Atul Pardeshi 3-20

Case history of Labor

I. General information

1. Patient: Olga Petrova

2. Age: 31 years

3. Parity: Second pregnancy, first birth

4. Time of admission: Jan 17, 2024 at 11:45 am

5. Complaints on admission: Contractions every 5 minutes since 9 am. Rupture of membranes at

11:30 am with meconium-stained fluid.

II. ANAMNESIS OF LIFE

1. No significant childhood diseases. Diagnosed with mild asthma at age 25, uses albuterol inhaler as
needed.

2. No history of injuries, fractures or operations.

3. No high degree myopia or eye surgeries.

4. Appendicectomy age 15, spinal anesthesia without complications.

5. Penicillin allergy - hives.

6. No hormonal drug use.

7. No blood transfusions.

8. Does not smoke or use alcohol or drugs.

9. Husband 35 years old, healthy, no bad habits.

III. Gynecological history

Menstrual function:

1. Menarche age 13, regular 30 day cycles, 5 days duration, moderate flow, no pain.

2. LMP April 12, 2023.

Sexual function:

First intercourse age 18. Married. Uses oral contraceptive pills previously.

No history of gynecological diseases, infections or surgeries.

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IV. Obstetrical history

First pregnancy in 2020, miscarriage at 10 weeks.

V. This pregnancy

First prenatal visit at 8 weeks. Normal prenatal course. Screening tests normal.

Gestational diabetes diagnosed at 28 weeks, diet controlled.

Currently 39 weeks by LMP and early ultrasounds. Gained 16 kg.

VI. Objective examination

General:

- Height: 162 cm

- Weight: 80 kg, BMI 30 kg/m2

- Afebrile

- No edema

- No abdominal scars

- No varicose veins

- BP 130/86, Pulse 88, RR 18

- Heart and lungs normal

- Normal urinary and bowel function

Obstetric:

1) Abdomen:

- Fundal height 37 cm

- Estimated fetal weight 3300 g

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2) Leopold's:

- Cephalic presentation, head 3/5 palpable, engaged

- Fetal back right side

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- Head ballottable

- Adequate pelvis

3) FHR baseline 155 bpm with minimal variability, no accelerations

4) Vaginal exam:

- Normal vulva/vagina

- Cervix 4 cm dilated, 70% effaced, soft

- Vertex at -1 station

- Meconium-stained fluid

- Vertex presentation

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VII. Clinical diagnosis:

Pregnancy 39 weeks. Cephalic presentation. Labor in active phase. Meconium-stained amniotic fluid.
Fetal distress.

VIII. Labor management plan:

Continuous FHR monitoring. IV access and fluid bolus. Prepare for possible operative delivery.

IX. Labor course:

I stage: Began at 9 am with contractions every 5 min. At 2 pm cervix dilated to 6 cm. FHR showed
recurrent variable decelerations. Started oxytocin augmentation. Emergency cesarean performed
under spinal anesthesia at 2:30 pm for nonreassuring FHR. Female infant delivered at 2:45 pm,
weighing 3400 g. Apgars 7 and 9. Thick meconium present. NICU attended delivery.

Placenta complete. Estimated blood loss 800 mL.

X. Postpartum course:

1 day postpartum: Mother doing well, afebrile. Incision clean, dry. Uterus firm. Lochia rubra normal.
Voided. Colostrum expressed from breasts. Infant transferred to NICU for observation due to
meconium aspiration.

2 days postpartum: Mother recovering well, ambulating. Incision healing well. Lochia
serosanguineous now. Breasts engorged, nipple care explained. Pumping breastmilk for infant in
NICU. Infant improving, may transfer out of NICU soon.

3 days postpartum: Mother and infant doing well. Both tolerating feeds. Lochia changing to lochia
alba. Mother discharged home with instructions to follow up with obstetrician in 2 weeks. Infant to
remain in NICU 2-3 more days then discharged.