CASE 004: MALPRESENTATION (BREECH)

BIOGRAPHIC DATA

Name: N.E Age: 28years IPNO: 2010

Address: Boroboro Tribe: Mugisu Religion: Catholic

Education level: Primary seven Occupation: Peasant farmer

Date of admission: 04/10/2020 Time of admission: 11:30am

LNMP: 10/01/2020 EDD: 17/10/2020 W.O.A: 38weeks+ 2days

Next of kin: O. P Relationship: husband Occupation: peasant farmer

MEDICAL HISTORY

Mother reported no history of chronic medical diseases like Hypertension, Diabetes mellitus,
Epilepsy, Sickle cell disease, among others, no history of infectious diseases like Tuberculosis,
no history of childhood illness like rickets, poliomyelitis, and rheumatic heart disease, no history
of sexually transmitted diseases like syphilis, gonorrhea, HIV/AIDS which could complicate or
be complicated by pregnancy.

SURGICAL HISTORY

Mother reported no history of trauma, no accident involving the spine, pelvis and lower limbs, no
history of obstetric operations like pelvic operation, no history of skeletal deformity and no
history of blood transfusion.

FAMILY HISTORY

Mother, reported that both of her parents have died. She also reported no history of familial
diseases like hypertension, diabetes mellitus, sickle cell disease, epilepsy, asthma, mental illness.
She reportedhistory of two sets twin deliveries.

SOCIAL HISTORY

Mother reported having been married for 3 years; she neither drinks nor smokes but the husband
drinks though he does not smoke. She reported that they live in huts, with a kitchen present, large
compound;the home sanitation is good with a pit latrine and bathroom present, water is collected
from a nearby protected well. She reported that her husband’s health condition is fair despite
drinking, source of income and financial support is from farming.

OBSTETRIC HISTORY

She reported no history of caesarian section or vacuum extraction, no history of still birth, no
history of antepartum hemorrhage, no history of retained placenta. She had history of postpartum
hemorrhage.Her menarche was at 13 years of age, she bleeds for 5 days and her menstrual cycle
takes 28days.
Pregnancy Year Abortion Preterm Term Type of Baby Baby Birth Puerperium Immunization
delivery alive sex weight
01 2010 No No Yes SVD Yes Male 2.7kg Normal Immunized

02 2016 No No Yes SVD Yes Female 3.0kg Normal Immunized

PRESENT OBSTETRIC HISTORY

Mother’s Last Normal Menstrual Period was on 10/01/2020, her Expected Date of Delivery was
on 17/10/2020 and Weeks of Amenorrhea were 38weeks+2days. Mother’s complaint on the
current pregnancy was labor like pain (lower abdominal pain radiating to the back and upper
thighs).

GYNECOLOGICAL HISTORY

She reported no history of abortion or ectopic pregnancy, no history of ovarian cyst, no history of
dilatation and curettage done, no history of myomectomy done. No history of vagino-vesicle
fistula, no vagino-rectal fistula.

CONTRACEPTIVE HISTORY

Mother reported having used IUCD and stopped using in October, 2019 because she wanted to
have another baby.

ANTENATAL EXAMINATIONS

Date Height Pre Eng. Position FHR Urine BP Oedema Weight

of
fundus
11/06/2020 22/40 P A L P A BL E MASS Not 105/65mmHg Nil 60kg
tested
13/07/2018 28/40 Cephalic Free ROA 150b/m Not 100/60mmHg Nil 62kg
tested
14/08/2020 32/40 Breech Free Sacral 139b/m Not 110/70mmHg Nil 65kg
anterior tested
26/09/2020 38/40 Breech Sacral 145b/m Not 100/65mmHg Nil 69kg
anterior tested
 ROUTINE TESTS

Date HB Group Rh HIV Syphilis MPS Ultrasound

11/06/2020 13.0g/dl B Positive Negative Non-reactive No MPS Not done
seen
26/09/2020 Positive Negative Not Viable fetus
tested in a breech
presentation

ADMISSION

Mother N.E, a G3P2+0, with LNMP 10/01/2020 and EDD 17/10/2020, was admitted in labor
ward on 04/10/2020 at 11:30 hours with history of labor like pain (lower abdominal pain
radiating to the highs) which she reported that it began at 05:30 hours on 04 /10/2020 with mild
pain which got relieved on exertion (walking) and became intensified on bed rest. She reported
the pain became more intense and severe in nature and frequency as time went on.

General examination

On General examination, the mother looked to be in pain, with a bent gait and stature, she was
smart, well oriented to time and space, and she had well-coordinated speech.

On quick examination, there was no jaundice, no anemia, no clubbing, no cyanosis, no oedema,

no lymphadenopathy and no dehydration.

Vital signs; BP- 100/70mmHg, Temperature- 37.1oC, Pulse- 82b/m, Respiratory Rate -19bpm

Baseline measurements; Height 164cm, weight =67kg

Abdominal examination

On inspection, the abdomen looked enlarged, ovoid in shape, with visible signs of pregnancy like
linea nigra below and above the umbilicus and stria gravidarum, no scar and no skin rashes were
seen. On superficial palpation, there was no tenderness; on deep palpation, no splenomegaly and
no hepatomegaly. Fundal height was 38/40, Presentation- Breech, Descent- 5/5, Lie-
longitudinal, and Position- Right Sacral Anterior and there were 2 moderate contractions each
lasting for 30 seconds within 10 minutes. On auscultation, fetal heart tones were heard strong
and regular at 140b/m.

Vaginal examination

On inspection, the vulva was soaked with show, pubic hair bushy. The vagina looked pink in
color, felt warm and moist. The cervix anteriorly located, it felt soft, thick and well applied to the
presenting part. Cervical os was 5cm dilated. The membranes were intact. The presenting part
was buttocks.
Internal pelvic assessment

The sacropromontary was not tipped at 12cm, Hollow of sacrum well curved, Ischial spines not
prominent, sub pubic arch accommodated 3 fingers, and Inter tuberous diameter accommodated
4 knuckles.

PROGRESS OF LABOR

First stage-monitored using a Partograph

From 11:30-15:30 hours, mother’s general condition remainedgood with the following
observations;

Fetal heart rate taken half hourly was heard strong and regular at the normal range of 136-
150b/m.

Cervical dilatation was assessed 4 hourly and ranged from 8cm- 10cm dilatation.

Contractions were counted half hourly and it ranged from 2:18:10 to 3:45:10 (3 strong
contractions).

Temperature was observed four hourly and was taken once, which was 37oC, blood pressure
taken two hourly ranged from 100/60-112/70mmHg, pulse taken half hourly ranged from 80-90
beats/minute, respiratory rate ranged from 16-18 breaths/minute throughout labor.

Urine output was monitored two hourly and the volume ranged from 50-200mls. Bowel was
opened once and it was at 12:30 hours.

Intravenous fluids were not given, no drug was given during first stage of labor, and urine test
was not done

Vaginal examination was repeated at 15:30 hours, cervical os was 10cm dilated, there was
moulding (++), presenting part was sacrum.

Also at 15:30 hours, membranes had ruptured and liquor was clear in colour.

Duration of first stage:10 hours

Plan of care:Inform the staffs that there is a mother with breech presentation

I planned to encourage the mother to take sweetened tea and ambulate around.

My plan was to counsel the mother and allay her anxiety.

To encourage the mother frequently pass urine

Prepare for newborn resuscitation

I planned to prepare for second stage of labor.

Second stage

I reassured the mother, explained the procedure to the mother and gained her participation called
for help from other staff on duty, positioned her in dorsal position with her buttocks on the edge
of the bed(Mac Roberts maneuver) and flex the legs, then swab vulva with antiseptic lotion,
instructed the assistant to encourage the mother to push with each contractions and relax between
the contractions while I waited to deliver the baby. As the baby’s buttocks in the perineum, the
legs were stuck so by use of my two fingers I grasped the popliteal fossa then the legs were
delivered automatically. I left the legs hanging and encouraged her to push with each contraction
until I saw the pelvic girdle, then immediately covered body parts hanging outside the perineum
with a clean warm cotton cloth, deliver the arms with lovset maneuvers then I waited until I
viewed the hair line then I did mauri Celle snelli vots maneuvers to deliver the baby’s head then I
delivered the baby, cleaned the face with clean baby’s sheet.

At 16:00 hours, mother had spontaneous vaginal breech delivery to a live baby girl with Apgar
score 8/10 at 1 minute and 10/10 at 5 minutes. Umbilical cord was quickly clamped and cut,
baby’s face and sex shown to the mother and baby placed on the mother’s abdomen for skin to
skin contact (kangaroo care) and covered with baby's sheet to provide warmth.Birth weight
3.5kg.

Third stage

Active management of Third stage of labor

I palpated mother’s abdomen to rule out undiagnosed twin, administered intramuscular oxytocin
10i.u within the first one minute of birth. At 16:10 hours I delivered the placenta and membranes
by controlled cord traction, did a quick examination of the placenta done and placenta was
complete, uterus massaged, clots expelled, bladder checked and wasnot full, birth canal (the
vulva, vagina and cervix) inspected for tears and lacerations and mother had first degree tears or
lacerations were seen so the tears were sutured using Nylon sutures under anesthesia. Mother
was appreciated for cooperating, cleaned, dressedand escorted to postnatal ward with her baby;
both of them were in good general condition.

Blood loss was approximately 400 milliliters.

SUMMARY OF PROGRESS OF LABOR

Labor Began Membranes Cervix Baby born Placenta Duration of

ruptured fully expelled labor
dilated

Date 04/10/2020 04/10/2020 04/10/2020 04/10/2020 04/10/2020 1st stage

10 hours

Time 05:30 15:30 hours 15:30hours 16:00 16:10hours 2nd stage

hours hours
30 minutes

3rd stage

10 minutes

Total

10 hours:40
minutes

POST DELIVERY OBSERVATION AND CARE OF THE MOTHER

I assessed and documented the mother’s tone of the fundus and the amount of lochia following
birth of the placenta every 30 minutes for the first 2 hours. The uterus was well contracted;
Fundal height of 16/40 weeks, lochia was rubra and approximately 20mls.

I inspected the perineum following birth of the placenta and the sustained tears were sutured.

I measured and documented the woman’s pulse as 84blm, respiration 17blm, Oxygen saturation
as 99%, blood pressure 110/65mmHg and temperature 37.3oC within an hour of the birth of the
placenta.

I cleaned and dried the mother, covered her with a bed sheet to keep her warm.

I encouraged the mother to maintain uninterrupted skin to skin contact with the baby following
birth for at least 1 hour.
I encouraged the mother to initiate infant breastfeeding of the baby.

I encouraged the woman to eat soft foods, drink plenty of fluids and have adequate rest.

I encouraged the mother to urinate frequently.

PLACENTA EXAMINATION

This was done in the delivery room for 1 minute under adequate light and on a flat surface. I
explained the procedure to the mother, put on gloves, laid the placenta with fetal side uppermost
on a flat surface. I examined the cord; lifted the placenta up by the cord, turned the placenta over
to inspect the maternal surface.

The placenta had metallic odor, was normal in size with approximately 3cm thickness, fetal
surface was shiny, gray and translucent, was complete with no missing cotyledons, the umbilical
cord had two umbilical arteries and one vein visible, and umbilical cord was marginallyattached
to the placenta, looked shorter in length (approximately 45cm long), had abundantWharton's
jelly, had no true knots. Maternal surface was dark maroon in color. Fetal membranes were gray,
wrinkled, shiny and translucent.

IMMEDIATE CARE TO THE NEWBORN

Immediately the baby was born, I cleared the airway and the face with clean baby’s towel to
enable the newborn to breathe effectively.

When baby was delivered, I scored the baby using Apgar scale and baby scored 7/10 at 1 minute
and 8/10 at 5 minutes after birth.

I dried the baby with dry sheets to keep baby warm.

I placed the baby on the mother's abdomen (skin-to-skin contact/ kangaroo care), and this was to
maintain the baby's temperature, encourage bonding and expose the baby to the mother's skin.

I clamped and cut the umbilical cord with sterile cord clamps and surgical blade to prevent
infections during separating the baby from the mother.

I took baby’s vital signs and Temperature 36.9oC, respiratory rate 52b/m, apex heart rate
128bpm, weight 3.0kg.

I applied tetracycline eye ointment antibiotic into the baby’s eyes to prevent infection from any
harmful organisms that the baby may have had contact with during delivery.

I administered Vitamin K 1mg intramuscularly on baby’s vastus lateralis muscle of the thigh to
prevent hemorrhage disease of the newborn.

I encouraged the mother to put baby to the breast within first hour of birthto encourage early
suckling/breast-feeding within the first hour after birth and to stimulate the nipple so as to
establish uterine contractions and prevent postpartum blood loss.
EXAMINATION OF THE NEWBORN

This was done on the first day of the baby’s life in a warm room with adequate light.

Prior to examining the newborn

I greeted the mother.

I created rapport to gain the mother’s confidence.

I explained the procedure to the mother that I was going to do examination of the baby to gain
mother’s understanding and obtain consent.

Hand washing was done

Newborn examination

Observation

I started by observing the skin color of the baby, the baby’s lips,and tongue andwas pink, no
pallor seen on comparing baby’s palm with mine, no jaundice seen on the skin when forehead
skin pressed. No bruising or marks seen on the baby. Baby’s arms and legs were well flexed and
moving showing normal muscle tone and activity. Baby turned over and back inspected, no
abnormality detected. On the hands and feet, no extra digits were seen.

Vital signs

Temperature 36.9oC, respiratory rate 52b/m, apex heart rate 128bpm, weight 3.0kg

Physical examination (head to toe)

Head: On inspection, the baby’s head was uneven in shape due to molding, both anterior and
posterior fontanelles seen; hair fairly distributed on the head; the face, ears, eyes, and nose
normal and intact with no abnormal discharges. On gentle palpation, the fontanelles felt soft,
baby’s bones felt symmetrical on both sides. Baby was able to suck my gloved fingertip properly
showing good sucking reflex.

Neck: skin was intact, clavicles symmetrical, no abnormality seen.

Chest: on inspection, skin intact, baby had swollen breasts, no abnormality detected. On
percussion, loud sound; on auscultation clear and normal breath sounds with respiration 52blm,
no extra sounds.
Abdomen; On inspection, skin intact, abdomen round in shape and moved with respiration,
umbilical cord clean, well tied and not bleeding, no redness, no swelling; On palpation, abdomen
felt soft or non-tender.

Back; no openings and no defects found whena baby was gently turned over and a finger gently
run down the spine, no sacral dimple between the buttocks.

Limbs; both upper and lower limbs present, two in number, 5 fingers on each hand and 5 toes on
each foot, no extra digits, normal palmar creases, no talipes on feet.

Genitalia; skin was intact, no abnormality seen, vagina was open, urethral opening present,
whitish discharge seen, anus patent. Baby passed urine 1 hour from birth and meconium after
3hours of birth.

The Moro reflex present when I held the baby on a semi sitting position and allowing the head
to drop 1-2 cm on my hand, the baby responded by abducting and extending the arms with
fingers open

Rooting Reflex, present and was done by stroking of the cheek or side of the mouth of the baby
was able to turn towards the source of the stimulus and open the mouth ready to suckle. Baby
had good rooting and suckling reflex

Grasp Reflex present and this was done by placing a finger in the baby’s palm and was able to
hold.

ADVICE ON DISCHARGE TO BOTH BABY AND MOTHER

Mother was advised to feed on a well-balanced diet, got from readily available foods like beans,
chicken for protein nutrients; cassava, posho, rice, irish, potatoes for nutrients from
carbohydrates; vegetables like dodo, boyo, malakwang; fruits like oranges, mangoes.

Mother was advised to come back to the hospital in case she experiences danger signs like heavy
bleeding.

Mother was taught postnatal exercises like Kegel’s exercises and advised to continue doing
them.

Mother was advised to take plenty of fluids like juice from fruits like mangoes, passion, pawpaw
fruit; to drink plenty of water at least 8 glasses per day.

Mother was advised to maintain good personal hygiene, baby hygiene and home sanitation.

Mother was advised to have enough rest and to have somebody she trusts to help her with
domestic work.

Mother was advised about family planning.

Mother was advised to come back together with baby for postnatal examination at 6 weeks
postpartum that is on 21/ 04/2019.

Mother taught how to care for the cord and advised to maintain cord care for the baby.

Mother was taught danger signs in neonates like convulsion, poor feeding, lethargy, high fever
and so on and advised to be cautious of them and to return to the hospital if she notices any of
them.

Mother was advised to breastfeed the baby exclusively for 6 weeks without introducing
supplementary foods yet.

She was advised to wash baby’s clothes separately and hang them on a wire not on grasses.

She was taught breast and hand hygiene and advised to practice it whenever she’s going to
breastfeed the baby.