Caesar Census July 2017

Dr. Komana & Dr. Evon

Supervisor: Dr. Azierah
 TOTAL DELIVERIES: 303
• VAGINAL DELIVERIES = 224 LSCS = 79
SVD TOTAL : 224 LSCS TOTAL : 79

SVD 208 ELLSCS 65

ABD 1 EMLSCS 11

INSTRUMENTAL 15 SEMI-LSCS 3

1. VACUUM 15

2. FORCEPS 0
 TOTAL DELIVERIES: 303
3 1
0.9% 0.3%

65
21.4%
SVD
VACUUM
11 ELLSCS
3.6% EMLSCS
15 208 SEMI ELLSCS
4.9% 69%
ABD
EPISIOTOMY RATE: 32%

32%

EPISIOTOMY
VAGINAL DELIVERIES

68%
Episiotomy: Primigravida vs Multigravida

32%

68% PRIMIGRVIDA
MULTIGRAVIDA
ELLSCS VS EMLSCS VS SEMI-ELLSCS

4%
14%

ELLSCS
82% EMLSCS
SEMI-ELLSCS
 INSTRUMENTAL DELIVERIES
16

14

12

10

8
15 Series 1
6

0
VACUUM
COMPLICATED VS UNCOMPLICATED
VAGINAL DELIVERIES
12%

COMPLICATED
UNCOMPLICATED
88%
COMPLICATED VAGINAL DELIVERIES

3.80%

PPH
SHOULDER DYSTOCIA
96.20%
 PPH IN VAGINAL DELIVERIES
Series 1
80%
72%
70%
60%
50%
40%
30%
20%
20%
10% 8%

0%
>500CC >1000-1500CC >1500CC
 COMPLICATED VAGINAL DELIVERIES
TOTAL 208 BLOOD LOSS NO OF CASES
500-1000cc 18
UNCOMPLICATED 182 • Primigravida 5

• Para 2-4 11
COMPLICATED 26
• >Para 5 2
>1000-1500cc 5
COMPLICATED 26 • Primigravida 2

• Para 2-4 3
PPH 25
500-1000cc 18 • >Para 5 0
>1500cc 2
>1000-1500 5 • Primigravida 0

• Para 2-4 2
>1500 2
• >Para 5 0
SHOULDER 1
DYSTOCIA
 PPH BREAKDOWN
PPH RETAINED UTERINE MULTIPLE THROMBIN
PLACENTA ATONY VAGINAL
WALL TEAR

500-1000cc 3 12 3 0

1 2 2 0
1000-1500cc

>1500cc 1 1 0 0
 SHOULDER DYSTOCIA
• CASE 1
– EBW : 3.2-3.4kg
- BW by scan : 3.4kg
- BW : 3.1KG
 ELECTIVE LSCS: 11
CAUSES NO OF CASES
2 PREVIOUS SCAR 1

BREECH PRESENTATION 4
2 cases with 1 prev scar
1 with oligo
1 fail ecv
DCDA TWINS 1

MATERNAL REQUEST- refused trial of scar 1

PLACENTA PREVIA TYPE II posterior 3

TRANSVERSE LIE 1
 SEMI- ELSCS: 3
CAUSES NO OF CASES

TRANSVERSE LIE 1

MACROSOMIC BABY 2
 EMERGENCY LSCS : 65
CAUSES NO OF CASES
FETAL DISTRESS 15
POOR PROGRESS 14
FAILED IOL 6
BREECH IN LABOR 9
SECONDARY ARREST 9
UNSTABLE LIE IN LABOR 1
PP TYPE II IN LABOR 1
PP TYPE III IN LABOR 1
REFUSED TRIAL OF SCAR in labor 4
2 PREVIOUS SCAR IN LABOR 4
MCMA TWINS IN LABOR 1
EMLSCS DATE DELIVERED ELLSCS DATE GIVEN
2 PREVIOUS SCAR IN LABOR 20/7/2017 @36W2D 2/8/2017

2 PREVIOUS SCAR IN LABOR 31/07/17 @ 34W6D To deliever at HSAJB

-baby passed
away@1244H
-grossly dysmorphic
features noted
2 PREVIOUS SCAR IN LABOR 6/7/2017 @37w NIL

2 PREVIOUS SCAR IN LABOR 2/7/2017@37W6D 5/7/2017

 EMLSCS for fetal distress
INDICATORS NO OF CASES

13
CTG
CTG + MECONIUM 2
 SEMI ELLSCS for suspected macrosomic
baby
• Case 1
-EFW : 3.6-3.8kg
- BW by scan : 3.88kg
-BW : 4.2kg

• Case 2
– EFW: 3.8-4.0kg
– BW by scan : 4.23kg
– BW :2.95
 ADMISSION TO SCN
INDICATION NO OF CASES
TTN 16
POST VACUUM 6
MAS 5
MACROSOMIC BABY 2
GBS +VE MOTHER 3
PREMATURITY 8
SHOULDER DYSTOCIA 1
LBW 4
UNBOOKED UNSCREENED 1
MATERNAL PYREXIA 1
MOTHER GDM ON INSULIN 1
 ADVERSE BABY OUTCOME
TYPE NO OF CASES
IUD 2

LOW AS 3
 Case Presentation 1
• Date of admission: 2/7/17
• 31 year old G2P1 @ 32w2d POG admitted for
placental abruption
• ANC: uneventful
 Case Presentation 1
2/7/17 Patient came in PAC @ 1630H with complaint of contraction pain since
1700H 1000H associated with PV bleeding @ 1000H and reduced fetal movement.
PAC She perceived her last fetal kick @ 1000H.
Otherwise she had no LL, no hx of trauma/ fall/massage, no anemic sx
Upon arrival to PAC, her vital signs was normotensive, not tachycardic.
However she appeared pallor (clinically Hb 6) (booking Hb 15)
Vital sign Bp:113/69, Hr:87, T:37, Sp02:99% RA
Cvs:DRNM
Lungs:clear
P/A: tense tender abdomen
ut @ 36w
S C 3/5
EFW 2.4-2.6kg
Liqour adequate
FH absent
 Case Presentation 1
Per speculum revealed blood oozing from os
TAS: S C
FH absent
Placental Anterior with retroplacental clots
parameter 32-33w
AFI 9.8cm
EFW 2.13kg
VE: VV NAD
cx 0.5cm
os 2cm
MI
St -2
vx
no cord,no placenta

Urine albumin 2+
 Case Presentation 1
FBC/RP/Coag taken STAT on admission
ABG: pH 7.47/pCO2 29/pO2 111/lact 1.1/Hco3 23/ Hb 7.6

∆ IUD secondary to placental abruption

Plan:
1) To send pt to LR for ARM and pitocin augmentation
2) To transfuse 2pint PC and 1 cycle DIVC
3) 2 large bore branulla
4) Insert CBD for strict I/o
5) V/s monitoring every 15mins
6) Run 1 pint NS/ 1 hour
 Case Presentation 1
2//7/17 Patient transferred from PAC to LR.
1715H Blood products not yet available.
LR
Vital sign: bp 113/6, hr71

Plan: for ARM after blood transfusion ongoing

 Case Presentation 1
2/7/17 Blood products arrived
1725H Ongoing first pint pc && first unit of plt transfusion
LR vital signs: bp 113/75, hr 77
p//a: tense
ut @ 36w
S C 3/5
efw 2.4-2.6kg

VE: VV NAD
cx 0.5cm
os 2cm
MI -> ARM -> 500cc blood stained liquor
St -2
vx
no cord,no placenta

Fbc: hb 7.9/wbc 17/ plt 115

RP/coag: pending result

Plan: 1) nrve in 4H @ 2125H

 Case Presentation 1
2/7/17 5mins in labour,not augmented
1730H Noted CTG tracing toco irregular contraction, uncoordinated

Plan: 1) start iv pitocin ½ u and titrate accordingly until contraction 4:10

strong

2/7/17 1½ H in labour, ½ H augmented, contraction 2:10:15, ongoing 2nd pint pc

1845H transfusion, completed 1 cycle of DIVC.Denied SOB/chest pain/palpitation
Vital signs remained stable : bp 124/8, HR 87, T 37, SpO2 99% RA
CVS DRNM
Lungs clear
p/a: tense
ut @ 36w
S C 3/5
efw 2.4-2.6kg
 Case Presentation 1
VE: VV NAD
cx effaced
os 2cm
MA->blood stained liquor
St -2
vx
no cord,no placenta
Noted utricaria rashes over both upper limbs and lower limbs

Case d/w Dr Suhana regarding pt’s utricaria rashes likely seondary to blood
transfusion reaction.was informed that as long as no respiratory failure
and vital sign stable,may continue blood transfusion with iv hydrocortisone
coverage with strict vital sign monitoring every 15mins

Rp: urea 2.7/ Na139/ K 4/ creat 52

Coagulation: pt 37/aptt 66/ inr 3.87

Plan: 1) to transfuse 2nd cycle of DIVC

2) repeat fbc and coagulation profile after completing 2nd cycle of
DIVC
3) NRVE as planned @ 2125H
 Case Presentation 1
• CTG post pitocin @ 1800H
• Toco 2-3:10
 Case Presentation 1
2/7/17 1 3/4 H in labour and augmented, contraction 2:10:25.
1900H Completed 1st cycle DIVC and ongoing 2nd pint pc transfusion
LR Developed mild allergic transfusion reaction, no SOB, no chest pain
Vital sign stable BP 120/65, HR 81, T 37, Sp02 100% RA
p/a: tense and tender
ut @ 36w
S C 3/5
Efw 2.4-2.6kg

VE: VV NAD
cx effaced
os 3cm
MA->blood stained liquour
St -2
vx
no cord,no placenta

TAS: S C, FH absent
Huge retroplacental clot from right lateral towards fundal
 Case Presentation 1
Plan: 1) NRVE as planned @ 2125H
2) To transfuse 3rd pint pc and 2 unit FFP
3) repeat fbc and coagulation 1H post total transfusion
4) aim for delivery within 6-8H
5) w/o for worsening blood transfusion reaction or fluid
overload symptoms
 Case Presentation 1
• CTG @ 1900H
• Toco 3:10
 Case Presentation 1
2/7/17 2 ½ H in labour and augmented, contraction 5:10:45
2045H Completed 1 cycle DIVC+ 2 u FFP, ongoing 2nd pint pc transfusion
LR Clinically pallor
Vital signs stable BP 115/66 HR 74 T 37 SpO2 100% RA
p/a: tense and tender
ut @ 36w
S C 2/5
efw 2.4-2.6kg

VE: VV NAD
cx effaced
os 5cm
MA->blood stained liquour
St -1
vx
no cord,no placenta

Plan: 1) NRVE @ 0025H

2) off IV pitocin
3) specialist to standby during 2nd stage of labour
 Case Presentation 1
• CTG @ 2020H
• Toco 5:10
 Case Presentation 1
2/7//17 Patient complains of bearing down after 4 ½ H in labor , Os fully @ 2145H
2145H Vital signs BP 121/75. HR 85 T 37 SpO2 100% RA
LR p/a: tense and tender
ut @ 36w
S C head not palpable
efw 2.4-2.6kg

VE: VV NAD
cx not felt
os fully
MA->blood stained liquour
St +2
vx
no cord,no placenta

Baby delivered via SVD wt 1.75kg

Perineum intact
Placenta delivered spontaneously without CCT
Retroplacental blood clot 2.4L
 Case Presentation 1
IM syntometrine x 2 given
IM hemabate x 1 given
Continuous uterine massage done
IV pitocin 80u ongoing

Bakri balloon inserted @ 2200H under ultrasound guidance, inflated with

270cc distilled water

Total EBL 3L

3rd pint pc given upon delivery of the baby

Vital sign after Bakri balloon insertion

BP 138/89, HR 78 T 37 SpO2 100% RA

Plan: 1) Keep pt in LR for close monitoring

2) To transfuse 4th pint pc after the current 3rd pint pc
3) Repeat FBC, RP, coagulation profile & ABG STAT
4) for Bakri balloon removal within 24H from insertion
5) to repeat IV pitocin 40u 1 H prior to removal of Bakri balloon
6) IV zinacef 750mg TDS and IV flagyl 500mg TDS
 Case Presentation 1
Plan: 1) keep pt in LR for close monitoring
2) To transfuse 4th pint pc after the current 3rd pint pc
3) Repeat FBC, RP, coagulation profile & ABG STAT
4) for bakri balloon removal within 24H from insertion
5) to repeat IV pitocin 40u 1 H prior to removal of bakri balloon
6) IV zinacef 750mg TDS and iv flagyl 500mg TDS

3/7/17 Blood ix taken STAT after delivery:

0020H FBC: HB 5.9/ wbc 13/ plt 43
LR RP: urea 2.5/ Na 140/ K 3.36/ creat 45
Uric acid 200/ ALT 14/ AST 31
Coag: PT 19/ aptt 50/ inr 1.72
ABG: pH 7.41/pCO2 32/ pO2 167/ HCO3 21/ lact 2.8/Hb 5.8

Plan: 1) to transfuse 4th pint pc and 2 unit platelets

2) repeat fbc and coagulation 6H post transfusion
 Case Presentation 1
3/7//17 32 year old para 2 ( 1 living child)
0840H ∆ 1) 12H post SVD complicated with APH and PPH for grade 4 placental
LR abruption and uterine atony with IUD

EBL 3L
Hb 7.9 -> 8.0
WBC 17 -> 15.6
PLT 115 -> 69

Total transfusion: 4 pint packed cell

4 unit platelets
6 unit ffp
6 unit cryo
∆ 2) treat as PE
Booking bp 110/70
Ufeme albumin @ 27week 4+ -> repeated negative
BP on arrival 106/65
 Case Presentation 1
Currently pt comfortable,no anemic sx, no giddiness, no IE sx
Clinically not pale
Vital sign BP 112/64 HR 64 T 37 SpO2 100% RA
Cvs: DRNM
Lungs Clear
p/a: soft non tender
ut @ 20w contracted

No calf tenderness

Bakri balloon removed

Bimanual ut @ 18w contracted

Adnexal/POD free
Noted cervical laceration @ 9 o’clock position, sutured with vicryl 2/0,
no active bleeding,
 Case Presentation 1
Plan: 1) review back pm
if pt remains asymptomatic,bp within normal range, may allow
transfer to gynae ward 9
2) tab Carbegoline 0.5mg stat and BD x 1/7
3) cont IV zinacef 750mg TDS
IV flagyl 500mg TDS
t.iberet I/I OD
4) keep CBD first
5) TED stocking

3/7/17 Pt remained well and comfortable, no anemic sx, no IE sx

1600H V/s stable
LR -> allowed transfer to gynae ward 9
 Case Presentation 1
4/7/17 32 year old para 2 ( 1 living child)
1000H ∆ 1) D1+ post SVD complicated with APH and PPH for grade 4 placental
W9 abruption and uterine atony with IUD

EBL 3L
Hb 7.9 -> 8.0 -> 5.8
WBC 17 -> 15.6 ->12
PLT 115 -> 69 ->76

Total transfusion: 4 pint packed cell

4 unit platelets
6 unit ffp
6 unit cryo
∆ 2) treat as PE
Booking bp 110/70
Ufeme albumin @ 27week 4+ -> repeated negative
BP on arrival 106/65
 Case Presentation 1
Pt remained comfortable,no anemic sx, no giddiness, no IE sx
Clinically not pale
Vital sign BP 112/64 HR 64 T 37 SpO2 100% RA
Cvs: DRNM
Lungs Clear
p/a: soft non tender
ut @ 18w contracted
No calf tenderness
Contraception: im depo

Plan: 1) keep pt till d5 post delivery

2) to collect 24H urine protein
3) for early booking in next pregnancy
4) for aspirin & CaCo3 in next pregnancy
5) daily FBC to look at platelet trends
6) cont PE charting
 Case Presentation 1
5/7/17 32 year old para 2 ( 1 living child)
1150H ∆ 1) D2+ post SVD complicated with APH and PPH for grade 4 placental
W9 abruption and uterine atony with IUD
∆ 2) treat as PE

EBL 3L
Hb 7.9 -> 8.0 -> 5.8 -> 6.0 Total transfusion: 4 pint pc
WBC 17 -> 15.6 ->12 ->8.3 4 u platelets
PLT 115 -> 69 ->76 ->96 6 unit ffp
6 unit cryo
Pt remained comfortable,no anemic sx, no giddiness, no IE sx
Clinically not pale
Vital sign BP 136/89 HR 64 T 37 SpO2 100% RA
Cvs: DRNM
Lungs Clear
p/a: soft non tender
ut @ 16w contracted
No calf tenderness
Plan: 1) for iv venofer 200mg OD for 3/7
 Case Presentation 1
7/7/17 32 year old para 2 ( 1 living child)
1530H ∆ 1) D4+ post SVD complicated with APH and PPH for grade 4 placental
W9 abruption and uterine atony with IUD
∆ 2) treat as PE

EBL 3L
Hb 7.9 -> 8.0 -> 5.8 -> 6.0->6.3 -> 7.3 Total transfusion: 4 pint pc
WBC 17 -> 15.6->12 ->8.3 ->8.3 ->9.1 4 u platelets
PLT 115 -> 69->76 ->96 ->137 ->201 6 unit ffp
6 unit cryo
*completed 3 doses of iv venofer*
Pt remained comfortable,no anemic sx, no giddiness, no IE sx
Clinically not pale
Vital sign BP 136/89 HR 64 T 37 SpO2 100% RA
Cvs: DRNM
Lungs Clear
p/a: soft non tender
ut @ 16w contracted
No calf tenderness

Urine albumin nil

 Case Presentation 1
Plan:
1)Allow D with advice
2)D with t.zinnat 250mg BD x 3/7
t.flagyl 00mg TDS x 3/7
t.iberet I/I OD x 1/12
3)TCA KP1 x 2/52 with fbc on arrival and to review 2H urine protein
4)Memo to KK for homevisit and EOD BP monitoring
 Case Presentation 1
23/7/17 32 year old para 2 ( 1 living child)
KP1 ∆ 1) Day 21 post SVD with APH secondary to grade 4 placental
abruption complicated with IUD and PPH secondary to uterine atony
(requiring blood transfusion and DIVC cycle)
∆ 2) treat as PE

Pt remained comfortable,no anemic sx, no giddiness, no IE sx

Clinically pink
EOP BP monitoring at KK was ranging from 120 to 130 over 80
Hb upon arrival was 12 with platelet 347

24H urine protein: 0.11g

 Case Presentation 2
• Date of admission: 8/7/17
• 28 year old G1P0 @ 39w5d POG admitted for
early phase of labour
• ANC: GDM on diet Dx @ 37w with MGTT: 5.6/11.3
modification HbA1c: not taken
Latest BSP @39w: 5.1/4.9/6.6/5.6
Maternal obesity Bookimg BMI: 32.5
Latest BMI: 36.4
Bronchial asthma On MDI ventolin 2p PRN
Last attack during early pregnancy
Mild anemia in Booking Hb: 14.5
pregnancy dx@36w with HB 10
On t.iberet I/I OD
Latest HB @ 39w:10.5
Not investigated
 Case Presentation 2
8/7/17 Pt came to PAC with complaints of contraction pain since 0000H ~ 1:10,
0740H increasing frequency and intensity.Otherwise no show, no LL, good FM.
PAC Alert,not pale
Vital sign BP:125/71 mmHg HR:90 bpm T:37
Per abdomen: soft non tender
ut @ 38week SFH 38cm
Singleton cephalic 3/5
EFW: 3.2-3.4kg
Liquor adequate
FHR: 142
VE: VV NAD
Cx 2cm
Os 1cm
MI
St -2
Vx
No cord no placenta
 Case Presentation 2
Scan @ 39w 5d POG:
TAS: S C
FH shown to mother
parameter 37-38w
placenta AUS
AFI 11
EFW: 3.4kg

Patient was then admitted to ward 10 for observation in view of her

express of worry regarding the increasing intensity of the contraction
pain and logistic issue (Patient lived in Chaah and no convenient
transportation available all times)
Explained to patient also regarding her current condition that she was
in early labour and would be observed for contraction timing and
regular VE. However if she was still not delivered by by EDD, would
proceed with IOL in view of GDM on diet modification. Patient
understood and keen for admission.
 Case Presentation 2
• Date: 9/7/177 (D1 of admission @ 39w6d POG)
9/7/17 During morning ward round
0945H Patient complains of contraction pain 2:10:20
W10 Per abdomen: soft non tender
ut @ term
S C 3/5
EFW: 3.4-3.6kg
Liquor adequate
FHR 145
VE: VV NAD
cx 1cm soft axial
os 4cm
St -2
MI -> SROM during VE -> LMSL
Vx
No cord no placenta

Plan: 1) Patient was then sent to LR for delivery

2) IV hydrocortisone 200mg STAT and 100mg QID intrapartum
3) Refer peads standby for LMSL
4) Delivery in lithomy position
 Case Presentation 2
• CTG prior to morning round
• Reactive, toco 2 in 10
 Case Presentation 2
9/7/17 Patient arrived in LR
1015H Contraction 2:10, still LL (LMSL), FM good
LR P/A: soft non tender
ut @ term
S C 3/5
EFW: 3.4-3.6
FHR 140
VE: VV NAD
cx 1cm
os 4cm
MA -> LMSL
St -2
vx
no cord,no placenta
 Case Presentation 2
Plan: 1) ctg in LR
2)NRVE in 1H, if no progress in cervical dilataion/contraction not
optimised/CTG reactive, to start Iv pitocin 2 u and titrate accordingly
until contraction 4: 10 strong
3)To refer peads standby for LMSL
4)Delivery in lithotomy position
5)GM 2Hly,if GM>7, to start ivi insulin sliding scale
6)time contraction, monitor FHR
7)IV hydrocortisone 200mg STAT and 100mg QID
 Case Presentation 2
CTG in LR:
Reactive, toco 2 in 10
 Case Presentation 2
9/7/17 1H in labour, not augmented, contraction 2:10:25, FM good
1115H P/A: : soft non tender
LR ut @ term
S C 3/5
EFW: 3.4-3.6
FHR 140
VE: VV NAD
cx 1cm
os 4cm
MA -> LMSL
St -2
vx
no cord,no placenta
 Case Presentation 2
Plan: 1) start Iv pitocin 2u and titrate accordingly until contraction 4:10
strong
2) ctg ½ H post pitocin
3) time contraction,monitor FHR
4) w/o for sign and symptoms of hyperstimulation
5) intermitent ctg tracing
6) peads standby for LMSL
7)Delivery in lithotomy position
8)GM 2Hly,if GM>7, to start ivi insulin sliding scale
9)IV hydrocortisone 100mg QID
 Case Presentation 2
• CTG post pitocin: reactive, toco 3:10
 Case Presentation 2
9/7/17 4 ½ H in labour, 3 ½ H augmented, contraction 4:10:45, FM good
1500H p/a: soft non tender
LR ut @ term
S C 2/5
EFW: 3.2-3.4
FHR 145
VE: VV NAD
cx 0.5cm
os 7cm
MA -> Liquor not demonstable
St -1
vx OT position small caput moulding grade I
no cord,no placenta

Ctg @ 1430H: Ctg reactive, toco 4:10

 Case Presentation 2
Plan: 1)maintain iv pitocin 2u 15dpm
2)hourly ctg tracing
3)Nrve @ 1815H/bearing down
4) peads standby for LMSL
5)Delivery in lithotomy position
6)GM 2Hly,if GM>7, to start ivi insulin sliding scale
7)IV hydrocortisone 100mg QID
 Case Presentation 2
• CTG @ 1430H
• Toco 4:10
 Case Presentation 2
• CTG @ 1550H: type 1 deceleration
• Toco 4:10
 Case Presentation 2
• CTG @ 1720H :
• Toco 4:10
 Case Presentation 2
97/17 8H in labour, 7H augmented, contraction 4:10 strong
1815H p/a: soft non tender
LR ut @ term
S C 1/5
EFW: 3.2-3.4
FHR 145
VE: VV NAD
cx effaced, anterior lip swelling
os 8cm
MA -> Liquor not demonstable
St 0
vx OT position small caput 1x1cm moulding grade I
no cord,no placenta
Plan: 1) nrve in 2H @ 2015H
2)Hly CTG
3)time contraction, monitor FHR
4)cont iv pitocin
5)peads standby for LMSL
5)Delivery in lithotomy position
6)GM 2Hly,if GM>7, to start ivi insulin sliding scale
7)IV hydrocortisone 100mg QID
 Case Presentation 2
• CTG @ 1900H: Ctg non reassuring
 Case Presentation 2
9/7/17 9 ½ H in labour, 8 ½ H augmented, contraction 4:10:45, good fm
2000H p/a: soft non tender
LR ut @ term
S C 0/5
EFW: 3.2-3.4
FHR 150
VE: VV NAD
cx not felt
os fully
MA -> Liquor not demonstable
St +1
vx OT position small caput 1x1cm moulding grade I
no cord,no placenta

Plan: 1)encourage pt to bear down with second stage CTG

2) delivery in lithotomy position
3)peads standby
 Case Presentation 2
9/7/17 Patient os fully for 10mins
2010H Noted ctg fetal bradycardia down to 80bpm with poor tracing
LR p/a: soft non tender
ut @ term
S C 0/5
EFW: 3.2-3.4
VE: VV NAD
cx not felt
os fully
MA -> Liquor not demonstable
St +1
vx OT position small caput 1x1cm moulding grade I
no cord,no placenta
Decided for VAD , kiwi cup applied @ 2012H,moderate traction x 2 applied
with every maternal push.
Head delivered @ 2017H, noted turtle neck sign, baby facing maternal left.
McRobert maneurver done to deliver anterior shoulder.
Baby was attended by peads mo, direct suction x 2 LMSL, AS 3@1,9@5,
cord VBG:pH 7.06, lactate 5.0. Baby then admitted to scn for risk of mas,
put under NPO2.
 Case Presentation 2
• CTG during second stage:
 Case Presentation 2
Noted intermittent uterine atony
Iv pitocin 5u bolus given
IV pitocin increased to 80u/6H
Subsequently uterus contracted

Perineal check:
Noted bleeding from right vaginal wall tear, bleeding secured with
hemostatic suture.
Left vaginal wall tear and episiotomy suture done.

∆ 28 year old para 1 post VAD for fetal bradycardia and shoulder
dystocia with episiotomy complicated with primary PPH secondary to
uterine atony and multiple vaginal wall tear
EBL: 800cc
 Case Presentation 2
11/7/17 ∆ 28 year old para 1 Day2 post VAD for fetal bradycardia and shoulder
1000H dystocia with episiotomy complicated with primary PPH secondary to
W10 uterine atony and multiple vaginal wall tear
EBL 800cc
preHb 11.8 -> 9.2
WBC: 10.8 -> 22.6
Plt:248 -> 243
Pt comfortable, no anemic sx, tolerating orally, ambulating, +PU, +passing
flatus

o/e: alert conscious not pale

v/s stabile
p/a:ut contracted @ 18week
No calf tenderness
Contraception: ocp

Patient was discharged well on D2 post partum

D meds: T.iberet I/I OD x 1/12
T.zinnat 250mg BD x 6/7
T.flagyl 400mg TDS x 6/7
S/c clexane 0mg OD x 8/7
 Case Presentation 2
Baby update
• Baby initially admitted to SCN for risk of MAS,
managed to wean off NPO2 after 2½ H, however
was covered for congenital pneumonia in view of
bibasal creps on ascultation, positive CXR findings
and raised white cell counts.
• Intrapartum shoulder dystocia but moro’s
complete and no obvious fracture seen on x-ray
• Subsequently baby was discharged well after
completion of abx for 5 days