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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
OBSTETRICAL HISTORY
G1P0
PREGNANCY
ORDER
PREGNANCY
OUTCOME
G1
PRESENT
PREGNANCY
YEAR
GESTATION SEX
BIRTH
COMPLETED
WEIGHT
PRESENT
STATUS
OBSTETRICAL HISTORY
LMP
: Oct 2,2015
AOG
: 40 1/7 weeks
GYNECOLOGY HISTORY
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, (-)
Weakness
Skin: (-) Rashes, (-) Itchiness
Head: (-) headache
Eye: (-) blurring of vision,
itching, redness or pain
Ear: (-) deafness, pain or
discharge
REVIEW OF
SYSTEM
Nose: (-) epistaxis, obstruction,
discharges
Mouth: (-) bleeding gums, (-)
Dental carries, (-) Sores
Throat: midline trachea
Neck: (-) stiffness or limitation in
motions
Pulmonary System: (-) cough,
(-) dyspnea, (-) asthma
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
Leopolds 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
normal
Internal 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
18 y.o
G1P0
40 1/7 wks AOG
LMP: Dec 26, 2014
Family history of DM
BMI = 34 (obese)
Physical Exam
Multifetal Pregnancy
RULE IN
Large fundic height (37cm)
RULE OUT
One fetus palpated on leopolds
One heart beat auscultated
(-) Family history of multifetal
pregnancy
Polyhydramnios
RULE IN
Large fundic height (37cm)
RULE OUT
Normal AFI = 12.4 cm
RULE OUT
(-) 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
Laboratory
1st Hospital Day
CBC
WBC Count
H 21.23
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
Monocytes
L 7.0
4
5-10
20-35
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
Laboratory
st
1 Hospital Day
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
Laboratory
1st Hospital Day
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
BP/FHT
UC
5:07 PM
BP: 120/80
FH: 37 cm
EFW: 4060 g
FHT 135 bpm
Moderate to
strong irregular
contraction
IE
REMARKS
5 cm
60% effaced
Cephalic
IBOW
station -3
Vaginal
delivery
IPM
CS if with
fetomaternal
indication
FHT/UC
monitoring
Moderate to
strong irregular
contraction
7 cm
60% effaced
Cephalic
IBOW
station -3
FHT/UC
monitoring
12.15 AM
BP: 115/80
FHT: 140 bpm
Moderate to
strong irregular
contraction
7 cm
60% effaced
Cephalic
IBOW
station -3
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
Objective
Assessment
Plan
(-)
abdominal
pain
(+) minimal
vaginal
bleeding
(-) nausea or
vomiting
(-) fever
(-) bowel
movement
(-) Flatus
Lying
comfortable
supine
No other
complaints
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/hr
Meds given
Vital signs
monitored
nd
Post Op Day
Objective
Assessment
Plan
(+) minimal
vaginal
bleeding
(-) nausea or
vomiting
(-) fever
(+) bowel
movement
(+) Flatus
Voiding
freely
Lying
comfortable
supine
No other
complaints
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
Dressing
changed
Meds given
Vital signs
monitored
rd
Post Op Day
Objective
Assessment
Plan
Lying
comfortable
supine
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
Meds given
No
subjective
complaints
Vital signs
monitored
MGH
4 Factors
Abnormalities of the
Passage
Pelvic Brim
Diagonal Conjugate
Obstetrical Conjugate
Sacrum
Side walls
Ischial Spines
Interspinous diameter
Sacrosciatic notch
INLET
THE CAVITY
Subpubic Angle
Bituberous diameter
Anteroposterior
Diameter
OUTLET
STAGES OF LABOR
FIRST STAGE
THIRD STAGE
SECOND STAGE
Latent phase
Active phase
Acceleration Phase
Decceleration Phase
Preparatory division
Dilatation
division
Pelvic
division
Mean
time
Longest
Mean
rate
Slowest
Nulliparo
us
6.4 h
20.1 h
3 cm/h
1.2cm/h
1.1 h
Multiparo
us
4.8 h
13.6 h
5.7cm/h
1.5cm/h
0.4 h
ABNORMAL LABOR
ABNORMAL LABOR
NULLIPARA
Protraction
MULTIPARA
<1.2 cm/hr
(dilation)
<1.5 cm/hr
(dilation)
< 1cm/hr
(descent)
< 2cm/hr
(descent)
Arrest
Arrest Of
Dilation
Arrest in
Descent
Prolonge
d Latent
Phase
Diagnostic
Criteria
Nullipar
a
Multipar
a
> 20
hours
>14
hours
Preferred
Treatmen
t
Exceptiona
l
Treatment
Bed rest
Oxytocin or
Cesarean
Delivery for
urgent
problems
Diagnostic
Criteria
Nullipar
a
Multipar
a
Protracted
Active
Phase
dilation
<1.2
cm/hr
<1.5
cm/hr
Protracted
Descent
<1
cm/hr
<2
cm/hr
Preferred
Treatment
Exceptional
Treatment
Expectant
and Support
Cesarean for
CPD
Arrest
Disorders
Prolonged
Deceleration
Phase
Secondary
arrest of
Dilation
Arrest of
Descent
Failure of
Diagnostic
Criteria
Nullipar
a
Multipar
a
> 3 hrs
> 1 hr
> 1 hr
> 1 hr
No descent in
Preferred
Treatment
Exceptional
Treatment
Evaluate for
CPD:
CPD: cesarean
No CPD:
oxytocin
Rest if
exhausted
Cesarean
Delivery
ARREST IN DILATATION
SECONDARY TO
CEPHALOPELVIC
DISPROPORTION
Secondary Arrest in
Dilation
The fetal head engages in the
occipitotransverse position and,
if it is well flexed and asynclitic,
will undergo rotation in the midcavity to the direct
occipitoanterior position.
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
Pinards Method
Muller-Kerrs Method
MANAGEMENT OF CPD
Mild disproportion: vaginal
delivery
Moderate: trial labor, if
failed then cesarean section
Marked: Cesarean Section
Suitable Cases
Young primigravida of
good health
Moderate disproprtion
Vertex Presentation
No outlet contractions
Average sized baby
Management
Arrest
Disorders
Diagnostic
Criteria
Nullip
ara
Multip
ara
Prolonged
Deceleratio
n Phase
>3
hrs
> 1 hr
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
Preferred
Treatment
Exceptional
Treatment
Evaluate for
CPD:
CPD:
cesarean
No CPD:
oxytocin
Rest if
exhausted
Cesarean
Delivery
Short stature as an
independent risk factor for
cephalopelvic disproportion
in a country of relatively
small-sized mothers
Maternal-Fetal Medicine
Archives of Gynecology and Obstetrics
June 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 34weeks. 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 145cm, short
stature was significantly associated with
higher rate of CPD with odds ratio of 2.4
(95% CI 1.83.0). The
odds=exp(4.0480.042Ht). 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 145cm 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..!