1.
PATIENT PARTICULARS:
NAME: Mrs. ABC
AGE: 28y
ADDRESS: Magadi, Bengaluru
EDUCATION: BA
OCCUPATION: Teacher
HUSBAND DETAILS: XYZ, 30y, businessman, B. Com, 40,000/month.
SOCIOECONOMIC STATUS: Upper Middle
LMP: 07/08/2023
EDD: 14/05/2024
GESTATIONAL AGE: 38 weeks 7 days
DOA: 07/05/2024
DOE: 07/05/2024
2. CHIEF COMPLAINTS:
G2P1L1A0 with 9 months of amenorrhea came for regular antenatal check-up
with no other complaints.
No history of pain abdomen, head ache, blurring of vision, swelling of legs,
bleed or leak PV. Fetal movements well perceived.
3. OBSTETRIC HISTORY:
Index: G2P1L1A0
4. HISTORY OF PRESENT PREGNANCY:
LMP: 07/08/2019
EDD: 14/05/2020
Booked case at Vani Vilas hospital, Bengaluru.
FIRST TRIMESTER:
Pregnancy was confirmed after one month of missed periods at hospital by
UPT.
History of spontaneous conception.
1st trimester scan (dating scan) was done and found to be normal and
corresponding with dates.
Folic acid tablets were taken.
No h/o burning micturition.
No h/o fever with rashes, excessive vomiting.
No h/o spotting or bleeding per vagina.
No h/o pain abdomen.
No h/o exposure to radiation and drug intake.
Regular ANC was done, weight gain was 1kg.
SECOND TRIMESTER:
Quickening was felt at 5th month.
2nd trimester scan (Anomaly Scan) was done and found to be normal.
2 doses tetanus toxoid were taken.
Iron and calcium tablets taken; weight gain was 6 kg.
No h/o fever, increased frequency/burning of micturition.
No h/o pedal edema, blurring of vision, headache.
No h/o of pain abdomen, leaking or bleeding per vagina.
THIRD TRIMESTER:
Continued perception of fetal movements.
Iron and calcium tablets taken; weight gain was 5 kg.
Obstetric scan was done and found to be normal.
No h/o fever, increased frequency/burning of micturition.
No h/o pedal edema, blurring of vision, headache.
No h/o of pain abdomen, leaking or bleeding per vagina.
5. HISTORY OF PREVIOUS PREGNANCY:
FIRST PREGNANCY
Antenatal events -uneventful, booked case at government hospital.
Perinatal details -Term baby, institutional delivery by caesarean section 3
years back on 05/05/2017.
Indication: breech presentation with fetal distress (MSAF)
Emergency LSCS at 39 weeks when patient had come with decreased
perception of fetal movements.
Baby cried immediately after birth, breast fed after 1hr, no h/o NICU
admission.
Outcome: Alive boy baby of 3kg birth weight, currently healthy and doing
well.
No fever or wound discharge in post operative period, sutures removed on
7th day.
Postnatal events – uneventful
6. MENSTRUAL HISTORY:
Age of attainment of menarche -13 years
Regular cycle of 28 to 30 days, flow for 4-5 days, changes 2-3 pads per day.
Not associated with dysmenorrhea, No h/o of passage of clots.
7. PAST HISTORY:
No h/o blood transfusion in the past
No h/o any recent surgery
Not known case of Hypertension, Diabetes mellitus, asthma, TB, epilepsy.
8. MARITAL HISTORY: Married life of 5 years and Non consanguineous
marriage.
9. CONTRACEPTIVE HISTORY: Oral Contraceptive Pills before first
pregnancy later barrier method (condom).
10. FAMILY HISTORY:
No history bleeding disorder.
No history of children with chromosomal anomaly/ birth defect.
No history of twining in the family.
No h/o Hypertension, Diabetes mellitus, asthma, TB, epilepsy.
11. PERSONAL HISTORY:
Diet -mixed
Appetite -normal
Sleep - adequate
Bowel and bladder -regular
No history of substance abuse
12. EXAMINATION
GENERAL PHYSICAL EXAMINATION
Patient is conscious, cooperative well oriented to time, place, and person
Vitals:
Patient is afebrile
Pulse - 90/min regular rhythm, normal volume, normal character, vessel wall
is not palpable and all peripheral pulse are felt.
Blood pressure -120/80mmhg right arm, supine position.
Respiratory rate -16/minute
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.
Height -160 cm
Pre pregnancy Weight -61 kg
Present weight -73 kg
BMI –23.8 kg/m2
HEAD TO TOE EXAMINATION:
Thyroid appears normal.
Breast examination shows normal changes of pregnancy.
Spine appears normal.
OBSTETRIC EXAMINATION
Position – Supine with legs semi-flexed
INSPECTION
Shape of the abdomen -distended and appears longitudinally oval with
fullness of flanks.
Corresponding quadrants moves equally with respiration.
Umbilicus is central and everted.
Linea nigra and stria gravidarum present.
No sinuses or dilated veins can be seen.
Hernial orifices are intact.
A horizontal scar of 10 cm noted about 3 cm above the pubic symphysis,
healed by primary intention without hypertrophy and keloid formation.
PALPATION:
No local rise of temperature or tenderness with relaxed uterus.
Abdominal girth is 102 cm, at the level of umbilicus.
Fundal height corresponds to period of gestation (32-34 weeks with flanks
full)
Symphysio-fundal height is 34cm, corresponds to gestational age.
OBSTETRIC GRIPS:
Fundal grip: broad, soft, irregular mass suggestive of breech.
Right Lateral grip: uniform curved resistance suggestive of spine.
Left lateral grip: multiple knob-like structures suggestive of fetal limb parts.
1stpelvic grip: hard non ballotable mass suggestive of fetal head.
2ndpelvic grip: fingers converge.
No scar tenderness.
AUSCULTATION:
FHS heard along right spino-umbilical line, rate -142/min
SYSTEMIC EXAMINATION:
Cardiovascular System: S1, S2 heard, no murmurs heard.
Respiratory system: Normal vesicular breaths sound. No added sounds.
Central nervous system: clinically no abnormality detected.
13. SUMMARY
28-year-old Mrs ABC, who is G2P1L1A0, LMP-07/08/2023, EDD-14/05/2024
and gestational age of 38 weeks 7 days presented for her regular antenatal
checkup. Also has a history of previous LSCS. She is a booked and
immunised case with regular ANC. Examination revealed a single live term
pregnant uterus with longitudinal lie and cephalic presentation.
14. PROVISONAL DIAGNOSIS:
A 28-year-old lady with obstetric index G2P1L1A0 with 38 weeks 7 days period
of gestation with live singleton intrauterine pregnancy, Longitudinal lie and
Cephalic presentation with previous LSCS, not in labour (or in labour pain,
admitted for safe confinement)
Follow ACOG Practice Guidelines
Education And Counselling
Preconceptionally
Provide ACOG Patient Pamphlet
Early During Prenatal Care
Develop Preliminary Plan
Revisit At Least Each Trimester
Be Willing To Alter Decision
Have Facilities Availability
Risk Assessment
Review Previous Operative Note(s)
Review Relative And Absolute Contraindications
Reconsider Risks As Pregnancy Progresses
Tread Carefully: >1 Prior Transverse CD, Unknown Incision, Twins,
Macrosomia
Labor And Delivery
Cautions For Induction unfavourable Cervix, High Station
Consider AROM
Avoid Prostaglandins
Respect Oxytocin know When To Quit
Beware Of Abnormal Labor Progress
Respect EFM Pattern Abnormalities
Know When To Abandon A Trial Of Labor
The Qureshi Grading System is utilized to evaluate the integrity of the lower
uterine segment (LUS) scar following a Cesarean section (C-section). It aids in
assessing the risk of uterine rupture during subsequent pregnancies or trial of
labor after cesarean section (TOLAC). The grades include:
Grade Description Risk Level Management
Grade Well-developed LUS scar Normal and
Standard monitoring
I (>3 mm thickness) Safest
Thin LUS scar (<3 mm Relatively Safe, Continued monitoring,
Grade
thickness), underlying Monitor consider additional
II
uterine contents not visible Further precautions
Scar dehiscence with
High-Risk, Immediate
Grade thinning and bulging of the
Repeat C- consideration of a
III LUS, underlying uterine
section Likely repeat C-section
contents visible
Complete uterine rupture
Life-
Grade with a large defect in the Immediate surgical
Threatening
IV LUS, exposing the intervention
Emergency
abdominal cavity
Factors affecting Qureshi Grade:
A. Number of previous C-sections: Higher number increases the risk of a thin
or dehiscent scar.
B. Type of previous C-section: Transverse lower segment C-section has a
lower risk compared to a classical C-section.
C. Time interval since the last C-section: Longer intervals allow for better scar
healing.
D. Presence of other risk factors: Placenta previa, placenta accreta, and
macrosomia increase the risk of uterine rupture.
Clinical Use:
• Preconception counselling: Evaluates LUS scar through ultrasound for
risk assessment.
• Intrapartum management: Monitors women with thin or dehiscent
scars closely during labour, considering C-section if necessary.
• Surgical decision-making: Guides surgeons in deciding TOLAC or repeat
C-section.
Limitations:
• Visual assessment basis: Does not consider factors affecting scar
integrity, such as tissue healing quality.
• Ultrasound reliability: May not always detect subtle scar abnormalities.
Overall, the Qureshi Grading System is a valuable tool for clinical decision-
making and improving outcomes in post-C-section pregnancies.
