Case Report

Name Age Address Admitted to Hospital : : : : Mrs. D 21 years old Pemenang, KLU Oct 23th 2012

TIME 23/10 2012 11.00

SUBJECTIVE Patient pregnant 6 month came to obstetric Policlinic confessed hadnt 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 : 18/04/12 EDD : 25/01/13 History of ANC : 3x at Polindes Last ANC : 11/10/2012 Resut : Normal Histori of USG : Never History of family planning : (-) Next family planning : Injection 3 month Obstetrical History : 1. This

OBJECTIVE General Status : GC : well Cons : CM E4V5M6 BP : 110/70 mmHg PR : 88 bpm RR : 20 bpm T : 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 : breech L2 : back on left side L3 : head L4 : 5/5 UFH : 20 cm UC : (-) FHR : (-) VT : 1cm, eff. 25 %, Amnion (+) clear, head palpable HI, denominator unclear, impalpable small part of fetal & umbilical cord.

ASSESMENT G1P0A0H0 26 - 27 weeks S/IUFD / IU head presentation

PLANNING - Observation mother well being. - DM consult to SPV suggest termination with oxytocin drip. SPV acc

TIME

SUBJECTIVE

OBJECTIVE Lab Examination : Hb : 11,2 g/dl HCT : 36,6% RBC : 4,06 M/uL WBC : 9,20 K/uL PLT : 178 K/uL HbsAg : (-)

ASSESMENT

PLANNING

12.00.

General Status : GC : well Cons : CM E4V5M6 BP : 120/70 mmHg PR : 100 bpm RR : 20 bpm T : 36,3oC UC: (-) UC: (-) UC: (-) UC: (-) UC: (-) UC: (-)

Drip Oxytocin (1st flash): 8 dpm

12.30 13.00 13.30 14.00 14.30

12 dpm 16 dpm 20 dpm 24 dpm 28 dpm

15.00 15.30 16.00. 16.30 17.00 17.30 18.00 18.30

UC: (-) UC: (-) UC: (-) UC: (-) UC: (-) UC: 1x10 ~10 UC: 2x10 ~15 General Status : GC : well Cons : CM E4V5M6 BP : 120/80 mmHg PR : 92 bpm RR : 20 bpm T : 36,5oC UC: 2x10 ~15 UC : 2x10 ~15 UC : 2x10 ~15

32 dpm 40 dpm 40 dpm 40 dpm 40 dpm 40 dpm 40 dpm

Drip Oxytocin (2nd flash): 40 dpm

19.00 19.30

40 dpm 40 dpm

20.00

UC : 2x10 ~20

40 dpm

20.30

UC: :2x10 ~20

40 dpm

21.00

General Status : GC : well Cons : CM E4V5M6 BP : 110/80 mmHg PR : 88 bpm RR : 20 bpm T : 36,7oC UC: :2x10 ~20 VT : 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 24/10/2012 10.00

SUBJECTIVE

OBJECTIVE General Status : GC : well Cons : CM E4V5M6 BP : 120/70 mmHg PR : 100 bpm RR : 20 bpm T : 36,3oC UC: :2x10 ~20 VT : 1cm, eff. 25 %, Amnion (+) clear, head palpable HI, denominator unclear, impalpable small part of fetal & umbilical cord. General Status : GC : well Cons : CM E4V5M6 BP : 120/80 mmHg PR : 92 bpm RR : 20 bpm T : 36,5oC UC: :2x10 ~20 VT : 1cm, eff. 25 %, Amnion (+) clear, head palpable HI, denominator unclear, impalpable small part of fetal &

ASSESMENT

PLANNING - SPV visite to VK teratai advice Insertion misoprostol 100 mcg/6 hours

16.00

Insertion misoprostol 100 mcg

22.00

General Status : GC : well Cons : CM E4V5M6 BP : 120/80 mmHg PR : 96 bpm RR : 20 bpm T : 36,7oC UC: :2x10 ~20 VT : 1cm, eff. 25 %, Amnion (+) clear, head palpable HI, denominator unclear, impalpable small part of fetal & umbilical cord. General Status : GC : well Cons : CM E4V5M6 BP : 110/70 mmHg PR : 80 bpm RR : 20 bpm T : 36,3oC UC: :2x10 ~20 VT : 1cm, eff. 25 %, Amnion (+) clear, head palpable HI, denominator unclear, impalpable small part of fetal & umbilical cord.

Insertion misoprostol 100 mcg

04.00

Insertion misoprostol 100 mcg