A.

Identifying details

1. B/O: Siti Suriyati

2. RN: 1269714
3. DATE OF ADMISSION: 25/4/2018
4. DATE OF CLERKING: 26/4/2018
5. DATE OF BIRTH: 25/4/2018
6. AGE ON ADMISSION: 2 hours of life
7. CURRENT GESTATIONAL AGE: 38 weeks 2 days
8. GESTATIONAL AGE AT BIRTH: 38 weeks 2 days
9. Birth weight: 3.17 kg Length: 54 cm HOC: 34 cm

The length is on 75th centile,

which is appropriate and
normal for his gestational
age.

The weight is between 10th

and 25th centile, which is
appropriate for his gestational
age.
 The head
circumference is on the
25th centile, thus
appropriate for
gestational age.

B. Chief complaint or reason for admission

Infant affected by vacuum-assisted delivery due to prolonged second stage of labour

with caput over occipital region.

C. Mother’s detail

Mother is 27 year old lady, Gravida 1 Para 0. Her LMP was on 31/7/2017 and her
EDD is on 7/5/2018. Urine pregnancy test (UPT) was done and was tested positive at
 8th week period of amenorrhea. Initial booking was done at Klinik Desa Permatang
Pasir, Balik Pulau in the same week. First scan was done at 20 weeks. There were no
antenatal malformations detected. Her blood group is B positive. Hep B, HIV and
VDRL were negative. There was no antenatal complication throughout her pregnancy
such as diabetes, hypertension, IUGR, risk of sepsis and others except for subclinical
hypothyroidism but not on medication and she was asymptomatic.

D. Delivery details

 Date of delivery and time : 25/4/2018, 6.50am

 Gender : Boy
 Liquor : Clear
 Prolonged rupture of membrane : No
 Dexamethasone : No
 Mode of delivery : Spontaneous vaginal delivery with vacuum-
assisted
Total ROM: 10 hours
Total second stage of labour: 35 minutes
Instrumental indication (vacuum-metal cup)
prolong 2nd stage of labour

Placenta: 500g Artery: 2 Vein: 1

 APGAR score : 8 at 1 minute and 9 at 5 minutes

 Immunization : Hep B and BCG were given
 Maternal fever in labour : No

 Delivery room management:

Case referred from O&G MO to paediatric MO at 6.42 am for vacuum-
assisted delivery for prolonged second stage of labour. Attended by paediatric team
prior to delivery. Baby born vigorous, poor tone, good cry, bluish, APGAR 81. Initial
steps done – indirect suction. Clear liquor. Noted that baby already PU and BO.
Reassess patient at 10 minutes of life, baby not tacypnoeic, no nasal flaring, no
recession, RR: 54, SPO2: 96% reduce RA, HR:142.
Reassess patient at 15 minutes of life, baby active, pink no nasal flaring, no grunting,
RR: 50, SPO2: 97% reduce RA, HR: 144.
No further resuscitation required.
E. Initial findings and management

25/4/2018 6:55am

Upon admission, temperature is stable, no desaturation, BP stable, tolerating cup

feeding 24cc/3hourly, BO and PU upon delivery.

Neonatal examination
General examination: On examination, patient is alert, active, pink, not tachypnoeic,
tone is good, CRT < 2s, warm peripheries

Vital signs: RR: 54

HR: 142
SPO2:(Pre-ductal: 96%)

Head: HC is 34 cm , caput over occipital region, non-tender, cranial sutures are

closely applied, anterior fontanelle is soft and flat.
Skin: Mongolian spots over bilateral gluteal.
Face: no dysmorphism, no ptosis, no jaundice, red reflex present, pinna is normal, no
clefts of the hard and soft palate.
Upper limbs: symmetrical in size and length, fingers correct number and morphology,
palms have to palmar creases on each hand, brachial pulse present.
Chest: no chest wall deformities, symmetrical chest wall expansion,
Umbilicus: no discharge or hernias
Genital: normal male genitalia
Lower limbs: symmetrical in size and length, good tone and movement, well felt
femoral pulse bilaterally, no oedema, no hyperextensile/dislocatable knees, no CTEV,
correct number of digits in each foot.
Hips: No Developmental Displacement of the Hip
Back and spines: no scoliosis, no hair tufts, no naevus, no abnormal skin patches, no
birthmarks, no sacral pits.
Reflexes: grasping reflex is normal
Moro’s reflex is complete and symmetrical
sucking reflex: good

CVS: S1 and S2 is heard and no added sound.

Lungs: vesicular breathing, equal air entry bilaterally, no added sound.
Abdomen: soft and non-tender, no hepatosplenomegaly
 Impression:
1. Infant affected by mother of subclinical hypothyroidism
2. Infant affected by vacuum-assisted delivery, indication by prolong 2nd stage of
labour
3. Term at 38 weeks+ 2 days, birth is 3.17 kg which is appropriate for gestational
age

Management:

1. Admit PBU
2. Start feeding 24 cc/ 3 hourly (TF: 60 cc/kg/day)
3. Trace G6PD and cTSH
4. Observe for jaundice (risk of jaundice in caput)
5. Head circumference 4 hourly monitoring

25/4/2018 9:55 am

On examination, patient is afebrile, caput over occipital region, not dysmorphic, no cleft
palate, CRT< 2s, not tachypnoiec, no recession

Lungs: clear

CVS: S1S2 best heard at left side

PA: soft and distended

B/L heard pulse palpable, normal male genitalia, spine is normal. Grasping well, suction well
and Moro’s complete. However, there is acrocyanosis.

Investigation:

1. Check temperature stat

2. Check SPO2 stat
3. HC stat 4 hourly

Results:

1. Temperature – 35 °C (hypothermia)
2. SPO2 – fluctuating +/- 80%
3. Head circumference – 34 cm

Management:

1. Review patient at noon for worsening scalp swelling

2. Continue feeding 24 cc 3 hourly
3. Reflo at 4 hours of life
4. If stable, can transfer out to N4 in the afternoon
 5. Keep baby warm
6. For double blanket
7. Put baby under warmer, recheck O2 saturation

25/4/2018 10:30 am

Review patient again under radiant warmer.

On examination, patient is not tachypnoeic, no recession, peripheries pink and warm,
Pulse rate - 113 beats/minute
SPO2 (post-ductal) – 85% under room air
(pre-ductal) – 96%

CVS – S1, S2 present, no added sound

Lungs – clear

Management:

1. NPO2 1L/minute
2. Pre and post ductal monitoring
3. 4 limbs blood pressure after 24 hour of life
4. SPO2 > 95%

Subsequently, post ductal SPO2 has gone up 97% under NPO2. Blood gas is tested and chest
x ray is done. The results show normal value of blood gas and chest x ray is clear. NPO2 is
then cut to 0.5L/minute. Since the patient is clinically stable as SPO2 has gone up to more
than 95%, at 2pm review, trial off SPO2 is done but SPO2 then drop and fluctuating from
88% to 96%. Hence, NPO2 is continued, SPO2 monitoring is continued and kept more than
95% and KIV off oxygen the next morning. However, at 8:45 pm review, the patient is
noticed to have mild subcostal recession despite 100% post ductal SPO2 under NPO2. If any
desaturation occurs, pre and post ductal SPO2 is to be done.

26/4/2018

Patient has no temperature instability, no desaturation, BP is stable, and head circumference

is static at 34 cm, tolerating feeding, PU regularly and bowel open 4 times yesterday.

On examination, there is tinge of jaundice, AFNT, respiratory rate is 46, tone is normal, no
recession
Lungs had equal air entry, 1st and 2nd heart sound were heard, abdomen soft and not
distended.
Investigation:

Serum bilirubin concentration (SBC) stat

Result:

SBC: 179.5 µmol/l

Management:

1. Start standard phototherapy

2. Transfer out to N4

F. Problem list:

1. Term baby at 38 weeks + 2 days with birth weight 3.17 kg which is appropriate
for gestational age.
2. Transient tachypnoe of newborn
3. Hypothermia
4. Infant affected by hypothyroidism mother
5. Infant affected by vacuum assisted delivery
6. Neonatal jaundice at 26 hour of life

G. Current condition and management:

26/4/2018 1:20pm

There Is no temperature instability, no desaturation under room air, head circumference is

static at 34 cm, Bp is stable, tolerating 36 cc/3 hourly, PU and BO once.

On examination, patient is active, had a tinge of jaundice, warm peripheries, CRT<2 seconds,
AFNT. Lungs are clear, 1st and 2nd heart sound were heard and abdomen is soft and non-
tender.

Investigation:

Serum bilirubin the next morning

Management:

1. Encourage breast feeding on demand

2. Continue feeding 36 cc/3 hourly
3. Allow discharge if stable under room air
4. Continue standard phototherapy
H. Student own examination

26/4/2018, 10:00am

On general inspection, baby had a tinge of jaundice, moving all four limbs symmetrically, no
respiratory distress, no nasal flaring, no grunting, no recession or chest deformity, not
syndromic and no dysmorphic features. The baby not attach to any medical adjuncts.

Respiratory rate: 50 breaths per minute, Blood pressure: 74/38 mmHg, Pulse rate: 138 bpm,
Temperature 37 oC, SpO2 97%, perfusion less than two seconds.

On full examination, head size and shape were appropriate, anterior and posterior frontanelle
not bulging or tense, 2 eyes, 2 nostrils, 2 ears, no cleft palate or lip, good sucking reflex, no
lump or excessive skin fold in neck.

Lungs were cleared with equal air entry and symmetrical intensity. No added sound heard.
CVS: Apex beat in the fifth intercostal space mid clavicular line. First and second heart sound
heard and no murmur.
Abdomen: Soft, not distended, no organomegaly. Umbilical cord was still intact and no
discharge.
Femoral pulses felt bilaterally.
Normal male genitalia present. Anus patent.
No developmental dysplasia of hip, no congenital talipes equinovarus.
Spine: normal
Moro reflex: complete

I. Summary:

In summary, this term (38/52 + 2/7) infant was born on 24/5/2018 via spontaneous vaginal
delivery with vacuum-assisted (cup-metal) due to prolong second phase of labour. Infant was
then admitted to neonatal ward for further observation. Infant weight was 3.17 kg which is
appropriate for gestational age. APGAR score was 8 at 1 minute and 9 at 5 minutes. Infant is
noted to have caput over occipital region but the head circumference is static throughout
monitoring and no raise in swelling. Infant is affected by mother who has hypothyroidism but
not on medication. At 3hours of life infant develop hypothermia. Infant also noted to have
transient tachypnoea of newborn and therefore was put on NPO2. At 26 hours of life a tinge
of jaundice was noticed and was put on standard phototherapy. Infant is tolerating cup
feeding and breastfeeding well.

J. Discussion:

This baby boy was born at term via spontaneous vaginal delivery with vacuum-assisted due
to prolonged second stage of labour. His weight is 3.17 kg and was appropriate for the
gestational age. APGAR score was 8 at 1 minute and 9 at 5 minute. He was admitted to the
ward for observation for any complications of vacuum-assisted delivery as complications can
present several hours after birth1. However, a few other problems were noted throughout his
admission. These include transient tachypnoea of new born, hypothermia and neonatal
jaundice. I would like to discuss each condition further.

As for the impact of vacuum-assisted delivery, one study shows that all vacuum-related in
term neonates were evident within 10 hours of birth2. This baby has caput succedaneum
which is normally present in new born. However, there should be raise suspicions in this case
as it might be exaggerated in vacuum-assisted delivery3. Hence, head circumference is
monitored 4 hourly to detect any abnormalities. The head circumference remains static at 34
cm in the first 24 hours of life.

At 3 hours of life, the temperature drop to 35.0 °C and the infant was noted to have
hypothermia. Hypothermia is defined as core temperature less than 36 to 36.5 °C4. Newborns
are prone to develop hypothermia due to their larger surface area per unit body weight,
decreased thermal insulation due to lack of subcutaneous fat and reduced amount of brown
fat. When the temperature fall below 36°C, it’s a sign of danger and prompt intervention of
warming the baby is needed. In this case, the baby had shown sign of acrocyanosis which is
the sign of peripheral vasoconstriction. Hence he is put under radiant warmer and regular
temperature monitoring.

At birth, the baby presented with hypotonia and bluish but improve after 10 to 15 minutes of
resuscitation. However, after 3 hours of life there was a drop of SPO2 level and the patient
was put on nasal prong. Spo2 level improves with nasal prong but at 5 hours of life mild
subcostal recession was noted. The patient is said to be in respiratory distress and most likely
due to transient tachypnoea of newborn (TTN). Even though TTN is more likely to happen in
term infant with caesarean delivery, but in this case, it is a diagnosis of exclusion. This is
because other points for common causes of respiratory distress in newborns like Acute
Respiratory Distress Syndrome (ARDS), early onset pneumonia and meconium aspiration
syndrome is absent in this case. TTN is self-limiting and normally occur and resolve within

1
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2672989/
2
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2672989/
3
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2672989/
4
https://www.msdmanuals.com/professional/pediatrics/perinatal-problems/hypothermia-in-neonates
24-hour to 72-hour of life5. It is due to delay in clearance of fetal lung fluid due to inability to
absorb lung liquid which make the infant harder to breath resulting in respiratory distress.

At 26 hours of life, a tinge of jaundice was noted on examination. Serum bilirubin was 179.5
µmol/l. This is plotted on the bilirubin chart. My patient is considered as infants at medium
risk as he is more than 38 weeks with risk factor of neonatal jaundice; caput succedaneum
following vacuum-assisted delivery.

The aetiology of neonatal jaundice after 24 hour could be pathological or physiological.

Neonatal jaundice in the 24 hour of life is abnormal and need urgent intervention6. In this
case, the cause might be likely due to caput succedaneum. Bruising caused by caput
succedaneum may break down into the bilirubin. There is a heightened risk of the baby
developing jaundice. Jaundice, if treated, typically won’t pose any problems. Yet, if left
undiagnosed and untreated, may lead to severe medical issues7. Nevertheless, full
investigation must be done to determine the cause of the jaundice and to prevent its
complications if left untreated such as acute bilirubin encephalopathy (Kernicterus) which
ends up causing cerebral palsy, learning difficulties, hearing loss, poor tooth enamel
development, permanent upward gaze and infant death.

Some other causes of neonatal jaundice includes haemolysis due to ABO or Rh-
isoimmunisation, G6PD deficiency, microspherocytosis, drugs, physiological jaundice,
cephalhaematoma, subaponeurotic haemorrhage, polycythaemia, sepsis septicaemia,
meningitis, urinary tract infection, intra-uterine infection, breastfeeding and breastmilk
jaundice, gastrointestinal tract obstruction: increase in enterohepatic circulation. Any patient
diagnosed with jaundice should have total serum bilirubin measured. The value is then
plotted on the bilirubin graph to determine the treatment.

5
https://emedicine.medscape.com/article/976914-overview#a6
6
http://www.moh.gov.my/penerbitan/CPG/QR%20Management%20of%20Neonatal%20Jaundice%20(Second
%20Edition).pdf
7
https://www.birthinjuryguide.org/birth-injury/types/caput-succedaneum/
 The total serum
bilirubin at 26
hours of life
(179.5 µmol/l)

The graph above shows that the point plotted is above the dotted line of infants at medium
risk. Hence, conventional phototherapy is indicated for this patient. According to the
guideline in Paediatric Protocols for Malaysian Hospital8, start conventional phototherapy at
total serum bilirubin 3mg/dL (50micromol/L) below the levels for intensive phototherapy. In
this case, TSB is half less below intensive phototherapy.

Besides treating the patient as jaundice due to caput succedaneum under phototherapy, other
causes of hyperbilirubinaemia due to underlying diseases should also be investigate to rule
out other possible causes of neonatal jaundice; Coombs test, G6PD status, Infant’s blood
group, maternal blood group, Direct Coombs’ test are indicated in Day 1 jaundice and severe
jaundice. Full blood count, reticulocyte count, peripheral blood films are done to assess any
evidence of haemoglobonipathies. Blood culture, urine microscopy and culture are done if
infection is suspected9. In my patient, G6PD status is normal and other tests are not indicated
for him as he is neither having severe jaundice, family history of bleeding disorder or
haemoglobinopathy nor infection.

Antenatal history reveals that mother has hypothyroidism but not on any medication. Cord
TSH level is normal (5.52 mIU/L, normal range of cord TSH 2.3-13.2 mIU/L). There are no
8
Haji Muhammad Ismail, Hussain Imam, Ng Hoong Phak, Terrence Thomas. Paediatric Protocols for Malaysian
Hospitals. 3rd edition. Kuala Lumpur: Ministry of Health Malaysia, 2015.
9
Haji Muhammad Ismail, Hussain Imam, Ng Hoong Phak, Terrence Thomas. Paediatric Protocols for Malaysian
Hospitals. 3rd edition. Kuala Lumpur: Ministry of Health Malaysia, 2015.
clinical features of hypothyroidism such as poor feeding, small stature, large anterior
fontanel, hypotonia and hoarse cry.

K. References:

1. Unzila A Ali, E. R. (2009). Vacuum-Assisted Vaginal Delivery. Review in Obstetric

& Gynecology, 5-17.

2. Robert L. Stavis, B. M. (2017). Hypothermia in Neonates. MSD MANUAL

PROFESSIONAL VERSION.
3. birth injury guide. (2018). Retrieved from birth injury guide website:
https://www.birthinjuryguide.org

4. KN Siva Subramanian, T. R. (2014). Transient Tachypnea of the Newborn Clinical

Presentation. Medscape Drugs&Disease.

5. providers, q. r. (second edition). Management of neonatal jaundice. Malaysia:

Ministry of Health Malaysia, Malaysian aeditrics Association, Academy of Medicine
Malaysia .

6. Haji Muhammad Ismail, Hussain Imam, Ng Hoong Phak, Terrence Thomas.

Paediatric Protocols for Malaysian Hospitals. 3rd edition. Kuala Lumpur: Ministry of
Health Malaysia, 2015.

7. Dr Giles Kendall, T. C. (May 2010). Clinical Guideline. London: Royal College of

Obstetricians and Gynaecologists.

8. Sofronescu, A. G. (2015, July 16). Medscape. Retrieved from Medscape: Laboratory

Medicine website: https://emedicine.medscape.com
 EVIDENCE BASED QUESTION

1. General question
Does vacuum-assisted delivery increase the risk of jaundice in neonates?

2. PICO

Patient Intervention/Exposure Comparison Outcome

Neonates Vacuum-assisted No vacuum- Onset of jaundice
delivery assisted delivery

3. Search terms and results of search

Search of the articles for evidence based question was done by using PubMed through
RCSI Library and full-article was retrieved from PMC.

No. of search Search Result

1 vacuum and neonatal jaundice (free full text) 3
 4. Article selected and brief description of the article
The article selected was “A Prospective Randomized Study Comparing Maternal
and Fetal Effects of Forceps Delivery and Vacuum Extraction”.

Citation:

Shekhar, S., Rana, N., & Jaswal, R. S. (2012). Journal of Obstetric & Gynaecology of
India. A Prospective Randomized Study Comparing Maternal and Fetal Effects of
Forceps Delivery and Vacuum Extraction, 63(2): 116–119.

Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3664693/

Summary:
A prospective randomized study was conducted on one hundred eligible women
requiring assisted vaginal delivery in the second stage of labour. They were
randomized to deliver by forceps or vacuum extraction to compare maternal and
neonatal effects of assisted vaginal delivery. The results show vacuum extraction has
significant less maternal trauma compared to forceps delivery but predispose the
neonates to an increase risk of neonatal jaundice and cephalhematoma.

5. Critical appraisal of the article

1. Is this a systematic review of randomised trials?
HINT: Yes. This is a review of randomised control trial because the participants are
If this is a review of randomly allocated to have forceps delivery or vacuum extraction.
observational
studies there are
higher risks of bias
than a review of
randomised
controlled trials
 2. Does this systematic review have a ‘methods’ section that adequately describes the methods?
HINT: Yes. Method of how the participants randomly allocated to the delivery
method are as follows:
Of how the included
how the included studies were found?
studies were found
One hundred eligible women in the second stage of labor requiring assisted
and how a decision
vaginal delivery
was made to include
them? how a decision was made to include them?
inclusion in the study were those with singleton pregnancies, a cephalic
presentation, and a gestation of at least 37 completed weeks and where
instrumental assistance was required for delivery during the second stage of labor
How the validity of
How the validity of the individual studies was assessed?
the individual
As soon as a decision had been taken to intervene, a random treatment allocation
studies was
to forceps or vacuum extractor was made by opening the top envelope in a box of
assessed?
serially numbered envelopes. Regardless of the ultimate mode of delivery, for the
purpose of analysis, the women remained in the group to which they were
originally allocated

3. Were the results consistent from study to study?

Did the studies all Yes.
give similar results
in a similar
direction or was
there a wide range
of results?
(Heterogeneity)

4. Were individual patient data used in the analysis (or aggregate data)?
HINT: Individual data is used in the analysis.
Is this a meta-
analysis of the
overall study results
or an individual
patient data meta-
analysis?

B. Decide whether the results of this systematic review is valid

6a. What is the main result?

HINT:
How are the results Results are presented in tables form.
represented?
Results:
What is the result? The women in the forceps group took significantly less time to deliver than those
Try to sum up the in the VE group (3.62 min for VE vs. 5.36 min for forceps, p < 0.05) after
bottom line results application of the instrument.
in one sentence.
Forceps delivery require more analgesia than vacuum extraction
Women with vacuum extraction suffer less injury
Some markings of the baby’s scalp were always present after vacuum extraction.
Many of the babies born by forceps also had some markings. In both groups
these marks generally disappeared quickly. Cephalhematoma was more common
in babies delivered by vacuum extractor; however, the difference was not
statistically significant.
There were no significant differences between the groups in terms of proportions
of babies with low apgar scores.
The incidence of jaundice was more in the vacuum extractor group than in the
forceps group (10 % in VE and 6 % in forceps, p > 0.05).
Try to sum up the bottom line results in one sentence:
On mother’s view point vacuum extraction is significantly better than
vacuum extraction but on neonate’s view point there is no significant
difference between the two methods.

6b. How important are the results

Magnitude is based on the confidence interval. The confidence interval is

narrow hence high precision.
HINT:

What is the
magnitude of the
treatment effect?

How precise is the

treatment effect?
 C. How might these results be applied?
7. Can the results be applied to the local population?

HINT:
Is your patient so Not much different.
different from those
in the studies that
its results cannot
apply?

Yes
Is it feasible to
apply in our
setting?

What are your Potential benefit is less injury, less usage of analgesia, less time of hospital
patient’s potential stay
benefits and harm might be higher incidence of neonatal injury with less experience
harms? operator

What are your

patient’s values and
preferences for
both the outcome
you are trying to
prevent and the
side-effects you may
cause?

8. Were all important outcomes considered?

HINT:
Often not covered
in studies designed
to test a particular Yes, it benefits everyone
hypothesis.
Consider outcomes
from the point of
view of the:
- your patient
- policy maker and
professionals
- family/caretakers
- wider community

9. Should policy or practice change as a result of the evidence contained in this trial?
HINT:
Consider whether Yes, it should be change especially with increase number of expertise
the benefits are nowadays.
worth the harms
and costs. If this
information is not
reported can it be
filled in from
elsewhere?