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Admitting Conference Gibaltar, Claire Hautea, Terese Valencia, Sheryl

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Presentation on theme: "Admitting Conference Gibaltar, Claire Hautea, Terese Valencia, Sheryl"— Presentation transcript:

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

2 M.E.B 30 y/o Married Roman Catholic G1P0 Chief Complaint: Labor pains

3 Past Medical History (+) PTB in 2003 (+) Endometriosis dx 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 Personal and Social Non-smoker Non-Alcoholic beverage drinker Previously employed as an audit staff

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

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

7 Obstetrical History G1P0 Prenatal history: 1st 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 Gynecologic History Coitarche: 29 yo 1 sexual partner (-) PCB, dyspareunia Last Papsmear: May 2009 – E/N findings (+) whitish, mucoid vaginal discharge (-) Vaginal bleeding

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

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

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

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

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

15 Physical Examination 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 Salient Features 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 Salient Features 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
Diagnosis: PU 37 5/6 weeks AOG, breech in beginning labor 30 yo, G1P0 PLAN: Primary CS

19 BREECH DELIVERY

20 Varieties of breech presentation
- 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 INCOMPLETE BREECH - One or both hips are not flexed and one or both feet or knees lie below the breech

22

23 RECOMMENDATIONS FOR DELIVERY
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 Uterine dysfunction Footling presentation An apparently healthy but preterm fetus of 26 weeks or more; mother in active labor or in need of delivery Severe IUGR Previous perinatal death or children suffering from birth trauma Request for sterilization

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

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

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

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

29 Vaginal Breech Delivery
Competent team: skillful obstetrician assistant anesthesiologist pediatrician

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

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

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

37 Extraction of Frank Breech
- 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 COMPLICATIONS OF BREECH DELIVERY
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 Tentorial tears, intracerebral bleed Cord prolapse Fracture of clavicle, humerus Paralysis of arm Broken neck Testicular injury

40 VERSION 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– manipulations done through abdominal wall
Internal Version– hand introduced into uterine cavity

42 External Cephalic Version
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 Internal Podalic Version
Feet grasped and drawn through cervix while body is pushed abdominally in opposite direction For delivery of second of twin

44 THANK YOU!! 


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