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WINDSOR UNIVERSITY SCHOOL OF MEDICINE

BRIGHTON ESTATE, CAYON, ST KITTS

OBSTETRICS AND GYNECOLOGY ROTATION

Joseph N France (JNF) General Hospital

PRECEPTOR: DR. ROSINA C. CASTANEDA

CASE REPORT #2

VAGINAL DELIVERY

NAME: ONYEDIKA EGBUJO

CLINICAL # 618

DURATION OF ROTATION: 24TH AUG – 2nd OCT, 2015


BIODATA

Name: N.H

Date of birth: 16th November 1989

Age: 24 years

Place of birth: St Kitts

Place of Residence: Philips village

Occupation: Sales clerk

Marital status: single

Religion: Christain

Denomination: Seventh-day Adventist

Blood group: B RH-Positive

PRESENTING COMPLAIN: Delivery date exceeded.

HISTORY OF PRESENTING COMPLAIN:


The patient, a 24yr old single mother of one came to the JNF hospital for routine antenatal
on Thursday the 3rd of Sept at 11am because her expected date of delivery, Wednesday the 2nd
of Sept just passed with no imminent signs of labor. Patient stated that she visited the clinic the
previous day where complete physical examination was completed and it was determined that
she wasn’t having cervical dilatation and so needs induction.

HISTORY OF CURRENT PREGNANCY:

First day of last menstrual period - 19th Nov, 2014.


Expected date of delivery: ultrasound date - 2nd Sept, 2014.

Naegele’s rule date – 26th Aug, 2014.


Patient noticed she missed her period in December 2014. When she visited her doctor, the test
came out positive for beta hCG, suggestive of pregnancy.

In her first trimester, pregnatal tablets and folic acid were prescribed for her and afterwards, she
came monthly for prenatal visits. She experienced nausea and vomiting which occurred daily
accompanied by mild temporal headaches.

During her second trimester she said the nausea and vomiting stopped. In her third trimester, she
said she experienced lower abdominal pain which she rated 6/10 with 10 most severe. She
characterized the pain as “tearing” with radiation to the lower back. She said the pain is relieved
with rest and aggravated by exertion to the pelvic area and spine. The patient also reported lower
limb weakness and easy fatigability from walking about 50meters.

PAST MEDICAL HISTORY:

Obstetrics History:
Gravida 2 Para 1

1st Pregnancy -
Date of delivery: 6th February 2012
Sex: Male
Weight: 6.6lb
Length of gestation: 40 weeks
Place of delivery: St Kitts
Mode of delivery: Induced vaginal delivery due to membrane rupture.
No complications during pregnancy and after delivery.
Child is healthy with no medical condition.

Gynecological History
Menarche was at 14years of age.
Last menstrual period: 19th Nov 2014
Cycle length: Patient said she doesn’t keep records
Number of days of period: 5days of light flow
Experiences dysmenorrhea sometimes which she takes 2 tablets of advil to relieve the pain
Number of pads per day: 3 pads
Mammogram: never been done
Pap smear: last done in January 2013 results showed inflammatory cells which she was given
medications for .
No sexually transmitted disease
Has one male sexual partner.
No pain during sexual intercourse
Doesn’t use condoms or oral contraceptives

Internal Medicine History:


Immunization is up-to-date
No known medical condition

PAST SURGICAL HISTORY: None

DRUG HISTORY:
Pregnatals, Folic acid

SOCIAL AND FAMILY HISTORY:


Lives with mother, two brothers and her son in a 3-bedroom apartment. Doesn’t smoke and
doesn’t drink alcohol

REVIEW OF SYSTEMS:
No known allergies.
Patient was conscious and alert, oriented to place and time

PHYSICAL EXAMINATION

INVESTIGATION:
Fetal heart rate 160 beats per minute
Temperature 99.2F
Pulse 80 beats per min
Respiratory rate 24 breaths per min
Blood pressure 109/60mmHg
Physical Findings:
Patient breathing spontaneously on room air, hair braided, scalp dry, mucous membrane pink and
moist. Nostril clear no drainage, ears no drainage, no lymph nodes palpated. Breast medium in
size, nipples flat but on stimulation colostrum present in both.
Abdominal Examination:
Abdomen round, sign of pregnancy noted, linea nigra and straie gravidaum noted, fundal height
36cm.
Pelvic and Perineal Examination: Vulva area healthy looking, shaving already done, no
hemorrhoids, enema withheld. Vagina warm and moist, cervix is posteriorly located, soft and
thick, it is about 30% effaced, presenting part cephalic -3 station. No cord felt, membrane flat,
whitish discharge on gloved finger.
Urine Test: Glucose negative, ketone negative .

DIAGNOSIS: Term pregnancy with no cervical dilatation

MANAGEMENT:

Labor induction.

4th Sep 2015:


Patient okay and doing well

5th Sep 2015:


Artificial rupture of membrane was done and clean fluid drained.
Spontaneous vaginal delivery of a live female infant at term cried shortly after birth. Post
delivery condition remains stable, fundus firm and contracted. Lochia and micturition normal.

Brief summary of delivery: Spontaneous vaginal delivery of a live female infant at term, cried
shortly after. Suction was done once, the infant was dried and warmth applied. Baby weight is
3.07kg(6.77lb), length 49cm , occipital circumference 35cm.

6th Sep 2015


DAY 1 POST DELIVERY:
Condition remains satisfactory, no definite complaints voiced. Baby put to the breast and
suckled. Patient tolerated diet, lochia and micturition normal, and so the patient was discharged
with the baby.

DISCUSSION: LABOR

DEFINITION:
Labor is a series of events occurring in a pregnant woman that involves regular, rhythmic,
painful uterine contractions resulting in the progressive cervical dilatation and effacement,
descent of the presenting part of the fetus, with the goal of expulsion of the products of
conception per vagina.
STAGES OF LABOR

Obstetricians have divided labor into 3 stages that delineate milestones in a continuous process.

First Stage of Labor

Begins with regular uterine contractions and ends with complete cervical dilatation at 10 cm
Divided into a latent phase and an active phase

The latent phase begins with mild, irregular uterine contractions that soften and shorten the
cervix. Contractions become progressively more rhythmic and stronger, usually takes 6 – 12
hours for multiparous women, and 12 – 18 hours for the nulliparous women. It took about 5
hours in the case of the patient above.

The active phase usually begins at about 3-4 cm of cervical dilation and is characterized by rapid
cervical dilation and descent of the presenting fetal part

Active Phase starts from when the cervix is 4cm dilated to when the cervix is fully dilated at 9-
10cm and usually 30 minutes per cm for multiparous women, and takes at most 1 hour for each
rise in cm for nulliparous women. It was about 30 minutes in the case of the patient above.

Second Stage of Labor

Begins with complete cervical dilatation and ends with the delivery of the fetus
In nulliparous women, the second stage should be considered prolonged if it exceeds 3 hours if
regional anesthesia is administered or 2 hours in the absence of regional anesthesia

In multiparous women, the second stage should be considered prolonged if it exceeds 2 hours
with regional anesthesia or 1 hour without it.

This took about 30 minutes in the patient above

Third Stage of Labor

The period between the delivery of the fetus and the delivery of the placenta and fetal
membranes

Delivery of the placenta often takes less than 10 minutes, but the third stage may last as long as
30 minutes. This took 13 minutes in the patient above.

Expectant management involves spontaneous delivery of the placenta

The third stage of labor is considered prolonged after 30 minutes, and active intervention is
commonly considered

Active management often involves prophylactic administration of oxytocin or other uterotonics


(prostaglandins or ergot alkaloids), cord clamping/cutting, and controlled traction of the
umbilical cord

Mechanism of labor

The mechanisms of labor, also known as the cardinal movements, involve changes in the
position of the fetus’s head during its passage/navigation through maternal pelvis, in labor. These
are described in relation to a vertex presentation. Although labor and delivery occurs in a
continuous fashion, the cardinal movements are described as the following 7 discrete sequences:

1. Engagement
2. Descent
3. Flexion
4. Internal rotation
5. Extension
6. Restitution and external rotation
7. Expulsion
Intrapartum Management of Labor
For proper management of labor all the following parameters have to be closely observed the
physical examination should include documentation of the following:

 Maternal vital signs


 Fetal presentation
 Assessment of fetal well-being
 Frequency, duration, and intensity of uterine contractions
 Abdominal examination with Leopold maneuvers
 Pelvic examination with sterile gloves
First Stage of Labor

On admission to the Labor and Delivery suite, a woman having normal labor should be
encouraged to assume the position that she finds most comfortable. Possibilities including the
following:

 Walking
 Lying supine
 Sitting
 Resting in a left lateral decubitus position
Management Includes The Following:

 Periodic assessment of the frequency and strength of uterine contractions and changes in cervix
and in the fetus' station and position
 Monitoring the fetal heart rate at least every 15 minutes, particularly during and immediately
after uterine contractions; in most obstetric units, the fetal heart rate is assessed continuously
Second Stage of Labor

With complete cervical dilatation, the fetal heart rate should be monitored or auscultated at least
every 5 minutes and after each contraction. Prolonged duration of the second stage alone does
not mandate operative delivery if progress is being made, but management options for second-
stage arrest include the following:
 Continuing observation/expectant management
 Operative vaginal delivery by forceps or vacuum-assisted vaginal delivery, or cesarean
delivery.
Delivery of the fetus

Positioning of the mother for delivery can be any of the following:

 Supine with her knees bent (, dorsal lithotomy position; the usual choice)
 Lateral (Sims) position
 Partial sitting or squatting position
 On her hands and knees
Episiotomy used to be routinely performed at this time, but current recommendations restrict its
use to maternal or fetal indications

Delivery maneuvers are as follows:

 The head is held in mid position until it is delivered, followed by suctioning of the oropharynx
and nares
 Check the fetus's neck for a wrapped umbilical cord, and promptly reduce it if possible
 If the cord is wrapped too tightly to be removed, the cord can be double clamped and cut
 The fetus's anterior shoulder is delivered with gentle downward traction on its head and chin
 Subsequent upward pressure in the opposite direction facilitates delivery of the posterior
shoulder
 The rest of the fetus should now be easily delivered with gentle traction away from the mother
 If not done previously, the cord is clamped and cut
 The baby is vigorously stimulated and dried and then transferred to the care of the waiting
attendants or placed on the mother's abdomen
Third stage of labor

The following 3 classic signs indicate that the placenta has separated from the uterus :

 The uterus contracts and rises


 The umbilical cord suddenly lengthens
 A gush of blood occurs
Delivery of the placenta usually happens within 5-10 minutes after delivery of the fetus, but it is
considered normal up to 30 minutes after delivery of the fetus.

REFERENCES:

• Dr. Rosina .C. Castaneda; Obstetrics and Gynecology, J.N. France hospital, St Kitts.
• Current Obstetric & Gynecologic Diagnosis & Treatment, 11th Edition – Lange.
• E medicine - medscape.com