Name : Mrs. DAge : 21 years oldAddress : Pemenang, KLUAdmitted to Hospital: Oct 23th 2012

Case Report

TIME SUBJECTIVE OBJECTIVE ASSESMENT

PLANNING

23/10

201211.0

0

Patient pregnant 6 month came to obstetric Policlinic confessed hadn’t feel fetal movement since 1 weeks ago (17/10/12). 2 Days ago patient have go to TBA to examine her gestation. No history of TBA massage. Abdominal pain (-), history rupture of membrane (-), bloody slim (-).History of HT, DM, asthma (-)

LMP : 18/04/12EDD : 25/01/13

History of ANC : 3x at PolindesLast ANC : 11/10/2012Resut : Normal

Histori of USG : Never

History of family planning : (-)Next family planning : Injection 3 month

Obstetrical History :1.This

General Status :GC : wellCons : CM E4V5M6BP : 110/70 mmHg PR : 88 bpmRR : 20 bpmT : 36,Oc

Local Status :Eye : anemis (-/-), icteric (-/-)Cor : S1S2 single regular, murmur (-), gallop (-).Pulmo : vesicular (+/+), wheezing (-), rhonki (-).Abdomen : scar (-), striae gravidarum (+), linea nigra (+).Extremity : edema (-/-), warm acral (+/+)Obstetrical Status :L1 : breechL2 : back on left side L3 : headL4 : 5/5UFH : 20 cmUC : (-) FHR : (-)VT : Ø 1cm, eff. 25 %, Amnion (+) clear, head palpable ↓HI, denominator unclear, impalpable small part of fetal & umbilical cord.

G1P0A0H0 26 - 27 weeks

S/IUFD / IU head

presentation

- Observation mother well being.

- DM consult to SPV suggest termination with oxytocin drip. SPV acc

TIME SUBJECTIVE OBJECTIVE ASSESMENT

PLANNING

Lab Examination :Hb : 11,2 g/dlHCT : 36,6%RBC : 4,06 M/uLWBC : 9,20 K/uLPLT : 178 K/uLHbsAg : (-)

12.00.

General Status :GC : wellCons : CM E4V5M6BP : 120/70 mmHg PR : 100 bpmRR : 20 bpmT : 36,3oCUC: (-)

Drip Oxytocin (1st flash):8 dpm

12.30

UC: (-) 12 dpm

13.00

UC: (-) 16 dpm

13.30

UC: (-) 20 dpm

14.00

UC: (-) 24 dpm

14.30

UC: (-) 28 dpm

15.00 UC: (-) 32 dpm

15.30 UC: (-) 40 dpm

16.00. UC: (-) 40 dpm

16.30 UC: (-) 40 dpm

17.00 UC: (-) 40 dpm

17.30 UC: 1x10’ ~10” 40 dpm

18.00 UC: 2x10’ ~15” 40 dpm

18.30 General Status :GC : wellCons : CM E4V5M6BP : 120/80 mmHg PR : 92 bpmRR : 20 bpmT : 36,5oCUC: 2x10’ ~15”

Drip Oxytocin (2nd flash):40 dpm

19.00 UC : 2x10’ ~15”

40 dpm

19.30 UC : 2x10’ ~15”

40 dpm

20.00 UC : 2x10’ ~20”

40 dpm

20.30 UC: :2x10’ ~20” 40 dpm

21.00 General Status :GC : wellCons : CM E4V5M6BP : 110/80 mmHg PR : 88 bpmRR : 20 bpmT : 36,7oCUC: :2x10’ ~20”VT : Ø 1cm, eff. 25 %, Amnion (+) clear, head palpable ↓HI, denominator unclear, impalpable small part of fetal & umbilical cord.

G1P0A0H0 26 - 27 weeks S/ IUFD / IU head presentation with Induction failed

- Obs mother well being- Suggest mother to bed rest

TIME SUBJECTIVE OBJECTIVE ASSESMENT PLANNING

24/10/201210.00

General Status :GC : wellCons : CM E4V5M6BP : 120/70 mmHg PR : 100 bpmRR : 20 bpmT : 36,3oCUC: :2x10’ ~20”VT : Ø 1cm, eff. 25 %, Amnion (+) clear, head palpable ↓HI, denominator unclear, impalpable small part of fetal & umbilical cord.

- SPV visite to VK teratai advice

Insertion misoprostol 100 mcg/6 hours

16.00 General Status :GC : wellCons : CM E4V5M6BP : 120/80 mmHg PR : 92 bpmRR : 20 bpmT : 36,5oCUC: :2x10’ ~20”VT : Ø 1cm, eff. 25 %, Amnion (+) clear, head palpable ↓HI, denominator unclear, impalpable small part of fetal & umbilical cord.

Insertion misoprostol 100 mcg

22.00 General Status :GC : wellCons : CM E4V5M6BP : 120/80 mmHg PR : 96 bpmRR : 20 bpmT : 36,7oCUC: :2x10’ ~20”VT : Ø 1cm, eff. 25 %, Amnion (+) clear, head palpable ↓HI, denominator unclear, impalpable small part of fetal & umbilical cord.

Insertion misoprostol 100 mcg

04.00 General Status :GC : wellCons : CM E4V5M6BP : 110/70 mmHg PR : 80 bpmRR : 20 bpmT : 36,3oCUC: :2x10’ ~20”VT : Ø 1cm, eff. 25 %, Amnion (+) clear, head palpable ↓HI, denominator unclear, impalpable small part of fetal & umbilical cord.

Insertion misoprostol 100 mcg