May 31, 2011 Umali, Ronalyn Lyra I. San Beda College

1. OB Case Conference May 31, 2011Umali, RonalynLyra I.San Beda College

2. General Data: • M.T.E. • 25 y/o • Single • Catholic • Marikina City • admitted for the first time in QMMC on May 15, 2011

3. Chief Complaint: • Labor pains

4. History of Present Illness • Few hours PTA • (+) labor pains • described as irregular contractions, occurring every 10-15 minutes, with a pain scale of 6/10, radiating to the pelvis and back. • No associated symptoms such as vomiting, fever and blurring of vision were noted. Persistence of symptoms prompted consult at QMMC OB-ER hence admitted

5. Review of Systems • General: (-) weight loss (-) easy fatigability • CNS: (-) loss of consciousness, headache • HEENT: (-) blurring of vision, eye pain, tinnitus, ear pain, epistaxis, sorethroat • RESP: (-) difficulty of breathing, (-) cough, (-) colds • CVS: (-) chest pain, (-) palpitations • GIT: (-) vomiting, (-) constipation • GUT: (-) dysuria, (-) hematuria, (-) oliguria • M/S: (-) limitation of movement, (-) joint pain

6. History of Present Pregnancy • LMP: August 05, 2010 • AOG: 39 weeks 2 days by LMP • PNCU x 4 : St. Vincent Hospital • PNCU x 3: QMMC

7. History of Present Pregnancy: • Prenatal medications: • Multivitamins – OD starting at the 1st trimester until 3rd trimester • Ferrous sulfate – OD starting at 2nd trimester until 3rd trimester

8. Menstrual History: • Menarche at the age of 12 • 28-30 days interval • Duration of 5-6 days • Able to use 2-3 pads per day, moderately soaked • Associated with dysmenorrheal symptoms

9. Sexual History: • First coitus at the age of 18 • With one partner • No history of sexually transmitted diseases

10. Contraceptive History: • Denies used of birth control methods (artificial or natural)

11. Past Medical History: • (-) Hypertension • (-) Diabetes mellitus • (-) Cardiac Diseases • (-) Pulmonary Diseases • (-) Kidney and Liver Diseases • (-) Allergies • (-) Surgeries

12. Family History : • (+) Hypertension- Mother • (+) Colon Cancer – Father (died of Myocardial Infarction) • (-) DM • (-) Pulmonary tuberculosis • (-) Goiter

13. Social and Personal History: • Housewife • Living in for 2 years to a 24 year old man • Non- smoker, non-alcoholic drinker • Denies any history of illicit drug use

14. Physical Examination General Survey: -patient is awake, alert, cooperative and not in cardiorespiratory distress Vital Signs: BP- 110/60 HR- 92 bpm RR – 18 cpm T emp.- 37.4 C HEENT anicteric sclera, pink palpebral conjunctiva

15. Physical Examination • Thorax and Lungs • Symmetrical chest expansion • (-) Retractions • Clear Breath Sounds • Cardiovascular • Adynamic precordium • Normal rate regular rhthym • No murmurs

16. Physical Examination • Abdomen • Globular • FH: 32 cms • FHT: 140 • Pelvic Examination • IE: cervix- 2 cms dilated, 50% effaced, Cephalic in presentation, Station (-) 3, (+) BOW, floating

17. Admitting Diagnosis: G1P0 (0000) Pregnancy uterine 39 weeks 2 days AOG by LMP, CIL

18. Principal Diagnosis: G1P1 (1001) PUFT Cephalic Arrest in Cervical Dilatation 20 to CPD, delivered via LTCS I to a live Boy AS 9.

19. Course in the Wards • Partograph

22. Discussion • Dystocia • Difficult labor • Characterized by abnormally slow progress of labor • Most common indication for primary CS

23. 4 Major Abnormalities • 1. Abnormalities of the expulsive forces • 2. Abnormalities of the maternal bony pelvis • 3. Abnormalities of the presentation, position or development of the fetus • 4.Abnormalities of soft tissues of the reproductive tract that form an obstacle to fetal descent

24. American College of Obstetricians and Gynecologists • 1. Abnormalities of the Powers (uterine contractility and maternal expulsive effort) • 2. Abnormalities involving the Passenger (the fetus). • 3. Abnormalities of the Passage (the pelvis).

25. ABNORMALITIES OF EXPULSIVE FORCES • UTERINE DYSFUNCTION • ABNORMAL LABOR PATTERNS • RUPTURE OF MEMBRANES W/O LABOR • PRECIPITOUS LABOR AND DELIVERY

26. UTERINE DYSFUNCTION • Failure of cervix to dilate or presenting part to descend • Characterized by lack of progress in any phase of cervical dilatation

27. FRIEDMAN’S CURVE

28. Active Phase Labor • At least 4 cm dilated • Regular, frequent, usually painful contractions • Dilate at least 1.2-1.5 cm/hr • Are not comfortable with talking or laughing during their contractions

31. CAUSES OF PROLONGED LATENT PHASE

32. CAUSES OF ARREST DISORDERS

34. Fetopelvic Disproportion • Diminished pelvic capacity • Excessive fetal size

35. Fetopelvic Disproportion • Diminished pelvic capacity • Any contraction of the pelvic diameters that diminishes the capacity of the pelvis that can create dystocia during labor • a. Contracted pelvic inlet • b. Contracted midpelvis • c. Contracted pelvic outlet • d. Pelvic fractures and rare contractures

36. Diagnosis of Diminished Pelvic Capacity • a. Xray Pelvimetry • b. Computer Tomographic Scanning • c. Magnetic Resonance Imaging

37. Fetopelvic Disproportion • Excessive fetal size • Fetal size alone is a seldom explanation for failed labor

38. Maternal Effects of Dystocia • a. Intrapartum Infection • After the membrane ruptured, bacteria can enter the amnionic fluid, traverse the amnion and invade the decidua and chorionic vessels thus causing maternal and fetal bacteremia and sepsis. • Infection may complicate prolonged labor and pose a serious danger both to mother and fetus. • b. Uterine Rupture • Abnormal thinning of the lower uterine segment that can create a serious danger during pronged labor.

39. c. Pathological Retraction Ring

40. d. Fistula Formation • e. Pelvic Floor Injury • f. Postpartum Lower Extremity Nerve Injury

41. Fetal Effects of Dystocia • a. Caput Succedaneum • b. Fetal Head Molding • Factors associated with molding: • 1. Nulliparity • 2. Oxytocin labor stimulation • 3. Delivery with a vacuum extractor

42. THANK YOU!