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7/29/2019 OB Case Pres
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OB CaseRejante, Tito Guillermo Sabong,Lerezyl Salazar, Zara MicahSantiago, Mahalla MaeSeeres,Anna Mercedita Sengco,
Catherine Tirado, AnnaShemei Uy, Jhoana MichelleVergara, Larraine Yap, RowelDavid
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General Data ADZ
22 years old
Female Filipino
Married
Housewife
Catholic
1392 Sta. Maria St., Tamaraw Hills, Valenzuela City Consulted for the 2nd time at FUMC on November
6, 2012.
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Chief Complaint
Enlarging Abdomen
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History of Present Pregnancy
LMP: March 23, 2012
PMP: March 13, 2012
EDC: December 30, 2012
AOG: 31 3/7 weeks
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First Trimester
(+) Dizziness
Vomiting every morning
(+) cessation of menses for one month pasther expected menstrual period
PT with positive result (last week of April, 2012 ) (+) monthly prenatal check-ups TVS confirmed pregnancy Multivitamins, ferrous sulfate and folic acid
(+) fever (late 1st trimester) paracetamol
(-) other maternal illnesses (-) exposure to radiation (-) teratogenic drugs were reported.
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Second Trimester
Quickening -16-18 weeks AOG
(-) morning vomiting episodes
(+) monthly prenatal check-ups
Multivitamins and ferrous sulfate continued (-) maternal illness, exposure to radiation
and intake of teratogenic drugs
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Second Trimester
Pelvic ultrasound (September 28, 2012) (34 weeksand 4 days AOG) Pregnancy uterine 32 weeks and 4 days by fetal
biometry live, single fetus in cephalic presentation BPD=82.5 mm 33 weeks 0 days FL=65.3 mm 33 weeks 2 days AC=296.5 mm 33 weeks 5 days HC=293.3 mm 31 weeks 0 days AFI = 12.5 cm Real time scan shows fetal cardiac activity of 157 bpm
and somatic movements Placenta is in posterior, left, grade II-III maturity,
adequate amniotic fluid Estimated fetal weight of 2201 g UTZ EDD = January 19, 2013.
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Third Trimester
(+) Monthly prenatal check-ups
Multivitamins and ferrous sulfatecontinued
(-) Maternal illnesses and teratogenicexposure
Fetal movements were noted
(-) Reports of hypogastric pain and anyvaginal bleeding or discharge
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Past Medical History
Complete childhood vaccination
(+) mumps, chickenpox and measles
during childhood (-) history of drug abuse, violent
tendencies, or suicidal attempts
(-) drug or food allergies
(-) history of blood transfusion Hospitalizations: 2008 and 2010 for
childbirth via LTCS and repeat LTCS
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Family Medical History
(+) diabetes (Paternal).
(+) hypertension (Paternal)
(-) asthma
(-) allergies
(-) TB
(-) CAD (-) malignancies
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Personal and Social History Born and raised in Valenzuela City
High school graduate
Fatherjeepney, motherwife
Currently a full-time housewife
1.5 pack years Occasional alcoholic beverage drinker
Stopped upon knowledge of pregnancy
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OB Gyne Gistory G3P2 (2002)
Menarche -12 years old
3 days duration 1-2 moderately soaked pads/day (+) dysmenorrhea (-) medications
Subsequent menses Irregular (every 1-2 months) 3 days duration 1-2 pads/day, moderately-soaked (-) dysmenorrhea
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OB Gyne History Coitarche - 18 and 2 sexual partner Last coitus - March 2012
(+) OCP use after the delivery of first baby
injectable contraceptives for 6 months(+ headaches) OCP
(-) history of any STI
G1 -2008, term, male, CS for breech presentation,
done at FUMC, no complications, 5.8 lbs G2 -2010, term, female, CS for repeat, done at
Valenzuela General Hospital, no complications, 5lbs
G3 -Present
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Review of Systems
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Review of Systems
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Review of Systems
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Review of Systems
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PE: General Survey
Conscious
Coherent
Cooperative
Well-developed
Ambulatory
Afebrile
Fairly nourished
Oriented X 4
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PE: Vital Signs
Temperature: 36.8 C
Pulse Rate: 78 bpm
Respiratory Rate: 18 cpm
Blood Pressure: 90/60 mmHg
Height: 53
Weight: 97 kg
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PE: Skin
Brown
Pinkish nail beds
Good capillary refill
(-) clubbing of nails noted
(-) good skin turgor
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PE: HEENT Eyes Eyebrows thin, black, well-distributed,
symmetrical Eyelashes black, short, oriented upward,
outward, no matting No retractions; pink palpebral conjunctivae, no
lesions Anicteric sclera; cornea transparent, iris brown
in color; pupils symmetrical, 2-3mm diameter,both eyes (+) direct & consensual pupillaryreflexes; normal accommodation; lenstransparent
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PE: HEENT Ear: normal, triangular in shape, symmetrical,
no lesions, deformities or tenderness; both
external auditory canals have cerumen,cerumen not impacted
Nose: nose symmetrical, bridge flat; no flaringof alae nasi; patent vestibule with short
vibrissae; mucosa pinkish in color, no swelling,lesions, secretions or bleeding; nasal septummidline, no perforations
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PE: HEENT Mouth and Throat
Lips symmetrical, pinkish in color, moist, smooth, no lesions
Buccal mucosa pink in color, no lesions
No tongue deviation on protrusion, frenulum midline
Gingiva pink; tonsils normal, not swollen, uvula midline
Teeth incomplete, no dentures
Neck:
Skin brown in color, no deformities; trapezius andsternocleidomastoid muscles well-developed, nodeviations, no tenderness
Trachea midline; thyroid gland not palpable; no difficultyof swallowing was noted; no enlargement of cervicallymph nodes upon palpation
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PE: Chest and Lumgs Skin is smooth, brown in color
Symmetrical, no gross deformities
No lesions
Normal muscle movement; no lagging, wideningand retractions of ICS
No superficial blood vessels
RR18 cpm; no orthopnea or platypnea
No tenderness or masses
Equal chest expansion, no lagging
Equal tactile fremitus
(+) Resonance
(+) Vesicular breath; no bronchophony, gophony,whispered pectriloquy, or wheezes.
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PE: Heart and Blood Vessels Adynamic
(-) bulging or visible pulsations
(-) jugular vein distention
Apical beat - 5th ICS, left MCL No tenderness, masses, heaves, thrills and lifts
CR 78 bpm, regular, no murmurs, gallops orextra heart sounds
Carotid pulse is strong, regular and equal,without bruits
Radial, brachial pulses are strong, regular andequal
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PE: Abdomen Globular
Skinbrown with minimal hair, well distributed
Umbilicus everted, no prominent blood vessels
Moderate striae (+) Transverse scar at lower abdomen
No visible peristalsis
Bowel sounds - normoactive
FH: 28 cm FHT: 135
EFW: 2480 grams
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PE: Pelvic Examination
Pelvic examination
Normal looking external genitalia; no gross
lesions; no bleeding
Internal examination
Vagina admits 2 fingers with ease, cervix
closed, uterus enlarged to AOG
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PE: Extremities
Grossly normal
No cyanosis
No edema
Full equal pulses
Good capillary bed refill
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Initial Diagnosis
G3P2 (2002), PU 31 3/7 weeks AOG
Cephalic, not in labor
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Plan
For CBC, Urinalysis, VDRL, HBcAg
Pap smear on next visit
FeSO4 1 tab OD
Multivitamins 1 tab OD
Advised to increase oral fluid intake
Advised 10 danger signs of pregnancy Follow-up on November 24, 2012 with lab
results
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Final Diagnosis
G3P3 (3003) PU 39 weeks AOG
Cephalic delivered repeat LTCS to termBaby Boy
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Caesarean Section
Definition: 2 incisions
Birth of a fetus through:
An abdominal incision: laparotomy
A uterine incision: hysterotomy
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Indications
Primary
Dystocia: 37%
Non-reassuring FHR: 25%
Abnormal presentation: 20%
Other: 15%
Unsuccessful trial of forceps or vacuum:3%
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Indications
Repeat cesarean:
No VBAC attempt: 82%
Maternal request
MC indication for a repeat
Failed VBAC: 17%
Unsuccessful trial of forceps or vacuum:0.4%
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Maternal Mortality
Maternal death: rare, 2.2 in 100 000cesarean deliveries
9-fold increased risk of maternal death foremergency CD over vaginal
3-fold increased risk of maternal death for
elective CD
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Maternal Morbidity
Increased 2-fold over vaginal delivery
Puerperal infection
Hemorrhage
Thromboembolism
Rehospitalisation
Bladder injury: 1.4 per 1000 procedures Ureteral injury: 0.3 per 1000
Uterine rupture in subsequent pregnancy
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CD by Choice Cesarean delivery by maternal request (CDMR)
Controversial: Avoidance of pelvic floor injury during vaginal birth
Avoidance of pain during labor & delivery
Reduction in fetal injury
Convenience
National institute of health, ACOG 2007
Need an informed consent
Babies at 37 or 38, the mortality is higher
recommended AOG for CS - 39 weeks unless there is
evidence of fetal lung maturity With CS , if she only wants to have 1, 2 or 3 children (accreta
increases 25%)
Should not be motivated by unavailability of painmanagement for labor
Ethics - To refuse?
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TechniquesAbdominal incisions: there are two incisions
Infraabdominal incisions: there are 2 incisions Vertical incision
Horizontal incision aka as a bikini cut
Vertical Quickest to create
Infant easier to deliver
Pfannensteil incision Advantage: cosmetic
Disadvantages: Exposure is not at optimal in repeat surgery, re-entry is more difficult and time consuming Re-entry is difficult b/c of adhesions
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Techniques
Uterine incisions: Kerr incision
MC incision with the least blood loss and chances
of rupture
Classical incision 2nd MC type is classical incision. Its a vertical
incision. Starts from fundus and up to middle of
uterus.
T-incision
If you do a kerr incision first and unable to deliver,
then you do a classical incision and it ends up to be
a T-incision
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Kerr incision:
Advantages Easier to repair
less likely to rupture
does not promote adhesion to bowel or
omentum to incisional lineDisadvantages
uterine arteries: so make a U and avoid
uterine arteries
if you are anticipating a large baby: i.e.transverse lie or position of baby is
abnormal
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Classical section:
Advantage
malpresentation
transverse lie
multiple fetuses premature, not in labor
Disadvantage Uterine rupture
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Indications of Classical CS1. Lower segment cannot be exposed due to thefollowing:a. Bladder densely adherentb. Myoma in lower uterine segmentc. Invasive carcinoma of the cervix.
2. Transverse lie of a large fetus, especially if the shoulder isimpacted in birth canal and back down
3. Placenta previa with anterior implantation
4. Very small fetus, breech presentation and lower segment has
not thinned out
5. Massive maternal obesity precluding safe access to loweruterine segment
6. Multifetal pregnancy
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Techniques1. Uterine incision
2. BOW rupture
3. Head is scooped with one hand
4. Head is delivered followed by the rest of the
fetal body
5. Cord is doubly clamped and cut in between
6. The placenta is manually extracted and
delivered. The uterus is inspected for retained
placental fragments.7. The uterus is repaired in three layers
8. The ovaries and fallopian tubes are inspected
9. The abdomen is closed in layers