OB Case Conference

 M.T.E.  25 y/o  Single  Catholic  Marikina City  admitted for the first time in QMMC on May 15, 2011

 Labor pains

 Few hours PTA  (+) labor pains ▪ described as irregular contractions, occurring every 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, 2010  AOG: 39 weeks 2 days by LMP  PNCU x 4 : St. Vincent Hospital  PNCU x 3: QMMC

 Prenatal medications: Multivitamins – OD starting at the 1 st trimester until 3 rd trimester Ferrous sulfate – OD starting at 2 nd trimester until 3 rd trimester

 Menarche at the age of 12  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 man  Non- smoker, non-alcoholic drinker  Denies 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 C HEENT anicteric 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

G 1 P 0 (0000) Pregnancy uterine 39 weeks 2 days AOG by LMP, CIL

G 1 P 1 (1001) PUFT Cephalic Arrest in Cervical Dilatation 2 0 to CPD, delivered via LTCS I to a live Boy AS 9.

 Partograph

DayMDs OrdersLabs And Imaging Medication IV Fluids Vital Signs and Symptoms Day 1: 5/15/11 1:00 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: 110/60 HR: 92 bpm RR: 18 cpm Temp: 37.4 C Day 1: 5/15/ :30 AM Anesthesia Post-OP orders:  S/P LTCS I under SAB  To RR  O2 2-3 LPM via nasal cannula  Hook to Pulse Ox  Monitor VS q15 x2 hours then q 30 until stable  NPO -  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-100 HR: 83 BP: 110/80 Day 1 5/15/ :00 PM  To ward E  Continue meds  Clear liquids  VS q4  Refer accordingly --

Day 2 5/16/2011 8:00 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 3 5/17/ :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 4 5/18/2011 8:00 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 DYSFUNCTION  ABNORMAL LABOR PATTERNS  RUPTURE OF MEMBRANES W/O LABOR  PRECIPITOUS 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 cm/hr  Are not comfortable with talking or laughing during their contractions

 Diminished pelvic capacity  Excessive 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 Pelvimetry  b. Computer Tomographic Scanning  c. 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 Formation  e. Pelvic Floor Injury  f. Postpartum Lower Extremity Nerve Injury

 a. Caput Succedaneum  b. Fetal Head Molding  Factors associated with molding: ▪ 1. Nulliparity ▪ 2. Oxytocin labor stimulation ▪ 3. Delivery with a vacuum extractor

 THANK YOU!