OB 1 (Tuesday April 11, 2017 1-3 PM)

Paper Case for SGD

GENERAL DATA:
Alice, 28 years old, G2P0 (0-0-1-0) teacher from Araneta Avenue Quezon City, admitted for the first time at the St. Lukes Medical
Center Quezon City on April 3, 2017.

CHIEF CONCERN: Labor pains

HISTORY OF PRESENT PREGNANCY:

Nine months prior to admission (July 2016), Alice noticed very scanty vaginal bleeding which lasted half a day, consuming one
pantyliner. She waited for heavier flow, but it never came. She felt nauseated upon waking up three times at night to empty her urinary
bladder.
Eight-and-a-half months PTA, she noted that her breasts felt heavier than usual and that they became sensitive to touch. She bought a
home pregnancy test kit which she used to test her urine one morning. The home pregnancy test showed a POSITIVE result. She then
consulted a physician who requested for an ultrasound examination. The transvaginal scan revealed a single live intrauterine
pregnancy, six weeks age of gestation by crown-to-rump length. She was prescribed Folate and was advised to have laboratory tests
done. From then on, her prenatal check-ups were scheduled until her pregnancy reached term.
The patients prenatal course was uneventful and all pertinent lab exams had normal results.

PAST MEDICAL HISTORY: Non-contributory

FAMILY HISTORY: Patients father has diabetes mellitus and is on Metformin and Glimepiride; maternal aunt died of breast cancer.

PERSONAL AND SOCIAL HISTORY: Alice is a public school teacher, married to a seafarer since age 24 years; she has no vices. Her
husband claims to be a one-woman man who is faithful to his wife. Her husband comes home to the Philippines middle of each year
and stays for three months. She has no history of sexually-transmitted infections.

MENSTRUAL HISTORY: Menarche at age 12 years, three days duration, three sanitary pads per day, with dysmenorrhea relieved by
Mefenamic acid.
Subsequent menses came regularly every month, with the same duration and character.
LNMP July 1-4, 2016; followed by half-day of vaginal spotting in the last few days of the same month
PMP June 2-5, 2016

GYNECOLOGIC/CONTRACEPTIVE HISTORY: No contraceptive was ever used.

OBSTETRICAL HISTORY:
G1 spontaneous abortion at 3 months AOG; completion curettage was done at a lying-in clinic in Quezon City, year 2015.

REVIEW OF SYSTEMS: Non-contributory

PHYSICAL EXAMINATION:
Patient alert and conversant, with the following vital signs:
BP: 100/60, PR: 82/min, RR: 20/min
Weight: 135 lbs. Height: 52
Pinkish palpebral conjunctivae, anicteric sclerae. No naso-aural discharge.
No nasal or tonsillo-pharyngeal congestion
Normal heart and lung findings
Abdomenglobular. FH 31 cm. EFW 2945 grams
Leopolds: LM1nodular
LM2fetal back at maternal right; FHT 140/min. Heard over RLQ
LM3hard round mass, ballottable
LM4left hand arrested over the left lower quadrant
Pelvic exam: normal-looking external genitalia; nulliparous introitus; vagina admitting two fingers with some difficulty.
Cervix uteri 2-3 cm dilated, 50% effaced, (+) BOW, cephalic, station (-)2

COURSE IN THE LR/DR:

Patient was allowed to walk around the Delivery Room/OB Complex while she could still withstand the uterine contractions. After two
hours, she requested that she be allowed to rest as the contractions were becoming unbearable. Cervix at this time was 5cm dilated,
70% effaced, (+) BOW, fetal head at (-) 2 station. After another two hours, she requested for epidural anesthesia. Post-epidural IE
showed a 7-8 cm dilated cervix. The contractions were noted to lag or decrease after one hour on anesthesia; amniotomy was then
done. The amniotic fluid was clear and free-flowing. After another hour, the cervix became 8-9 cm dilated and fully effaced, with the
head at station 0. One and a half hours later, the cervix was fully dilated, head was at station (+) 1. A soft triangular depression was
palpated at the 1 oclock position. After an hour of pushing, the patient eventually delivered spontaneously to a 3 kg baby girl with a
very lusty cry and Apgar score of 9 at 1 minute and 5 minutes. Baby was thoroughly dried and was later encouraged to latch onto the
mothers breast. The third stage of labor was managed actively and the placenta was delivered after 15 minutes. Repair of the right
mediolateral episiotomy that involved the skin and the fascia was then carried out. Mother and baby dyad stayed together in the Hold-
over/Recovery Area of the OB Complex for two hours before their transfer to the ward.
In relation to the case, answer the following:

1. Account for the scanty bleeding in July 2016.

2. What signs and symptoms of pregnancy did this patient manifest?

3. How should the first prenatal check-up have been conducted? What should have been the objectives? What lab exams should
have been requested?

4. What are the benefits of a first trimester ultrasound?

5. Why give Folate/Folic acid? What other oral supplements are given during pregnancy?

6. How frequent would subsequent prenatal visits have been, if this were a normal pregnancy?

7. What other lab exams are done in succeeding prenatal check-ups?

8. What phase of parturition was the patient in when she was admitted? Which phase of labor?

9. Interpret the findings on Leopolds maneuvers.

10. Plot the labor curve of the patient.

11. What was the position of the presenting part? What are the implications of this noted position?

12. What kind of laceration was incurred? What degree?

13. Describe the advantages and disadvantages of the episiotomy performed in this case.

14. Describe the features of a normal umbilical cord and a normal placenta.

15. What is active management of the 3rd stage of labor (AMTSL)? How is it done?

16. What steps of Essential Intrapartum and Newborn Care (EINC) were demonstrated here?

17. What is the final diagnosis?

18. What instructions are given to post-partum patients upon discharge from the hospital?

END