DELIVERY OF PRETERM

INFANT
J. Siekei O’Mogire
V. Maloba Awori
 Patient Data
• M. S. T. 22 yr old lady from Huruma
• Date of Admission:06/07/2009
• LNMP 12th Jan, 2009 –reliable??
• Para 1+2 with no living child, Gravida
4
• EDD 19th October, 2009
• Gestation By Dates 25 weeks
 History of presenting
condition
• Complained of spotting for I day prior
to admission
• Patient on routine antenatal follow up
@ the HRC
• No History of lower abdominal pain,
no drainage of liquor.
• ? Fetal movements
• Was first seen 4 months ago @ GBD 10
weeks
– Blood group B+ve, Hb 12g/dl
– VDRL & PITC negative
– Urinalysis normal
• Impression of BOH due cervical
incompetence was made
• Plan then: Patient advised for
McDonald’s stitch @ 16/40
• She did not come back for booked
appointment
 Obstetric history
•Para 1+2 with no living child, Gravida 4
•EDD 19th October, 2009
•Gestation By Dates 25 weeks
Year Place of Gestatio Mode Outcome
delivery n of
deliver
1st 2007 Hospital Term SVD
y Female FSB
pregnancy
2nd 2008 Hospital @ 18 - Abortion
pregnancy weeks
3rd 2008 Hospital @ 21 - Abortion
pregnancy weeks

• Puerperium normal
 Gynecological history
• LNMP 12th Jan, 2009
• ?
 PMHx/FSHx/Personal Hx
• PMSHx –
• Family Hx-
• Married with no living children
• Form 4 leaver, housewife
• Husband 29 year old, businessman
 Summary
• MTS, a 22yr old married lady, para
1+2 with no living child, Gravida
4,LNMP 12th Jan 09,EDD 18th October
09, GBD 25 weeks, presenting with
spotting for 1 day PTA.
 EXAMINATION
• General exam recorded as normal
• BP 100/70mmHg
ABDOMINAL EXAM
• No scars, striae gravidarum present
• Fundal height @ 24 weeks,
presentation cephalic, engagement
5/5, position LOA
• No contractions felt
• FHR 150/min
VAGINAL EXAM
• Digital exam
– Cervix dilated at 3 cm
– Bulging membranes
• Speculum exam
– Cervical Os open
– Membranes bulging

Other system exam findings not

recorded, probably normal
• Impression made:
– Inevitable early pregnancy loss with
– Bad obstetric history
 Plan on 6 @ 10:30am
th

• Admitted to RMBH
– Nurse in the delivery room with resuscitation
eqpt
• IV fluids 1.5 litres N/saline
• MgSO4 1g/hour
• Buscopan 40 mg TDS
• Dexamethasone 20mg IM stat
• IV Ceftriaxone 2g OD
• Salbutamol infusion 1mg in N/saline, run for
6-8hrs
• Monitor FHR quarter hourly
• Inform neonatologist
• Patient stable
• Fetal heart rate reassuring (142 –
158/minute)
• No contractions felt
 2 nd
day/7 July @ 8:30am
th

• FHR 164/min
• MO review
– Suggested Obstetric U/S to
• Confirm fetal status
• Gestation
• Determine state of cervix
– Patient given warm fluids to take &
discouraged from voiding
• @ 10:40am – mild contractions,
taken for U/S
 Investigations
• U/S
– “single Intrauterine fetus, in cephalic
presentation, cervix wide open with
bulging membranes, gestation by femur
length and bi-parietal diameter
approximately 24 weeks”
– Impression: sonographic features of
inevitable abortion
• Urinalysis – Normal
• @ 11:30 am
– Mild contractions noted
– Neonatologist informed
– Consultant review
• Manage as inevitable abortion @ 24 weeks
• Allow natural labour
• Manage 3rd stage actively
• @ 1:30 pm
– Moderate contractions
– Fetal heart sound spresent
• @ 3:15pm
– Strong urge to push
– Delivered SVD
– Live male infant did not cry immediately
– APGAR score 4/1 ,5/5 ,8/10 ,8/20
– Suctioned, ambubagged, kept warm
– Admitted to NBU, Weighed in NBU 870g
– Placenta and membranes delivered
– Minimal PV loss, about 100mls
 Labor & delivery ctd
• No drugs given to the mother
• Perineum intact
• Duration of labor (as recorded)
– 1st stage 12 hours 30 minutes
– 2nd stage 5mins
– 3rd stage 5mins
– TOTAL = 12hours 40 mins
• Fundus below umbilicus, mother
stable, placenta not weighed
 Baby progress
• Baby was given 0.25mg vitamin K IM
• Respiratory rate 52breaths/min
• Heart rate 132 beats/min
• Noted to be in respiratory
distress,with grunting.
• Had Flaring of alae nasi,severe chest
wall indrawing,with reduced air entry
bilaterally.
• In cardiovascular exam,had
peripheral cyanosis.
• PLAN
•Start IVF at 120mls/kg
•Monitor vitals
•Patient needs surfactant
•Placed on CPAP
• 8th July
– Patent (mother)stable
– ? Lochia, Fundal Height
– Patient declined IV medications
10th July
• Neonate had several apneic attacks
• Resuscitation done,with ambubag
• Aminophylline at 5mg IV
– Stopped breathing
– No cardiac activity
– Neonate certified dead at 5pm
– Neonate passed away in NBU
– Mother counseled
– Discharged