Obstetric case sheet
Patient profile
Name : Madam Siti Norhasine Nasir
Age :27 years old
Parity index : Gravida 1 para 0
Last menstrual period :24/7/2014
Expected date of delivery :30/4/2015
Period of gestation :38 weeks
Address : Sungai mati
Occupation :Pusat internet in melaka
Date of admission :17/4/2015 (Time:5.00a.m.)
Date of examination :17/4/2015 ( Time:3.30p.m)
Chief complaints :
Patient complaint irregular contraction and per vaginal leakage of
fluid with show 11 hours back ( time: 4.30 a.m ).
History of presenting illness
Patient experienced sudden gush of warm fluid and she noticed her
thigh waswet at 4.30 am early in the morning.The fluid was clear
,odourless,and large in volume with no bleeding.There is no associated with
abdominal pain,contraction pain ,fever and urinary symptom.
Her parents brought her immediately to Muar hospital and admitted
emergency at 5.00am .Blood test was done and were normal.CTG done and it
was reactive.Besides, her fetal movement was good.Vaginal examination was
done and the cervical os was 1cm dilated.She was reassured by doctor that
she
and her baby were in stable condition ,no medication were taken.
Currently,there is slight amount of per vaginal leaking without
bleeding and abdominal pain and she is wearing vulval pad .she was advised
by the doctor to wait for another 24 hours , if it no labour pain or strong
uterine contraction ,then induction of labour should be taken.
History of presenting pregnancy
1st trimester :
It was planned pregnancyand she was diagnosed her pregnancy by urine
pregnancy test at home after missing periods for 2 months.she visited a
private
clinic(Klinik Sungai Mati) for comfirmation and was told to be at 12 weeks
of
gestation.She did her booking visit at Klinik Sungai Mati at
12/10/2014.Routine blood and urine investigation was done,her blood group
is o positive.
Hemoglobin level was normal.Supplements were given.Blood pressure and
body weight were recorded.There is no fever ,rash ,vaginal discharge
,itchiness,dysuria during first trimester.Dating scan was done on
12/10/2014.
2nd trimester:
She felt quickening at the 19th weeks ,and tetanus toxoid injection is
given at
28th weeks.Her blood pressure and body weight gain normal.Hemoglobin level
normal.2nd trimester ultrasound scan was done on 29/10/2014 and fetus
normal.
3rd trimester:
Fetal movement was good .Growth scan was done and normal.
Past obstetrics history
She got married on 30/5/2014 at the age of 26 .This was her first
pregnancy,and she has no previous child before.no contraceptive used .
Menstrual history
She attained menarche at the age of 12 years.
Menstrual cycle :once in 28 days ,regular,with 7-8 days of flow,moderate
flow ,no dysmenorrhea.No oral contraceptive pills taken.
Past history
No significant past medical and surgical history.
Personal history
Her sleep and appetite is good .She has the normal balanced adult
diet.
Her bladder habit was normal however she had constipation since pregnancy.
She does not smoke and consume alcohol.No known drug or food allergy.
Family history
Both parents are well and healthy ,no diabetes mellitus ,hypertension
,
asthma and tuberculosis .She has 4 siblings and all of them healthy.
She was eldest among 4 siblings .
Socioeconomic status
She was staying with her parents .Her husband work as pengawai awam,
29 years old,adequate income (RM1900 per month),financially stable.
House condition was good ,concrete house and was 10 minutes away from
hospital by car.
Summary
Mrs Puan Siti Norhazline Binti Nasir,27 years old,primigravida,G1P0 with
period of gestation 38 weeks 2 days came with per vagina leaking of
fluid,no associate with abdominal pain and bleeding.Currently fetal
movement was good ,she was kept in ward for monitoring and planned for
induction of labour due to premature rupture of membrane.
General examination
Patient is lying down comfortably in supine position on bed .She is
moderately built and moderately nourished.Her height is 160cm,weight 48kg
and BMI is 18.75kg/m2. There is no IV cannula on both dorsum of hand.
Hands : warm,no pallor on the palms and nail bed for both hands.
Eye :no jaundice in sclera , no pallor on conjunctiva.
Oral cavity :tongue pink and moist ,no glossitis ,tonsils not enlarge.
Overall oral hygiene good.
Neck :no thyroid swelling.
Breast :no lumps ,no nipple retraction, no nipple discharge.
Pedal edema :mild present.
Vital signs :
Temperature:37
Pulse:100 beats per minutes,regular rhythm,normal volume and character
Respiratory rate :20 breath per minutes
Blood pressure :108/100mmHg taken in sitting position
Systemic Examination
Cardiovascular system:S1 andS2 heard.
No murmurs
Respiratory system :Normal vesicular breath sounds heard.
No adventitious sounds
Obstetric Examination
Inspection:
Abdomen is uniformly distended, flank full.
Linea nigra and striae gravidarum are present.
Umbilicus is centrally placed and flat.
All quardrants moves symmetrically with respiration.
No obvious fetal movements .
No surgical scar seen in lower abdomen.
Hernia orifices are intact.
Palpation:
Clincal fundal height:34 weeks
Symphysio fundal height:34 cm
Fundal grips :irregular,soft to firm mass ,
not ballotable ,suggest fetal buttock
Lateral grips :curved smooth and broad surface felt at the maternal
right side suggestive of fetal spine.
Irregular knobbing structure felt at maternal
left side
suggestive of fetal limbs.
Pelvic grip:hard,round,ballotable mass felt ,suggestive fetal head.
The head 3/4th palpable.
Summary of grips:Singleton pregnancy with cephalic presentation in
longitudinal lie .
Auscultation:fetal sounds are heard right lower quadrant.
Diagnosis :
Primigravida with cephalic presentation with premature rupture of membrane.
Investigation
CTG interpretation:
Baseline fetal heart rate :135 beats per minutes
Baseline variability :5-10 per minutes
Present of accelerations.
No decelerations.
Uterine contraction :40%
Ultrasound scan
No.of fetus:single
Presentation :cephalic
Biparietal diameter :37 + 0 weeks
Femur length :34 weeks + 0 days
Head circumference :36 weeks +4 days
Abdominal circumference :35 weeks +5 days
Amniotic fluid index:16.62cm
Estimated fetal weight :2705.16g
Fetal heart rate present.
Management plan
-Patient advice bed rest .
-Sterile vulval pad is applied to observe any further leakage .
-Pad chart if any per vaginal discharge.
-Monitor the maternal pulse ,temperature and fetal heart rate 4th hourly in
ward .
-Monitor sign and symptoms of chorioamnionitis at least 12 hourly
-Monitor the fetal kick sound ( just reassure the mother )
-Ultrasound scan once in 2 weeks
-CTG twice weekly
Further management
-If the patient does not start within the stipulated time , induction of
labour
with the oxytocin is started.
-Caeserean section is performed with obstetrics indication.
-Antibiotics is given to minimize maternal and the perinatal risk of
infection.
-IV ampicillin and erythromycin for 48 hours follow by oral therapy for 5
days until delivery is recommend.
Discussion
Prelabor rupture of membrane ( prom) is defined as rupture of membrane
after 37 weeks completed of gestation until onset of labour .
The estimated incidence of PROM is 10 % of all pregnancies.
The risk factors for PROM is genital tract infection .
Eg.chlamydia trachomatis ,Neisseria gonorrhoea, Bacteria vaginosis
infection produce PGE2,PGF2 and cytokines,this may reduce the
collagen and weakens the membrane .Besides ,progressive weakening
the
fetal membrane,stress on the membranes (polyhydramnios) ,past
history of PROM ,nutritional deficiency and smoking.
The diagnosis of spontaneous rupture of membranes best achieved
by history followed by sterile speculum exammination.
Sudden gush of warm fluid per vagina indicated rupture of membrane and
drainage of amniotic fluid.
Comfirmatory test can be do : ultrasound scan ,litmus test ,nitrazine
tests,
ferning on slide and amnisure.
Complication of PROM:For maternal:ascending infection,abruptionplacenta.
For fetal :fetal pneumonia ,lims
deformities.
Management for gestation more than 37 weeks (PROM)
Wait for spontaneous onset of labour
If not established in 24 hours
Induction of labour
Currently ,patient is admitted at gestational age of 38 weeks with
prelabour
rupture of membrane ,if not established in 24 hrs ,she is advised to
induction of labour.
Prepared by :
Tung Qian Ying
121303171
Batch 31 ,Group J1
