cpd

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 PTAPatient had sudden onset of irregular Abdominal pain radiating to the lower back Associated with brownish mucoid vaginal dischargeThere was no watery discharge noted.

Patient tolerated the symptoms and did not seek consultation

• 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

YEAR GESTATION COMPLETED

SEX BIRTH WEIGHT

PRESENT STATUS

G1 PRESENT PREGNANCY

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 : 9kgMedication: 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, (-) WeaknessSkin: (-) Rashes, (-) ItchinessHead: (-) headacheEye: (-) blurring of vision, itching, redness or painEar: (-) deafness, pain or discharge

REVIEW OF SYSTEM

Nose: (-) epistaxis, obstruction, dischargesMouth: (-) bleeding gums, (-) Dental carries, (-) SoresThroat: midline tracheaNeck: (-) stiffness or limitation in motionsPulmonary System: (-) cough, (-) dyspnea, (-) asthma

Cardiac: (-) palpitations, (-) chest pain Abdomen: (+)Hypogastric pain, (-)vomiting, (-)nausea, (-)epigastric painGenito-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•Leopold’s 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 normalInternal 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 Physical Exam

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

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 RULE OUT

Large fundic height (37cm) One fetus palpated on leopoldsOne heart beat auscultated(-) Family history of multifetal pregnancy

Polyhydramnios

RULE IN RULE OUT

Large fundic height (37cm) Normal AFI = 12.4 cm

Gynecologic Tumor with Pregnancy

RULE IN RULE OUT

Large fundic height (37cm) (-) 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

Laboratory1st Hospital Day

CBC

WBC Count H 21.23 5-10

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 L 7.0 20-35

Monocytes 4 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

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



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 bpmVariablity: moderateAcceleration: (+)Deceleration: absentUC: moderate to strong irregular Uterine Contraction

Course In The Ward

BP/FHT UC IE REMARKS

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

Moderate to strong irregular contraction

• 5 cm• 60% effaced• Cephalic• IBOW• station -3

• Vaginal delivery• IPM• CS if with

fetomaternal indication

• FHT/UC monitoring

8.00 PM•BP: 120/80•FHT: 145 bpm



• FHT/UC monitoring

12.15 AM•BP: 115/80•FHT: 140 bpm



• 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 Day1st Post Op Day

Subjective Objective Assessment Plan

(-) abdominal pain(+) minimal vaginal bleeding (-) nausea or vomiting(-) fever(-) bowel movement(-) FlatusLying comfortable supineNo other complaints

Stable vital signsPink palpebral conjuctivaeAnicteric scleraeClear breath soundEqual chest expansionAdynamic percordiumFull pulses, CRT < 2 secsClear adequate urine outputDry 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/hrMeds givenVital signs monitored

2nd Post Op Day1st Post Op Day


(+) minimal vaginal bleeding (-) nausea or vomiting(-) fever(+) bowel movement(+) FlatusVoiding freelyLying comfortable supineNo other complaints

Stable vital signsPink palpebral conjuctivaeAnicteric scleraeClear breath soundEqual chest expansionAdynamic percordiumFull pulses, CRT < 2 secsClear adequate urine outputDry well coaptated operative site


Dressing changed

Meds given

Vital signs monitored

3rd Post Op Day1st Post Op Day


Lying comfortable supine

No subjective complaints

Stable vital signsPink palpebral conjuctivaeAnicteric scleraeClear breath soundEqual chest expansionAdynamic percordiumFull pulses, CRT < 2 secsClear adequate urine output


Meds given

Vital signs monitored

MGH

4 Factors

Dystocia is the consequence of 3 abnormalities that Dystocia is the consequence of 3 abnormalities that may exist singly or in combinationmay exist singly or in combination

1-Abnormalities of the powers uterine contractility maternal expulsive forces2-Abnormalities of the passage maternal boney pelvis the soft tissue of the reproductive tract3-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

INLETINLET

THE CAVITYTHE CAVITY

• Subpubic Angle• Bituberous diameter• Anteroposterior Diameter

OUTLETOUTLET

STAGES OF LABOR

FIRST STAGE

SECOND STAGE

Latent phaseActive phase

Acceleration Phase Decceleration Phase

THIRD STAGE

Phase Of Max Slope

Preparatory division

Pelvic divisionDilatation

division

LABOUR TIME FRAMESPhases/ Stages of labourPhases/ Stages of labour NulliparousNulliparous MultiparousMultiparous

Latent Latent phasephase

Mean timeMean time 6.4 h6.4 h 4.8 h4.8 h

Longest Longest 20.1 h 20.1 h 13.6 h13.6 h

Active Active phasephase

Mean rateMean rate 3 cm/h3 cm/h 5.7cm/h 5.7cm/h

Slowest Slowest 1.2cm/h1.2cm/h 1.5cm/h1.5cm/h

22ndnd Stage Stage Mean timeMean time 1.1 h1.1 h 0.4 h0.4 h

Longest Longest 2.9 h2.9 h 1.1 h1.1 h

SHOULD NOT BE DIAGNOSED BEFORE ACTIVE STAGE OF LABOR

ABNORMAL LABOR

Abnormal labor patterns can be divided into two general types

– Protraction – Arrest

NULLIPARA MULTIPARA

Protraction <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

Abnormal Labor Patterns, Diagnostic Criteria and Methods of Treatment

Labor Patterns

Diagnostic Criteria Preferred Treatment

Exceptional TreatmentNullipara Multipara

Prolonged Latent Phase

> 20 hours

>14 hours

Bed rest Oxytocin or Cesarean

Delivery for urgent

problems


Protraction Disorders

Diagnostic Criteria Preferred Treatment


Protracted Active Phase

dilation

<1.2 cm/hr

<1.5 cm/hr Expectant and

SupportCesarean for

CPD

Protracted Descent

<1 cm/hr <2 cm/hr


Arrest Disorders Diagnostic Criteria Preferred Treatment


Prolonged Deceleration Phase

> 3 hrs > 1 hr

Evaluate for CPD:CPD: cesarean

No CPD: oxytocin

Rest if exhaustedCesarean Delivery

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

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

The fetal head engages in the occipitotransverse position and, if it is well flexed and asynclitic, will undergo rotation in the mid-cavity to the direct occipitoanterior position.

Secondary Arrest in Dilation

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

• Pinard’s Method• Muller-Kerr’s 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.

Arrest Disorders Diagnostic Criteria

Preferred Treatment

Exceptional Treatment

Nullipara

Multipara

Prolonged Deceleration

Phase

> 3 hrs > 1 hr

Evaluate for CPD:CPD: cesarean

No CPD: oxytocin

Rest if exhaustedCesarean Delivery

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

Management

Short stature as an independent risk factor for cephalopelvic disproportion in a country of relatively small-sized mothersMaternal-Fetal MedicineArchives of Gynecology and ObstetricsJune 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 34 weeks. 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 145 cm, short stature was significantly associated with higher rate of CPD with odds ratio of 2.4 (95% CI 1.8–3.0). The odds = exp(4.048 − 0.042 × Ht). 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 145 cm 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..!

cpd

Documents

weeks aog edd

hypogastric pain

month aog total weight

chest pain abdomen

weeks prenatal check

eye discharge

watery discharge

weight change