+)
Head was palpable, transverse sagitalis suture at HI-II
D/ G1P0A0H0 parturient posterm 1st take laten phase kala I
Fetal alive, singleton, intra uterine, head presentation transverse sagital suture at HI-II
M/ evaluate 2 hours again
Control GA, VS, FHS, Uterine Contraction
P/ Vaginal delivery

At 14.30 :
An/ Feeling of pain from to region which referred to the groin (+)
Fetal movement (+)
Physical Examination :
GA Cons BP PR RR T FHS Uterine Contraction
mdt CMC 110/70 86 22 af 148 3-4/40/strong

Genitalia :I V/U normal

VT  1 jari
Amnionic sac (+)
Head was palpable, transverse sagital suture at HI-II
D/ G1P0A0H0 parturient posterm 42-43 weeks 1st take active phase kala I
Fetal alive, singleton, intra uterine, head presentation occiput left transverse
at HI-II
M/ evaluate 2 hours again
Control GA, VS, FHS, Uterine Contraction
P/ Vaginal delivery

At 16.30 :
An/ Feeling of pain from to region which referred to the groin (+)
Fetal movement (+)
Physical Examination :
GA Cons BP PR RR T FHS Uterine Contraction
mdt CMC 120/70 88 20 af 148 2-3/45/strong

Genitalia :I V/U normal

VT  8-9 cm
Amnionic sac (-), residu clear
Head was palpable, occiput left transverse at HII-III
D/ G1P0A0H0 parturient posterm 1st take active phase kala I
Fetal alive, singleton, intra uterine, head presentation occiput left transverse
at HII-III
M/ evaluate 2 hours again
Control GA, VS, FHS, Uterine Contraction
P/ Vaginal delivery

At 18.30 :
An/ Feeling of pain from to region which referred to the groin (+)
Fetal movement (+)
Physical Examination :
GA Cons BP PR RR T FHS Uterine Contraction
mdt CMC 120/70 88 20 af 148 2-3/55/strong

Genitalia :I V/U normal

VT  complete
Amnionic sac (-), residu clear
Head was palpable, occiput left transverse at HIII (+)
D/ G1P0A0H0 parturient posterm 1st take active phase kala I
Fetal alive, singleton, intra uterine, head presentation occiput left transverse
at HIII(+)
M/ evaluate 2 hours again
Control GA, VS, FHS, Uterine Contraction
P/ Vaginal delivery

At 16.30 :
An/ Feeling of pain from to region which referred to the groin (+)
Fetal movement (+)
Physical Examination :
GA Cons BP PR RR T FHS Uterine Contraction
mdt CMC 120/70 88 20 af 148 2-3/45/strong

Genitalia :I V/U normal

VT  8-9 cm
Amnionic sac (-), residu clear
Head was palpable, occiput left transverse at HII-III
D/ G1P0A0H0 parturient posterm 1st take active phase kala I
Fetal alive, singleton, intra uterine, head presentation occiput left transverse
at HII-III
M/ evaluate 2 hours again
Control GA, VS, FHS, Uterine Contraction
P/ Vaginal delivery

At 19.30 :
An/ Feeling of pain from to region which referred to the groin (+)
Fetal movement (+)
Physical Examination :
GA Cons BP PR RR T FHS Uterine Contraction
mdt CMC 110/70 88 22 af 148 2-3/55/strong

Genitalia :I V/U normal

VT  8-9 cm
Amnionic sac (-), residu clear
Head was palpable, occiput left transverse at HIII(+)
D/ G1P0A0H0 parturient posterm 1st take active phase kala I
Fetal alive, singleton, intra uterine, head presentation occiput left transverse
at HIII(+)
M/ evaluate 2 hours again
Control GA, VS, FHS, Uterine Contraction
P/ Vaginal delivery