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Gibaltar, Claire Hautea, Terese Valencia, Sheryl Gabriel, Katrina July 28, 2009.

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Presentation on theme: "Gibaltar, Claire Hautea, Terese Valencia, Sheryl Gabriel, Katrina July 28, 2009."— Presentation transcript:

1 Gibaltar, Claire Hautea, Terese Valencia, Sheryl Gabriel, Katrina July 28, 2009

2 30 y/o Married Roman Catholic G1P0 Chief Complaint: Labor pains

3 (+) PTB in 2003  underwent 6 months of antiKoch’s Tx (+) Endometriosis dx in 2003  Given DMPA injections and OCPs (+) Bronchial asthma, non in acute exacerbation (+) Skin allergy to chicken (-) Hypertension (-) Diabetes mellitus (-) Thyroid problem (-) Cancer (-) Cardiac disease (-) Kidney disease (-) PTB

4 Non-smoker Non-Alcoholic beverage drinker Previously employed as an audit staff

5 (+) Hypertension – mother (+) Bronchial asthma – sibling (+) PTB - mother (-) DM (-) Thyroid Problem (-) CA (-) Kidney Disease

6 Menarche: 12 years old Interval: monthly, regular Duration: 5 days Amount: 2-3 pads per day Pain: (+) dysmenorrhea LMP: November 11, 2009

7 G1P0 Prenatal history:  1 st PNCU (20 4/7 wks)  BTRh: B+; HsbAg – NR; CBC – normal  MVT + Folic acid  (+) UTI (32wks) – Tx: Cefalexin 500mg x 7days  Repeat UA – normal  USG: breech at 28 4/7 weeks  USG: breech at 34 weeks

8 Coitarche: 29 yo 1 sexual partner (-) PCB, dyspareunia Last Papsmear: May 2009 – E/N findings (+) whitish, mucoid vaginal discharge (-) Vaginal bleeding

9 PNCU at SLMC-OPD (+) irregular uterine contractions (+) good fetal movements (-) passage of watery or bloody vaginal discharge (-) change in urinary or bowel habits IE: beginning labor Interim Admission

10 Consult at SLMC-OPD  mass = 8cm  Advised surgery No complaints of vaginal bleeding, changes in urinary or bowel habits Admission May 2009

11 (-) weakness, fatigue, weight loss (-) visual dysfunction, deafness, nasal discharge, throat soreness (-) dysphagia, anterior neck mass, neck stiffness (-) breast tenderness (-) dyspnea, cough, sputum production (-) chest pain, chest discomfort, palpitation (-) nausea, vomiting, hematemesis, hematochezia

12 (-) urinary odor, color, dysuria (-) back pain (-) heat-cold intolerance, thyroid problems (-) pallor, easy bruisability (-) dizziness, headache (-) anxiety, depression, interpersonal relationship difficulies

13 General Survey: Conscious, coherent, no CPD Vital Signs: BP:120/80 HR: 90PR: 90 RR: 18Temp:36.8 Wgt: 60kg Hgt: 152 cm Skin: No lesions Eyes: Pink palpebral conjunctivae, anicteric sclerae, clear cornea, intact EOMs

14 Neck: supple, (-) mass, (-) CLADs Throat: (-) TPC Thorax: SCE, CBS, (-) rib retractions Lungs: Normal breath sounds Heart: AP, NRRR, Precordium at 5 th ICS midclavicular, S1>S2 at apex, S2>S1 at base Pulses: Full and equal

15 Abdomen: Globular, non-tender, symmetrical FH = 35 cm; FHT = 140s/min Leopold’s manuever: L1: (+) ballotable mass L2: fetal back at the maternal right L3: breech L4: unengaged Internal Examination: 1-2 cm/50% effaced/station -3/(+) BOW

16 Subjective: 30 year old G1P0 LMP: November 11, 2008 Pelvic USG: breech at 34 weeks (+) irregular hypogastric pains (+) good fetal movements (-) passage of bloody or watery vaginal discharge (-) urinary symptoms or changes in bowel movements

17 Objective Abdomen: Globular, non-tender, symmetrical FH = 35 cm; FHT = 140s/min Leopold’s manuever: L1: (+) ballotable mass L2: fetal back at the maternal right L3: breech L4: unengaged Internal Examination: 1-2 cm/50% effaced/station -3/(+) BOW

18 PU 37 5/6 weeks AOG, breech in beginning labor 30 yo, G1P0 PLAN: Primary CS

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20 - Buttocks towards the pelvis - Bitrochanteric diameter presents - Varying relations between lower extremities & buttocks determine: 1) FRANK BREECH - lower extremities flexed at the hips; extended at the knees  feet lie close to head; most common at term

21 2) COMPLETE BREECH -Lower extremities flexed at the hips; one or both knees are flexed 3) INCOMPLETE BREECH - One or both hips are not flexed and one or both feet or knees lie below the breech

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23  CAESAREAN DELIVERY: 1. a large fetus 2. any degree of contraction or unfavorable shape of the pelvis 3. a hyperextended head 4. no labor, with maternal/fetal indication for delivery (e.g. PIH, ruptured membranes for 12 hrs or more)

24 5. Uterine dysfunction 6. Footling presentation 7. An apparently healthy but preterm fetus of 26 weeks or more; mother in active labor or in need of delivery 8. Severe IUGR 9. Previous perinatal death or children suffering from birth trauma 10. Request for sterilization

25 VAGINAL DELIVERY - for a frank breech presentation with: 1. Adequate pelvis on X-ray 2. EFW < 3600 gms. 3. Normal labor course w/ good dilatation & effacement 4. Competent & available OB, Anesth, Pedia

26 1. Spontaneous breech delivery – infant expelled entirely spontaneously w/o any traction or manipulation other than support of the infant; rare in mature infants 2. Partial breech extraction – infant delivered spontaneously up to umbilicus, but remainder of body extracted

27 3. Total breech extraction - entire body of the infant is extracted by the obstetrician

28  Initial assessment/management - Cervical dilatation & effacement - Fetal condition (anencephaly, hydrocephaly) - Intravenous infusions - Fetal monitoring esp. after ROM CHECK FOR PROLAPSED CORD!

29 - Competent team: skillful obstetrician assistant anesthesiologist pediatrician

30  Remember! - liberal episiotomy, preferably MLE - use towel for firmer grasp (vernix caseosa) - apply gentle, steady, downward traction until lower halves of scapulas are outside vulva

31 - nuchal - nuchal arm better diagnosed by X-ray a. Mauriceau Maneuver = index & middle finger of one hand over maxilla to flex head, while fetal body rests upon palm and forearm of obstetrician

32 b. Prague maneuver – Kiwisch of Prague (1846) ; two fingers grasp shoulders of back- down fetus while other hand draws feet up over abdomen of mother

33 c. Bracht c. Bracht Maneuver - breech - breech delivers up to umbilicus; fetal body held against maternal symphysis (gravity); uterine contractions + supra-pubic pressure  spontaneous delivery

34 d. Forceps (Piper) - should be applied only when the head is well within pelvic cavity - wrap body in towel to keep arms out of the way

35 e. Entrapped head - Duhrssen incisions at 2, 6, 10 o’clock; cervix should be fully effaced and at least 7 cms dilated

36 f. Abdominal Rescue - for entrapped head  emergency Caesarean Section - DON’T PANIC!!

37 - delivered by moderate traction exerted by a finger in each groin - breech decomposition (convert frank to footling breech); Pinard maneuver pushes fetal knee from the midline  spontaneous flexion

38 MATERNAL 1. Infection 2. Uterine rupture 3. Cervical lacerations 4. Uterine atony But prognosis for mother better in vaginal breech delivery than Caesarean Section.

39 FETAL – poorer prognosis if vaginal - more complications the higher the presenting part at beginning of extraction 1. Tentorial tears, intracerebral bleed 2. Cord prolapse 3. Fracture of clavicle, humerus 4. Paralysis of arm 5. Broken neck 6. Testicular injury

40 - An operation in which the presentation of the fetus is altered artificially a. Substitute one pole of a longitudinal presentation for the other b. Converting an oblique or transverse lie into a longitudinal lie (cephalic or podalic)

41 External Version– abdominal External Version– manipulations done through abdominal wall Internal Version Internal Version– hand introduced into uterine cavity

42 - Usually with tocolysis - Hook to fetal monitor - Each hand grasps a fetal pole  the preferred presenting part is gently stroked to the pelvic inlet - Have OR ready

43 - Feet grasped and drawn through cervix while body is pushed abdominally in opposite direction - For delivery of second of twin

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