Hello I am Dr Nadira Rahman ,one of the senior doctors in labour ward night shift .

May
I have your name please?

Hi I am ketie Devonshire,you can call me ketie.

Please feel free to call me Nadira.Could you please confirm your age?

I am 29 years old.

Ok.I understand from your notes that you are currently 31 weeks pregnant.So ,Ketie what
brings you here tonight?

I was awoken 1 hour before and thought I wet myself.I am feeling dump down below.

Are you concerned that it’s fluid around the baby?

Yes, I feel so as it is clear fluid & does not smell like urine.

I see.For how long you feel you are leaking?

Since 1 hour.

Is there any bleeding down below or pain in your tummy?

No .

Do you feel any fever or any bowel/bladder complaints(sp dysuria)

No.

Any foul smelling discharge down below?

No.

How about the baby’s movement?

Yeah,she is moving fine.

Well ,ketie I want to ask you few questions so that I know more about you & later I
want to examine you & I may order some tests. is that ok,ketie ?

Yeah.

Could you remember your LMP in this pregnancy?were your periods regular?

I can”t remember it rt now,its written in my notes,yes,my periods were regular.acc to my

LMP & my dating scan I am 31 weeks pregnant.

At which time did you book in this pregnancy?you told you had a dating scan.have you
had your routine screening tests & routine scan at 20 weeks as well telling everything
fine?

Yes,exactly so,I booked at 10 weeks,Also I had my folic acid at 1st 3 months in this
pregnancy.

That’s good.

What about booking blood tests?may I know your blood group?

All of my booking blood test were normal.My blood group is A positive.

Have you had any pregnancy before?

Well this is my first ongoing pregnancy,I had a miscarriage 6 month before whie I was
7 weeks pregnant.

Any complications about last miscarriage?did you require a evacuation?

No it spontaneously cleared.

Any medical/surgical history so far?

No,I am fine.

Any significant family history?No.

Are you updated with your smears?Yes.

Any specific drug allergies?No.

Do you smoke?No

Do you drink alcohol?very occasional one glass of wine.

How abt recreational drugs?No

Thanks for sharing the information with me.

I want check for your pulse,blood Pressure,temperature,examine your baby in your

tummy,would like to check baby’s heart beat with a Doppler.I want to examine you down
below with the help of a speculum that is an instrument used to separate the walls of the
vagina to look at your entrance to the womb see if the leaking fluid is amniotic fluid. With
this I will also be able to see if the cervix is changing in preparation for labour. A swab will
usually be taken at the time of the vaginal inspection to check for infection.

If its obvious from speculum examination that you are leaking fliud around your baby
no further tests should be done to come up to a Dx,however if it still doesn”t show your
water has broken I will offer a test of your vaginal fluid.I would like to do a usg to
check that your baby is fine & also its current position & amount of amniotic fluid.I
would like to do urine dipstick to check if it is fine.

So Your vitals are normal so as my examination in your tummy, & urine dipstick ,that’s
good news.My speculum exam confirms that you are leaking your fluid around the
baby,my examination & USG reveals your baby is currently bottom first/feet first
position in the womb which is called breech & one of the baby’s feet is below its
bottom which is called footling breech & your amniotic fluid is decreased.
Is Admission necessary?

I would like to advise you to admit initially for at least 48 hours to monitor the events like
your leaking amount,whether you develop pain or not,how remain your vitals,how your
baby coping.

The membranes form a protective barrier around the baby and, after these have broken, there is a
risk of infection getting into the womb that can trigger a premature birth.
The symptoms of infection include a raised temperature, an unusual vaginal discharge with an
unpleasant smell, a fast pulse rate and/or pain in your lower abdomen. Your baby’s heart rate
may also be faster than normal.If you have an infection, your baby may need to be born soon to
prevent a more serious infection. You blood will be checked to see some cell counts(WBC)
& other parameter(CRP) as well as symptoms .

Why do you take swab,I did not have any infection before,Do you think I am dirty?
I am sorry if my words came to you in that way.It”s to make sure there is no infection
ongoing as to take necessary measures in time. However, treatment may be offered to reduce
the risk of infection and to help reduce the risk of prematurity. This may include:
•A course of antibiotics ,its Erythromycin 250 mg 4times a day for 10 days to reduce both
the risk of an infection getting into the uterus (womb) and the risk of the baby being born too
early. Antibiotics also reduce the risks of infection in the baby.
•A course of two steroid injections 24 hours apart(corticosteroids) to help with your baby’s
development and reduce the chance of problems caused by being born early. Steroid drugs, also
known as corticosteroids, are synthetic forms of natural human hormones. When pregnant
women are given steroid injections, the medication travels to the baby’s body and lungs through
their bloodstream. Having steroid Rx mean to your baby she will have better chance of
survival,lower risks of breathing problems,much lower risk of bleeding in the brain,lower
risk of serious bowel condition known as NEC.
When should I seek help if I go home?
Well, I would like to advise you to admit because I am concerned about your your
baby’s position& less amniotic fluid & ,still if you decide to go home I would advise
you to contact your doctor or midwife and return to the hospital immediately if you experience
any of the following:
•raised temperature (more than 37 °C)
•flu-like symptoms (feeling hot and shivery)
•vaginal bleeding
•if the leaking fluid becomes greenish or smelly
•contractions
•abdominal pain
•if you are worried that the baby is not moving as normal.
Do the antibiotics have any side effects?
Most side-effects of antibiotics are not serious. Common side-effects include soft stools
(faeces), diarrhoea, or mild stomach upset such as feeling sick (nausea). Less commonly, some
people have an allergic reaction to an antibiotic and some have died from a severe allergic
reaction - this is very rare.
But common antibiotics that are generally considered safe during pregnancy include penicillins
(such as amoxicillin and ampicillin), cephalosporins (such ascephalexin), and erythromycin.
Erythromycin is commonly prescribed during pregnancy, with no known harmful effects for the
developing baby. 

Does the fact that my waters have broken mean that my baby will be born early?
Most women will go into labour themselves within the first week after their waters break.

What can be the problem if my baby born early?

Premature babies (born before 37 weeks) can have an increased risk of health problems,
particularly with breathing, feeding and infection. At 31 weeks,your baby is still immature at
birth and will require several weeks of NICU care, most 31 and 32 weekers quickly catch up to
their peers and have few long-term effects of prematurity.
Between 31 and 32 weeks, babies gain a lot of body fat. Premature babies born at this age may
be able to maintain a good body temperature without the help of an incubator.
Being a tertiary level hospital our neonatology department is well equipped,I may connect
to you with a neonatologist or you may have a neonatology tour once your condition
settled so that you can have more information in case the chance of your baby being born
early.
If I am having my labour pain how are you going me to treat?
We will be monitoring you for the s/s of preterm labour like pain in your
tummy/contractions.if we suspect this, you will be offering usg scan through your vagina
to detect length of entrance of womb as there can be shortening if labour starts .We used
to offer medicines to slow down labour in such cases but usually in patients with intact
membranes,for your case I am afraid it would not be a suitable option as your water
broke. I have already offered you steroid injection ,while you are in established labour, you
may be offered medicine called magnesium sulfate to help protect your baby's brain.Magnesium
sulfate is given through a drip until the baby is born or for 24 hours (whichever comes first). If
you have magnesium sulfate you will need regular tests, such as pulse and blood pressure
checks,to make sure it isn't causing you any problems.
Is erythromycin the right drug?I haven”t heard it before.surely penicillin based drug could
be the best?
(Impotance of antibiotics in structured viva-Preterm prelabour rupture of membranes (P-
PROM) is a major risk factor for intrauterine infection/chorioamnionitis, which itself can be the
cause of maternal sepsis (the leading direct cause of maternal death) and a major contributor to
neonatal morbidity (such as pneumonia) and neonatal mortality. ) The use of antibiotics
following PPROM is associated with a statistically significant reduction in chorioamnionitis,
Antibiotic therapy also delays delivery, thereby allowing sufficient time for prophylactic prenatal
corticosteroids to take effect. In summary, although antibiotics given to mothers with P-PROM
seem to have little effect on the long-term health outcomes of children, the short-term advantages
(reducing neonatal infection and delaying birth)
Both Oral erythromycin & oral penicillin can be the antibiotic of choice. there are
additional potential benefits of erythromycin as the choice of antibiotic in women with P-PROM.
Firstly, erythromycin is not reported to increase the risk of serious bowel injury known as
necrotising enterocolitis. Secondly, it can be administered orally to (target group B
streptococcus, other streptococcal and staphylococcal infections, bacteria relevant to early-onset
sepsis, and other micro-organisms)a number of organisms affecting the woman and baby
before labour. Thirdly, erythromycin offers a theoretical advantage (for the woman, rather than
the baby) in that it can counteract (mycoplasma infection)/some specific ifection that is
implicated in the early stages of (chorioamnionitis)/severe life threatening infection – this effect
is not seen with penicillins). Finally, the absorption of erythromycin across (the gastrointestinal
tract)/your digesting system and (the placenta)/afterbirth is limited, which suggests a potential
benefit in terms of minimising the baby's exposure to antibiotics.
Can my baby still be turned?
Unfortunately,the version to make your baby to head first position can”t be carried out
as your water broke.
When is the right time to give birth?
Once your waters have broken, carrying on with the pregnancy reduces the risk of your baby
having problems by being born prematurely but increases the risk of an infection getting into the
uterus.we both need to balance the risks & benefits as situation progress.While we will
try to reach at least 34 weeks after which we will deliver the baby provided that you &
your baby are doing fine,on the other hand if there is any concern about infection
/compromise condition of you/your baby ,we will deliver the baby irrespective of
gestation.
How will this affect a future pregnancy?
Having had your baby early means that you are at an increased risk of having a premature birth
in a future pregnancy compared with women who have never had a premature baby. However,
you are still more likely to have a baby born at more than 37 weeks next time.
You will be advised to be under the care of a consultant obstetrician in your next pregnancy, who
will discuss with you a plan for your pregnancy.
So what’s your plan for me?
As I said you need to admit & we will monitor your condition as well as your baby (vitals,baby”s
movement,Vag discharge,onset of pain) & will soon start antibiotics& steroids as explained.If you
get your labour pain early as most women do for you at footling breech with less liqor after
water broke at 31 weeks I would like to offer you caesarian section that is delivering the baby
through a cut into your tummy & womb.
Why caesarian?can you explain me more?
Of course,I will explain.As your baby is bottom first position with feet down below its
bottom,  Footling and kneeling breeches have a higher risk of cord prolapsed/prolapse of
connecting cord bet afterbirth & fetal tummy button and head entrapment/ the failure of the fetal
head to negotiate the maternal midpelvis. This complication severely diminishes oxygen flow to the baby and
the baby must be delivered immediately (usually by Caesarean section[18]) so that he or she can breathe. the
relative head size of a preterm baby is greater than the fetal buttocks. If the baby is preterm, it may be possible
for the baby’s body to emerge while the cervix has not dilated enough for the head to emerge.
 Most caesarean sections are lower segment caesarean sections. There is usually a horizontal
cut low down on your tummy, and then a horizontal cut across the lower part of the womb
(uterus). This type of section causes the least blood loss and has fewer complications for the
mother, as well as allowing her to consider a vaginal birth in the next pregnancy.

 A classical caesarean section involves cutting the womb longways. A low vertical incision
caesarean section is similar to a classical section, but the cut is as low as possible in the womb.
These types of caesarean section are sometimes performed at very early gestations (when the
lower segment of the uterus has not yet formed). It is more prone to complications, and any
woman who has had a classical section is usually advised to have an elective section in
subsequent pregnancies.

Have I answerwd all of your questions?

Yes

Do you have further questions?

No.

What do you think then?

I think I will admit.

Ok,I am arranging your admission & also involving a nurse into your care.I would like
to give you necessary information leaflet as I spoke to you in different matters so that
while resting you can read them & clear your thoughts & feel free to ask me if you
have any doubts,here is my number.thanks for your time.See you in pregnancy ward soon.

bye