OBSTETRICS HISTORY

PATIENT PARTICULAR:
Name: Puan Siti Effa Address: Kubu Gajah
Age: 25 years Part time clerk
Gravida 3, Para 1+1 miscarriage @ 40 weeks + 7days Malay, Muslim

CHIEF COMPLAINT
Patient is admitted to the ward for induction of labour due to postdate pregnancy, she’s at term plus
7 days.
HISTORY OF PRESENTING COMPLAINT
25 year old, Puan Siti Effa, is G3 P1+ 1miscarriage, Malay lady is at 41 weeks of gestation is admitted
for induction of labour due to pregnancy has extended by 1 week from EDD. Her LMP was
03/08/2017, She has regular 28days/cycle, therefore her EDD is on 10/05/2018. She is currently 7
days due from EDD. Her new EDD was 16/05/2018, however she has not experienced strong
contractions, thus the doctor is inducing. She is without show and has complained of whitish mucus
from vagina. There is no liquor leaking. She has no fever, her fetal movements are good. There is no
anemia or signs of UTI.

MENSTRUAL HISTORY
She attained menarche at 11 years old, 7 days duration, regular flow 28days/cycle, 2-3 pads/day. She
does not experience dysmenorrhea, no post coital bleeding, no intermenstrual bleeding. She has no
history of taking any form of contraceptive. She had a PAP smear done once.

HISTORY OF PRESENT PREGNANCY

She is G3 P1+1m, @ 41 weeks unplanned pregnancy, found to be pregnant from late period by 2 week
at UPT at home. Her dating scan was done at 10 weeks. Her booking was done at KK Merbau at week
12 of her gestation. In her first trimester, she had vomiting, nausea. She had her MGTT done twice,
with normal results. She has gone to >10 sessions of antenatal checkups. Her color coding for booking
at HSB is green. She’s had low Hb in her second trimester, was treated for it.

PAST OBSTETRICS HISTORY

Her first pregnancy was at 2012- she had a miscarriage when she was 2 weeks pregnant.
Her second pregnancy was at 2015-she had an emergency c-section from failed induction due to fetal
distress (3 times- Prostin inserted). She delivered a healthy baby boy, 2.28kg, jaundice after birth for
one month. Breastfed till 3 years old, Patients had PIH at 39 weeks, relieved 1 month after.

PAST GYNAECOLOGY HISTORY

At 2013, she was suspected to have fibroids based on ultrasound. At the time of admission, she has
no fibroids.
At 2015, PAP smear was done. Results came back normal.

PAST MEDICAL AND SURGICAL HISTORY

At 2013, she’s suspected with fibroid but not diagnosed. The tissue shrank before the biopsy is taken.
The second time, she was warded for induction of pregnancy, and had an emergency C-section. The
surgery went well and she had no complications.

FAMILY HISTORY
Mom had hypertension, she passed away at the age of 53. Father is diabetic, he’s alive and well. She
has five siblings, her second sister has hypertension. She has family history of twins, her father and
husband have twins. She has no family history of fetus abnormality, no malignancy in first degree
relatives. Her aunt on her maternal side was suspected to have breast cancer.

SOCIAL HISTORY
She is a working woman, who actively breastfeeds her child. She works half day as a clerk because she
takes care of her child at home till her babysitter arrives. Her husband works as cook, he’s a smoker.
Their house income is about RM 3000. The 3 of them, live in a terrace house with good sanitation,
water and electricity. She usually has Malay diet, she mostly eats out. She lives 15mins away from
HSB. She has no smoking or drinking habits and no history of taking recreational drugs.

SUMMARY
Puan Siti Effa is a working, Malay woman who’s pregnancy is at 41 weeks.

PHYSICAL HISTORY

GENERAL EXAMINATION
Patient is sitting in supine position. The patient is a plump woman. She is alert to time place, person
and she communicates well. She is experiencing pain as she has been induced at 8 am. She has no
pallor, no jaundice. She has good oral hygiene. Her tongue is coated and oral mucosa is moist, there is
no cyanosis, no glossitis, no gum bleeding or hypertrophy.
Her hands are warm and dry, capillary refill time is less than 2 seconds, no finger clubbing, and no
palmar erythema. She has a branula on her left dorsum of hand. Her pulse is 98 beats per minute,
good volume and rhythm.
Her legs are warm and dry. There is no bilateral pedal edema, no varicose veins and no calf
tenderness.
VITALS:
Afebrile, Blood Pressure: 102/78 mmHg, Respiratory Rate:19 Pulse Rate: 98 beats per min

BREAST EXAMINATION
Nipple is everted, areola is dark. On palpation there is no nodules and lump.There was no discharge
from nipple. She has slight breast tenderness.

ABDOMINAL EXAMINATION
On inspection, the abdomen is distended by a gravid uterus, evidenced by very prominent linea nigra,
striae gravidarum and striae albicans. The umbilicus is central. There is a low suprapubic transverse
scar, healed healthily. No scar tenderness is noted.
The symphysiofundal height (SFH) measured is 34 cm. There is a single fetus present, in a longitudinal
lie with cephalic presentation,there is adequate liquor volume. The fetal head is not enganged. The
fetal back is on the left side. Fetal heart sound is heard. The estimated fetal weight is 2.5- 3.5kg.

CARDIOVASCULAR EXAMINATION
S1 and S2 is heard, no murmur heard. Nil.

RESPIRATORY EXAMINATION
Air entry on both sides of the lung is clear. Normal vesicular breath sound. No added sound is heard.

PELVIC EXAM: NOT DONE, ideally should be done to complete the examination.
DISCUSSION POINTS
1. WHAT’S INDUCTION OF LABOR?
2. WHAT IS AUGMENTATION OF LABOR?
3. INDICATION FOR INDUCTION OF LABOR?
4. POSTDATES MANAGEMENT IN MALAYSIA

DISCUSSION
Ripening the cervix vs Induction of labor.
Ripening of the cervix is done before induction, thus the procedure is done in the wards.
Prostin is the commonest ripening agent used in Malaysia. Next, is Foley’s catheter used intrauterine
extraamniotically. And finally Dilapan,the laminaria tent.
Prostin- it is 3mg prostaglandin, bullet shaped pessary, white in color, it is must be stored under 4
degree celcius. The prostin will be denatured if kept in room temperature. This is why some patient’s
have history of using few pellets of Prostin because of improper storage and transportation of the
drug.
Foley’s catheter is inserted into the cervix between the membrane and uterine cavity pushed up, the
buld is blown up using 10 to 15 ml of distilled water. Gentle traction is given to check if its easily slides
out which means the cervix is ripe.

Laminaria tent is a small matchstick, made of seaweed. It is inserted into the cervix, the laminaria
works by absorbing water and dilates causing dilatation of the cervix. All these three devises causes
the natural release of prostaglandin and help efface and dilate the cervix.
Sweep and stretch is a rarely used induction method which has a risk of neurogenic shock if not done
properly.
When the cervix is ripe, the patient is sent to the labor room for induction of labor. Medical induction
or surgical induction is available. Oxytocin regime is started in the labor room, along with artificial
rupture of membrane (ARM) is usually done together. This is done to reduce the induction delivery
time. This is a form of active management of labor.

Oxytocin regime used for IOL is 10 units of oxytocin in 500ml normal saline, titrated via dropmet.
Every half hour, the dose is doubled till strong contraction is achieved and the dosage is maintained.
The same regime is used for augmentation of labor. Strong contractions is characterised as 4 in 10
contractions lasting more than 45 seconds. The surgical method (ARM )using the aminohook, release
the liqour, ensure there is no cord prolapse, the color of of liquor is documented.

Induction of labor is usually done in the case of post date pregnancy, GDM, placenta previa, IUGR,
pre-eclampsia, reduced fetal movement at term, oligohydroamnios, planned induction, previous scar
with post-dates and congenital abnormalities in fetus that are not compatible with life.

Patient is identified as postdate case, first I would like to ensure if her dates are correct. Firstly using
Naegle’s rule with her first day of her LMP. Then her Pink antenatal book is checked to find when the
ultrasound dating scan is done, the details of CRL is recorded to confirm that she is a post date. If
she’s unsure of her first day of her LMP, I would like to know if she’s got any breastfeeding
ammenorrhea. Her history of taking oral contraceptive pills rules out post pill amenorrhea. She is
confirmed to be at term plus 7 days as her dating scan was done on her first trimester.

Ultrasonography is done to confirm the pregnancy details. Details of baby, AFI and placenta
localization is recorded.
CTG was done, result was reactive thus confirming that the baby is alright.

She is admitted when there is vacancy for induction, so she is planned to be induced at term plus 7 th
day.

Next, pelvic exam is done for pelvic assessment and bishop score. The score was at 4, cervix is not
favourable thus induction with Prostin is given as planned.
Post dates in Malaysia are usually induced at term plus 10 days. However, in RCOG guidelines, they
recommend to induce on the term plus 7th day. Senior consultants have their personal preferences
can be different too.

Postdates patients should be managed carefully and actively. There are cases where the mother had
come to the hospital with full term pregnancy and doctor had to give her the bad news of baby not
moving at the eleventh hour. It would be the most traumatic episode in a mother’s life. With that in
mind, it is always better to plan for induction as soon as possible for post-dates baby.

Induction of labor is a procedure, that requires consent from both the patient and her husband must
be informed. This is because the procedure has a few risks that comes with it, for example, the risk of
the patient going for emergency C-Section is higher compared to a mother having normal vaginal
delivery. Contractions in induction of labor is more painful than the normal contractions.

Following the patient’s plan in the hospital, she has been admitted to the ward, she has been planned
to be induced in the morning at 6.30am. It is done in the morning to prevent the patient going into
labor wee in the morning. Induction can be planned, by giving a date to the patient to come for
induction at the hospital. In this case, she is given a date to be induced at term + 7 th day.
Again a CTG was done, the CTG was reactive, the fetus is alright. Pelvic exam is done to check her
bishop scoring, and since the score was still low, she has been induced with Prostin in the ward.

The prostin pessary is inserted by the medical officer. The prostin is wet with normal saline, and
inserted into the posterior fornix. Following the prostin insertion, the patient is instructed to lay down
in bed for an hour. The nurse is instructed to take a CTG for half hour after an hour post Prostin, this is
to detect any hyperstimulation. In this case, the patient was not having any hyperstimulation after an
hour.

The labor progress chart is done every half hour, to check if contractions are improving. She was
reviewed after 6hrs, to see if her cervix is favorable. In this case, the patient’s Bishop score is 6. She
was ready for induction in the labor room, thus the labor room was informed, and she was called to
the labor room once there is a vacant bed.

As soon as she arrived in the labor room, ARM is done. Maintainence IV drip is started with branula,
along with Pitocin was started

INDUCTION INCREASES THE RISK OF PATIENT GOING FOR EMERGENCY C-SECTION.