Gibaltar, Claire Hautea, Terese Valencia, Sheryl Gabriel, Katrina July 28, 2009.
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ADMITTING CONFERENCE
Gibaltar, ClaireHautea, TereseValencia, SherylGabriel, Katrina
July 28, 2009
M.E.B
30 y/oMarriedRoman CatholicG1P0
Chief Complaint: Labor pains
PAST MEDICAL HISTORY(+) 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
PERSONAL AND SOCIALNon-smokerNon-Alcoholic beverage drinkerPreviously employed as an audit
staff
FAMILY HISTORY(+) Hypertension – mother(+) Bronchial asthma – sibling(+) PTB - mother(-) DM(-) Thyroid Problem(-) CA(-) Kidney Disease
MENSTRUAL HISTORY
Menarche: 12 years oldInterval: monthly, regularDuration: 5 daysAmount: 2-3 pads per dayPain: (+) dysmenorrhea
LMP: November 11, 2009
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
GYNECOLOGIC HISTORYCoitarche: 29 yo
1 sexual partner
(-) PCB, dyspareunia
Last Papsmear: May 2009 – E/N findings
(+) whitish, mucoid vaginal discharge
(-) Vaginal bleeding
HPI
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
HPI
Consult at SLMC-OPDmass = 8cmAdvised surgery
No complaints of vaginal bleeding, changes in urinary or bowel habits
Admission
May 2009
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
REVIEW OF SYSTEMS(-) urinary odor, color, dysuria(-) back pain(-) heat-cold intolerance, thyroid
problems(-) pallor, easy bruisability(-) dizziness, headache(-) anxiety, depression, interpersonal
relationship difficulies
PHYSICAL EXAMINATIONGeneral Survey: Conscious, coherent,
no CPDVital Signs: BP:120/80 HR: 90 PR: 90
RR: 18 Temp:36.8 Wgt: 60kg Hgt: 152
cmSkin: No lesionsEyes: Pink palpebral conjunctivae,
anicteric sclerae, clear cornea, intact EOMs
PHYSICAL EXAMINATION
Neck: supple, (-) mass, (-) CLADsThroat: (-) TPCThorax: SCE, CBS, (-) rib retractionsLungs: Normal breath soundsHeart: AP, NRRR, Precordium at 5th ICS
midclavicular, S1>S2 at apex, S2>S1 at base
Pulses: Full and equal
PHYSICAL EXAMINATION
Abdomen: Globular, non-tender, symmetrical FH = 35 cm; FHT = 140s/min Leopold’s manuever:
L1: (+) ballotable massL2: fetal back at the maternal rightL3: breechL4: unengaged
Internal Examination: 1-2 cm/50% effaced/station -3/(+) BOW
SALIENT FEATURES
Subjective:
30 year old G1P0LMP: November 11, 2008Pelvic 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
SALIENT FEATURES
Objective
Abdomen: Globular, non-tender, symmetrical FH = 35 cm; FHT = 140s/min Leopold’s manuever:
L1: (+) ballotable massL2: fetal back at the maternal rightL3: breechL4: unengaged
Internal Examination: 1-2 cm/50% effaced/station -3/(+) BOW
DIAGNOSIS:
PU 37 5/6 weeks AOG, breech in beginning labor
30 yo, G1P0
PLAN: Primary CS
BREECH DELIVERY
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
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
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)
5. Uterine dysfunction6. Footling presentation7. An apparently healthy but preterm fetus
of 26 weeks or more; mother in active labor or in need of delivery
8. Severe IUGR9. Previous perinatal death or children
suffering from birth trauma10. Request for sterilization
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
METHODS OF VAGINAL DELIVERY
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
3. Total breech extraction
- entire body of the infant is extracted by the obstetrician
MANAGEMENT OF LABOR Initial assessment/management- Cervical dilatation & effacement- Fetal condition (anencephaly,
hydrocephaly)- Intravenous infusions- Fetal monitoring esp. after ROM
CHECK FOR PROLAPSED CORD!
VAGINAL BREECH DELIVERY- Competent team:
skillful obstetrician
assistant
anesthesiologist
pediatrician
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
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
DELIVERY OF HEADb. Prague maneuver – Kiwisch of
Prague (1846) ; two fingers grasp shoulders of back-down fetus while other hand draws feet up over abdomen of mother
DELIVERY OF HEADc. Bracht Maneuver
- breech delivers up to umbilicus; fetal body held against maternal symphysis (gravity); uterine contractions + supra-pubic pressure spontaneous delivery
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
DELIVERY OF HEADe. Entrapped head
- Duhrssen incisions at 2, 6, 10 o’clock;
cervix should be fully effaced and at
least 7 cms dilated
DELIVERY OF HEAD
f. Abdominal Rescue- for entrapped head
emergency Caesarean Section
- DON’T PANIC!!
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 midlinespontaneous flexion
COMPLICATIONS OF BREECH DELIVERYMATERNAL
1. Infection
2. Uterine rupture
3. Cervical lacerations
4. Uterine atony
But prognosis for mother better in vaginal breech delivery than Caesarean Section.
FETAL – poorer prognosis if vaginal - more complications the higher
the presenting part at beginning of extraction
1. Tentorial tears, intracerebral bleed2. Cord prolapse3. Fracture of clavicle, humerus4. Paralysis of arm5. Broken neck6. Testicular injury
VERSION- An operation in which the presentation of the fetus is altered artificiallya. Substitute one pole of a longitudinal presentation for the otherb. Converting an oblique or transverse lie into a longitudinal lie (cephalic or podalic)
External Version– manipulations done through abdominal wall
Internal Version– hand introduced into uterine cavity
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
INTERNAL PODALIC VERSION- Feet grasped and drawn through
cervix while body is pushed abdominally in opposite direction
- For delivery of second of twin
THANK YOU!!
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