Case Presentation

By Muhammad Firdaus
 On Admission
4/5/15 1 pm

28 yo, G1 P0 @ date + 9d
LMP : 18/7/14 sod regular menses
not on OCP
EDD : 25/4/15 given by scan @13
weeks subsequent scan follow EDD
 Antenatally
1. H/O admission @ 21 weeks for UTI
- treated with tab Cefuroxime 250mg
for 1 week

2. Maternal obesity
- BMI : 32

MOGTT x1
30 w : 4.5 / 3.7
 TAS
FH+
BPD 9.38 36+3
HC 33.27 36+4
AC 33.38 37+3
FL 7.14 37+3
EFW 3276
AFI 5.67cm
 Presented with
Ieaking of liquor @ 8 am today
- multiple episode
- dribbling, no gushing,
- soaked @ dependent area
- no foul smelly
Show (-)
Irregular contraction pain
- Not increase in frequency and intensity
FM good
No fever
No UTI / UTRI Sx
 o/e
Alert, conscious, pink
Bp: 119/72
Pr: 100
T: 37 C
 P/A
Soft, non tender
UT @ TS
Single-turn , cephalic
HPA: 3/5
EFW : 3.0 - 3.2 kg
Contraction: 1 : 10 : 20 sec
 Speculum
No pooling of liquor
Cough reflex (+)
No foul smelly
 V/E
V/v: NAD
Cx : 1.5 cm
Os: 1 cm
MI
No cord, no placenta
CTG on admission
 Impression
28 yo, G1 P0 @ date + 9d POA

1. PROM < 18 H
 Patient was admitted to ward
NRVE if contraction persisten 2:10
For BS and IOL next morning if not
delivery
 2nd day admission
28 yo G1 P0 @ date + 10 H

Pb :
1. PRON > 18Hy
2.Date + 10 d
 No show
No leaking
Good FM
irregular contraction

1st prostin 3mg was inserted @

posterior fornix
Dilation of OS : 1cm
Length of cervix : 1-2 cm
Contraction : 1:10:15 sec
IV ampicillin 1 gram 4 hourly
 At 1.00 pm 5/5/15 (NRVE post prostin
x1)

Pb : 1. PROM >18H
2. Date + 10d

Increase contraction pain a/w show

No leaking
Good FM
No fever
 VE Finding
V/V : NAD
Cervix : 1 cm
Os : 2 cm
MI
Station : -2

NRVE was planned at 5 PM

CTG Post Prostin
 At 5.00 pm 5/5/15 (NRVE)

Pb : 1. PROM > 18 H
2. Date + 10d

Increase contraction pain a/w show

No leaking
Good FM
No fever
 VE Finding
V/V : NAD
Cervix : 1 cm
Os : 3 cm
No Cord, no placenta

Patient was trasfer out to Labour

Room for ARM
 5/5/15
5.45 pm
Was attended by MO
Vital sign stable
FM good
Contraction 2 : 10 : 20 sec
VE
v/v NAD
Cx : effaced
OS : 3 cm
St : -2
MI ARM done, thin MSL
 Plan
CTG post ARM
Time contraction
Plot partograf
NRVE 4 hour @ 10 pm
Cont FHR monitor with intermitant CTG
trace
IVD 100cc / 1H
Cont Ampicillin
IM nubain 10 mg 6 Hourly
CTG post ARM
 5/5/15
10 pm
Was attended by MO
Vital sign stable
FM good
Contraction 4 : 10 : 45 sec
CTG Tracing
Baseline : 113
Variability : 5 - 15
Accelaration : present, not
obvious
Decelaration : Nil
Impression : Suspicous CTG
VE
v/v NAD
Cx : effaced
OS : 9 cm
Caput 2 x 2 cm
 Plan
NRVE 1 H at 11 pm
Time contraction
Cont IV pitosin
Cont FHR monitor with intermitant
CTG trace
Cont Ampicillin
IM nubain 10 mg 6 Hourly
 5/5/15
11 pm
Was attended by MO
Vital sign stable
FM good
Contraction 4 : 10 : 45 sec

Pb : 1. 6 H of labour with thin MSL

- 4H latent phase
- 1H active phase
- 6H on IV pitocin, current unit 24mu/min
 2. PROM > 24H
on IV Ampicillin 4 hourly

3. Date + 10d
 o/e : alert, concious, pink
Bp : 137/76
PR : 100
T : 37
VE
v/v NAD
Cx : effaced
OS : fully at 11.15 pm -> encouraged pt to
bear down. Baby slowly decend with every
pushing.
liquor not seen
St : 0, OT Position
Caput 2 x 2 cm
No Cord, No placenta
 5/5/15
11.40 pm
Was attended by MO
Pt already 25 minutes of 2nd stage
Vital sign stable
FHR monitor every 5 minutes (90-
145 bpm)
VE
v/v NAD
Cx : Not felt
OS : fully
St : 0
Caput 3 x 4 cm, moulding grade 1
Liquor not seen
 After 45 minutes of 2nd stage, pt and
husband has been counselled
regarding need of EMLSCS.
Risk explained such infection,
bleeding , internal organ injury
Both understood.
How ever, not keen for EMLSCS.
 After 10 minutes, baby still not deliver.
Recounsule back regarding EMLSCS,
risk of MAS, and intubation explained.
Both understood. However not keen
for EMLSCS
Peads team was informed and on
standby.
 After 1 Hour of bearing down, baby
delivered and was attended by pead's
team.
Plan :
Keep pt in L/R
May T/O to PNW after PNR
Iv Pitosin 40u in 1 pint NS / Hours
Stict pad chart
V/S monitor
 Post natal review
6/5/15 (3 am)
28 yo, para 1
6H post SVD with episiotomy repaired
Delivered baby girl, BW 3.3 Kg , AS 5' intubated
Admitted ward 2
EBL 200 cc

Pb : 1. PROM > 24H

- On IV Ampicillin 2 gr Stat, 1 gr 4 Hourly
Patient comfortable ,assymptomatic of anemia, no fever
, no sob, no chestpain, tolerating orally
 OE: Alert, conscious, mild pallor
Bp : 121/81
Pr: 82
T; 37

PA
Soft non tender
UT well contracted at 20 wks

Perineal inspection
No active bleeding
Plan:
T/O to PNW
Strict Pad Chart, to inform if increase
PV bleeding
Cont Iv pitosin
encourage ambulating, orally
V/S monitor
 Baby update
BO Siti Munirah, D6 of life, girl, Bw : 3.3
Clinical Stable
already extubate
off ionotropes
still on IV C-Pen and Gentamisin

Baby now admit under room air.