Flores, Ian Patrick Gabriel F.

Case: A 20 years old primigravid came in for prenatal check-up. She claimed to have missed
period. LMP – April 13, 2020 (Date of consult: June 1, 2020). Her past medical history and family
history was unremarkable.

Questions:

1. AOG and EDC?

a. AOG: 7 weeks
b. EDC: January 20, 2021

2. What routine laboratories will be requested?

- Primigravid patients that are on their first visit usually undergo the following routine laboratory
tests
o Hematocrit and Hemoglobin
o Blood type and Rh factor
o Antibody screen
o Pap smear screening
o Urine protein assessment
o Urine culture
o Rubella serology
o Syphilis serology
o Chlamydial screening
o Hepatitis B serology
 3. What advise will be given to the patient with regards to:

a. Signs and symptoms

 Amenorrhea
 Fetal movement
 Lower reproductive tract changes
 Uterine changes
 Breast and skin changes

b. Nutrition

 Monitor weight gain

 Dietary recall
 Recheck Hemoglobin and Hematocrit
 Give the following supplementations:
 Simple iron salts
 Folate
 Iodine

c. Other laboratories that can be done and when (AOG) it is done?

11 - 14 weeks or 15 - 20 weeks Fetal Aneuploidy

15 - 20 weeks Neural Tube Defect Screening
24 - 28 weeks Gestational DM Screening
28 - 32 weeks Hemoglobin and Hematocrit, Syphilis Serology
36 weeks (before) HIV Testing repeated (for high risk)
At the time of delivery if high risk Hepatitis B Infection
28 - 39 weeks Unsensitized Rh negative with antibody screen
retesting
35 - 37 weeks Group B streptococcal infection (vaginal and
rectal cultures)
 d. Follow-up schedule
o Every 4 weeks until 28 weeks
o Every 2 weeks until 36 weeks
o Weekly from 36 weeks
 Every 1-2 weeks interval for complicated pregnancy

Patient had unremarkable course during her prenatal check-ups. Few hours prior to consult at
39 weeks AOG, she felt intermittent hypogastric pain and spotting. At around 6am, patient
complained of frequent uterine contractions and still with spotting. She then decided to go to the
emergency room.

4. At the ER, how are you going to do the physical examination of pregnant examination of a
pregnant patient at 39 weeks AOG?

- First is to assess the vital signs, to have a baseline data for the patient. Take the heart rate,
respiratory rate, blood pressure (systolic and diastolic), and temperature. Record the findings
and then proceed to weighing the patient (maternal weight). After that measure for the fundic
height. This is performed to assess fetal growth and development. Lastly, check for fetal heart
and position. For checking of fetal heart, stethoscope or a fetoscope is used, while Leopold’s
Maneuver is used for the determining the position of the fetus.

5. What laboratory tests are you going to request on admission?

o Syphilis Serology (STS)

o Gonococcal Culture
o Chlamydial culture
o Hepatitis B serology
o HIV Serology
o Group B Streptococcal culture

At around 6am, patient complained of frequent uterine contractions and still with spotting.
She then decided to go to the emergency room. Patient was then admitted at the labor room:

6. What stage of labor is the patient in?

- Latent stage (Phase 1) - progressive cervical effacement and dilation is observed

7. What are the components of a regular uterine contraction?

o Oxytocin
o Prostaglandins
o Endothelin 1
o Angiotensin II
8. How are you going to manage a patient at this stage of labor?

- Intrapartum fetal monitoring

o For low risk pregnancies, fetal heart rate should be checked immediately after a
contraction at least every 30 minutes and then every 15 minutes during the second
stage

o For high risk pregnancies, fetal heart auscultation is performed at least every 15 minutes
during first-stage labor and every 5 minutes during the second stage.

- Uterine contractions
o Assessment is done by simply placing the palm of the hand resting lightly on the surface
of the uterus. Onset of contraction, peak of contraction, end of contraction, frequency
and duration should be noted.

- Maternal Vital Signs

o Especially the temperature and blood pressure to be monitored at least every 4 hours
(every hour if there is premature rupture of membrane).

- Subsequent cervical examinations

o This includes monitoring of cervical changes and determination of fetal position and
presenting part.

- Oral intake
o Oral intake is withheld at the start of active labor and delivery. Clear liquids can be
consumed by the patient, provided that her pregnancy is uncomplicated or low risk.

- IV fluids
 o Have a limited need during this stage of labor. But when labor is prolonged, IV fluids
with glucose, sodium, and water at a rate of 60-120 ml/hr are given in order to prevent
dehydration and acidosis.

- Maternal position
o The mother may assume any position that she finds most comfortable, usually a lateral
recumbent position. Avoid supine position because of risk for aortocaval compression
and potential lower uterine perfusion. Use of chair is also allowed.

- Analgesia
o Depends on the mother if she needs it or not

- Amniotomy
o Done if cervical dilation is less than 1cm per hour. If with PROM on admission, give
oxytocin. This is also done if the patient experiences hypotonic contractions and no
cervical dilations after 2-3 hours.

- Urinary bladder function

o Bladder distention should be avoided to prevent a retarded descent of the presenting
part and subsequent bladder hypotonia and infection. Therefore, bladder distention
assessment is important. If the bladder seen/palpated is above the symphysis pubis,
encourage voiding or catheterize when indicated.

The following is the course of labor of the patient.

Plot the FRIEDMAN’S CURVE based on the following findings:
6am: regular uterine contractions IE: 4cm, 50%, intact bag of waters, cephalic station -3 lag in the uterine
contractions were noted, Oxytocin was started at a low dose rate
8am - IE: 6cm, 50% effaced intact bag of waters, cephalic station -3
10am: regular uterine contractions IE: 7cm, 60% effaced, intact bag of waters, cephalic, station -1
1pm: regular uterine contractions, spontaneous rupture of membrane of clear amniotic fluid IE: 9cm, almost fully
effaced, ruptured bag of waters, cephalic, station +2
2pm: regular uterine contractions, patient claims to have a feeling of bearing down
IE: fully dilated, fully effaced, station +5.

9. What
stage of
labor is
the
patient
in?
 o Phase 3, Stage 1

10. What is the management at this stage of labor?

o Pelvic examination is performed each hour for the next 3 hours, and thereafter at a 2-
hour interval. If there is rupture of membrane before admission, oxytocin is begun for
no progress at the 1-hour mark.

o A 4-hour wait is recommended before intervention when the active phase is slow. A
cervical dilatation of 3-4 cm or more in the presence of uterine contractions or women
in active labor are admitted if rupture of membranes is confirmed.

o If there are signs of ineffective labor such as failure of dilatation within 2 hours of
admission, amniotomy is performed and labor progress is determined at the next 2-hour
evaluation. In non-progressive labors, intrauterine pressure catheterization is done to
assess uterine function. A criteria of dilation rates of 1-2 cm are accepted as progress
after satisfactory uterine activity has been established with oxytocin. This will require up
to 8 hours or more before cesarean delivery is performed for dystocia. The cumulative
time required to affect this stepwise management approach permits many women to
establish effective labor.

11. Patient then delivered vaginally with median episiotomy and repair. In a table form:
Differentiate median episiotomy and repair vs right mediolateral episiotomy and repair.

The rest of the postpartum stay was unremarkable. And patient was to be discharged after 48
hours of hospital stay.
12. What advise/home instructions are you going to advise as to?
a. Resumption of menses
 Women who breastfeed ovulate much less frequently compared with people
who don't, but there are great variations. Timing of ovulation depends on
individual biological variation still because the intensity of breastfeeding.
Lactating women may first menstruate as early because the second or as late
because the 18th month after delivery. Women not breastfeeding have a return
of menses usually within six to eight weeks.

b. Breastfeeding
 Breastmilk is the ideal food for neonates because it contains specific nutrients,
promotes cellular growth and differentiation, and it provides immunological
factors. Both mother and infant, the advantages of breastfeeding are long-term.
 There are sure necessities as far as breastfeeding. The areola and nipple must be
dealt with care. Its tidiness must be kept up and focus on crevices that might be
available as this may prompt tenderness and they may impact milk production.
These breaks likewise give an entryway of passage to pyogenic microorganisms.

 Since dried milk is probably going to gather and irritate the nipples, washing it
with water and a mild soap is useful when nursing. At the point when the
nipples are fissured, it might be important to utilize topical lanolin and a nipple
shield for 24 hours or more. In the case of when the fissure is extreme, the
newborn child ought not to be allowed to drink on the influenced side. Rather,
the breast ought to be exhausted consistently with a breast pump until the
sores are recuperated. Moms must be cautioned of the medications which may
influence the infant during breastfeeding.

c. Lochia discharge
 For the first few days after delivery, there is blood sufficient to color it red—
lochia rubra. After 3 or 4 days, lochia becomes progressively pale in color—
lochia serosa. After approximately the 10th day, because of an admixture of
leukocytes and reduced fluid content, lochia assumes a white or yellow-white
color—lochia alba. The average duration of lochia discharge ranges from 24 to
36 days.

d. Resumption of activity
 Following labor, most social standards didn't limit day to day activities, and
around half anticipated that resumption of full activities is within two weeks.
Ideally, the consideration and support of the newborn child ought to be given by
the mother with sufficient assistance from the father.

e. Family planning
 Breastfeeding acts as a natural contraception in the early months after delivery.
Lactational Amenorrhea Method (LAM) is a method that allows women to safely
rely on breastfeeding as a family planning method.