SUMMARYMadam Rabaiyah binti Shazali, 29 years old, Melanau, Gravida 4 Para 3+0, at 37 and 3 days of gestations was admitted to the maternity ward of Hospital Sibu on 9th December 2014 at 4.00 pm after being referred from a local clinic for abnormal fetal lie. From the transabdominal ultrasound scan done previously, the fetal lie was breech at 32 weeks of gestations and was in cephalic lie at 36 weeks of gestations. Latest scan revealed that the current fetal lie is in oblique lie. She was then referred for further management and follow up after being diagnose as unstable lie. On 13th December 2014 at 9.45 am, she was leaking liquor. She describe the fluid as clear and it was dribbling down her feet. The liquid was also foul smelling. She also mentioned that it was high in volume and soaked her sarong. She also had contraction pain once every hour that lasts for 10 seconds. Otherwise, there was no show present or any blood seen. Leaking liquor was not associated with pain and there was no itchiness felt. She also has no fever or any sign of urinary tract infection such as dysuria or increase frequency of micturition.Patient was unsure of her last menstrual period (LMP). Her cycle was previously regular with 28 days cycle. Her revised expected date of delivery (REDD) was on the 27th December 2014. This was an unplanned pregnancy and she did not take any contraceptive measures. She did her booking scan at 8 weeks of gestation and it was normal. Antenatally, she had an uneventful pregnancy. For past obstetric history, she had 3 children previously. All of them were delivered via spontaneous vaginal delivery and birth weight was from 2.7 kg to 3.1 kg. Currently all her children are healthy. There is no known medical or surgical history. There is also no relevant family history. She also has no known allergy and is not on any medication. She is a non-smoker and does not take alcohol.

PHYSICAL EXAMINATIONFor general examination, she was afebrile and her blood pressure was 114/86 mmHg. Her pulse rate was 98 beats per minutes with strong volume and regular rhythm. Her respiratory rate was 20 breath per minute and her BMI is 31.7 which is considered as maternal obesity. There was no sign of edema, no pallor, no sign of lymphadenopathy and no thyroid enlargement.For systemic examination, normal heart sound was heard without murmurs. She also had vesicular breaths sound with no wheezing or crepitation. Central nervous system was also normal.Obstetric examination revealed a grossly distended abdomen with gravid uterus on inspection. There was also presence of linea nigra and stria gravidarum. There was no dilated veins or surgical scars seen. On palpation, the temperature was normal. The abdomen was soft and non-tender. The fundal height was at 38 weeks of gestations. Symphysio-fundal height was measured at 37 cm. It is a single pregnancy with longitudinal lie and in cephalic presentation. Fetus was at right lateral position. Head was 4/5th palpable and not engaged. On auscultation, fetal heart sound was heard at 145 beats per minutes, strong and regular. Estimated fetal weight was 2.4 to 2.6 kg.

Vaginal examinationVulva: No abnormalities detectedCervical Os: Tip of fingerCervical position: AnteriorStation: -2Cervix: Not effacedPresenting part: CephalicMembrane: IntactUltrasound was done and revealed normal single fetus. The estimated fetal weight was 2.4 kg. Amniotic fluid index (AFI) shows normal level. No evidence of low lying placenta.CTG was done and showed a reactive CTG.CTG tracingBaseline: 140 beats per minuteVariability: More than 5Acceleration: PresentDeceleration: AbsentUterine contraction: None

Comment:Maternal vital signs was within normal range. Current fetal lie is in longitudinal lie with cephalic presentation. There was no other abnormalities detected. As for vaginal examination, cervical os was at tip of a finger dilated with intact membrane. She is currently not in labour. CTG tracing was also reactive.

Management:1. Fetal kick chart and CTG monitoring2. For lie chart monitoring3. To look out for signs and symptoms of labour. Then, confirm fetal presentation once patient is in labour.

Physical examination at 2.00 pm (13th December 2014)General examination revealed no abnormalities. Her blood pressure was 122/78 mmHg. Her pulse rate was 82 beats per minute with regular rhythm and strong volume. Respiratory rate was 20 breaths per minute. No abnormalities detected for systemic examination.On obstetric examination, the engagement was 5/5th palpable and was not engaged. Fetal heart rate was heard at 141 beats per minute, strong and regular.Vaginal examination:Vulva: No abnormalities detectedCervical Os: 1 cmCervical position: AnteriorStation: -2Cervix: 25% effaced, softPresenting part: CephalicMembrane: Ruptured, clear fluid (spontaneous)CTG tracing:Baseline: 140 beats per minuteVariability: More than 5Acceleration: PresentDeceleration: AbsentUterine contraction: 1 in 10 minutes

Comment:Maternal vital signs was within normal range. Current fetal lie is in longitudinal lie with cephalic presentation. There was no other abnormalities detected. As for vaginal examination, cervical os was 1cm dilated with spontaneous rupture of membrane with clear fluid. She is currently in latent phase of labour. CTG tracing was also reactive.

Management:1. Plot partograph to monitor progress of labour2. Fetal kick chart3. Encourage ambulatingPhysical examination at 6.00 pm (13th December 2014)General examination revealed no abnormalities. Her blood pressure was 116/90 mmHg. Her pulse rate was 70 beats per minute with regular rhythm and strong volume. Respiratory rate was 20 breaths per minute. No abnormalities detected for systemic examination.On obstetric examination, the engagement was 5/5th palpable and was not engaged. Fetal heart rate was heard at 152 beats per minute, strong and regular.Vaginal examination:Vulva: No abnormalities detectedCervical Os: 4 cmCervical position: AnteriorStation: -2Cervix: 50% effaced, softPresenting part: CephalicMembrane: Ruptured, clear fluid (spontaneous)CTG tracing:Baseline: 150 beats per minuteVariability: More than 5Acceleration: PresentDeceleration: AbsentUterine contraction: 2 in 10 minutes for 20 seconds

Comment:Maternal vital signs was within normal range. Current fetal lie is in longitudinal lie with cephalic presentation. There was no other abnormalities detected. As for vaginal examination, cervical os was 4 cm dilated with spontaneous rupture of membrane with clear fluid. She is currently in active phase of labour. CTG tracing was also reactive.

Management:1. Continuous maternal vital signs and CTG monitoring2. Vaginal examination 2 hourly3. Set IV line Physical examination at 8.00 pm (13th December 2014)General examination revealed no abnormalities. Her blood pressure was 128/88 mmHg. Her pulse rate was 72 beats per minute with regular rhythm and strong volume. Respiratory rate was 20 breaths per minute. No abnormalities detected for systemic examination.On obstetric examination, the engagement was 3/5th palpable and was not engaged. Fetal heart rate was heard at 148 beats per minute, strong and regular.Vaginal examination:Vulva: No abnormalities detectedCervical Os: 6 cmCervical position: AnteriorStation: 0Cervix: 75% effaced, softPresenting part: CephalicMembrane: Ruptured, clear fluid (spontaneous)CTG tracing:Baseline: 150 beats per minuteVariability: More than 5Acceleration: PresentDeceleration: AbsentUterine contraction: 2 in 10 minutes for 30 seconds

Comment:Maternal vital signs was within normal range. As for vaginal examination, cervical os was 6 cm dilated with spontaneous rupture of membrane with clear fluid. CTG tracing was also reactive. Uterine contraction is 2 in 10 minutes for 30 seconds.

Management:1. Continuous maternal vital signs and CTG monitoring2. Vaginal examination 2 hourly3. Look out for signs of poor progress of labour

Physical examination at 10.00 am (14th December 2014)General examination revealed no abnormalities. Her blood pressure was 120/76 mmHg. Her pulse rate was 80 beats per minute with regular rhythm and strong volume. Respiratory rate was 22 breaths per minute. No abnormalities detected for systemic examination.On obstetric examination, the engagement was 2/5th palpable and was not engaged. Fetal heart rate was heard at 140 beats per minute, strong and regular.Vaginal examination:Vulva: No abnormalities detectedCervical Os: 6 cmCervical position: AnteriorStation: 0Cervix: 75% effaced, softPresenting part: CephalicMembrane: Ruptured, clear fluid (spontaneous)CTG tracing:Baseline: 142 beats per minuteVariability: More than 5Acceleration: PresentDeceleration: AbsentUterine contraction: 3 in 10 minutes for 30 seconds

Comment:Maternal vital signs was within normal range. As for vaginal examination, cervical os was 6 cm dilated with spontaneous rupture of membrane with clear fluid. CTG tracing was also reactive. Uterine contraction is 3 in 10 minutes for 30 seconds.

Management:1. Continuous maternal vital signs and CTG monitoring2. Vaginal examination 2 hourly3. Look out for signs of poor progress of labour

Physical examination at 12.00 am (14th December 2014)General examination revealed no abnormalities. Her blood pressure was 120/76 mmHg. Her pulse rate was 80 beats per minute with regular rhythm and strong volume. Respiratory rate was 22 breaths per minute. No abnormalities detected for systemic examination.On obstetric examination, the engagement was 2/5th palpable and was not engaged. Fetal heart rate was heard at 138 beats per minute, strong and regular.Vaginal examination:Vulva: No abnormalities detectedCervical Os: 6 cmCervical position: AnteriorStation: 0Cervix: 75% effaced, softPresenting part: CephalicMembrane: Ruptured, clear fluid (spontaneous)CTG tracing:Baseline: 138 beats per minuteVariability: More than 5Acceleration: PresentDeceleration: Type 1 early decelerationUterine contraction: 3 in 10 minutes for 45 seconds

Comment:Maternal vital signs was within normal range. There was no other abnormalities detected. As for vaginal examination, cervical os was 6 cm dilated and cervix is 75% effaced only. CTG showed early deceleration. Uterine contraction was 3 in 10 minutes for 45 seconds.

Management:Despite the strong contractions and the spontaneous ruptures of membranes, the head descent was still poor at station 0. The progress of labour was poor as the partograph showed cervix dilatation that moves to the right. CTG also shows suspicious tracing of early deceleration. Thorough assessment was carried out thus resulted in Emergency Lower Segment Caesarian Section (EMLSCS).1. Monitor maternal vital signs2. Continuous CTG monitoring3. Inform consent from patient4. Pre-operative assessment5. Anesthesia team review

Reasons for EMLSCSEmergency Lower Segment Caesarian Section (EMLSCS) was done on Madam Rabaiyah is due to poor progress of the active phase of labour that was because of obstructed labour and suspicious CTG.

Post-delivery summaryMadam Rabaiyah delivered a healthy male baby with birth weight of 2.33 kg on 14th December 2014 at 1.17 am via emergency lower segment caesarian section.

Post-operative management1. Transfer out to post-natal ward once patient is stable2. Allow orally3. Vital signs every hourly until patient is stable4. Strict pad charting5. Intravenous drip of 5% dextrose until patient can tolerate orally6. Subcutaneous Heparin, 5000U BD until patient ambulating well7. IV cefobid 1g BD8. Wound inspection on day 2 post-operative9. IV Pitocin 40U for 6 hours

DISCUSSIONNormal labor is defined as uterine contractions that result in progressive dilation and effacement of the cervix. Meanwhile, dystocia of labor is defined as difficult labor or abnormally slow progress of labor. Other terms that are often used interchangeably with dystocia are dysfunctional labor, failure to progress (lack of progressive cervical dilatation or lack of descent), and cephalopelvic disproportion (CPD).Below are the 3 stages of labor:1. The first stage starts with uterine contractions leading to complete cervical dilation and is divided into latent and active phases. In the latent phase, irregular uterine contractions occur with slow and gradual cervical effacement and dilation. The active phase is demonstrated by an increased rate of cervical dilation and fetal descent. The active phase usually starts at 4 cm cervical dilation and is subdivided into the acceleration, maximum slope, and deceleration phases.2. The second stage of labor is defined as complete dilation of the cervix to the delivery of the infant.3. The third stage of labor involves delivery of the placentaIn general, abnormal labor is the result of problems with one of the 3 P' s:1. Passenger (infant size, fetal presentation [occiput anterior, posterior, or transverse])2. Pelvis or passage (size, shape, and adequacy of the pelvis)3. Power (uterine contractility)A prolonged latent phase may result from oversedation or from entering labor early with a thickened or uneffaced cervix. It may be misdiagnosed in the face of frequent prodromal contractions. Protraction of active labor is more easily diagnosed and is dependent upon the 3 P:1. The first P, the passenger, may produce abnormal labor because of the infant's size (eg, macrosomia) or from malpresentation.2. The second P, the pelvis, can cause abnormal labor because its contours may be too small or narrow to allow passage of the infant. Both the passenger and pelvis cause abnormal labor by a mechanical obstruction, referred to as mechanical dystocia.3. With the third P, the power component, the frequency of uterine contraction may be adequate, but the intensity may be inadequate. Disruption of communication between adjacent segments of the uterus may also exist, resulting from surgical scarring, fibroids, or other conduction disruption. Whatever the cause, the contraction pattern fails to result in cervical effacement and dilation. This is called functional dystocia. For uterine contractile force to be considered adequate, the force produced must exceed 200 MVUs during a 10-minute contraction period. Arrest disorders cannot be properly diagnosed until the patient is in the active phase and had no cervical change for 2 or more hours with the contraction pattern exceeding 200 MVUs. Uterine contractions must be considered adequate to correctly diagnose arrest of dilation.