Case Presentation

Case Presentation Obstestrics m5

Pt ID : 247321280 38/F

Chief Complaint Amenorrhea for 41 + 1 weeks

Obstetric HistoryPara : (0) - (0) - (0)(,) - (0)(0,0) : 2010-09-04 : 2011-06-11 (by LMP)

: (29)

IVF-ET (#2, at ) s/p IUI #4~5 failed (at )IVF-ET : In Vitro Fertilization - Embryo Transfer IUI : Intrauterine insemination 3Present IllnessPN check at , ()PN check at SMC OBGY since 10 + 5 by Pf

Routine OB Lab : (No) HbsAb/Ag(+/-) Rubella IgG/IgM(+/-) AB+Last Pap : 2009 (No)Serum screening test - Quad test : Down syndrome (+)Amniocentesis : Karyotype ( ) not done refused50g oral GTT : 117mg/dLCBC : (No)

Level II (2011.2.10, PA 22+5wks) : WNLLast USG (2011.6.16, PA 40+5wks) : Vx. / decreased(deepest 2.45cm) / Post. / 3513(50-75P)Level II : *Level II (2011.2.10, PA 22+5wks) : WNL*Last USG (2011.6.16, PA 40+5wks) : Vx./decreased(deepest 2.45cm)/Post./3513(50-75P)4Ultrasonography (2011-06-19)

Other HistoryPMHx.HTN/DM/Tb/hepatitis/Allergy ( - / - / - / - / - ) : (No) : (Yes) ; appendectomy, 1986

FHx.

SHx.Marriage : (30)smoking: noalcohol: no

Glibenclamide : sulfonylurea 6Review of SystemGeneral symptoms : 62kg : 79.3kg

7Physical Exam (2011-06-19 15:07) 100/57 mmHg 79.3 kg 174.6 cm BMI 26.01 kg/m2

General appearanceNot so ill lookingMental status : Alert

AbdomenPalpitation : Distended d/t pregnancyTenderness (No) Rebound tenderness (No)

Physical Exam FHR : Normal by USGPresenting part : CephalicCervix dilatation : FingertipEffacement : Partial effacementStation : FloatingVaginal discharge : NormalRupture of membrane (No) Vaginal bleeding (No) Assessment Pregnancy : 41 + 1 weeksfor IVPelderly (amniocentesis refused)oligohydramniosPlan: induction prn) augmentation

: PP#2 Hospital Course2011-06-19 (41+4 weeks)FT(0), PE(0), Floating(0), Posterior(0), Soft(2)Bishop score 2 Propess

2011-06-20 - Baby 1Induction Augmentation(Yes) Prostaglandin (Yes) - Dinoprostone (Yes) Oxytocin (Yes) : (3.13)kgApgar score : 1min (9), 5min (9)MS (0) CN (1) GA (No) : cord pH 7.293NR

Hospital Course2011-06-21 PP#1 ------------------------------------------------------------Hb, Blood g/dL 2011-06-1912.1 2011-06-21 10.9WBC, Blood x103/uL 2011-06-19 7.81 2011-06-21 12.79PLT, Blood x103/uL 2011-06-19 124 2011-06-21 115------------------------------------------------------------

Dressing done : episiotomy site clear, no hematoma

Mechanisms of LaborLie of fetusLongitudinal, transversePresentationCephalic presentation (96%)Breech presentation (3.5%)

VertexSinciputBrowFace

Transverse lie. Right acromiodorsoposterior (RADP). The shoulder of the fetus is to the mother's right, and the back is posterior.15Mechanisms of LaborFetal position

Dx - Fetal Presentation and PositionLeopold maneuvers1st identification of which fetal pole occupies the uterine fundus.2nd .3rd , 4th

1) 1 : . .2) 2 : . .3) 3 : . . 1 .4) 4 : . . 17Dx - Fetal Presentation and Position

, Labor 31st stage: (10cm) 2nd stage: 3rd stage: Friedman 1 3Preparatory : , Dilatation : , .Pelvic : cardinal movement Latent, active phase

Mechanisms of Labor w/ OA PresentationCardinal movement

, , , , , , Engagement, Descent, Flexion, IR, Extension, ER, Delivery

21Mechanisms of Labor w/ OA PresentationCardinal movement

, , , , , , Engagement, Descent, Flexion, IR, Extension, ER, Delivery

22Changes in Shape of the Fetal HeadCaput succedaneum ()Molding ( )

Caput succedaneum : . 23~36 .Molding : .23 Admission ProceduresIdentification of laborVital signs and review of pregnancy recordDetection of ruptured membraneFHR monitoringVaginal examinationCervical examinationLab studies

1 30 FHR ( 15)

: : 4 : , , FHR , : 2FHR 15, 5

Dorsal lithotomy position, , , (crowning)

:

:

:

:

: 4~5cm ,

(Ritgen maneuver) : 5cm , . .

27

First-degree lacerations involve the fourchette, perineal skin, and vaginal mucous membrane but not the underlying fascia and muscle (Fig. 17-34). These included periurethral lacerations, which may bleed profusely.Second-degree lacerations involve, in addition, the fascia and muscles of the perineal body but not the anal sphincter. These tears usually extend upward on one or both sides of the vagina, forming an irregular triangular injury.Third-degree lacerations extend farther to involve the anal sphincter.A fourth-degree laceration extends through the rectum's mucosa to expose its lumen.28 ,

: 3~4cm

ReferencesWilliams Obstetrics, 23rd Edition Chapter 17. Normal Labor and Delivery