OB Case Conference

M.T.E.25 y/o SingleCatholicMarikina Cityadmitted for the first time in QMMC

on May 15, 2011

Labor pains

Few hours PTA (+) labor pains

▪ described as irregular contractions, occurring every 10-15 minutes, with a pain scale of 6/10, radiating to the pelvis and back.

▪ No associated symptoms such as vomiting, fever and blurring of vision were noted. Persistence of symptoms prompted consult at QMMC OB-ER hence admitted

General: (-) weight loss (-) easy fatigability CNS: (-) loss of consciousness, headache HEENT: (-) blurring of vision, eye pain,

tinnitus, ear pain, epistaxis, sorethroat RESP: (-) difficulty of breathing, (-) cough,

(-) colds CVS: (-) chest pain, (-) palpitations GIT: (-) vomiting, (-) constipation GUT: (-) dysuria, (-) hematuria, (-) oliguria M/S: (-) limitation of movement, (-) joint

pain

LMP: August 05, 2010AOG: 39 weeks 2 days by LMP

PNCU x 4 : St. Vincent HospitalPNCU x 3: QMMC

Prenatal medications: • Multivitamins – OD starting at the 1st

trimester until 3rd trimester• Ferrous sulfate – OD starting at 2nd

trimester until 3rd trimester

Menarche at the age of 12

28-30 days interval

Duration of 5-6 days

Able to use 2-3 pads per day, moderately soaked

Associated with dysmenorrheal symptoms

First coitus at the age of 18

With one partner

No history of sexually transmitted diseases

Denies used of birth control methods (artificial or natural)

(-) Hypertension (-) Diabetes mellitus (-) Cardiac Diseases (-) Pulmonary Diseases (-) Kidney and Liver Diseases

(-) Allergies (-) Surgeries

(+) Hypertension- Mother (+) Colon Cancer – Father (died of

Myocardial Infarction)

(-) DM (-) Pulmonary tuberculosis (-) Goiter

Housewife Living in for 2 years to a 24 year old

manNon- smoker, non-alcoholic drinkerDenies any history of illicit drug use

General Survey:-patient is awake, alert, cooperative and not in cardiorespiratory distress

Vital Signs: BP- 110/60 HR- 92 bpm RR – 18 cpm T emp.- 37.4

C

HEENTanicteric sclera, pink palpebral conjunctiva

Thorax and Lungs Symmetrical chest expansion (-) Retractions Clear Breath Sounds

Cardiovascular Adynamic precordium Normal rate regular rhthym No murmurs

Abdomen Globular FH: 32 cms FHT: 140

Pelvic Examination IE: cervix- 2 cms dilated, 50% effaced,

Cephalic in presentation, Station (-) 3, (+) BOW, floating

G1P0 (0000) Pregnancy uterine 39 weeks 2 days AOG by LMP, CIL

G1P1 (1001) PUFT Cephalic Arrest in Cervical Dilatation 20 to CPD, delivered via LTCS I to a live Boy AS 9.

Partograph

Day MDs Orders Labs And Imaging MedicationIV Fluids

Vital Signs and Symptoms

Day 1: 5/15/111:00 AM

Admit to LR/DR Secure Consent NPO VS + FHT and progress of

labor every hour

• CBC results normal

• IV Ampicillin 2g ( )ANST• IVF D5 LR x 8 hour

BP: 110/60HR: 92 bpmRR: 18 cpmTemp: 37.4 C

Day 1:5/15/201110:30 AM

Anesthesia Post-OP orders:S/P LTCS I under SABTo RRO2 inhalation @ 2-3 LPM via nasal cannulaHook to Pulse OxMonitor VS q15 x2 hours then q 30 until stableNPO

- IVF: D5LR 1L x 8 hours + 20 iu oxy

D5NM 1L x 8 hours D5LR 1L x 8 hours Ketorolac 30 mg IV q8 x 3

doses Nalbuphine 10 mg IV q4 x 6

doses Omeprazole 40 mg IV OD

while NPO Ampicillin 1g IV q6 () ANST

02 Sat-100HR: 83BP: 110/80

Day 15/15/201112:00 PM

To ward E Continue meds Clear liquids VS q4 Refer accordingly

- -

Day 25/16/20118:00 AM

S/P CS Day 1 May have water and

tea/crackers; then soft diet for dinner

IVF to consume VS q4 please Remove IFC Refer accordingly

Hgb 127 Cefalexin 500 mg capsule TID x 7 days

Mefenamic Acid 500 mg cap q6

Vit C tab OD FeSO4 tab OD

Stable VS(-) Flatus(-) BM

Day 35/17/20118 :00AM

S/P CS Day 2 Soft diet then DAT

once w/ BM Continue Oral Meds For COD today VS q4 please Refer accordingly

- - Stable VS(+) Flatus(+) BM

Day 45/18/20118:00 AM

S/P CS Day 3 Continue Meds Continue Daily Wound

Care Advise for discharge Sched OPD

WBC: 7.0 Amoxicillin 500 mg capsule every 6 hours x 7 days

Mefenamic Acid 500 mg cap q6

Stable VS(-) Pallor(-) Fever

Dystocia Difficult labor Characterized by abnormally slow

progress of labor Most common indication for

primary CS

1. Abnormalities of the expulsive forces

2. Abnormalities of the maternal bony pelvis

3. Abnormalities of the presentation, position or development of the fetus

4.Abnormalities of soft tissues of the reproductive tract that form an obstacle to fetal descent

1. Abnormalities of the Powers (uterine contractility and maternal expulsive effort)

2. Abnormalities involving the Passenger (the fetus).

3. Abnormalities of the Passage (the pelvis).

UTERINE DYSFUNCTIONABNORMAL LABOR PATTERNSRUPTURE OF MEMBRANES W/O

LABORPRECIPITOUS LABOR AND DELIVERY

Failure of cervix to dilate or presenting part to descend

Characterized by lack of progress in any phase of cervical dilatation

At least 4 cm dilated Regular, frequent,

usually painful contractions

Dilate at least 1.2-1.5 cm/hr

Are not comfortable with talking or laughing during their contractions

Diminished pelvic capacityExcessive fetal size

Diminished pelvic capacity Any contraction of the pelvic diameters

that diminishes the capacity of the pelvis that can create dystocia during labor▪ a. Contracted pelvic inlet▪ b. Contracted midpelvis▪ c. Contracted pelvic outlet▪ d. Pelvic fractures and rare contractures

a. Xray Pelvimetryb. Computer Tomographic

Scanningc. Magnetic Resonance Imaging

Excessive fetal size Fetal size alone is a seldom explanation

for failed labor

a. Intrapartum Infection▪ After the membrane ruptured, bacteria can enter

the amnionic fluid, traverse the amnion and invade the decidua and chorionic vessels thus causing maternal and fetal bacteremia and sepsis.

▪ Infection may complicate prolonged labor and pose a serious danger both to mother and fetus.

b. Uterine Rupture▪ Abnormal thinning of the lower uterine segment

that can create a serious danger during pronged labor.

c. Pathological Retraction Ring

d. Fistula Formatione. Pelvic Floor Injury f. Postpartum Lower Extremity Nerve

Injury

a. Caput Succedaneumb. Fetal Head Molding

Factors associated with molding:▪ 1. Nulliparity▪ 2. Oxytocin labor stimulation▪ 3. Delivery with a vacuum extractor

THANK YOU!