PERCEPTOR: DR.

MAE BANGUYON SAN JOSE

NAME:HARINITAMILSELVAN

ROLL NO:112

IMD17A

GENERAL DATA

NAME: Mrs Mary Fatima Ong

AGE: 25 years old

OB SCORE: G2P1 (1001)

LMP: August 30, 2019

AOG: 39 weeks and 3 days

EDC: June 5, 2020

RELIGION: Catholic

MARITAL STATUS: Married

OCCUPATION: Home maker

ADDRESS: Millionaire’s lot

RELIABILITY: 85%

INFORMANT: Patient

DATE AND TIME OF INTERVIEW: June 1,2020 at 2:30 pm

CHIEF COMPLAINT:

Watery vaginal discharge

HISTORY OF PRESENT ILLNESS:

One night prior to consultation patient had the onset of regular uterine contractions every 8 mins at
11:00 pm with a tolerable pain radiating from upper part of the uterus going to the back. The
severity of the pain increased at 10:00 am of the consulting day and the frequency of uterine
contraction was every 5 minutes. Patient didn’t take any medications for the pain.

1 hour and 30 minutes prior to consultation patient had the onset of watery vaginal discharge. This
prompted the patient to seek consultation.

OBSTETRIC HISTORY:

LMP – August 30, 2019

OB SCORE – G2P1 (1001)

AOG – 39 weeks and 3 days

Pregnancy Pregnancy Year Gestation Sex Birth Present Complication
order outcome completed weight status
G1 Normal - Term Boy 2500 Alive None
delivery grams

G2 2019 39 weeks - - - -
and 3 days

ANTENATAL HISTORY:

 Patient had UTI at 4 months AOG and was treated with cefuroxime 2x a day for 7 days.
Repeat urine analysis was taken after 2 weeks and the results were normal.
 Immunizations received during the pregnancy were tetanus toxoid at 4 months and 5
months AOG, Influenza vaccine at 6 months AOG and Tdap at 8 months AOG.
 Patient’s blood type is O positive
 Patient’s screening tests for VDRL and hepatitis B were non reactive.
 Patient had regular prenatal visits once every 4 weeks since 8 weeks AOG, every 2 weeks
from 28 weeks AOG and weekly after 36 weeks AOG.
 Patient took supplements like iron, calcium and multivitamins with DHA since first trimester.

GYNE HISTORY:

MENARCHE – 12 years

MENSTRUAL FLOW – Regular, soaking 2-3 pads/day

DURATION – for 5 days

CONTRACEPTION:

Patient took DIANE 35 Pills for 2 years

PAP SMEAR:

Patient’s last pap smear was during first trimester and the results were normal.

PAST MEDICAL HISTORY:

Patient has no history of medical illnesses like diabetes, hypertension, asthma

Patient has no history of surgery in the past

Patient has no history of food or medication allergy

Patient has no history of psychiatric illness.

FAMILY HISTORY:

Patient’s father has hypertension

Patient’s maternal grandmother has diabetes

PERSONAL/SOCIAL HISTORY:

Patient lives with her husband, son and two helpers in a concrete house in millionaire’s lot

Patient’s usual diet is pork/fish and rice

Patient exercises daily, 30 minutes walking and does yoga with her personal yoga teacher.

Patient has a good relationship with her husband

Patient’s house has a good water supply from Davao city water district.
Patient has no history of smoking and alcohol consumption.

REVIEW OF SYSTEMS:

General: (-) weakness, (-) Fever (-) Chills , weight gain of 6 kg

Skin: (-) Rashes (-) Lumps (-) Color Change (-) Itching (-) Dryness (-) Change in
nails
Hair: (-) Baldness (-) Excess hair
Head: (-) Dizziness (-) Lightheadedness
Endocrine: (-) polydipsia (-)polyphagia. (-) cold intolerance (-) heat intolerance
Eyes: (-) Pain (-) redness (-) Blurring of vision
Ears: (-) Discharge (-) itching (-) Pain
Nose: (-) Epistaxis (-) Discharge (-) Obstruction
Mouth and Throat: (-) Bleeding gums (-) Hoarseness (-) Dysphagia
Neck: (-) Stiffness (-) Lump
Musculoskeletal: (-) Muscle weakness (-) Muscle pain (-) Stiffness(-) Joint pain
Respiratory: (-) Hemoptysis (-) Cough (-) dyspnea (-) orthopnea
Cardiac: (-) Palpitation (-) Cyanosis (-) Edema (-) Easy fatiguability
Gastrointestinal: (-) nausea (-) vomiting (-) diarrhea (-) constipation
Vascular: (-) abnormal bleeding (-) Varicosities
Genito-Urinary: (-) discharges. (-) dysuria, (-) polyuria
Hematologic: (-) bruising, (-) anemia (-) abnormal bleeding
Neurological: (-) abnormal tingling sensation,(-)head trauma, (-)pain
Psychiatric: (-) anxiety,(-)depression,(-)emotional instability, (-)nightmares and
illusions.

PHYSICAL EXAMINATION:

GENERAL- Patient was alert, ambulatory, gravid and uncomfortable with contractions

VITAL SIGNS

BP is 100/70 mmHg (normotensive)

Heart rate – 98 bpm (normal)

Respiratory Rate – 18 breaths/min (normal)

Temperature – 36.3’ C

ANTHROPOMETRIC MEASUREMENT

Height – 5’1”

Weight - 59 kg

 Skin - warm, moist, no abnormal lesions, no tenderness, no cyanosis

 Head – normocephalic, no abnormal pattern hair loss, no lesions
 Eyes – anicteric sclera, pink palpebral conjunctiva
 Nose – septum midline, no nasal discharge, no nasal obstruction
 Throat – uvula midline, no lesions, no dental carries
 Neck – trachea midline, no masses, no lymphadenopathy
 Breast – symmetrical, no lesions, no nipple retraction, no tenderness
 CHEST
Inspection – symmetrical chest expansion
Percussion – dullness over the precordium
Palpation – PMI at apex, no heaves, no thrills
Auscultation – normal heart sounds, no murmers
 ABDOMEN

Inspection – gravid, globular, presence of linea nigra, striae gravidarum, fundic height is 34
cm

Auscultation – normal bowel sounds, fetal heart rate 140 bpm (right lower quadrant)

Percussion – tympanic

Palpation – soft, nontender, strong uterine contractions every 5 minutes of 50 seconds

duration

Leopold’s Maneuver 1 – Breech

Leopold’s Maneuver 2 – Fetal back, right maternal side
Leopold’s Maneuver 3 – cephalic, engaged
Leopold’s Maneuver 4 – not done, patient couldn’t tolerate pain
 PELVIC EXAMINATION
Cervix 5 cm dilated, 50% effaced, station -3, ruptured bag of water, cephalic presentation
Sacral promontory cannot be reached
Pelvic sidewalls slightly convergent
Ischial spines not prominent
Intertuberous diameter more than 8 cm
 Musculoskeletal – no muscle atrophy, no tenderness
 Extremities – no edema, no tenderness, no clubbing of fingers

PLAN

To admit the patient, monitor her progress of labor and anticipate spontaneous vaginal delivery.

SALIENT FEATURES

 25 years old
  G2P1 (1001)
 AOG 39 weeks and 3 days
 Fundal height – 34 cm
 Had UTI at 4 months AOG
 Significant weight of 6 kg
 Watery vaginal discharge
 Frequent painful uterine contraction every 5 minutes lasting for 50 seconds
 Pain radiating from uterine fundus to the back
 Cervix 5 cm dilated, 50% effaced, station -3, ruptured bag of water.

INITIAL IMPRESSION

G2P1 (1001), 39 weeks and 3 days AOG, pregnancy uterine, cephalic presentation, ruptured bag of
water,in labor, active phase of labor

DIFFERENTIAL DIAGNOSIS

Disease Rule in Rule out

Premature rupture of Watery vaginal discharge Presence of contractions

membrane within 1 hour , absence of
bloody vaginal discharge
Vaginitis Vaginal discharge Absence of purulent ,yellow
vaginal discharge, absence of
pain in introitus, absence of
itching, absence of
malodorous vaginal discharge

Cervicitis Vaginal discharge Absence of yellow or grey or

whitish discharge, absence of
malodorous discharge

FINAL DIAGNOSIS

G2P1 (1001), 39 weeks and 3 days AOG, Pregnancy uterine, Cephalic presentation, ruptured bag of
water, protracted active phase dilatation, arrest of descent, normal delivery

LABOR

Patient delivered a baby boy of 2900 grams birth weight via spontaneous vaginal delivery, apgar
score- 8 to 9.

CASE DISCUSSION

Patient is 25 yrs old, G2P1 (1001), 39 weeks and 3 days AOG, with watery vaginal discharge,
painful uterine contractions every 8 minutes at 11:00 pm of night prior to consultation and
pain radiating from uterine fundus to the back. The contractions on the consulting day at
10:00 am was strong and frequency was every 5 minutes and the severity of the pain
increased. Patient was alert, ambulatory, gravid and uncomfortable with contractions.
 Patient’s BP is 100/70 mmHg (normotensive), Heart rate – 98 bpm (normal), Respiratory
Rate – 18 breaths/min (normal), Temperature – 36.3’ C (normothermia), fundal height 34 cm
and fetal heart rate 140 bpm. Leopold’s Maneuver 1 – Breech, Leopold’s Maneuver 2 – Fetal
back, right maternal side, Leopold’s Maneuver 3 – cephalic, engaged, Leopold’s Maneuver 4
– not done, patient couldn’t tolerate pain. On pelvic examination at the time of admission
the Cervix was 5 cm dilated, 50% effaced, station -3, with ruptured bag of water, strong
uterine contractions occurring every 5 minutes lasting for 50 seconds and cephalic
presentation. After 2 hours and 30 minutes of admission there were same internal
examination findings and uterine contraction frequency and an intervention was done. After
5 hours and 30 miutes of admission the cervix 7 cm dilated, fully effaced, station -3, rbow,
contractions every 3 minutes lasting 60 seconds. After 7 hours and 30 minutes of admission
the cervix fully dilated, fully effaced, station +2. The patient was in active phase of labor at
the time of admission and the patient had protracted active phase dilatation and fetal
descent arrest in the labor progress. The patient was monitored anticipating for
spontaneous vaginal delivery.
NORMAL LABOR
A women with intact membrane ,cervical dilation of 3-4cm or greater is presumed to be a
reasonably reliable threshold for the diagnosis of labor.

First stage of labor-This stage starts when painful contractions become regular ( 5 minutes
apart for 1 hour) and ends with cervical dilatation.

Two types of cervical dilatation is defined by Freedman, Latent phase (preparatory division) and
active phase-(functional division)

Latent phase- The latent phase for most women ends once dilation of 3-5 cm is
achieved. More recently, a consensus committee of American college of obstetricians and
gynecologists and society for maternal fetal medicine (2016c) has redefined active labor to
begin at 6 cm cervical dilatation.
Active phase- The threshold for active labor is defined as cervical dilation of 3 to 6 cm
or more ,in the presence of uterine contractions.

The rate of cervical dilatation in nullipara is 1.2cm/hr and in multiparas 1.5cm/hr.Descent

begins in later stage of active labor,commencing at 7-8 cm in nullipara and becoming most rapid
after 8 cm.

Second stage of labor- This stage begins with complete cervical dilation and ends with fetal
delivery. The median duration is approximately 50 minutes for nulliparas and about 20 mins for
multiparas but it is highly variable.

Third stage of labor- This stage begins immediately after fetal delivery and involves
separation and expulsion of the placenta and membranes.

Reference : William's obstetrics, 25th edition

FRIEDMAN CURVE:.