OBSTETRIC STATUS
Mother’s Age
Pregnancy
Gestational Age
Complications during pregnancy : -
Complications of childbirth
Ruptures of the membranes
Type of Delivery`
Indication
: 33 th
: G2P1A0
: 37-38 weeks
:-
: before operation
: Sectio Caesaria
: -re sectio caesarea
- ruptures of the membran
- history cystectomy
NEONATAL STATUS
Date of Baby Born : 13-12-2018
Gender : girl
Weight : 4150 gr
Lenght : 51 cm
Head circumference : 33 cm
 APGAR SCORE
0 1 2 APGAR SKOR 1’ 5’ 10’

Tidak ada <100 >100 Denyut jantung 2 2 2

Tidak ada Tidak Baik Pernapasan 1 2 2

teratur

Lemah Sedang Baik Tonus otot 2 2 2

Tidak ada Meringi Menangi Peka rangsang 2 2 2

s s
Biru / Putih tubuh Seluruh Warna 1 1 2
merah, merah
ekstrem
itas biru
NEW BALLARD SCORE
Kesan: total ballard score is 38  38+5 weeks
DOWN SCORE

Conclussion : not distress respiratory

 Gafik Lubchenko

12/15/2018

7
Conclussion : large for date, term
PHYSICAL EXAMINATION
A. General Appearance
Heart rate : 136 x/menit
Respiratory Rate : 40 x/menit
 temperature : 37,3 ºC
General appearance : Crying Strongly, Active Motion
Skin : - Color : red
- Turgor : Normal
- Tonus : Normal
* Gesture : Flexion
* Reflexes : - Moro : (+) - rooting: (+)
- palmar : (+) - plantar: (+)
- Tonus leher : (+)
B. HEAD

Shape : Normochepal
Sutura : Normal, moulage (-)
Fontanela : soft, open sinciput, horizontal
Eyes : Normal, sekret (-)
Nose : Normal, nostrils breath (-)
Ear : Normal
Mouth : Normal
Caput succedaneum :-
Cephal hematom :-
C. Neck : tonus normal
D. Thorax :
- Heart : hearth sound SI= reguler, SII= split constant,
hearth noisy (-)
- Lung : Vesikuler Sound (+) Normal
E. Stomach : Supel, turgor normal, fresh umbilical cord
F. Genitalia : Normal, the testes are down, miksi (+)
G. Anus : (+) Normal, mekonium (+)
H. Ekstremitas : Normal, fingers on four extremities are normal
I. Backbone : normal
J. Another anomaly : not found
ASSESMEN

Large body weight baby, Term, large for gestational age,

delivery with sectio caesaria on indication ruptures of the
membran, re sectio caesarea, history cystectomy
GDS = 16 mg/dl
GDS = 16 mg/dl
GDS = 18 mg/dl
bolus dextrosa 2ml/kgBB minimal 60 ml/kgBB/hari(1 hari)
GIR 6-8 mg/kg/menit
Oral tetap diberikan bila tidak ada kontra indikasi
BB 4150
4,15 X 6mg/kg/menit =24.9 mg/hari= 24,9 x 60 x 24 = 35856
mg/hari
Bla dipakai D 10% ARTINYA 10 g/100cc bila perlu
35856mg/hari atau 35,856 g/hari berarti perlu 35.856 g
/10gx100cc= 358,56 D10 % / hari
MANAGEMENT PLAN
Early breastfeeding initiation
Vit K1 intramuscular injection, 1 mg dose in the anterolateral left
thigh
Hepatitis B vaccine intramuscular injection 0,5 ml in the
anterolateral right thigh, 1 hour after giving vit K injection
Observation in the NICU
Blood sugar examination and routine blood examination
TERIMAKSIH