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Admitting Conference

Admitting Conference. Gibaltar , Claire Hautea , Terese Valencia, Sheryl Gabriel, Katrina July 28, 2009. M.E.B. 30 y/o Married Roman Catholic G1P0 Chief Complaint: Labor pains. Past Medical History. (+) PTB in 2003 underwent 6 months of antiKoch’s Tx

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Admitting Conference

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  1. Admitting Conference Gibaltar, Claire Hautea, Terese Valencia, Sheryl Gabriel, Katrina July 28, 2009

  2. M.E.B 30 y/o Married Roman Catholic G1P0 Chief Complaint: Labor pains

  3. Past Medical History (+) PTB in 2003 • underwent 6 months of antiKoch’sTx (+) 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

  4. Personal and Social Non-smoker Non-Alcoholic beverage drinker Previously employed as an audit staff

  5. Family History (+) Hypertension – mother (+) Bronchial asthma – sibling (+) PTB - mother (-) DM (-) Thyroid Problem (-) CA (-) Kidney Disease

  6. Menstrual History Menarche: 12 years old Interval: monthly, regular Duration: 5 days Amount: 2-3 pads per day Pain: (+) dysmenorrhea LMP: November 11, 2009

  7. 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

  8. Gynecologic History Coitarche: 29 yo 1 sexual partner (-) PCB, dyspareunia Last Papsmear: May 2009 – E/N findings (+) whitish, mucoid vaginal discharge (-) Vaginal bleeding

  9. 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

  10. HPI Consult at SLMC-OPD • mass = 8cm • Advised surgery No complaints of vaginal bleeding, changes in urinary or bowel habits May 2009 Admission

  11. 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

  12. Review of Systems (-) urinary odor, color, dysuria (-) back pain (-) heat-cold intolerance, thyroid problems (-) pallor, easy bruisability (-) dizziness, headache (-) anxiety, depression, interpersonal relationship difficulies

  13. Physical Examination General Survey: Conscious, coherent, no CPD Vital Signs: BP:120/80 HR: 90 PR: 90 RR: 18 Temp:36.8 Wgt: 60kg Hgt: 152 cm Skin: No lesions Eyes: Pink palpebral conjunctivae, anictericsclerae, clear cornea, intact EOMs

  14. Physical Examination Neck: supple, (-) mass, (-) CLADs Throat: (-) TPC Thorax: SCE, CBS, (-) rib retractions Lungs: Normal breath sounds Heart: AP, NRRR, Precordium at 5th ICS midclavicular, S1>S2 at apex, S2>S1 at base Pulses: Full and equal

  15. Physical Examination Abdomen: Globular, non-tender, symmetrical • FH = 35 cm; FHT = 140s/min • Leopold’s manuever: • L1: (+) ballotable mass • L2: fetal back at the maternal right • L3: breech • L4: unengaged Internal Examination: • 1-2 cm/50% effaced/station -3/(+) BOW

  16. Salient Features Subjective: 30year old G1P0 LMP: November 11, 2008 Pelvic 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

  17. Salient Features Objective Abdomen: Globular, non-tender, symmetrical • FH = 35 cm; FHT = 140s/min • Leopold’s manuever: • L1: (+) ballotable mass • L2: fetal back at the maternal right • L3: breech • L4: unengaged Internal Examination: • 1-2 cm/50% effaced/station -3/(+) BOW

  18. Diagnosis: PU 37 5/6 weeks AOG, breech in beginning labor 30 yo, G1P0 PLAN: Primary CS

  19. BREECH DELIVERY

  20. 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

  21. 2) COMPLETE BREECH • Lower extremities flexed at the hips; • one or both knees are flexed • INCOMPLETE BREECH • - One or both hips are not flexed and one or both feet or knees lie below the breech

  22. 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)

  23. Uterine dysfunction • Footling presentation • An apparently healthy but preterm fetus of 26 weeks or more; mother in active labor or in need of delivery • Severe IUGR • Previous perinatal death or children suffering from birth trauma • Request for sterilization

  24. VAGINAL DELIVERY - for a frank breech presentation with: • Adequate pelvis on X-ray • EFW < 3600 gms. • Normal labor course w/ good dilatation & effacement • Competent & available OB, Anesth, Pedia

  25. Methods of vaginal delivery • Spontaneous breech delivery – infant expelled entirely spontaneously w/o any traction or manipulation other than support of the infant; rare in mature infants • Partial breech extraction – infant delivered spontaneously up to umbilicus, but remainder of body extracted

  26. Total breech extraction - entire body of the infant is extracted by the obstetrician

  27. Management of labor • Initial assessment/management • Cervical dilatation & effacement • Fetal condition (anencephaly, hydrocephaly) • Intravenous infusions • Fetal monitoring esp. after ROM CHECK FOR PROLAPSED CORD!

  28. Vaginal Breech Delivery • Competent team: skillful obstetrician assistant anesthesiologist pediatrician

  29. Vaginal Breech Delivery • Remember! - liberal episiotomy, preferably MLE - use towel for firmer grasp (vernixcaseosa) - apply gentle, steady, downward traction until lower halves of scapulas are outside vulva

  30. 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

  31. Delivery of head b. Prague maneuver – Kiwisch of Prague (1846) ; two fingers grasp shoulders of back-down fetus while other hand draws feet up over abdomen of mother

  32. Delivery of head c. Bracht Maneuver - breech delivers up to umbilicus; fetal body held against maternal symphysis (gravity); uterine contractions + supra-pubic pressure  spontaneous delivery

  33. 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

  34. Delivery of head • Entrapped head - Duhrssen incisions at 2, 6, 10 o’clock; cervix should be fully effaced and at least 7 cms dilated

  35. Delivery of head • Abdominal Rescue - for entrapped head emergency Caesarean Section - DON’T PANIC!!

  36. 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 midlinespontaneous flexion

  37. COMPLICATIONS OF BREECH DELIVERY MATERNAL 1. Infection 2. Uterine rupture 3. Cervical lacerations 4. Uterine atony But prognosis for mother better in vaginal breech delivery than Caesarean Section.

  38. FETAL – poorer prognosis if vaginal - more complications the higher the presenting part at beginning of extraction • Tentorial tears, intracerebral bleed • Cord prolapse • Fracture of clavicle, humerus • Paralysis of arm • Broken neck • Testicular injury

  39. VERSION • An operation in which the presentation of the fetus is altered artificially a. Substitute one pole of a longitudinal presentation for the other b. Converting an oblique or transverse lie into a longitudinal lie (cephalic or podalic)

  40. External Version– manipulations done through abdominal wall Internal Version– hand introduced into uterine cavity

  41. 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

  42. Internal Podalic Version • Feet grasped and drawn through cervix while body is pushed abdominally in opposite direction • For delivery of second of twin

  43. THANK YOU!! 

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