PAGLINAWAN, MARTINCLYDE G.

October 11, 2021

PRETERM LABOR CASE MANAGEMENT

IDENTIFYING DATA

Stacy, 27 yo G3P2 (0201) from Iligan city, elementary school teacher

LMP = FEB. 27, 2021

32 weeks 6 days AOG by LMP

CC: uterine contractions, abdominal pain

HPI

contractions last 40-45s, interval= 4-5 mins, moderate intensity

PHYSICAL EXAMINATION

• FH= 32 cm
• LM = L1 breech occupies the fundus, L2 = back at right, fetal extremities at left, L3 head
unengaged,
• VS
o BP 125/70 HR 93, RR 22, O2 SAT 98, TEMP 36.4, WT 62KG, HT 160CM
• PELVIC EXAM
o cervix is 3cm dilated, 75% effaced, station -2, intact bag of water

IMPRESSION: Pregnancy Uterine, 32 weeks 6 days AOG by LMP, cephalic in presentation, in preterm
labor, unruptured bag of water

MANAGEMENT

• Admit the patient

• IV Plain NSS
• Labs:
o CBC
o Blood typing
o Transvaginal Ultrasound
• Ritodrine 50 µg/min and increased every 20 minutes by 50 µg/min until contractions are
inhibited
• Dexamethasone 6 mg IM given for 4 doses 12 hours apart
• Ampicillin 2 g intravenous (IV) q6 hours plus Gentamicin 1.5 mg/K q 8 hour
• Monitor VS q 4 hrs
• Continuous EFM
• For Cervical Cerclage
• Refer accordingly