ADMITTING CONFERENCE

Gibaltar, ClaireHautea, TereseValencia, SherylGabriel, Katrina

July 28, 2009

M.E.B

30 y/oMarriedRoman CatholicG1P0

Chief Complaint: Labor pains

PAST MEDICAL HISTORY(+) PTB in 2003

underwent 6 months of antiKoch’s Tx

(+) Endometriosis dx in 2003 Given DMPA injections and OCPs

(+) Bronchial asthma, non in acute exacerbation(+) Skin allergy to chicken(-) Hypertension(-) Diabetes mellitus(-) Thyroid problem(-) Cancer(-) Cardiac disease(-) Kidney disease(-) PTB

PERSONAL AND SOCIALNon-smokerNon-Alcoholic beverage drinkerPreviously employed as an audit

staff

FAMILY HISTORY(+) Hypertension – mother(+) Bronchial asthma – sibling(+) PTB - mother(-) DM(-) Thyroid Problem(-) CA(-) Kidney Disease

MENSTRUAL HISTORY

Menarche: 12 years oldInterval: monthly, regularDuration: 5 daysAmount: 2-3 pads per dayPain: (+) dysmenorrhea

LMP: November 11, 2009

OBSTETRICAL HISTORY

G1P0

Prenatal history: 1st PNCU (20 4/7 wks)

BTRh: B+; HsbAg – NR; CBC – normal MVT + Folic acid

(+) UTI (32wks) – Tx: Cefalexin 500mg x 7days Repeat UA – normal

USG: breech at 28 4/7 weeks USG: breech at 34 weeks

GYNECOLOGIC HISTORYCoitarche: 29 yo

1 sexual partner

(-) PCB, dyspareunia

Last Papsmear: May 2009 – E/N findings

(+) whitish, mucoid vaginal discharge

(-) Vaginal bleeding

HPI

PNCU at SLMC-OPD

(+) irregular uterine contractions(+) good fetal movements(-) passage of watery or bloody vaginal

discharge(-) change in urinary or bowel habits

IE: beginning labor

Interim

Admission

HPI

Consult at SLMC-OPDmass = 8cmAdvised surgery

No complaints of vaginal bleeding, changes in urinary or bowel habits

Admission

May 2009

REVIEW OF SYSTEMS(-) weakness, fatigue, weight loss(-) visual dysfunction, deafness, nasal

discharge, throat soreness(-) dysphagia, anterior neck mass, neck

stiffness(-) breast tenderness(-) dyspnea, cough, sputum production(-) chest pain, chest discomfort, palpitation(-) nausea, vomiting, hematemesis,

hematochezia

REVIEW OF SYSTEMS(-) urinary odor, color, dysuria(-) back pain(-) heat-cold intolerance, thyroid

problems(-) pallor, easy bruisability(-) dizziness, headache(-) anxiety, depression, interpersonal

relationship difficulies

PHYSICAL EXAMINATIONGeneral Survey: Conscious, coherent,

no CPDVital Signs: BP:120/80 HR: 90 PR: 90

RR: 18 Temp:36.8 Wgt: 60kg Hgt: 152

cmSkin: No lesionsEyes: Pink palpebral conjunctivae,

anicteric sclerae, clear cornea, intact EOMs

PHYSICAL EXAMINATION

Neck: supple, (-) mass, (-) CLADsThroat: (-) TPCThorax: SCE, CBS, (-) rib retractionsLungs: Normal breath soundsHeart: AP, NRRR, Precordium at 5th ICS

midclavicular, S1>S2 at apex, S2>S1 at base

Pulses: Full and equal

PHYSICAL EXAMINATION

Abdomen: Globular, non-tender, symmetrical FH = 35 cm; FHT = 140s/min Leopold’s manuever:

L1: (+) ballotable massL2: fetal back at the maternal rightL3: breechL4: unengaged

Internal Examination: 1-2 cm/50% effaced/station -3/(+) BOW

SALIENT FEATURES

Subjective:

30 year old G1P0LMP: November 11, 2008Pelvic USG: breech at 34 weeks(+) irregular hypogastric pains(+) good fetal movements (-) passage of bloody or watery vaginal discharge(-) urinary symptoms or changes in bowel

movements

SALIENT FEATURES

Objective

Abdomen: Globular, non-tender, symmetrical FH = 35 cm; FHT = 140s/min Leopold’s manuever:

L1: (+) ballotable massL2: fetal back at the maternal rightL3: breechL4: unengaged

Internal Examination: 1-2 cm/50% effaced/station -3/(+) BOW

DIAGNOSIS:

PU 37 5/6 weeks AOG, breech in beginning labor

30 yo, G1P0

PLAN: Primary CS

BREECH DELIVERY

VARIETIES OF BREECH PRESENTATION

- Buttocks towards the pelvis- Bitrochanteric diameter presents

- Varying relations between lower extremities & buttocks determine:

1) FRANK BREECH- lower extremities flexed at the hips; extended at the knees feet lie close to head; most common at term

2) COMPLETE BREECH

- Lower extremities flexed at the hips;

one or both knees are flexed

3) INCOMPLETE BREECH

- One or both hips are not flexed and one or both feet or knees lie below the breech

RECOMMENDATIONS FOR DELIVERY

CAESAREAN DELIVERY:

1. a large fetus

2. any degree of contraction or unfavorable

shape of the pelvis

3. a hyperextended head

4. no labor, with maternal/fetal indication

for delivery (e.g. PIH, ruptured membranes for

12 hrs or more)

5. Uterine dysfunction6. Footling presentation7. An apparently healthy but preterm fetus

of 26 weeks or more; mother in active labor or in need of delivery

8. Severe IUGR9. Previous perinatal death or children

suffering from birth trauma10. Request for sterilization

VAGINAL DELIVERY- for a frank breech presentation with:

1. Adequate pelvis on X-ray

2. EFW < 3600 gms.

3. Normal labor course w/ good dilatation & effacement

4. Competent & available OB, Anesth, Pedia

METHODS OF VAGINAL DELIVERY

1. Spontaneous breech delivery – infant expelled entirely spontaneously w/o any traction or manipulation other than support of the infant; rare in mature infants

2. Partial breech extraction – infant delivered spontaneously up to umbilicus, but remainder of body extracted

3. Total breech extraction

- entire body of the infant is extracted by the obstetrician

MANAGEMENT OF LABOR Initial assessment/management- Cervical dilatation & effacement- Fetal condition (anencephaly,

hydrocephaly)- Intravenous infusions- Fetal monitoring esp. after ROM

CHECK FOR PROLAPSED CORD!

VAGINAL BREECH DELIVERY- Competent team:

skillful obstetrician

assistant

anesthesiologist

pediatrician

VAGINAL BREECH DELIVERY Remember!

- liberal episiotomy, preferably MLE

- use towel for firmer grasp (vernix caseosa)

- apply gentle, steady, downward traction

until lower halves of scapulas are outside vulva

DELIVERY OF HEAD

- nuchal arm better diagnosed by X-ray

a. Mauriceau Maneuver = index & middle finger of one hand over maxilla to flex head, while fetal body rests upon palm and forearm of obstetrician

DELIVERY OF HEADb. Prague maneuver – Kiwisch of

Prague (1846) ; two fingers grasp shoulders of back-down fetus while other hand draws feet up over abdomen of mother

DELIVERY OF HEADc. Bracht Maneuver

- breech delivers up to umbilicus; fetal body held against maternal symphysis (gravity); uterine contractions + supra-pubic pressure spontaneous delivery

DELIVERY OF HEAD d. Forceps (Piper)

- should be applied only when the head is well within pelvic cavity

- wrap body in towel to keep arms out of the way

DELIVERY OF HEADe. Entrapped head

- Duhrssen incisions at 2, 6, 10 o’clock;

cervix should be fully effaced and at

least 7 cms dilated

DELIVERY OF HEAD

f. Abdominal Rescue- for entrapped head

emergency Caesarean Section

- DON’T PANIC!!

EXTRACTION OF FRANK BREECH

- delivered by moderate traction exerted by a finger in each groin

- breech decomposition (convert frank to footling breech); Pinard maneuver pushes fetal knee from the midlinespontaneous flexion

COMPLICATIONS OF BREECH DELIVERYMATERNAL

1. Infection

2. Uterine rupture

3. Cervical lacerations

4. Uterine atony

But prognosis for mother better in vaginal breech delivery than Caesarean Section.

FETAL – poorer prognosis if vaginal - more complications the higher

the presenting part at beginning of extraction

1. Tentorial tears, intracerebral bleed2. Cord prolapse3. Fracture of clavicle, humerus4. Paralysis of arm5. Broken neck6. Testicular injury

VERSION- An operation in which the presentation of the fetus is altered artificiallya. Substitute one pole of a longitudinal presentation for the otherb. Converting an oblique or transverse lie into a longitudinal lie (cephalic or podalic)

External Version– manipulations done through abdominal wall

Internal Version– hand introduced into uterine cavity

EXTERNAL CEPHALIC VERSION- Usually with tocolysis- Hook to fetal monitor- Each hand grasps a fetal pole

the preferred presenting part is gently stroked to the pelvic inlet

- Have OR ready

INTERNAL PODALIC VERSION- Feet grasped and drawn through

cervix while body is pushed abdominally in opposite direction

- For delivery of second of twin

THANK YOU!!