4History of Present Illness: 8 hours PTAclear watery vaginal dischargeassociated with abdominal pain-contractingevery 5-10 minuteswith a pain scale 5/10radiating to the pelvis and backNo associated symptoms such as vomiting, fever and blurring of vision were noted.
5History of Present Illness: 3 hours PTAbloody vaginal dischargeabdominal pain- pain scale of 8/10- occurring more frequently- radiating to the back and pelvis.No other associated symptoms were noted.
6History of Present Illness: Due to the persistence of the abdominal pain and vaginal discharge and the suspicion of labor, the patient was rushed to the QMMC OB Emergency room.
7Review of Systems: (-) rashes (-) dyspnea (-) change in urine color (-) weight loss (-) cough (-) change in stool color(-) jaundice (-) diarrhea (-) oliguria(-) dyspahagia (-)constipation (-) dysuria
8LMP: August 5, 2010 EDC: May 12, 2011 AOG: 39 weeks by LMP OB history:LMP: August 5, 2010EDC: May 12, 2011AOG: 39 weeks by LMP
9Complications/outcome OB history:G5P4 (4004)GravidityYearMode of deliveryBirth weightComplications/outcome12003NSD*largest baby is 3.o kgNONE220063200742009
10OB history:Prenatal check-up: Culiat Quezon City health Center for four timesPrenatal medications:Multivitamins – OD starting at the 1st trimester until 3rd trimesterFerrous sulfate – OD starting at 2nd trimester until 3rd trimesterPrenatal disease/ infections: unremarkable
11Past Medical History:UnremarkableFamily History:Unremarkable
12Menstrual History: Menarch at the age of 11 Duration of 3 to 5 days, regularModerate flow, making used of 2-3 napkins a dayAssociated with abdominal and pelvic pain.
13Sexual History: first coitus - age of 17 with one partner having 3-4 sexual intercourse a week.
14Contraceptive History: denies any history of contraceptive use.Personal and Social History:non-smokeroccasional alcoholic drinker of 1 t0 2 times a month of 2 -3 bottles of beerdenies any history of illicit drug use.
15Physical examinations: General survey: well nourished looking, in pain, conscious, coherent, not in cardio respiratory distress.Vital Signs:BP: 110/ HR: 80 bpmRR: 16 breaths/min Temp: afebrile (36. 3 °C)
16Physical examinations: HEENTHead: scalp without lesionsEyes: anicteric sclera, pale conjunctiva, pupils equally reactive to light, extraocular movements intactEars: no lesions, acuity good to whispered voiceNose: musoca is pink, midline septum, no mucosal dischargeMouth: moist pink oral mucosa, tongue midline, no exudates and inflammation, with poor dentitionNeck: trachea midline, no lymphadenopathyThyroid: palpable, not enlarged
17Physical examinations: THORAX AND LUNGS:no scars, no lesion, no tenderness, with equal tactile fremiti, equal chest expansion, clear breath sounds, resonant on all lung fieldsCARDIOVASCULAR:apical impulse is discreet and tapping on 5th ICS left midclavicular line, good S1 S2, no murmurs
18ABDOMEN: Physical examinations: L1: hard,round, readily ballotable head L2: R – fetal parts, L – fetal backL3: buttocks / breech L4: not engagedFundic height: 30 cmFetal heart tone: 140’s/min
19Physical examinations: INTERNAL EXAMINATION: Cervical dilatation: 8 cmPresentation: frank breechStation: -2Effacement: 50%Bag of water: (-)
20Physical examinations: EXTREMITIES:no scars, no lesion, CRT of less than 2 seconds, full pulses on all extremities, grade 2 edema on both lower extremities
21diagnosis: PRINCIPAL DIAGNOSIS: ADMITTING DIAGNOSIS:G5P4 (4004) Pregnancy uterine 39 weeks AOG by LMP frank breechPRINCIPAL DIAGNOSIS:G5P5 (5005) Pregnancy uterine full term frank breech delivered via partial breech extraction to a live baby boy.
22Course in the ward: Day (date and time) Doctors orders medicines LaboratoriesProcedures5/5/11Day 112:00 PM2 pmAdmitted to LR, NPO, IVF (D5LR 1L x 8º),Blood request, Monitor progress of labor, Inform pedia, referOxygen inhalation 2-3 lmp via nasal cannula, hook to pulse oximetry, monitor VS q15 x 2 hrs then q30 until stable, dat once fully awake, IVF D5LR 500cc + 10 units/minMonitor vital and record, refer accordinglyTransfer to wardContinue medicationsSuggest BTLVS q4DATRefer accordingly-Cefalexin 500mg/cap, 1 cap TID for 7 daysMefenamic acid 500mg/ cap, 1 cap q6 on full stomachAscorbic acid 500 mg 1 tab, 1 tab ODFeSO4 1 tab ODCBC and BTBaseline EFMAnesthesia via pudendal block, s/p NSD via PBE
23Course in the ward: Day (date and time) Doctors orders medicines LaboratoriesProcedures5/6/11Day 2(-) pallor(-) dizziness(+) porfuse vaginal bleeding(-) DOB(-) BOVIE ok5/7/11Day 3CBC5/8/11Day 4DATFor BTL, secure consentContinue medsDaily perineal hygieneEncourage brestfeedingMonitor VS q4referShift cefalexin to ampisolbactamTPAG, CBC1st degree dehiscence5/10/11Day 6High protein diet, 2 egg white/mealContinue oral medsDaily perineal hygiene and full body bathEncourage breastfeedingVSq6TP- 55Albumin 24GCAB – 31.8A/G- 0.8(-) profuse vaginal bledding (IE)No subjective complains(+) necrotic debris at dehisce site
24Course in the ward: Day (date and time) Doctors orders medicines LaboratoriesProcedures5/11/11Day 7Refused BTLContinue medsInc. OFIDaily perineal hygiene and full body bathEncourage breastfeedingVSq4refer1 cm dehisce(-) necrotic tissue(-) discharge(-) pallor5/12/11Day 8Patient advised but refused BTLMay go homeContinue oral medsDaily perineal hygiene gynepro TIDfull body bathAdvised family planningOPD follow-up on 5/19advised
25Laboratory results Ultrasound (4/26/11) Uterus is regularly enlarged containing a single live male fetus breech presentation. FHT is 138 bpm. Absence of gross fetal abnormality. Amniotic fluid is normal/ placenta is posterior, high lying grade weeks and 1 day AOG. Estimated weight: 2543 g.
29discussions I. Definition: Breech presentation – is when the buttocks of the fetus enter the pelvis first. Most often, however, the fetus turns spontaneously before the onset of labor so that breech presentation persist only about 3-4% of singleton deliveries.
30discussions II. Types of Breech presentation FRANK COMPLETE INCOMPLETE/FOOTLING
31DISCUSSIONS III. Etiology/ Risk factors 1. gestational age 2. uterine relaxation associated with great parity3. multiple fetuses4. hydramnios5. oligohydramnios6. hydrocephalus7. anencephalus8. previous breech delivery9. uterine anomaly10. pelvic tumors
32DISCUSSIONS IV. Complications of breech presentation 1. Perinatal morbidity and mortality2. low birth weight from preterm delivery, growth restriction or both3. prolapsed cord4. placenta previa5. fetal, neonatal and fetal anomalies6. uterine anomalies and tumors7. multiple fetuses8 operative intervention (cesarian delivery)
34DISCUSSIONS VI. Management of Labor 1. Stage of Labor 2. Fetal condition3. Fetal monitoring4. Recruitment of nursing and medical personality
35DISCUSSIONS VII. Delivery The choice of abdominal or vaginal delivery is based upon the following:1. type of breech2. flexion of the head3. fetal size4. quality of uterine contraction5. size of maternal pelvis
36DISCUSSIONS Recommendations for cesarian/abdominal delivery: 1. large fetus2. any degree of contraction or unfavorable shape of the pelvis (platypelloid and android)3. A hyperextended head (stargazer fetus/ the flying fetus – increased risk for injury of the spinal cord)4. no labor with maternal indication (preeclampsia, ruptured membranes for 12 hours or more)5. uterine dysfunction6. footling presentation7. preterm fetus of 25 to 26 weeks AOG or more, with the mother in active labor or in need of delivery8. severe fetal growth restriction9. previous perinatal death or children suffering form birth trauma10. request for sterilization
37DISCUSSIONS Vaginal Delivery Timing of delivery – the ability to proceed with immediate breech extraction should exist when the buttocks or feet appear at the vulva.- women with selected frank breech presentation estimated to be about 2000g or more but less than about 3500g are frequently offered planned vaginal delivery.
38DISCUSSIONS Methods of vaginal delivery 1. Spontaneous breech delivery 2. Partial breech extraction3. Total breech extraction.
39DISCUSSIONS VII. Maneuvers for vaginal deliveries Mauriceau maneuver Prague maneuver
40DISCUSSIONS Bracht maneuver VII. Maneuvers for vaginal deliveries USE OF FORCEPS
41DISCUSSIONS VIII. Special topics A. Head entrapment – occasionally, especially with preterm infants. Gentle traction of the fetal body, the cervix at times, maybe manually slipped over the occiput, or do bracht maneuver, if not successful do dürhrssen incision in the cervix, if still unsuccessful do abdominal rescue which the replacement for the fetus higher into the vagina followed by cesarian delivery.
42DISCUSSIONSB. Version – is the procedure in which the presentation of the fetus is altered artificially.1. external version – performed exclusively on through the abdominal wall2. internal version – entire hand is introduced into the uterine cavity.
43DISCUSSIONSEXTERNAL VERSION/EXTERNAL CEPHALIC VERSION
44DISCUSSIONS Indications for external cephalic version: 1. breech presentation is diagnosed in the last week of pregnancy2. provided there is no marked feto-pelvis disproportion3. provided there is no placenta previaContraindication: women with previous cesarian delivery.
45DISCUSSIONS Factors for successful version: 1. normal amniotic fluid 2. gestational age ( the earlier the better)3. presenting part has not descended into the pelvis4. fetal back is positioned posteriorly5. woman is not obese
46DISCUSSIONS Technique: Should be carried out in area that has already access to facility equipped for emergency cesarian delivery.Complications :1. placental abruption fetomaternal hemorrhage2. uterine rupture preterm labor3. amniotic fluid embolism fetal distress7. fetal demise