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7/26/2019 WH Case Write Up OBS

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WH Case Write Up Obstetric

History Taking

Venue: Hospital Sultan Ismail Ward 4A (obstetrics ward)

Date: 10!"01#

$atient%s identi&cation: A !" 'ears old ala' emale* w+o is ,4$1-" and currentl'wit+ !.w-#d period o /estation S+e wors as a nurse and married or 2 'ears

Gestation

3$ # # "012DD b' dates "2 ! "01#DD b' scan 1" ! "01#

Presenting complaint

5+is is a reerred case rom Hospital 6ota 5in//i or electi7e lower se/mentcaesarean section due to persistent trans7erse lie

History of Presenting Complaint

5+e &rst ultrasound scan was done at wee 8 o pre/nanc' and a trans7erse lie wasnoted S+e was reerred to amil' medicine specialist or "9weel' monitorin/ oetal lie Howe7er* t+e etal lie was remained at trans7erse position t+rou/+out t+ew+ole pre/nanc' At /estation o !.w-1d* s+e was admitted to Hospital 6ota 5in//iand +ad a counsellin/ re/ardin/ t+e mode o deli7er' wit+ t+e ;, specialist S+e+as been re 'ears and +ad persistent trans7erse lie S+e was not een or e?ternal cep+alic7ersion and decided to accept =aesarean section $ostoperati7e =aesarean sectionris was e?plained and s+e understood At /estation o !.w-4d* s+e was t+enreerred to Hospital Sultan Ismail and t+e date o operation was sc+eduled

History of pregnancy

S+e suspected pre/nanc' because o t+e missed period or " wees A urinar'pre/nanc' test was done b' +ersel and t+e result was positi7e 5+e pre/nanc' wascon&rmed b' ultrasound scan in t+e 6lini 6esi+atan At t+at time* it was wee . opre/nanc' 5+ere was no an' s'mptoms o earl' pre/nanc' suc+ as mornin/sicness* tiredness* breast tenderness and re


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s $ostnatalcomplications

t

1 "00>

!>w Breec+presentationwit+ success

e?ternalcep+alic7ersion

Va/inaldeli7er'

!2/ ale

" "008

4w iscarria/e 9 9 9

! "01"

>w iscarria/e 9 9 9

Past gynaecological history

enarc+e: 1" 'ears old

Csual menstrual c'cle: !!0

?perience d'smenorr+ea occasionall' on t+e &rst da' o menstruation

IB$=B: @o

C5I (7a/inal disc+ar/e): @o

=ontraception: @o

S+e +as annual cer7ical smear since +er marria/e 5+e last cer7ical smearwas done in last 'ear and t+e result was normal

@o +istor' o se?uall' transmitted disease

S+e +as > 'ears o subertilit' problem wit+out tain/ an' medications

Dilation and curetta/e was done twice or t+e pre7ious miscarria/e

Past medical history

@o si/ni&cant past medical +istor'

1 Absence o an' c+ronic medical conditions (diabetes* +'pertension*cardiac disease)

" @o pre7ious admission to +ospital ot+er t+an t+e &rst c+ild deli7er'

! @o +istor' o blood transusion

Drug history

olic acid ; 7itamins (at booin/)

errous umarate or anaemia

2


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@o aller/' to dru/ or ood

@ot on an' lon/ term medication

Social history

S+e is li7in/ wit+ +er +usband and son wit+ ade


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Blood pressure 1!2>1mmH/

=onFuncti7al pallor

,ood +'dration

@o s'mptoms o labour (uterine contraction pain* rupture o membrane) etal mo7ements are well percei7ed @o ot+er acti7e complaints

!bdominal eamination

InspectionDistention o abdomen consistent wit+ pre/nanc'

3inea ni/ra and striae /ra7idarum

@o pre7ious sur/ical scars

@o 7isible etal mo7ements

S'mp+'sioundal +ei/+t is 40cm

PalpationAbdomen is sot and non9tender

5rans7erse lie and breec+ presentation

Ade


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6eep t+e continuous bladder draina/e until ambulator' well

Spinal care or # +ours

Allow oral intae as tolerated

Strict I c+art

Strict pad c+art (to inorm i more t+an " ull' soaed pad wit+in 1 +our)

IV ceuro?ime .20m/ tds or " da's t+en switc+ to tablets or 2 da's

S= +eparin .200 units bd until disc+ar/e

=ontinue IV $itocin >0C or 1" +ours

Anal/esia as per re

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