Morning Report

September, 10th 2014

Supervisor:
Dr. Agus Thoriq, SpOG
DM Jaga:
Faisol, Santi, Lala

Morning Report
th
September 4 2014
Case Resume
NORMAL
LABOR

PATHOLOGIES 1. G1P0A0L0 19-20 weeks/S/IUFD/IU

LABOR

Case 1
Name : Mrs. N
Age : 37 years old
Address : Telagawaru, Lobar
Admitted : 09-09-2014
No. RM : 10-53-79
G1P0A0L0 19-20 weeks/S/IUFD/IU

Time

Subject

09-092014
10.00

Patient come to NTB GH,

referred from spesialist
with G1P0A0L0 19-20
weeks IUFD.
Patient confessed
abdominal pain since 1
weeks ago, bloody came
out from her vagina (+),
water came out from her
womb (-) and FM (-)
since 2 days ago.
No history of DM, HT,
asthma.
LMP : 23-04-2014
EDD : 30-01-2015
History ANC : 2x at
Polindes
Last ANC : 09-09-2014
result: BP : 110/70, FHB
(-)

Object
General status
GC : well
GCS: CM (E4V5M6)
BP : 120/80 mmHg
HR: 80 x/m
RR: 20 x/m
T: 36,8 C
Local status
Eye : an (-/-), ict (-/-)
Pulmo: ves (+/+), rh (-/-),
wh (-/-)
Cor : S1S2 single regular,
M(-), G(-)
Abd : striae gravidarum
(+), linea nigra (+), scar
(-)
Ext : edema (-/-), warm
(+/+)
Obstetric status
UFH: as high as
umbilicus
UC : (-)
FHB : (-)
VT: (-)

Assessment
G1P0A0L0 19-20
weeks S/IUFD/IU

Planning
Co to SPV, adv:
induction with
misoprostol
4x50 g

Time

Subject
History of USG : 3x at
specialist.
Last USG: 9-9-14
G1P0A0L0 16-18
weeks/IUFD
History of family
planning : Next family planning :
History of obstetric :
I. This

Object
Lab (3/09/2014):
HGB = 11.8 g/dl
RBC = 3.65 K/ul
WBC = 7.98 M/ul
HCT = 34,0 %
PLT = 219 M/ul
HBsAg = (-)
BT = 215
CT = 600

Assessment

Planning

Time

Subject

Object

Assessmen
t

Planning

10.15

GC: well
BP: 120/80 mmHg
HR: 78 bpm
T 360C
RR 16 x/m
UC: FHB: -

Insertion of misoprostol
50 g (I)

16.15

GC: well
BP: 120/80 mmHg
HR: 78 bpm
T 360C
RR 16 x/m
UC: FHB: -

Insertion of misoprostol
50 g (II)

18.00

Patient
confessed
abdominal pain

GC: well
BP: 110/80 mmHg
HR: 78 bpm
T 360C
RR 18 x/m
UC: 1x/10 ~ 15
FHB: -

Obs. inpartu

22.15

Patient
confessed
abdominal pain

GC: well
BP: 110/80 mmHg
HR: 78 bpm
T 360C
RR 18 x/m
UC: 1x/10 ~ 15
FHB: -

Insertion of misoprostol
50 g (III)

Timec
01.15

Subject
Mother
confessed
abdominal pain
mor frequently
and wants to
bearing down

Object
UC: 3x/10 ~ 40
FHB: (-)
Inspection: opening vulva
(+), bulging of perineum
(+), pressure of anus (+)

Assessmen
t
Abortus
insipien

19.15
21.20

Planning
Conduct labor

Death conceptus was

born, female, 200 gram,
GC: well
GCS: E4V5M6
BP: 110/70 mmHg
PR: 80x/m
RR: 20x/m
T: 37 0C
UC: (+) well
UFH : 2 finger above
simfisis
Active bleeding: (-)
UO: +
Lokea rubra (+)

Abortus
complete

Observation mother and

baby well being
Suggest mother to eat
and drink
Suggest mother to
mobilization

Timec
01.15

Subject

Object

GC: well
GCS: E4V5M6
BP: 110/70 mmHg
PR: 80x/m
RR: 20x/m
T: 37 0C
UC: (+) well
UFH : 2 finger above
simfisis
Active bleeding: (-)
UO: 400 cc
Lokea rubra (+)

Assessmen
t

today

Planning

Continue
medication