nsd

Department of Obstetrics and Gynecology

October 15. 2012

24 years old

Gravida 2 Para 1 (1000)

admitted for the first time on November 11, 2011

General Data:

Birthdate: October 7, 1987 Birthplace: Manila Status: Single Religion: Roman Catholic Occupation: Sales agent Habits: Non-smoker, non alcohol

drinker Attitude: Cooperative Availability of relatives: Near

Patient’s Profile:

LMP: March 7, 2011 PMP: February, 2011 AOG: 37 weeks and 2 days EDC: November 26, 2011

History of the Present Pregnancy:

Usual symptoms of early pregnancy – nausea and vomiting

First month of missed menses (April 2011) self PT = positive Consult with obstetrician in a government

hospital

History of the Present Pregnancy: First Trimester

Complete Blood Count – Normal Urinalysis - Normal Blood Typing – “O” positive Hepatitis B – nonreactive Transvaginal Ultrasound – single

intrauterine pregnancy compatible with 10 weeks age of gestation

Pap Smear – bacterial vaginosis

Bacterial vaginosis

Metronidazole, 500mg/tab, twice a day

for 7 days (taken regularly)

GRAM STAIN of cervicovaginal discharge (after completion of

antibiotics) –NORMAL RESULTS

History of the Present Pregnancy: First Trimester No history of dysuria, hypogastric

pain, vaginal spotting or bleeding and fever

Quickening – 5th month of pregnancy Regular prenatal check-up Regular intake of:

Multivitamins, 1 tablet once a day Ferrous sulfate, 1 tablet once a day Calcium tablet, 1 tablet twice a day Prenatal milk, 1 glass twice a day

History of the Present Pregnancy: Second Trimester

Ultrasound (7th month of pregnancy) – single, live, intrauterine pregnancy compatible with 29 weeks age of gestation

No history of dysuria, hypogastric pain, vaginal spotting or bleeding and fever

History of the Present Pregnancy: Second Trimester

Regular prenatal check-up at our OB OPD

Regular intake of: Multivitamins, 1 tablet once a day

Ferrous sulfate, 1 tablet once a day

Calcium tablet, 1 tablet twice a day

Prenatal milk, 1 glass twice a day

History of the Present Pregnancy: Third Trimester

No history of dysuria and fever


3 hours prior to admission: The patient went to the OPD for her weekly

prenatal check-up

Crampy, intermittent, hypogastric pain, radiating to the lumbosacral area, associated with scanty, bloody vaginal discharge


ADMISSION

Mumps and chicken pox during childhood

Non-diabetic, non-asthmatic No history of accidents, trauma,

major illnesses, operations and exposure to radiation or toxic chemicals

Past Medical History

Father: 50 years old, separated from patient’s family since childhood

Mother: 48 years old, apparently well 1 sibling No heredofamilial diseases, such as

hypertension, diabetes mellitus, asthma, and diseases of the breast, thyroid, heart, lung and/or kidney.

Family History

Eldest among 2 College graduate Sales agent Lives with partner (24 years old) for 7

years Non-smoker, non-alcohol beverage

drinker No food preference No known allergy to food and drugs

Personal and Social History

Lasted for 5 days Moderate in flow Consumed 5

napkins per day No

dysmenorrhea

Reproductive History: Gynecologic

28-30 days interval

Lasting for 5 days Consuming 3-5

napkins per day No associated

dysmenorrhea

MENARCHE: 14 years oldSUBSEQUENT MENSES:

regular

Reproductive History: Obstetric

Gravida 2 Para 1 (1000)Gravi

daHow Where Outcome Remarks

1

Normal spontane

ous delivery

Hospital

No fetomater

nal complicati

ons

After a month, baby died due to

sudden infant death syndrome

2 Present pregnancy

Coitarche – 17 years old 1 sexual partner No dyspareunia, post coital bleeding,

and leucorrhea No sexually transmitted disease

Sexual History

Oral contraceptive pills for 6 years after giving birth

Method of Contraception

CONSTITUTIONAL : no fever, no chills HEMATOLOGY: no rashes CENTRAL NERVOUS SYSTEM: no headache, no

dizziness, no loss of consciousness, no seizure

HEENT: no blurring of vision, no hearing loss RESPIRATORY: no difficulty of breathing, no

cough and colds CARDIOVASCULAR: no chest pain, no orthopnea GASTROINTESTINAL: no nausea, vomiting,

diarrhea and constipation GENITOURINARY: no dysuria, no frequency, no

urgency NEUROMUSCULAR: no arthralgia, no myalgia, no

numbness

Review of Systems

Physical Examination General Survey

Conscious, coherent, afebrile, not in cardiorespiratory distress

BP: 120/80

CR: 89 bpm

RR: 19 cpm

Temperature: 36.7 0C

Physical Examination HEENT

Pink palpebral conjuctivae, anicteric sclerae, no nasoaural discharge, no tonsillopharyngeal congestion

Neck Supple, no neck vein engorgement, no

cervicolymphadenopathy

Physical Examination Chest Symmetrical chest expansion, no retractions,

no lagging

Lungs Vesicular breath sounds, no crackles, no

wheezes

Heart Adynamic precordium, normal rate, regular

rhythm, no murmur

Physical Examination Abdomen Globularly enlarged, with fundic height of 32

cm, fundus occupied by breech, fetal back on the right, fetal small parts on the left, unengaged, cephalic, fetal heart tone of 130s bpm, best heart at the right lower quadrant with estimated fetal weight of 3000 to 3200 grams

Physical Examination Extremities

No gross deformities, full and equal pulses

Skin No active dermatoses

Speculum Not done

Physical Examination Internal Exam Normal looking external genitalia, parous

introitus, and vagina admits 2 fingers with ease, cervix is 4cm dilated, beginning effacement, intact bag of waters, unengaged, cephalic, and station 2

Physical Examination Clinical Pelvimetry Adequate

Sacral promontory not reached at 11.5 cm

Sacrosciatic notch average

Ischial spines not prominent

Sacrum deep and well-curved

Sidewalls not convergent

Pubic arch wide

Complete Blood Count – Normal resultsRESULT NORMAL VALUES

RBC count 4.62 x1012/L 4.5-5.5 x1012/L

Hemoglobin 13.6 x g/d 12-14 x g/d

Hematocrit 0.38 L/L 0.37-0.47 L/L

MCV 83.9 fl. 80-100 fl.

MCH 29.4 pg. 27-33 pg.

MCHC 35.1 % 32-38 %

Platelet Count 247 x 109/L 160-380 x 109/L

WBC Count 8.84 x 109/L 5-10 x 109/L

Color: Yellow Character: HazyBilirubin: Negative Urobilinogen: NormalProtein: Negative Nitrite: NegativepH: 7.0 Specific Gravity: 1.010

Blood: NegativeKetone: NegativeGlucose: NegativeLeukocytes: Negative

Casts: None /lpf Pus cells: 0-1 /hpfCrystals: None A. Urates/Phosphates: RareRed Blood Cell: None Bacteria: Rare

Urinalysis – Normal results

ADMISSION DIAGNOSIS:Gravida 2 Para

1 (1000)Pregnancy Uterine 37

weeks, Cephalic In Labor

PLAN For complete blood count,

urinalysis, and baseline cardiotocogram

For amniotomy Awaits spontaneous vaginal

delivery

ADMISSION

Salient Features 24 year old, Gravida 2 Para 1 (1000) Lives with partner (24 years old) for

7 years LMP: March 7, 2011 PMP: February, 2011 AOG: 37 weeks and 2 days EDC: November 26, 2011

Salient Features First Trimester

Usual symptoms of early pregnancy – nausea and vomiting

Self PT = positive Bacterial vaginosis = urinalysis and pap smear;

treated Transvaginal Ultrasound – single intrauterine

pregnancy compatible with 10 weeks age of gestation

Blood Typing – “O” positive Hepatitis B – nonreactive

Salient Features Second Trimester

Quickening – 5th month of pregnancy

Ultrasound (7th month of pregnancy) – single, live, intrauterine pregnancy compatible with 29 weeks age of gestation

Third Trimester Crampy, intermittent, hypogastric pain,

radiating to the lumbosacral area, associated with scanty, bloody vaginal discharge

Salient Features Physical Examination: Abdomen Globularly enlarged, with fundic height of 32 cm,

fundus occupied by breech, fetal back on the right, fetal small parts on the left, unengaged, cephalic, fetal heart tone of 130s bpm, best heart at the right lower quadrant with estimated fetal weight of 3000 to 3200 grams

Physical Examination: Internal Exam Normal looking external genitalia, parous introitus,

and vagina admits 2 fingers with ease, cervix is 4cm dilated, beginning effacement, intact bag of waters, cephalic, and station 2

NORMAL LABOR AND DELIVERY At the onset of labor, the position of the

fetus with respect to the birth canal is critical to the route of delivery.

Fetal orientation relative to the maternal pelvis is described in terms of FETAL LIE, PRESENTATION, ATTITUDE, AND POSITION.

Fetal Lie – relation of the long axis of the fetus to that of the mother Longitudinal Transverse Oblique


present in over 99 percent of labors at term


PERPENDICULAR

Predisposing factors:

Multiparity

Placenta previa

Hydramnios

Uterine anomalies


fetal and the maternal axes cross at a 45-degree angle

unstable and always becomes longitudinal or transverse during the course of labor

Fetal Presentation presenting part is that portion of

the fetal body that is either foremost within the birth canal or in closest proximity to it

Fetal Presentation Cephalic

A.VERTEX OR OCCIPUT PRESENTATION

B.SINCIPUTC.BROWD.FACE

Fetal Presentation Breech

A.FRANKB.COMPLET

EC.INCOMPL

ETE/FOOTLING

Fetal Attitude “habitus” characteristic posture fetus forms an ovoid mass that

corresponds roughly to the shape of the uterine cavity – characteristic posture results from the mode of fetal growth and its accommodation to the uterine cavity.

Fetal Attitude

Abnormal exceptions to this attitude occur as the fetal head becomes progressively more extended from the vertex to the face progressive change in fetal attitude from a convex (flexed) to a concave (extended) contour of the vertebral column

Fetal Position relationship of an arbitrarily chosen

portion of the fetal presenting part to the right or left side of the birth canal

with each presentation there may be two positions — right or left

Fetal Position

Leopold’s Maneuver diagnosis of fetal presentation and

position

L1, L2, L3 – examiner stands at the side of the bed that is most convenient and faces the patient

L4 – examiner reverses this position and facesher feet for the last maneuver

Leopold’s Maneuver Examiner gently

palpates the fundus with the tips of the fingers of both hands to define which fetal pole is present in the fundus

Breech – gives the sensation of a large, nodular body

Cephalic – head feels hard and round and is more freely movable and balottable

Fundus occupied by breech

Leopold’s Maneuver The palms are placed

on either side of the abdomen and gentle but deep pressure is exerted

Back – hard, resistant structure

Extremities – numerous small, irregular and mobile parts

Fetal back on the right

Fetal small parts on the left

Leopold’s Maneuver Using the thumb and

fingers on one hand, the lower portion of the abdomen is grasped just above the symphysis pubis

If the presenting part is not engaged, a movable body will be felt, usually the head

unengaged

Leopold’s Maneuver If the cephalic prominence is on

the same side as the small parts, the head must be flexed, and therefore the vertex is the presenting part

When the cephalic prominence of the fetus is on the same side as the back, the head must be extended

If the presenting part is deeply engaged, however, the findings from this maneuver are simply indicative that the lower fetal pole is fixed in the pelvis, the details are then defined by the last maneuver

unengaged

Leopold’s Maneuver The examiner faces the

mother’s feet and, with the tips of the first 3 fingers of each hand, exerts deep pressure in the direction of the axis of the pelvic inlet.

cephalic

Leopold’s Maneuver Vertex Presentation –

the prominence is on the same side as the small parts

Face Presentations – on the same side as the back

cephalic

Leopold’s Maneuver A transverse lie: Inspection: abdomen is unusually wide, whereas

the uterine fundus extends to only slightly above the umbilicus

No fetal pole is detected in the fundus, and the ballottable head is found in one iliac fossa and the breech in the other.

Back is anterior = hard resistance plane extends across the front of the abdomen; Back is posterior = irregular nodulations are felt through the abdominal wall.

Labor Uterine contractions that bring about

demonstrable effacement and dilatation of the cervix

PREPARATORY DIVISION DILATATIONAL DIVISION PELVIC DIVISION

Labor: First Stage

PREPARATORY DIVISION cervix dilates little, its connective tissue

components change considerably; sedation and conduction analgesia are capable of arresting this division of labor

DILATATIONAL DIVISION PELVIC DIVISION

Labor: First Stage

PREPARATORY DIVISION, DILATATIONAL DIVISION dilatation proceeds at its most rapid rate

unaffected by sedation or conduction analgesia.

PELVIC DIVISION

Labor: First Stage

PREPARATORY DIVISION, DILATATIONAL DIVISION PELVIC DIVISION commences with the deceleration phase of

cervical dilatation

engagement, flexion, descent, internal rotation, extension, and external rotation principally take place

Labor: First Stage

the point at which the mother perceives regular contractions

for most women ends at between 3 and 5 cm of dilatation

may be clinically useful, for it defines cervical dilatation limits beyond which active labor can be expected

PROLONGED: exceeding 20 hours in the nullipara or 14 hours in the multipara

Labor: First Stage—Latent Phase

cervical dilatation of 3 to 5 cm or more, in the presence of uterine contractions, can be taken to reliably represent the threshold for active labor.

Labor: First Stage—Active Labor

Contractions occur at regular interval Intervals gradually shorten Intensity gradually increases Discomfort is in the back and abdomen Cervix dilates Discomfort is not stopped by sedation

Labor: True

irregular intervals long intervals intensity remains unchanged Discomfort is chiefly in lower abdomen Cervix does not dilate Discomfort is usually relieved by

sedation

Labor: False

Labor: True vs False

Amniotic fluid seen pooling in the posterior fornix or clear fluid passing from the cervical canal

Testing the pH of the vaginal fluid: Normal pH = 4.5-5.5 whereas the amniotic fluid: 7.0-7.5

pH above 6.5 is consistent with ruptured membranes

Detection of Ruptured Membranes

Nitrazine simple and fairly reliable

test papers impregnated with dye

color of the reaction is interpreted by comparison with a standard color chart


Other Tests : arborization or ferning of vaginal fluid – suggests

amniotic rather than cervical fluid

detection of alpha-fetoprotein in the vaginal vault to identify amniotic fluid

injection of various dyes into amniotic sac via abdominal amniocentesis ex. Evans Blue, Methylene Blue, Indigo Carmine, or Fluorescein


Cervical Dilation Estimating the average diameter of the cervical opening

expressed in cms

10 cms – fully dilated

Cervical Effacement Expressed in terms of length of cervical canal compared

to uneffaced cervix

If reduced by ½ - 50% effaced

If thin as the adjacent lower uterine segment – completely or 100% effaced

Cervix

Cervical Position Relationship of cervical as to fetal lie categorized as

posterior, midposition or anterior

Cervix

The level—or station—of the presenting fetal part in the birth canal is described in relationship to the ischial spines, which are halfway between the pelvic inlet and the pelvic outlet.

When lowermost portion of presenting part is at level of ischial spines designated as ZERO STATION

Station

The American College of Obstetricians and Gynecologists classified stations dividing the pelvic above and below the spines into fifths represent centimeters above and below the spines into fifths

Station

Station +5 corresponds to fetal head visible at the introitus

If the head is unusually molded, or if there is an extensive caput formation, or both, engagement might not have taken place even though the head appears to be at 0 station

Station

Monitoring fetal well-being during labor

Fetal heart rate stethoscope or any Doppler ultrasound devices fetal heart auscultated after contraction fetal jeopardy FHR <100/min

Management of theFirst Stage of Labor

American College of OB-GYNE recommends

1. First Stage of Labor

FHR checked after contraction at least every 30 minutes then every 15 minutes during second stage



2. High Risk Pregnancies

Continuous electronic monitoring evaluation oftracing

o Every 15 minutes : 1st stage of labor

o Every 5 minutes : 2nd stage of labor




Uterine contractions

o Evaluate frequency, duration quantified as to degree

o of firmness or resistance to indentation




Continuous electronic monitoring evaluation of tracing

o Every 15 minutes : 1st stage of labor

o Every 5 minutes : 2nd stage of labor


Subsequent vaginal examinations Vary during the 1st stage

When membranes rupture – examination repeated expeditiously if fetal head was not definitely engaged at the previous vaginal examination

FHR checked immediately and during the next uterine contraction to detect an occult umbilical cord compression

Maternal Monitoring

Oral intake – NPO Food withheld during active labor and delivery

Gastric emptying time is prolonged once labor is established and analgesics are administered

Intravenous fluids – D5LR 1L x 8 hours Advantageous during the immediate puerperium to

administer Oxytocin prophylactically and at times therapeutically when uterine atony persists

With longer labors, administration of glucose, sodium, and water at a rate of 60-120 mL/hr to prevent dehydration and acidosis

Maternal Monitoring

begins when cervical dilatation is complete and ends with fetal delivery

Median duration ~ 50 minutes for nulliparas and about 20 minutes for multiparas – can be highly variable

Labor: Second Stage

10

8

6

4

2

0

-3

-2

-1

0

+1

+2

+3

+4

+52 4 6 8

Amniotomy done(clear amniotic

fluid)

Oxytocin 6 units

incorporated to IVF

Outcome: Baby Girl, live, term, delivered via Normal Spontaneous Delivery

with an AS: 9 & 10; BW: 3130g; BL: 47cm; BS: 37 weeksAppropriate for gestational age

Mean length of first- and second-stage labor ~

9 hours in nulliparous women without regional analgesia, and that the 95th percentile upper limit was 18.5 hours

for multiparous women, about 6 hours with a 95th percentile maximum of 13.5 hours

Identification Full cervical dilatation

Bearing down efforts lasting 1 ½ minutes

Descent of presenting part with urge to defecate

Labor: Second Stage

May be prolonged due to: large fetus

with conduction analgesia

intense sedation

Labor: Second Stage

Labor: Cardinal Movements The positional changes in the presenting

part required to navigate the pelvic canal constitute the mechanisms of labor.

The cardinal movements of labor are engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion

EngagementDescentFlexion Internal rotationExtensionExternal rotationExpulsion

Labor: Cardinal Movements

Labor: Cardinal Movements EngagementDescentFlexion Internal

rotationExtensionExternal

rotationExpulsion

Fetal heart rate Low risk fetus auscultation every 15 minutes

High risk fetus every 5 minutes interval

Slowing of FHR can be induced by head compression

Descent may likely tighten a loop or loops of umbilical cord around the fetus especially the neck

Management of theSecond Stage of Labor

Coaching Legs = half-flexed so that she can push with them against

the mattress

Intruct = Take a deep breath as soon as the next uterine contraction begins, and with her breath held, to exert downward pressure exactly as though she were straining at stool

While actively bearing down, the fetal heart rate immediately after the contraction is likely to be slow, but should recover to normal range before the next expulsive effort.

Management of theSecond Stage of Labor

The occiput is being kept close to the symphysis by moderate pressure to the fetal chin at the tip of the maternal coccyx

RITGEN MANUEVER OR MODIFIED RITGEN MANUEVER

Forward pressure on the chin of the fetus through the perineum just in front of the coccyx, at the same time, the other hand exerts pressure superiorly against the occiput

Labor: Second Stage—Delivery of the Head

EPISIOTOMY – right mediolateral Prevents pelvic relaxation ex. Cystocele, rectocele,

urinary incontinence

Shoulder dystocia or Breech delivery

Forceps or vacuum extractor operations

Occiput posterior positions

Instances where failure to perform episiotomywill result in perineal rupture

Labor: Second Stage—Delivery of the Head

Labor: Second Stage—The Cord

Labor: Second Stage—The Cord Clamping the Cord The umbilical cord is cut between two clamps placed 4 to 5

cm from the fetal abdomen, and later an umbilical cord clamp is applied 2 to 3 cm from the fetal abdomen

After delivery the newborn is placed at or below the level of the vaginal introitus for 3 minutes and the fetoplacental circulation is not immediately occluded by cord clamping, an average of 80 mL of blood may be shifted from the placenta to the neonate

This provides approximately 50 mg of iron, which reduces the frequency of iron deficiency anemia later in infancy

delivery of infant to expulsion of placenta

Watchful waiting until the placenta is separated as long as the uterus remains firm and there is no unusual bleeding

Hand is rested on the fundus frequently to make certain that the organ does not become atonic and filled with blood behind a separate placenta

Labor: Third Stage

signs of placental separation Calkin’s Sign – the uterus becomes globular and, as a

rule, firmer; earliest to appear

Sudden gush of blood

the uterus rises in the abdomen

Lengthening of the umbilical cord

Labor: Third Stage

Expression of the placenta should never be forced before placental separation lest the uterus becomes inverted

Traction on the umbilical cord must not be used to pull the placenta out of the uterus.

Uterine inversion is one of the grave complications associated with delivery, and it constitutes an emergency requiring immediate attention

Labor: Third Stage—Placenta

Manual removal

brisk bleeding

placenta cannot be delivered by these techniques

This is especially common in cases of preterm delivery


UTERINE MASSAGE following placental delivery is recommended by many to prevent postpartum hemorrhage.

OXYTOCIN, ERGONOVINE, AND METHYLERGONOVINE are all employed widely in the normal third stage of labor

If they are given before delivery of the placenta, however, they may entrap an undiagnosed, undelivered second twin


OXYTOCIN (pitocin, syntocinon)

Synthetic form of the octapeptide Oxytocin

Spontaneously laboring uterus very likely to be exquisitely sensitive to Oxytocin

Not effective by mouth

Half-life : 3 minutes (intravenous)


OXYTOCIN (pitocin, syntocinon)

Inappropriate dose uterus may contract so violently as to kill the fetus

Cardiovascular effects :

o Transient fall in arterial blood pressure

o Increase in cardiac output

Antidiuresis


ERGONOVINE AND METHYLERGONOVINE

An alkaloid obtained from ergot

Powerful stimulants of myometrial contraction

Parental administration sometimes initiates transient severe hypertension


Demerol 25mg+Phenergan 25 mg, ½ IM, ½ IV

Meperidine hydrochloride – fast acting opioid analgesic drug

Promethazine- a first-generation antihistamine of the that has anti-motion sickness, antiemetic, and anticholinergic effects, as well as a strong sedative effect; also used to potentiate any opiates

Oxytocin 6 units Carboprost 250mg TIV

Medications

Demerol 25mg+Phenergen 25 mg, ½ IM, ½ IV

Oxytocin 6 units

Carboprost 250mg TIV

Medications

Demerol 25mg+Phenergen 25 mg, ½ IM, ½ IV

Oxytocin 6 units Carboprost 250mg TIV

synthetic prostaglandin analogue of PGF2α (with oxytocic properties)

induces contractions and can trigger abortion in early pregnancy; also reduces postpartum bleeding

Medications

hour immediately following delivery Post partum hemorrhage as the result of

uterine atony is more likely at this time perineum inspected to detect excessive

bleeding

maternal BP and pulse recorded immediately after delivery and every 15 minutes for the 1st hour

Labor: Fourth Stage

Labor: Fourth Stage First degree

laceration

Fourchette

Perineal skin

Vaginal mucous membrane

Labor: Fourth Stage Second

degree laceration

Skin

Mucous membrane

Fascia

Muscles

Perineal body

Labor: Fourth Stage Third degree

laceration

Skin

Mucous membrane

Perineal body

Sphincter

Labor: Fourth Stage Fourth degree

laceration

Extends through the rectal mucosa to expose the lumen of the rectum

Gravida 2 Para 2 (2001)

Pregnancy Uterine 37 weeks Cephalic – Delivered

Amniotomy – Clean Amniotic Fluid

Normal Spontaneous Delivery

Right Mediolateral Episiotomy and Repair

FINAL DIAGNOSES

nsd

Documents

present pregnancy

month of pregnancy single

daycalcium tablet

trimesterno history

hypogastric pain

years oldgravida

years oldsubsequent

vaginal spotting