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OCTOBER 31, 2015

BY
PARIMALA VARSHA
RAJ MICHELLE
RAJKUMAR EUNICE

OUTLINE

HISTORY
REVIEW OF SYSTEMS
PHYSICAL EXAMINATION
SALIENT FEATURES
DIFFERENTIAL DIAGNOSIS
COURSE IN THE WARD
CASE DISCUSSION
RESEARCH

GENERAL DATA

CHIEF COMPLAINT

Labor pains

HISTORY OF PRESENT ILLNESS


12hrs PTA
Patient had sudden onset of
irregular Abdominal pain
radiating to the lower back
Associated
with
brownish
Patient tolerated the symptoms
mucoid vaginal
anddischarge
There
wasseek
no watery
discharge
did not
consultation
noted.

The above symptoms persisted


until 4hours prior to admission,
The patient noticed increase in
the frequency of the pain
associated with bloody vaginal
discharge soaking 1 pad.
This prompted her to seek
consultation in this institution.
Admission was advised.
Hence complied

OBSTETRICAL HISTORY
G1P0

PREGNANCY
ORDER

PREGNANCY
OUTCOME

G1

PRESENT
PREGNANCY

YEAR

GESTATION SEX
BIRTH
COMPLETED
WEIGHT

PRESENT
STATUS

OBSTETRICAL HISTORY
LMP

: Dec 26, 2014

PMP :Nov 25,2014


EDC

: Oct 2,2015

AOG

: 40 1/7 weeks

Prenatal check up: 1st


check up- February 2015( 6
weeks AOG) followed by
regular monthly pre-natal
visits

1ST Ultrasound: March, 2015 (12


weeks AOG)- could not recall
EDD.
2nd Ultrasound: October 1, 2015
(39 3/7 weeks AOG)
EDD Sep 28,2015
Date of Quickening : 5th month
AOG
Total weight gain : 9kg
Medication: Multivitamins, FeSO4

GYNECOLOGY HISTORY

PAST MEDICAL HISTORY


(-) food or drug allergies
No maintenance
medications
(-) TB exposure
(-)hypertension
(-) thyroid disorders
(-) Diabetes Mellitus

FAMILY HISTORY
(-) hypertension
(+) diabetes Mellitus
(-) cancer
(-) tuberculosis
(-) cardiovascular disease
(-) renal disease

PERSONAL/SOCIAL
HISTORY
College student
(-) Smoker
(-) Alcohol/Beverage
Drinker
Eats 3-5x meal/day
(-) Exercise

REVIEW OF SYSTEMS
General: (+) Weight change,
(-) Fatigue, (-) Anorexia, (-)
Weakness
Skin: (-) Rashes, (-) Itchiness
Head: (-) headache
Eye: (-) blurring of vision,
itching, redness or pain
Ear: (-) deafness, pain or
discharge

REVIEW OF
SYSTEM
Nose: (-) epistaxis, obstruction,
discharges
Mouth: (-) bleeding gums, (-)
Dental carries, (-) Sores
Throat: midline trachea
Neck: (-) stiffness or limitation in
motions
Pulmonary System: (-) cough,
(-) dyspnea, (-) asthma

Cardiac: (-) palpitations,


(-) chest pain
Abdomen:
(+)Hypogastric pain,
(-)vomiting, (-)nausea,
(-)epigastric pain
Genito-urinary: (-)
Dysuria (-) polyuria

PHYSICAL EXAMINATION
VITAL SIGNS
T = 36.2
PR = 100bpm
RR= 20cpm
BP=120/80mmHg
Weight=76.4kg/ 67.4
Weight gain in pregnancy:
Height=150 cm
BMI=34(obese 1)

HEENT
Normocephalic, fine smooth
hair texture,
Pink palpebral conjunctivae,
no ear or eye discharge, nasal
septum midline, no tonsillar
swelling.
CHEST
Heart: Adynamic precordium,
Normal heart rate and rhythm,
negative murmurs
Lungs : ECE, clear breath
sounds, no crackles

Abdomen
Globular, gravid uterus
Leopolds Manuver
L1 = breech
L2 = fetal back at
maternal left side
L3 = Cephalic, floating

Fundic height = 37 cm
FHT = 155-160 bpm
EFW= 4030gm

Pelvic Examination
External Genitalia and Vagina: grossly
normal
Internal Examination:
Dilatation: 5cm
Effacement: 60%
Cephalic
Station: -3
Membranes: Intact
UC: moderate to strong; occuring
every 2-3 minutes; lasting for 50-60 secs

Pelvic Examination
Clinical Pelvimetry:
Inlet : The sacral promontory is not
reached at 11.5 cms .
Midplane : Curved sacrum, Side
walls Convergent , Non prominent
Ischial spines.
Outlet : Intertuberous diameter is
> 8 cm

Extremeties
Good range of motion
No deformities noted
(-) edema, clubbing or
cyanosis noted
Capillary refill time: <2
secs

Salient Features
History

18 y.o
G1P0
40 1/7 wks AOG
LMP: Dec 26, 2014
Family history of DM
BMI = 34 (obese)

Physical Exam

Convergent Side walls


Internal Examination:
cervical dilatation: 5
cm
cervical effacement:
60%
cervical
position:
midline
Cephalic
station -3
intact membranes
FH=37 cms
FHT= 134 bpm
EFW= 4 kg

Multifetal Pregnancy

RULE IN
Large fundic height (37cm)

RULE OUT
One fetus palpated on leopolds
One heart beat auscultated
(-) Family history of multifetal
pregnancy

Polyhydramnios

RULE IN
Large fundic height (37cm)

RULE OUT
Normal AFI = 12.4 cm

Gynecologic Tumor with


Pregnancy
RULE IN
Large fundic height (37cm)

RULE OUT
(-) vaginal bleeding/ spotting
(-) abdominal pain
(-) history of gynecologic illness

Admitting Impression
G1P0 Pregnancy Uterine 40 1/7
weeks AOG by LMP, Cephalic in
Active Phase of Labor, T/C Fetal
Macrosomia

PLAN
Admit
NPO
Trial of Labor
FHT/UC monitoring
Labs
Baseline IPM
CS if with fetomaternal
Indication

Laboratory
1st Hospital Day
CBC
WBC Count

H 21.23

Hemoglobin

116.0

115.0-155.0

Hematocrit

0.35

0.36-0.48

RBC Count

4.22

4.20-6.10

Neutrophil

89

55.00-75.00

Lymphocytes
Monocytes

L 7.0
4

5-10

20-35
2-10

Eosinophils
Basophils
Platelets

322

150-400

MCV

83.40

79.40-94.80

MCH

27.5

25.60-32.20

MCHC

33.0

32.20-35.50

Laboratory
st
1 Hospital Day
Urinalysis

Reference Values

Protein

Trace

Negative

pH

6.0

Specific Gravity

1.023

Glucose

Negative

RBC

16

0-28

WBC

60

0-27

Epithelial Cells

8.0

0-7

Bacteria

8.0

0-111

Nitrite

negative

negative

Laboratory
1st Hospital Day
Blood Type : O Positive
HBsAg Qualitative : NonReactive

Abdominal ultrasound
Single live intrauterine pregnancy
in cephalic presentation with
composite gestational age of 40
weeks
AFI = 12.4 normohydramnios
EDC by ultrasound 28 september
Fetal genitalia apears male
Estimated fetal weight = 4.137 kg

Baseline FHT: 125-130 bpm


Variablity: moderate
Acceleration: (+)
Deceleration: absent
UC: moderate to strong irregular Uterine

BP/FHT

UC

5:07 PM
BP: 120/80
FH: 37 cm
EFW: 4060 g
FHT 135 bpm

Moderate to
strong irregular
contraction

IE

REMARKS

5 cm
60% effaced
Cephalic
IBOW
station -3

Vaginal
delivery
IPM
CS if with
fetomaternal
indication
FHT/UC
monitoring

Course In The Ward


8.00 PM
BP: 120/80
FHT: 145 bpm

Moderate to
strong irregular
contraction

7 cm
60% effaced
Cephalic
IBOW
station -3

FHT/UC
monitoring

12.15 AM
BP: 115/80
FHT: 140 bpm

Moderate to
strong irregular
contraction

7 cm
60% effaced
Cephalic
IBOW
station -3

STAT CS for
arrest in
cervical
dilatation
secondary to
CPD

Friedman's Curve

Intraoperative Findings
Primary Low Segment
Transverse Cesarean Section
Intraoperative Findings:
The gravid uterus was enlarged to the
appropriate gestational size
The amniotic fluid was moderate and clear

Intraoperative Findings
Extracted a live baby boy, term with a
ballard score of 40 weeks and apgar
score of 8,9
The placenta was implanted
anteroposteriorly
Right and left ovaries were grossly
normal
Estimated blood loss of 200cc

Fetal Outcome
Apgar score : 8, 9
Ballard score: 40
weeks
Birth Weight :
3.648 kg
Length : 53 cm
Head
Circumference :
34 cm
Chest :36 cm

Final Diagnosis

1st Post Op Day


1st Post Op Day
Subjective

Objective

Assessment

Plan

(-)
abdominal
pain
(+) minimal
vaginal
bleeding
(-) nausea or
vomiting
(-) fever
(-) bowel
movement
(-) Flatus
Lying
comfortable
supine
No other
complaints

Stable vital signs


Pink palpebral
conjuctivae
Anicteric sclerae
Clear breath
sound
Equal chest
expansion
Adynamic
percordium
Full pulses, CRT <
2 secs
Clear adequate
urine output
Dry well
coaptated
operative site

G1P1(1001)
Pregnancy
Uterine delivered
Term Cephalic
Live Baby Boy by
Primary Low
Segment
Transverse
Cesarean Section
for Arrest in
Cervical
Dilatation
secondary to
Cephalopelvic
Disproportion

IVF: = D5LR 1L +
10 units Oxytocin
AT 120 c/hr
Meds given
Vital signs
monitored

nd

Post Op Day

1st Post Op Day


Subjective

Objective

Assessment

Plan

(+) minimal
vaginal
bleeding
(-) nausea or
vomiting
(-) fever
(+) bowel
movement
(+) Flatus
Voiding
freely
Lying
comfortable
supine
No other
complaints

Stable vital signs


Pink palpebral
conjuctivae
Anicteric sclerae
Clear breath
sound
Equal chest
expansion
Adynamic
percordium
Full pulses, CRT <
2 secs
Clear adequate
urine output
Dry well
coaptated
operative site

G1P1(1001)
Pregnancy
Uterine delivered
Term Cephalic
Live Baby Boy by
Primary Low
Segment
Transverse
Cesarean Section
for Arrest in
Cervical
Dilatation
secondary to
Cephalopelvic
Disproportion

Dressing
changed
Meds given
Vital signs
monitored

rd

Post Op Day

1st Post Op Day


Subjective

Objective

Assessment

Plan

Lying
comfortable
supine

Stable vital signs


Pink palpebral
conjuctivae
Anicteric sclerae
Clear breath
sound
Equal chest
expansion
Adynamic
percordium
Full pulses,
CRT < 2 secs
Clear adequate
urine output

G1P1(1001)
Pregnancy
Uterine delivered
Term Cephalic
Live Baby Boy by
Primary Low
Segment
Transverse
Cesarean Section
for Arrest in
Cervical
Dilatation
secondary to
Cephalopelvic
Disproportion

Meds given

No
subjective
complaints

Vital signs
monitored
MGH

4 Factors

Dystocia is the consequence of 3


abnormalities that may exist singly or in
combination
1-Abnormalities
of the powers
uterine contractility
maternal expulsive forces
2-Abnormalities of the passage
maternal boney pelvis
the soft tissue of the reproductive
tract
3-Abnormalities of the passenger
presentation
position
development of the fetus
size

Abnormalities of the
Passage
Pelvic Brim
Diagonal Conjugate
Obstetrical Conjugate
Sacrum
Side walls
Ischial Spines
Interspinous diameter
Sacrosciatic notch

INLET

THE CAVITY

Subpubic Angle
Bituberous diameter
Anteroposterior
Diameter

OUTLET

STAGES OF LABOR

FIRST STAGE

THIRD STAGE

SECOND STAGE

Latent phase

Active phase

Acceleration Phase

Decceleration Phase

Phase Of Max Slope

Preparatory division

Dilatation
division

Pelvic
division

LABOUR TIME FRAMES


Phases/ Stages of
labour
Latent
phase
Active
phase

Mean
time
Longest
Mean
rate
Slowest

2nd Stage Mean


time

Nulliparo
us
6.4 h
20.1 h
3 cm/h

1.2cm/h
1.1 h

Multiparo
us
4.8 h
13.6 h
5.7cm/h

1.5cm/h
0.4 h

SHOULD NOT BE DIAGNOSED


BEFORE ACTIVE STAGE OF
LABOR

ABNORMAL LABOR

Abnormal labor patterns


can be divided into two
general types
Protraction
Arrest

ABNORMAL LABOR
NULLIPARA
Protraction

MULTIPARA

<1.2 cm/hr
(dilation)

<1.5 cm/hr
(dilation)

< 1cm/hr
(descent)

< 2cm/hr
(descent)

Arrest
Arrest Of
Dilation

2 hours with no cervical change

Arrest in
Descent

1 hour without fetal descent

Abnormal Labor Patterns,


Diagnostic Criteria and Methods of
Treatment
Labor
Patterns

Prolonge
d Latent
Phase

Diagnostic
Criteria
Nullipar
a

Multipar
a

> 20
hours

>14
hours

Preferred
Treatmen
t

Exceptiona
l
Treatment

Bed rest

Oxytocin or
Cesarean
Delivery for
urgent
problems

Abnormal Labor Patterns,


Diagnostic Criteria and Methods of
Treatment
Protraction
Disorders

Diagnostic
Criteria
Nullipar
a

Multipar
a

Protracted
Active
Phase
dilation

<1.2
cm/hr

<1.5
cm/hr

Protracted
Descent

<1
cm/hr

<2
cm/hr

Preferred
Treatment

Exceptional
Treatment

Expectant
and Support

Cesarean for
CPD

Abnormal Labor Patterns,


Diagnostic Criteria and Methods of
Treatment

Arrest
Disorders

Prolonged
Deceleration
Phase
Secondary
arrest of
Dilation
Arrest of
Descent
Failure of

Diagnostic
Criteria
Nullipar
a

Multipar
a

> 3 hrs

> 1 hr

> 2 hrs > 2 hrs

> 1 hr

> 1 hr

No descent in

Preferred
Treatment

Exceptional
Treatment

Evaluate for
CPD:
CPD: cesarean
No CPD:
oxytocin

Rest if
exhausted
Cesarean
Delivery

Factors Influencing the


First Stage of Labor
Uterine contractions
Cervical Resistance
Forward pressure exerted
by the leading fetal part

ARREST IN DILATATION
SECONDARY TO
CEPHALOPELVIC
DISPROPORTION

Secondary Arrest in
Dilation
The fetal head engages in the
occipitotransverse position and,
if it is well flexed and asynclitic,
will undergo rotation in the midcavity to the direct
occipitoanterior position.

Cephalopelvic
Disproportion
1. Absolute Disproportion: There
is no possibility of normal
Delivery even if the progress
of Labor is completely normal
2. Relative Disproportion: This
means that the baby is large
but would pass through the
Pelvis if the Mechanisms of
Labor function correctly

CPD tests
Pinards Method
Muller-Kerrs Method

MANAGEMENT OF CPD
Mild disproportion: vaginal
delivery
Moderate: trial labor, if
failed then cesarean section
Marked: Cesarean Section

Why Trial of Labor?


It is a clinical test for the
factors that cannot be
determined beofre the start of
labor:
Efficiency of uterine
contraction
Moulding of the head
Yeilding of the pelvis and soft
tissue

Suitable Cases
Young primigravida of
good health
Moderate disproprtion
Vertex Presentation
No outlet contractions
Average sized baby

Termination of Trial Of Labor


Vaginal delivery:
either spontaneously or by
forceps if the head is engaged.
Caesarean section if:
failed trial of labour i.e. the head
did not engage or
complications occur during trial
as foetal distress or prolapsed
pulsating cord before full
cervical dilatation.

Management
Arrest
Disorders

Diagnostic
Criteria
Nullip
ara

Multip
ara

Prolonged
Deceleratio
n Phase

>3
hrs

> 1 hr

Secondary
arrest of
Dilation

>2
hrs

>2
hrs

Arrest of
Descent

> 1 hr > 1 hr

Failure of
Descent

No descent in
deceleration
phase or
second stage

Preferred
Treatment

Exceptional
Treatment

Evaluate for
CPD:
CPD:
cesarean
No CPD:
oxytocin

Rest if
exhausted
Cesarean
Delivery

Short stature as an
independent risk factor for
cephalopelvic disproportion
in a country of relatively
small-sized mothers
Maternal-Fetal Medicine
Archives of Gynecology and Obstetrics
June 2012, Volume 285, Issue 6, pp 1513-1516

Objective
To clarify the relationship between maternal
height and cesarean rate due to cephalopelvic
disproportion (CPD) in singleton pregnancies
among ethnic groups of relatively short stature.
Methods
A retrospective cohort study was performed on
Thai singleton pregnancies at gestational age of
more than 34weeks. Logistic regression analysis
was performed to correlate the maternal height
and a risk for CPD. The short stature was defined
by a cut-off value at 5th percentile ranking.
Odds ratio for CPD was determined.

Results
Considering cut-off value of 145cm, short
stature was significantly associated with
higher rate of CPD with odds ratio of 2.4
(95% CI 1.83.0). The
odds=exp(4.0480.042Ht). After
control of other variables, the relationship
between maternal height and rate of CPD
was still high.

CONCLUSION
Mothers with short stature were significantly
correlated with a higher rate of CPD, even after
control of birth weight, parity and type of
attendance. Clinical points could be drawn from
this study including
(1) definition of short statue must be developed
for particular geographic or ethnic groups. In Thai
population, using 145cm as a cut-off value, odds
of CPD is 2.4;
(2) Probability of CPD may be estimated by
maternal height as a single variable or multiple
variables using logistic regression equations.

Thank You..!