OB Case

Rejante, Tito Guillermo Sabong, Lerezyl Salazar, Zara Micah Santiago, Mahalla MaeSeeres, Anna Mercedita Sengco, Catherine Tirado, Anna Shemei Uy, Jhoana Michelle Vergara, Larraine Yap, Rowel David

General Data

ADZ 22 years old Female Filipino Married Housewife Catholic 1392 Sta. Maria St., Tamaraw Hills, Valenzuela City Consulted for the 2nd time at FUMC on November 6, 2012.

Chief Complaint
Enlarging

Abdomen

History of Present Pregnancy

LMP:

March 23, 2012 PMP: March 13, 2012 EDC: December 30, 2012 AOG: 31 3/7 weeks

First Trimester

(+) Dizziness Vomiting every morning (+) cessation of menses for one month past her expected menstrual period PT with positive result (last week of April, 2012 ) (+) monthly prenatal check-ups
TVS confirmed pregnancy Multivitamins, ferrous sulfate and folic acid (+) fever (late 1st trimester) paracetamol (-) other maternal illnesses (-) exposure to radiation (-) teratogenic drugs were reported.

Second Trimester
Quickening

-16-18 weeks AOG (-) morning vomiting episodes (+) monthly prenatal check-ups

Multivitamins and ferrous sulfate continued

(-)

maternal illness, exposure to radiation and intake of teratogenic drugs

Second Trimester

Pelvic ultrasound (September 28, 2012) (34 weeks and 4 days AOG)

Pregnancy uterine 32 weeks and 4 days by fetal biometry live, single fetus in cephalic presentation BPD=82.5 mm 33 weeks 0 days FL=65.3 mm 33 weeks 2 days AC=296.5 mm 33 weeks 5 days HC=293.3 mm 31 weeks 0 days AFI = 12.5 cm Real time scan shows fetal cardiac activity of 157 bpm and somatic movements Placenta is in posterior, left, grade II-III maturity, adequate amniotic fluid Estimated fetal weight of 2201 g UTZ EDD = January 19, 2013.

Third Trimester
(+)

Monthly prenatal check-ups Multivitamins and ferrous sulfate continued (-) Maternal illnesses and teratogenic exposure Fetal movements were noted (-) Reports of hypogastric pain and any vaginal bleeding or discharge

Past Medical History

Complete

childhood vaccination (+) mumps, chickenpox and measles during childhood (-) history of drug abuse, violent tendencies, or suicidal attempts (-) drug or food allergies (-) history of blood transfusion Hospitalizations: 2008 and 2010 for childbirth via LTCS and repeat LTCS

Family Medical History

(+)

diabetes (Paternal). (+) hypertension (Paternal) (-) asthma (-) allergies (-) TB (-) CAD (-) malignancies

Personal and Social History

Born and raised in Valenzuela City High school graduate Father jeepney, mother wife Currently a full-time housewife 1.5 pack years Occasional alcoholic beverage drinker Stopped upon knowledge of pregnancy

OB Gyne Gistory

G3P2 (2002) Menarche -12 years old

Subsequent menses

3 days duration 1-2 moderately soaked pads/day (+) dysmenorrhea (-) medications Irregular (every 1-2 months) 3 days duration 1-2 pads/day, moderately-soaked (-) dysmenorrhea

OB Gyne History

Coitarche - 18 and 2 sexual partner Last coitus - March 2012 (+) OCP use after the delivery of first baby injectable contraceptives for 6 months (+ headaches) OCP (-) history of any STI
G1 -2008, term, male, CS for breech presentation, done at FUMC, no complications, 5.8 lbs G2 -2010, term, female, CS for repeat, done at Valenzuela General Hospital, no complications, 5 lbs G3 -Present

Review of Systems

Review of Systems

Review of Systems

Review of Systems

PE: General Survey

Conscious

Coherent
Cooperative Well-developed Ambulatory Afebrile Fairly

nourished Oriented X 4

PE: Vital Signs

Temperature:

36.8 C Pulse Rate: 78 bpm Respiratory Rate: 18 cpm Blood Pressure: 90/60 mmHg Height: 53 Weight: 97 kg

PE: Skin
Brown

Pinkish

nail beds Good capillary refill (-) clubbing of nails noted (-) good skin turgor

PE: HEENT

Hair: black in color, long, abundant, welldistributed, smooth texture; scalp slightly mobile along cranium, no masses or tenderness upon palpation; no lice or lesions were noted. Cranium: normocephalic, symmetrical; temporal arteries visible, with moderate pulsations Face: round, symmetrical; no facies, no melasma; can move facial muscles with ease

PE: HEENT

Eyes

Eyebrows thin, black, well-distributed, symmetrical Eyelashes black, short, oriented upward, outward, no matting No retractions; pink palpebral conjunctivae, no lesions Anicteric sclera; cornea transparent, iris brown in color; pupils symmetrical, 2-3mm diameter, both eyes (+) direct & consensual pupillary reflexes; normal accommodation; lens transparent

PE: HEENT

Ear: normal, triangular in shape, symmetrical, no lesions, deformities or tenderness; both external auditory canals have cerumen, cerumen not impacted Nose: nose symmetrical, bridge flat; no flaring of alae nasi; patent vestibule with short vibrissae; mucosa pinkish in color, no swelling, lesions, secretions or bleeding; nasal septum midline, no perforations

PE: HEENT

Mouth and Throat

Lips symmetrical, pinkish in color, moist, smooth, no lesions Buccal mucosa pink in color, no lesions No tongue deviation on protrusion, frenulum midline Gingiva pink; tonsils normal, not swollen, uvula midline Teeth incomplete, no dentures

Neck:

Skin brown in color, no deformities; trapezius and sternocleidomastoid muscles well-developed, no deviations, no tenderness Trachea midline; thyroid gland not palpable; no difficulty of swallowing was noted; no enlargement of cervical lymph nodes upon palpation

PE: Chest and Lumgs

Skin is smooth, brown in color Symmetrical, no gross deformities No lesions Normal muscle movement; no lagging, widening and retractions of ICS No superficial blood vessels RR18 cpm; no orthopnea or platypnea No tenderness or masses Equal chest expansion, no lagging Equal tactile fremitus (+) Resonance (+) Vesicular breath; no bronchophony, gophony, whispered pectriloquy, or wheezes.

PE: Heart and Blood Vessels

Adynamic (-)

bulging or visible pulsations (-) jugular vein distention Apical beat - 5th ICS, left MCL No tenderness, masses, heaves, thrills and lifts CR 78 bpm, regular, no murmurs, gallops or extra heart sounds Carotid pulse is strong, regular and equal, without bruits Radial, brachial pulses are strong, regular and equal

PE: Abdomen

Globular Skin brown with minimal hair, well distributed Umbilicus everted, no prominent blood vessels Moderate striae (+) Transverse scar at lower abdomen No visible peristalsis Bowel sounds - normoactive

FH: 28 cm FHT: 135 EFW: 2480 grams

PE: Abdomen
Leopolds

Maneuver

L1: fundus occupied by soft, nodular, nonballotable mass, breech L2: fetal back at the right side, fetal small parts at the left side L3: cephalic L4: not engaged

PE: Pelvic Examination

Pelvic

examination

Normal looking external genitalia; no gross lesions; no bleeding

Internal

examination

Vagina admits 2 fingers with ease, cervix closed, uterus enlarged to AOG

PE: Extremities
Grossly

normal No cyanosis No edema Full equal pulses Good capillary bed refill

Initial Diagnosis
G3P2

(2002), PU 31 3/7 weeks AOG Cephalic, not in labor

Plan
For

CBC, Urinalysis, VDRL, HBcAg Pap smear on next visit FeSO4 1 tab OD Multivitamins 1 tab OD Advised to increase oral fluid intake Advised 10 danger signs of pregnancy Follow-up on November 24, 2012 with lab results

Final Diagnosis
G3P3

(3003) PU 39 weeks AOG delivered repeat LTCS to term

Cephalic

Baby Boy

Caesarean Section
Definition: Birth

2 incisions

of a fetus through:

An abdominal incision: laparotomy A uterine incision: hysterotomy

Indications
Primary Dystocia: 37% Non-reassuring FHR: 25% Abnormal presentation: 20% Other: 15% Unsuccessful trial of forceps or vacuum: 3%

Indications
Repeat cesarean: No VBAC attempt: 82%

Maternal request MC indication for a repeat

Failed

VBAC: 17% Unsuccessful trial of forceps or vacuum: 0.4%

Maternal Mortality
Maternal

death: rare, 2.2 in 100 000 cesarean deliveries

9-fold increased risk of maternal death for emergency CD over vaginal 3-fold increased risk of maternal death for elective CD

Maternal Morbidity
Increased 2-fold over vaginal delivery Puerperal infection Hemorrhage Thromboembolism Rehospitalisation Bladder injury: 1.4 per 1000 procedures
Ureteral

injury: 0.3 per 1000

Uterine

rupture in subsequent pregnancy

CD by Choice

Cesarean delivery by maternal request (CDMR) Controversial:

Avoidance of pelvic floor injury during vaginal birth Avoidance of pain during labor & delivery Reduction in fetal injury Convenience Need an informed consent Babies at 37 or 38, the mortality is higher recommended AOG for CS - 39 weeks unless there is evidence of fetal lung maturity With CS , if she only wants to have 1, 2 or 3 children (accreta increases 25%) Should not be motivated by unavailability of pain management for labor

National institute of health, ACOG 2007

Ethics - To refuse?

Techniques

Abdominal incisions: there are two incisions Infraabdominal incisions: there are 2 incisions
Vertical incision Horizontal incision aka as a bikini cut

Vertical

Quickest to create Infant easier to deliver

Pfannensteil incision

Advantage: cosmetic Disadvantages:

Exposure is not at optimal in repeat surgery, re-entry is more difficult and time consuming
Re-entry is difficult b/c of adhesions

Techniques
Uterine incisions: Kerr incision

MC incision with the least blood loss and chances of rupture

Classical

incision

2nd MC type is classical incision. Its a vertical incision. Starts from fundus and up to middle of uterus. If you do a kerr incision first and unable to deliver, then you do a classical incision and it ends up to be a T-incision

T-incision

Kerr incision: Advantages

Easier to repair less likely to rupture does not promote adhesion to bowel or omentum to incisional line
uterine arteries: so make a U and avoid uterine arteries if you are anticipating a large baby: i.e. transverse lie or position of baby is abnormal

Disadvantages

Classical section:
Advantage

malpresentation
transverse

lie

multiple fetuses premature, not in labor

Disadvantage

Uterine rupture

Indications of Classical CS
1. Lower segment cannot be exposed due to the following: a. Bladder densely adherent b. Myoma in lower uterine segment c. Invasive carcinoma of the cervix. Transverse lie of a large fetus, especially if the shoulder is impacted in birth canal and back down Placenta previa with anterior implantation Very small fetus, breech presentation and lower segment has not thinned out Massive maternal obesity precluding safe access to lower uterine segment Multifetal pregnancy

2. 3. 4. 5. 6.

Techniques
1. 2. 3. 4. 5. 6. Uterine incision BOW rupture Head is scooped with one hand Head is delivered followed by the rest of the fetal body Cord is doubly clamped and cut in between The placenta is manually extracted and delivered. The uterus is inspected for retained placental fragments. The uterus is repaired in three layers The ovaries and fallopian tubes are inspected The abdomen is closed in layers

7. 8. 9.