P4A3 MATURE DELIVERY WITH

SECTIO CAESAREA IN INDICATION

CHIN POSTERIOR FACE
PRESENTATION AND GESTATIONAL
HUSNA
HYPERTENSION
1102011120
PRECEPTOR:
Dr. H. Dadan Susandi, SpOG

IDENTITY
Wife

Name
: Mrs. Ani
Age
: 33 years Old
Address : Cibiuk
Education : Junior High
School
Occupation : Housewife
Medical Record : 832418
Date of Hospitalized : 24th
Jan 2016
Time of Hospitalized : 10.55
am

Husband

Name
: Mr. Endang
Age
: 33 years old
Address : Cibiuk
Education : Elementary
School
Occupation : Salesman

REFERENCE

This
patient
has no
reference
s

MAIN COMPLAINT
Fluid out of the
vagina

ANAMNESIS
G7P3A3 in 9 months pregnant, comes with complaint
that fluid out of the vagina since 6 hours ago. Colored
translucent liquid coming out cloudy, with a rancid
odor, the liquid is not mixed with blood. The amount of
liquid that comes out spend three fabrics in a day.
Patient denied theres a greenish liquid out of vagina.
Patient admitted that she has been feeling the labor
since 4 hours ago. The labor increasingly stronger and
more frequent.

ANAMNESIS
Theres also a brownish bloody mucus, but occur just a
little. Patient has been feeling the fetal movement since 5
months ago, until now. Patient denied the complaints of
any heartburn, severe headache, and blurred vision.
Patient has no history of high blood pressure before or
during the pregnancy.

OBSTETRIC HISTORY
AGE OF

PREGNAN

PLACE

CY

DELIVER

I
II
III

BABYS

DELIVER

WEIGHT

SEX

AGE

ALIVE/DEATH

Abortion in 2 month pregnant

Home
Hospita
l

Midwife
Doctor

IV
V

PREGNANC

HOW TO

Premature
Mature

Spontaneo
us
Spontaneo
us

1800gr
3300gr

2
days
10
years

Dead
Alive

Abortion in 3 month pregnant

Home

Paraji

Mature

Spontaneo
us

4000gr

VI

Abortion in 3 month pregnant

VII

CURRENT PREGNANCY

7
years

Alive

ADDITIONAL
INFORMATION
Marital Status

Menstruation

Contraception

First Marriage
20 years old, JHS,
Housewife
25 years old,
Elementary school,
salesman

The first day of the last

menstrual period: 23rd
April 2015
Estimated Delivery: 30th
January 2016
Regular Cycle
Amount of blood: normal
No pain
Length: 7 days
Menarche: 14 years old

Last contraception:
Injection, 3 month
every injection
From 2009 until 2014
She stopped the
injection because of
willing a new baby

ADDITIONAL INFORMATION
Prenatal Care

Complain
During
Pregnancy

Midwife
9 times
examination
Theres no
Last exam about 1 complain during
week ago
the pregnancy

Past Medical
History
No history

PRESENT STATUS
98 x/minute

170/110 mmHg

20 x/minute

Blood
Pressur
e

Pulse
Rate

Respirat
ion Rate

Tempe
rature

36,7 0C

PRESENT STATUS
Tender
Raised, No
pain and
Ascites
Neither
extremities
edema nor
Varicose
Veins in this
Patient
Abdomial & Extremities

Cor 1st and

2nd sound
regular, no
Gallops and
Murmur
Vesicular
Breathing
Sound
Symmetrical
Cor and Pulmo

Head and Neck

Conjunctiva
and Sclera in
normal
situation
Thyroid and
Lymph Nodes
are normal

OBSTETRIC STATUS
EXTERNAL EXAMINATION
High
of
Fundu
s Uteri

Head/
Right
Back/
4/5

34
cm

Fetal
Presentatio
n

Abdominal
circumference

95
c
m

Labor

Estimated
Fetal
Weight

1-2 x/10
minutes

136
x/minute,
Regular

10-20
seconds

Fetal Heart
Rate

3105
gra
m

OBSTETRIC STATUS
Inspectio
n
Fornices
Palpation

Nitrazine Test (+)

Palpable hard

OBSTETRIC STATUS
INTERNAL EXAMINATION
No
Vulv
abnormaliti
a
es

Dilation
Cervix

Is not
done

No
Vagina
abnormaliti
es

Is
not
Portio
done

AmnionIs not
Fluid done

The Is not
Lowest
Part done

EARLY DIAGNOSIS
G7P3A3 Gestation 39-40
Weeks with Premature
Rupture of the Membranes
and Suspect Severe
Preeclampsia

G
MANAGE
MENT
Planning management

Observation General State,

Vital Signs, Labor, Fetal
Heart Rate, Delivery
Progress

Informed Consent

Infusion Ringers Lactate

500 cc 20 gtt/minute

Check Hematology and

Urine Routine

Dopamet 3 x 500 mg PO
Nifedipine 3 x 10 mg PO

G
MANAGE
MENT
Planning management

Inj Cefotaxime 2 x 1 gr
VI
MgSO4 loading dose of
4 grams in 100 cc
Ringer Lactate out in 15
minutes
MgSO4 maintenance
dose of 10 grams in 500
cc Ringer's lactate, 20
gtt/min
Contraception: Patient
agreed about IUD

24th January
2016
12.15

LABORATORY EXAMINATION
Hematology

Hemoglobin: 11,8 g/dL

Hematocrit : 35%
Leukocyte : 9240/mm3
Platelets : 171.000/mm3
Erythrocyte : 4,12
million/mm
3

Urine
Density Urine : 1.015
Blood Urine
: POS (+++)
Lekosit Estrase : Negative
pH Urine
: 8,0
Nitrit Urine
: Negative
Protein Urine : Negative
Glukosa Urine : Negative
Keton Urine
: Negative
Urobilinogen Urine : Normal
Bilirubin Urine : Negative

MONITORING FIRST STAGE

OF LABOR

11.45:
Dopamet (+),
Nifedipin (+), Inj
Cefotaxime 1 gr IV.
Fetal Heart Rate:
136x/minute

14.45:
Fetal heart rate 134
x/minute

15.00
Fetal heart rate 138
x/minute
Portio tender thin,
cervix dilation 3-4 cm

12.00
MgSO4 loading dose
of 4 grams in 100 cc
Ringer Lactate out in
15 minutes

13.45:
Fetal heart rate 133
x/minute

Amnion fluid (-), Chin

Posterior Face
Presentation, at 7
oclock

12.45:
Fetal heart rate 149
x/minute

Advice from dr.

Dhanny, SpOG:
Sectio Caesaria

12.15:
Portio tender thick, cervix
dilation 2-3 cm,
presentasion (?)
MgSO4 maintenance
dose of 10 grams in 500
cc Ringer Lactate 20

ADVANCED DIAGNOSIS
G7P3A3 Parturient 39-40
Weeks first stage of labor
active phase with Chin
Posterior Face Presentation
+ Premature Rupture of the
Membranes and Gestational
Hypertension

OPERATION REPORT
Time Start:
17.00 WIB

Time End:
17.40 WIB

Duration:
40 Menit

Operator:
dr. Dhanny Prima, Sp.OG

Assistant 1:
Ajat
Instrument:
Desi

Anesthesiologist:
dr. Dhadi, Sp.An

Anesthesia Assistant:
Fauzi

Pre Surgery Diagnosis:

G7P3A3 Parturient 39-40 Weeks first stage of labor active phase
with Chin Posterior Face Presentation + Premature Rupture of the
Membranes and Gestational Hypertension

Post Surgery Diagnosis:

P4A3 Mature Delivery with Sectio Caesarea in indication Chin
Posterior Face Presentation and Gestational Hypertension

24th

Acute :
January 2016

Type of Anesthesia:
Spinal with Bupivacaine

Indication:
Chin Posterior Face
Presentation
Type of Operation:
SCTP and IUD insertion

OPERATION REPORT
A baby was born with SC at 17.10 oclock
Gender: Male
Weight: 3100 grams
Length: 49 cm
APGAR Score 1: 5 5: 7
Anal (+)
Disorders: (-)

FINAL DIAGNOSIS
P4A3 Mature Delivery with
Sectio Caesarea in
indication Chin Posterior
Face Presentation and
Gestational Hypertension

FOLLOW UP
ARE ATTACHED

DISCUSSION I:
FACE
PRESENTATION

FACE PRESENTATION
Fetal presentation occurs when the fetal head is
hyperextended such that the fetal face, between the
chin and orbits, is the presenting part. The incidence is
about 1 in 500 deliveries.

the occiput attached

with the back of the
fetus so the lowest
part of the fetus is
chin or mentum

Symphysi
s Pubic

ETIOLOGY & RISK FACTOR

The etiology of face
presentation is
somewhat
enigmatic. During
normal vertex
delivery, the fetal
head is markedly
flexed, with the fetal
occiput as the
leading part.

Mult
i
parit
ies
Coil
the
umbil
ical
cord
in the
neck

Narr
ow
Pelvi
c

Prema
turity
Ane
cep
halic
a

Big
Bab
y
Con
geni
tal
Ano
mali
es

DIAGNOSIS
The diagnosis of face presentation is
usually made at the time of vaginal
examination during labor, when the
soft tissues of the fetal mouth and the
nose are noted adjacent to the malar
bones and orbital ridges.
Face presentation is then confirmed by
sonography or by radiography.
Because anecephalica fetuses
uniformly present face first,
anencephaly should be ruled out when
the face presentation is suspected.

HOW TO DIAGNOSE?
may be
palpable
bulge of
fetal head
near the
back of the
fetus

Vaginal
Exam

We found
mouth, nose,
orbital edge,
chin

Abdominal
Palpation

When
deliver the
baby

the face becomes

edema, so the
diagnosis can be
mistaken as a
breech
presentation

PROTAP UNPAD

DIAGNOSIS

Face
Presentation

Labor stage II

Chin anterior

Spontaneous
delivery
Forceps
Extraction

Chin Posterior

Chin rotate to
the anterior

Spontaneous
delivery
Forceps
extraction

Chin rotate to
the posterior

SC

MECHANISM OF LABOR
15%
men
tum
tran
sver
se

25%
mentum
posterior
60% mentum
anterior

The mechanism of labor with a

face presentation is similar to
the vertex presentation in that
the longest diameter (mentum
to brow) enters the pelvis
transversely.

MECHANISM OF LABOR
Engageme
nt

Internal
rotation

Flexion

Additional
movemen
t
(extensio
n)

External
Rotation

Expulsion

MECHANISM OF LABOR
if the
Face
descends
to the
midplane

mentum
rotates
posteriorly

the fetal head

will be unable
to extend
farther to
complete the
expulsive
process

internal
rotation
occurs into
the vertical
axis

Forceps
, but no
vacuu
m

must be

the mentum rotates

anteriorly under the
symphysis pubis

vaginal
delivery
should be
expected

delivered
by
caesarean
birth

DISCUSSION II:
PREMATURE
RUPTURE OF THE
MEMBRANES

PREMATURE RUPTURE OF
THE MEMBRANES
Premature rupture of the membranes (PROM) is defined as
amniorrhexis (spontaneous rupture of membranes as opposed to
amniotomy) before the onset of labor at any stage of gestation.
PPROM should be used tpo define those patients who are preterm with
ruptures membranes, whether or not they have contractions.

ETIOLOG
Y AND
RISK
FACTOR

Nutriti
onal
deficie
ncies

Vagin
al
Infect
ions

Cervi
cal
Infect
ions

Incom
petent
cervic

Abnor
mal
mem
brane
physi
ology

DIAGNOSIS

History of vaginal loss

of fluid

Confirmation of
amniotic fluid in the
vagina

Speculum vagina to
confirm diagnosis, to
assess cervical
dilation and length

Speculum vagina for

preterm to obtain
cervical culture and
amnion fluid samples
for pulmonary
maturation tests.

Pooling of amnioticn
fluid in fornix
posterior.

A Valsava maneuver
or slight fundal
pressure expel fluid
from the cervical os,
which is diagnostic of
PROM.

CONFIRM THE DIAGNOSIS!

USG: to rule out fetal

anomalies and to
assess gestational age
and amniotic fluid
volume

Placing a sample on a
microscopic slide, air
drying, and examining
for ferning.
Testing the fluid with
Nitrazine paper will turn
blue in the presence of the
alkaline amniotic fluid

PROM

Oligohidramnion +
PROM at less than 24
weeks gestation
Development of
pulmonary
hypoplasia

Amniotic Fluid Index

< 5 cm

PRO
M

PROM occurs at 36
weeks or later and
condition of the
cervix is favorable
labor should be
induces after 6 to 12
hours if no
spontaneous
contractions occur.

CONSERVATIVE
MANAGEMENT
PPROM
Continue the pregnancy until the lung
profile is mature
To recognize chorioamnionitis High maternal
temperature and a tender (>38,0C), sometimes
irritable, uterus, fetal tachycardia, leucocytosis

In cases of subclinical infection

diagnosis and treatment may be delayed
Ampicillin or erythromycin prolong the
interval to delivery in patients with PPROM

Greater
risk

Cerebra
l Palsy
Damage
the
preterm
babys
brain

BE
CAREFUL!

MANAGEMENT OF
CHORIOAMNIONITIS
Chorioamnioniti
s

Combination
antibiotic

Cephalosporin

Ampicillin
and
Gentamycin

Labor
should be
induced

Planning
to
cesarean
delivery

If cervix is
unfavorable

Thers
evidence of
fetal
developmen
r

OUTPATIENT
MANAGEMENT
Observation 2 to 3
days without any
evidence of infections

Restricted physical
activity, no coital
activity, monitor the
temperature at least 4
times per day.

Patient with
oligohidramnion is not a
candidate for outpatient
management

Consider to outpatient
management

The patient should be

reliable, fully informed
regarding the risks
involved, and
prepared to
participate in her own
care

Fetal Kick Count

In 1 hour 3 times
If only 1 kick

Monitor in 12 hours
If 10 time good
If < 10 Go to
hospital as soon as
possible

LABOR AND DELIVERY

PROM

Oligohidramnio
n

Decrease
Amniotic Fluid

Early cord
compression

Consider
Cesarean
DElivery

Both vertex or
breech
presentations

Presence of
variable fetal
heart
decelerations

DISCUSSION III:
HYPERTENSION
DISORDER IN
PREGNANCY

PROTEIN URINE (+)

PROTEIN URINE (+)
PROTEIN URINE (-)
PROTEIN URINE (-)

BEFORE
PREGNANT

20 WEEKS

HYPERTENSION
IN PREGNANCY

40 WEEKS

12 WEEKS POST
DELIVERY

RED : SUPERIMPOSED PREECLAMPSIA

DARK BLUE: GESTATIONAL HYPERTENSION
YELLOW: PREECLAMPSIA
LIGHT BLUE: CHRONIC HYPERTENSION

ETIOLOGY AND RISK FACTOR

First Pregnancy
Hyperplacentosis
Age of mother
Family history
Hypertension and Renal Disorder History

THEORY OF
HYPERTENSION

Abnormality of
Placenta
Vascularization

Inflammation
stimulus

Ischemic of
Placenta,
Stress
Oxidative,
Endothelial
Disfunction

Geneti
c

Immunologic
Intolerance

Cardiovascular
adaptation

HYPERTENSION
IN PREGNANCY

DIAGNOSIS

Elev
ated
seru
m
enzy
me
level

Visu
al
dist
urb
anc
es

Elev
atio
n
Bloo
d
Pres
sure

Ser
um
Uric
Aci
d
Prot
ein
uria

Wei
ght
gain
and
ede
ma

THERA
PY

IV

Labetalol

Direct
vasodilator

Hydralazine

B1 and A1
nonselective
blocker

Sodium
nitroprusside

Loading dose
Medication

MgSO4 20% or
40%

Oral

Providing
minute-tominute control
of blood
pressure
4 gram in 100
cc Ringer
Lactate in 15
minutes

Maintenance
dose

10 gram in 500
cc Ringer
Lactate, 20
gtt/minute

Nifedipine

Calcium
Channel Blocker

Metildopa

IDENTIFICATION
CASE

HOW TO
DIAGNOSE THIS
PATIENT?

This is her 7th Pregnancy, has suffered miscarriage 3

times, has delivery 3 babies G7P3A3

Patient feels this is her in 9 months pregnant, has been

feeling the fetal movement since 5 months ago, The
first day of the last menstrual period: 23rd April 2015,
High Fundus 34 cm Gestation 39-40 weeks
Anamnesis: the labor has appeared since 4 hours ago. The labor
increasingly stronger and more frequent. Obstetrics Exam: Cervix
dilation 3-4 cm, fetal presentation chin posterior face
presentation first stage of labor active phase with Chin
Posterior Face Presentation

Anamnesis: that fluid out of the vagina since 6 hours ago.

Colored translucent liquid coming out cloudy, with a rancid
odor. The amount of liquid that comes out spend three fabrics
in a day. Obstetrics Exam: Amnion fluid (-), Nitrazine test (+)
Premature Rupture of the Membranes
Anamnesis: Patient denied the complaints of any heartburn,
severe headache, and blurred vision and has no history of
high blood pressure before or during the pregnancy, blood
pressure 170/110 mmHg, Protein urine (-) Gestational
Hypertension

G7P3A3 Parturient 39-40 Weeks first stage of labor

active phase with Chin Posterior Face Presentation
+ Premature Rupture of the Membranes and
Gestational Hypertension

HAS THE
MANAGEMENT
BEEN
APPROPRIATE?

Management

Chin Posterior Face

Presentation

Sectio Caesarea

Premature Rupture
of the Membranes

Inj Cefotaxime 2 x
1 gr IV

MgSO4 loading and

maintenance dose
Gestational
Hypertension

Dopamet 3 x 500
mg PO
Nifedipin 3 x 10 mg
PO

HAS ABOUT THE

PROGNOSIS?

Quo ad functionam
Quo ad functionam
Quo ad vitam:
ad bonam
Reproductive
function:
ad bonam
Sexual function: Ad bonam