CASE REPORT

P3A0 PARTUS MATURUS WITH CAESAREA

POSITION WITH EBW>3500 + SC HISTORY
D I S USECTION
S U N O LE.C
E HBREECH
:
M FADLI SYAHDEMA
1102012150
PRECEPTOR :
D R . H . D A D A N S U S A N D I , S P.O G

DIBAWAKAN DALAM RANGKA KEPANITERAAN SMF OBSTETRI GINEKOLOGI

FAKULTAS KEDOKTE RAN UNIVERSITAS YARSI JAKARTA
RSUD DR SLAMET GARUT
2016

PATIENS IDENTITY

Name
: Mrs. S
Age
: 33 years old
Address : Tarogong Kidul
Graduate : Junior High School
Occ
: Housewife
No. Medical Record : 883xxx
Date of Admission : 21 August

Husbands name : Mr. N

Age
: 33 tahun
Address
: Tarogong Kidul
Graduate : Senior High School
Occupation : Entrepreneur

2016

MAIN COMPLAINT

Uterine
Contraction

ANAMNESIS (HISTORY TAKING)

Patient, G3P2A0 at 9 months of gestation
She complained about her uterine contraction
She also complained bleeding from the birth canal, but denied any liquor leak or
mucus.
She had a history of taking SC ec breech position
She went to RSU dr. H. Slamet for consulting about her uterine contraction
Patient has been feeling the fetal movements since five months ago till now.

GESTATIONAL HISTORY
Kehamilan

Tempat

Penolong

Cara Kehamilan

Cara Persalinan

BB Lahir

Jenis Kelamin

Usia

Keadaan :
Hidup /
Mati

Rumah Bidan

Bidan

Aterm

Spontan

4000

RS

Dr.SpOG

Aterm

SC

2900

Kehamilan Saat Ini

ADDITION INFORMATION
First marriage
25 years, junior high school, housewife
25 years, senior high school, self employed
HPHT : 20 November 2015
TP : 27 August 2016
UK : 439-40 weeks
Mestrual history
Cycle : Regularly, 7 days
Blood : usual
Pain
: No
Menarche
: 12 years old

Last Contraception :
PILLS
Acceptor contraception since 2011
until 2012
Reason for stop the contraception:
menstruation irregularity
Prenatal Care
Midwife, 9 times
Last PNC 1 week ago
Complaints during pregnancy : Past medical history
:-

PHYSICAL EXAMINATION
General condition : Compos Mentis
Blood pressure : 120 / 70 mmHg
Pulse rate
: 80 x/mnt
Respiratory rate : 20 x/mnt
Temperature
: AF 0C
Head
: Conjuctiva: anemis -/- Sklera: ikterik -/ Neck
: no abnormalities.
KGB = no abnormalities
Thoraks
: heart : S I & S II reguler, G(-), M(-)
lung : VBS left = right, Rh(-), Wh(-)
Abdomen
: soft, distended, tenderness (-), DM (-)
Liver
: no abnormalities
Lien
: no abnormalities
Ekstremities
: Edema: - Varises: -

OBSTETRIC STATUS
EXTERNAL EXAMINATION
Symphycial fundal height
: 37 cm
Abdominal circumference
: 105 cm
Fetal Position
: breech, back on left side, 2/5
Number of contraction : three times per 10 minutes for 20
seconds
Fetal heart rate
: 138x/minute
EBW
: 3780
SPECULUM EXAMINATION
not performed

VAGINAL EXAMINATION
Vulva
: No Abnormality
Vagina
: No Abnormality
Portio
: Thick Soft
Dilataion
: 2-3cm
Amnion Fluid
: positif
Presentation
: breech

Factor

Zatuchni Andros SCORE

0

PARITY

GESTATIO
NAL
AGES
(WEEKS)

39

36

37

TBBA

3500

30003500

< 3000

BREECH
LABOR

Never

2 or more

DILATATI
ON

STATION

-3

-2

-1

SCORE

PLANNING MANAGEMENT

Observation of general condition, vital signs, contraction, BJA

Check for Hematology Routine
Infusion RL 500 cc 20 gtt
Sectio Caesarean planning
Motivation for Contraception : MOW disagree
: IUD agree

DIAGNOSIS

G3P2A0 Parturien 39-40 minggu with Breech

Presentation with EBW >3500 + SC History

PROBLEM

IS THE DIAGNOSIS OF THIS PATIENT CORRECT?

This is her third pregnancy, she has given birth two times and she
never miscarriage . G3P2A0
There is 2-3cm dilatation parturien
HPHT 20 November 2015, TP 27 Agustus 2016, date of admission
21 Agustus 2016 39-40 weeks
Leopold 1-4 : breech
Has a SC Hystory SC history

Is the treatment for this patient correct?

Patient :
Observation of GS, VS, His, FHR
Infusion of RL 500cc 20 gtt
Check hematology Routine
Induction was not done because she had SC History, but because of
her EBW is more than normal and her zatuchni andros score is 3
so she has the indication for SC

Add 0 Points

Add 1 Point

Add 2 Points

39+

38

<37

EFW (lb)

7-8

<7

Previous breech

Dilatation

Station

-3

-2

-1

Parity
Gestational age
(wk)

Zatuchni-Andros Breech Scoring : 2

LABORATORY INVESTIGATION
Date 21-08-2016 time 19:56
Hematology
Routine blood
1. Hemoglobin : 11,7 g/dl ( n 12.0 - 16.0 )
2. Hematocryte : 35 %
( n 35 - 47)
3. leukocyte : 32.760 /mm3
( n 3.800 10.600 )
4. Trombosit : 292.000 /mm3 ( n 150.000 440.000 )
5. Erytrocyte : 3.53 juta/mm3 ( n 3,6 5,8 )

FOLLOW UP- POST OPERATION DAY 1

Date,
Note
Times
22/08/2016 S/ O/ GS
: CM
POD I
Blood pressure
: 120/90 mmHg
Respiratory rate
: 19 x/mnt
Pulse rate
: 80 x/mnt
temp
: AF 0C
Eye
: Ca -/- , Si -/Abdomen
: soft, flat, tenderness (-),
DM (-)
Breast Milk
: -/Symphycial fundal height : 1 finger under
umbilical
Surgical wound
: bandage covered
Lochia
: + rubra
bleeding
: few
Bowel/urine output : - / dc
Flatus
:+
Bowel sounds
:+
A/ P3A0 Partus matures with SC + IUD insertin

Intruction
P/ Th :
Obs KU, TTV

Inf Rl 500
cc 20 tpm

Inj
Cefotaxim 2
x 1 gr iv

Mefenamat
Ac 3 x 500
mg iv

Kaltrofen
Supp 2x1

Aff DC

Mobilization

FOLLOW UP-DAY 2
Date, time
23/08/2016 S/ Cough
O/ GS
POD II
Blood pressure
Respiratory rate
Pulse rate
Temp
Eye
Breast Milk
Abdomen
DM (-)
SFH
Surgical wound
Bleeding
Bowel/urine output

Notes

Instruction
P/ Th :
Aff Infus

: CM
: 100/60 mmHg

: 20x/mnt
: 108 x/mnt
: AF 0C

: Ca -/- Si -/: -/: Soft, Flat, Tenderness (+),

: 1 finger under umbilical
: dry
: a few
:-/-

Cefadroxil
2 x 500
mg po
Metronida
zol 3 x
500 mg
po

As.Mefena
mat 3 x
500 mg
op

A/ P3A0 Partus matures with SC + IUD insertin a.c

breech with EBW > 3500 gr + SC History

Change
bandage
Mobilizati
on

FOLLOW UP-DAY 3
Date, times
24/08/2016
POD III

Notes
S/ O/ GS
: CM
Blood pressure: 100/60 mmHg
Respiratory rate : 20 x/mnt
Pulse rate
: 80 x/mnt
Temp
: AF 0C
Eye
: Ca -/- Si -/Abdomen
: soft, tenderness(-), DM
(-)
Breast milk
: +/+
SFH
: 3 finger under
umbilicus
Lochia
: + rubra
Surgical wound: dry
Bleeding
:Bowel/urine output : - / A/ P3A0 Partus matures with SC + IUD
insertin a.c breech with EBW > 3500
gr + SC History

Intruction
P/ Th :
Cefadroxil 2 x 500
mg po

Metronidazol 3 x
500 mg po

As. Mefenamat 3
x 500 mg op

Changed bandage

FINAL DIAGNOSIS
A/ P3A0 Partus maturus with SC + IUD insertion
e.c breech presentation with EBW > 3500 gr +
SC History

THEORY

BREECH PRESENTATION
Breech presentation is defined as a fetus in a longitudinal lie with
the buttocks or feet closest to the cervix.
This occurs in 3-4% of all deliveries.

CLASSIFICATION

PREDISPOSING FACTORS

PATHOPHYSIOLOGY
Fetal and uterine size can influence breech presentation. Preterm
infants are more likely to change their in utero position due to the
smaller size. Larger fetuses may be forced into a cephalic
presentation in late pregnancy due to space or alignment
constraints within the uterus.

 Primiparity, fetal congenital anomalies, and multiple pregnancies

may all be indirectly related through association with small for
gestasional age.
Parity-related relaxation of the uterine wall may reduce breech
presentation by contributing to a higher spontaneous version and
external cephalic version rate in multiparous women.

SIGN AND SYMPTOMPS

Leopold

Vaginal
examination

USG

LEOPOLD MANEUVERS
Leopold I

Leopold III

The hard, round, ballottable

fetal head may be found to
occupy the fundus

Leopold II

If not engaged, the breech is

movable above the pelvic
inlet.

Lepold IV

The back to be on one side of

the abdomen and the small
parts on the other.

The firm breech to be

beneath the symphysis.

VAGINAL EXAMINATION
Frank Breech
o No feet are palpable, but the fetal ischial tuberosities, sacrum, and anus are
usually palpable.
o After further fetal descedance, the external genitalia may also be
distinguished.
o Especially when labor is prolonged, the fetal buttocks may become markedly
swollen, rendering differentiation of a face and breech is difficult.

Complete Breech
The feet may be felt alongside the buttocks.

Footling Presentations
One or both feet are inferior to the buttocks.

TREATMENT
Contraindication of
ECV
1. Hipertention
2. narrow pelvic
External cephalic version

Knee
chest
position
(if there
is no contraindication

3. Oligohydramnion
4. gemelli

5. antepartum
haemorrhage

DELIVERY

Vaginal delivery
Caesarean
delivery

VAGINAL DELIVERY
Terms of vaginal delivery in breech position :
Complete or frank breech
Clinical adequate
The fetus is not too large
No history of caecarean with indication of CPD (Cephalo-Pelvic
Disproportion)
Head flexion

TYPE OF VAGINAL DELIVERY

Spontaneous labor (Brach labor)
Manual Aid
Extraction Breech

MANUAL AID

Step one
breech birth
until the navel is
born with his
own mother's
strength and
power

Step two
birth the
shoulders and
arms with the
helper
(classic
(Deventer),
Mueller, Lovset,
Bickenbach)

Step Three
The birth of
head
Mauriceau ( Veit
- Smellie ),
Najouks, Wigand
Martin
Winckel,Parague
reversed,
cunam piper)

STEP TWO

CLASSIC (DEVENTER)

LOVSET

CLASSIC AND MULLER

MUELLER

BICKHENBACH

STEP THREE (AFTER COMING HEAD)

Mauriceau
(Veit
Smellie)

Najouks

Parague
reversed

cunam
piper

PARTIAL BREECH EXTRACTION

No downward or outward
traction is applied to the
fetus until the umbilicus has
been reached.

PARTIAL BREECH EXTRACTION

With a towel wrapped around
the fetal hips, gentle downward
and outward traction is applied
in conjunction with maternal
expulsive efforts until the
scapula is reached. An assistant
should be applying gentle
fundal pressure to keep the
fetal head flexed.

PARTIAL BREECH EXTRACTION

After the scapula is reached,

the fetus should be rotated
90 in order to delivery the
anterior arm.

T H E A N T E R I OR A R M I S F OLLOW E D T O
T H E E L BO W , A N D T H E A R M I S S W E P T
O U T O F T H E VAG I N A.

T H E F E T U S I S R O TAT E D 1 8 0 , A N D T H E
C O N T RA L AT E RA L A R M I S D E L I V E R E D I N A
S I M I L A R M A N N E R A S T H E F I R S T. T H E I N FA N T
I S T H E N R O TAT E D 9 0 T O T H E B A C K- U P
P O S I T I O N I N P R E PA RAT I O N F O R D E L I V E RY O F
THE HEAD.

T H E F E TA L H E A D I S M A I N TA I N E D I N A F L E X E D
P O S I T I O N BY U S I N G T H E M A U R I C E A U - S M E L L I E VEIT MANEUVER, WHICH IS PERFORMED
BY
PL ACING THE INDEX AND MIDDLE FINGERS OVER
T H E M A X I L L A RY P R O M I N E N C E O N E I T H E R S I D E O F
T H E N O S E . T H E F E TA L B O DY I S S U P P O RT E D I N A
N E U T RA L
POSITION
WITH
CARE
TO
NOT
OVEREXTEND THE NECK.

MAURICEAU MANEUVER

D E L I V E RY O F T H E A F T E RC O M I N G H E A D U S I N G
T H E M A U R I C E A U M A N E U V E R. N O T E T H AT A S T H E
F E TA L H E A D I S B E I N G D E L I V E R E D , F L E X I O N O F
THE
HEAD
IS
M A I N TA I N E D
BY
S U P RA P U B I C
P R E S S U R E P R O V I D E D BY A N A S S I S TA N T.

PIPER FORCEPS APPLICATION

P I P E R S A R E S P E C I A L I Z E D F O RC E P S U S E D O N LY F O R
T H E A F T E RC O M I N G H E A D O F A B R E E C H P R E S E N TAT I O N .
THEY ARE USED TO KEEP THE HEAD FLEXED DURING
E X T R A C T I O N O F T H E F E TA L H E A D . A N A S S I S TA N T I S
N E E D E D T O H O L D T H E I N FA N T W H I L E T H E O P E R AT O R
G E T S O N O N E K N E E T O A P P LY T H E F O RC E P S F R O M
B E L O W.

LO W 1 - M IN U T E A P G A R S C O R E S A R E N O T U N C O M M O N
A F T E R A VA G I N A L B R E E C H D E L I V E RY. A P E D I AT R I C I A N
S H O U L D B E P R E S E N T F O R T H E D E L I V E RY I N T H E
E V E N T T H AT N E O N ATA L R E S U S C I TAT I O N I S N E E D E D .

EXTRACTION BREECH

Total
breech
extraction

For frank
breech

Foot
extractio
n

Breech
extractio
n

CAESAREAN DELIVERY
IF :
1. Vaginal Childbirth estimated difficult and dangerous (Feto Pelvic Disproportion
or scor Zachtucni Andros 3 )
2. Umbilical cord prolapse in primi/multigravida
3. Obstained Dystonia
4. Age of Pregnancy
5. The value of children (only consideration)
6. History of labor : a history of poor labor, fetal high social value.

ZATUCHNI ANDROS SCORE

Factor

Zatuchni Andros SCORE

0

PARITY

GESTATIO
NAL
AGES
(WEEKS)

39

36

37

TBBA

3500

30003500

< 3000

BREECH
LABOR

Never

2 or more

DILATATI
ON

STATION

-3

-2

-1

SCORE

Information :
3 : labor
perabdominal .
4 : reevaluation
carefully , especially
BBJ , if the value can still
be born vaginally
5 : born vaginally

Persalinan Pervaginam

Seksio Sesaria

- Letak sungsang bokong murni

- Berat janin >3500 gr atau <1500

- Umur kehamilan >=34 minggu

gr
- Ukuran pelvis yang sempit atau
perbatasan

- Taksiran berat badan janin 2000

3500 gr

- Kepala janin yang defleksi atau

hiperekstensi

- Kepala janin fleksi

- Pecah ketuban yang lama

- Ukuran pelvis yang memadai

- Bagian bawah janin yang tidak

engaged

- Tidak ada indikasi ibu maupun - Primi tua

anak
untuk seksio sesaria

- Janin yang preamatur (umur

kehamilan 25-34 minggu)

- Presentasi kaki

COMPLICATION

MOTHER :
1.Bleeding because trauma of the
birth canal, atonic uterus,
retained placenta.
2.Infection occurs because
ascendens trought trauma
(endometritis)
3.Labor trauma such as trauma of
the birth canal, symphisidiolisis

Infants factors :
bleeding , such as intracranial hemorrhage ,
intracranial edema , hemorrhage vital tools intra
-abdominal .
Infections due to manipulation
Trauma labor such as
dislocation / fracture extremities ,
joints neck
rupture vital tools intra -abdominal ,
damage to the brachial plexus and the facial
damage to the central vital in the medulla
oblongata
direct trauma to vital tools ( eyes , ears , mouth
asphyxia
stillbirth

PROGNOSIS
With rapid recourse to
cesarean section, use of
banked blood, and expertly
administered anesthesia, the
overall maternal mortality
has fallen to less than 1 in
1000.

VBAC, SC HISTORY
Risk for the fetus
Still Birth (1,3 per 1000 in
15.515 deliveries, Smith, dkk
(2012))
Hipoxyc Ischemic
Encephalopaty

Risk for the mother

Need for blood transfusion
Histerektomy

Reported by Shipp dkk (2001), evaluating relation beetween

labour and rupture uterus on 2.409 women having at least
one SC History, Rupture uterus occure on 29 wanita-1,4 %
Reported by Macones dkk (2005), increasing of rupture uterus is
twice on women who undergo delivery trial after having SC Twice
1,8% -- compared to women that just have once SC 0,9 %. (2)

THANK YOUU