SUMMARY

Madam Rabaiyah binti Shazali, 29 years old, Melanau, Gravida 4 Para 3+0, at 37 and 3 days of
gestations was admitted to the maternity ward of Hospital Sibu on 9th December 2014 at 4.00 pm
after being referred from a local clinic for abnormal fetal lie. From the transabdominal
ultrasound scan done previously, the fetal lie was breech at 32 weeks of gestations and was in
cephalic lie at 36 weeks of gestations. Latest scan revealed that the current fetal lie is in oblique
lie. She was then referred for further management and follow up after being diagnose as unstable
lie. On 13th December 2014 at 9.45 am, she was leaking liquor. She describe the fluid as clear
and it was dribbling down her feet. The liquid was also foul smelling. She also mentioned that it
was high in volume and soaked her sarong. She also had contraction pain once every hour that
lasts for 10 seconds. Otherwise, there was no show present or any blood seen. Leaking liquor
was not associated with pain and there was no itchiness felt. She also has no fever or any sign of
urinary tract infection such as dysuria or increase frequency of micturition.
Patient was unsure of her last menstrual period (LMP). Her cycle was previously regular with 28
days cycle. Her revised expected date of delivery (REDD) was on the 27th December 2014. This
was an unplanned pregnancy and she did not take any contraceptive measures. She did her
booking scan at 8 weeks of gestation and it was normal. Antenatally, she had an uneventful
pregnancy. For past obstetric history, she had 3 children previously. All of them were delivered
via spontaneous vaginal delivery and birth weight was from 2.7 kg to 3.1 kg. Currently all her
children are healthy. There is no known medical or surgical history. There is also no relevant
family history. She also has no known allergy and is not on any medication. She is a non-smoker
and does not take alcohol.

PHYSICAL EXAMINATION
For general examination, she was afebrile and her blood pressure was 114/86 mmHg. Her pulse
rate was 98 beats per minutes with strong volume and regular rhythm. Her respiratory rate was
20 breath per minute and her BMI is 31.7 which is considered as maternal obesity. There was no
sign of edema, no pallor, no sign of lymphadenopathy and no thyroid enlargement.
For systemic examination, normal heart sound was heard without murmurs. She also had
vesicular breaths sound with no wheezing or crepitation. Central nervous system was also
normal.
Obstetric examination revealed a grossly distended abdomen with gravid uterus on inspection.
There was also presence of linea nigra and stria gravidarum. There was no dilated veins or
surgical scars seen. On palpation, the temperature was normal. The abdomen was soft and nontender. The fundal height was at 38 weeks of gestations. Symphysio-fundal height was measured
at 37 cm. It is a single pregnancy with longitudinal lie and in cephalic presentation. Fetus was at
right lateral position. Head was 4/5th palpable and not engaged. On auscultation, fetal heart sound
was heard at 145 beats per minutes, strong and regular. Estimated fetal weight was 2.4 to 2.6 kg.

Vaginal examination
Vulva

: No abnormalities detected

Cervical Os

: Tip of finger

Cervical position

: Anterior

Station

: -2

Cervix

: Not effaced

Presenting part

: Cephalic

Membrane

: Intact

Ultrasound was done and revealed normal single fetus. The estimated fetal weight was 2.4 kg.
Amniotic fluid index (AFI) shows normal level. No evidence of low lying placenta.
CTG was done and showed a reactive CTG.
CTG tracing
Baseline

: 140 beats per minute

Variability

: More than 5

Acceleration

: Present

Deceleration

: Absent

Uterine contraction

: None

Comment:
Maternal vital signs was within normal range. Current fetal lie is in longitudinal lie with cephalic
presentation. There was no other abnormalities detected. As for vaginal examination, cervical os
was at tip of a finger dilated with intact membrane. She is currently not in labour. CTG tracing
was also reactive.

Management:
1. Fetal kick chart and CTG monitoring
2. For lie chart monitoring
3. To look out for signs and symptoms of labour. Then, confirm fetal presentation once
patient is in labour.

Physical examination at 2.00 pm (13th December 2014)

General examination revealed no abnormalities. Her blood pressure was 122/78 mmHg. Her
pulse rate was 82 beats per minute with regular rhythm and strong volume. Respiratory rate was
20 breaths per minute. No abnormalities detected for systemic examination.
On obstetric examination, the engagement was 5/5th palpable and was not engaged. Fetal heart
rate was heard at 141 beats per minute, strong and regular.
Vaginal examination:
Vulva

: No abnormalities detected

Cervical Os

: 1 cm

Cervical position

: Anterior

Station

: -2

Cervix

: 25% effaced, soft

Presenting part

: Cephalic

Membrane

: Ruptured, clear fluid (spontaneous)

CTG tracing:
Baseline

: 140 beats per minute

Variability

: More than 5

Acceleration

: Present

Deceleration

: Absent

Uterine contraction

: 1 in 10 minutes

Comment:
Maternal vital signs was within normal range. Current fetal lie is in longitudinal lie with cephalic
presentation. There was no other abnormalities detected. As for vaginal examination, cervical os
was 1cm dilated with spontaneous rupture of membrane with clear fluid. She is currently in
latent phase of labour. CTG tracing was also reactive.

Management:
1. Plot partograph to monitor progress of labour
2. Fetal kick chart
3. Encourage ambulating

Physical examination at 6.00 pm (13th December 2014)

General examination revealed no abnormalities. Her blood pressure was 116/90 mmHg. Her
pulse rate was 70 beats per minute with regular rhythm and strong volume. Respiratory rate was
20 breaths per minute. No abnormalities detected for systemic examination.
On obstetric examination, the engagement was 5/5th palpable and was not engaged. Fetal heart
rate was heard at 152 beats per minute, strong and regular.
Vaginal examination:
Vulva

: No abnormalities detected

Cervical Os

: 4 cm

Cervical position

: Anterior

Station

: -2

Cervix

: 50% effaced, soft

Presenting part

: Cephalic

Membrane

: Ruptured, clear fluid (spontaneous)

CTG tracing:
Baseline

: 150 beats per minute

Variability

: More than 5

Acceleration

: Present

Deceleration

: Absent

Uterine contraction

: 2 in 10 minutes for 20 seconds

Comment:
Maternal vital signs was within normal range. Current fetal lie is in longitudinal lie with cephalic
presentation. There was no other abnormalities detected. As for vaginal examination, cervical os
was 4 cm dilated with spontaneous rupture of membrane with clear fluid. She is currently in
active phase of labour. CTG tracing was also reactive.

Management:
1. Continuous maternal vital signs and CTG monitoring
2. Vaginal examination 2 hourly
3. Set IV line

Physical examination at 8.00 pm (13th December 2014)

General examination revealed no abnormalities. Her blood pressure was 128/88 mmHg. Her
pulse rate was 72 beats per minute with regular rhythm and strong volume. Respiratory rate was
20 breaths per minute. No abnormalities detected for systemic examination.
On obstetric examination, the engagement was 3/5th palpable and was not engaged. Fetal heart
rate was heard at 148 beats per minute, strong and regular.
Vaginal examination:
Vulva

: No abnormalities detected

Cervical Os

: 6 cm

Cervical position

: Anterior

Station

:0

Cervix

: 75% effaced, soft

Presenting part

: Cephalic

Membrane

: Ruptured, clear fluid (spontaneous)

CTG tracing:
Baseline

: 150 beats per minute

Variability

: More than 5

Acceleration

: Present

Deceleration

: Absent

Uterine contraction

: 2 in 10 minutes for 30 seconds

Comment:
Maternal vital signs was within normal range. As for vaginal examination, cervical os was 6 cm
dilated with spontaneous rupture of membrane with clear fluid. CTG tracing was also reactive.
Uterine contraction is 2 in 10 minutes for 30 seconds.

Management:
1. Continuous maternal vital signs and CTG monitoring
2. Vaginal examination 2 hourly
3. Look out for signs of poor progress of labour

Physical examination at 10.00 am (14th December 2014)

General examination revealed no abnormalities. Her blood pressure was 120/76 mmHg. Her
pulse rate was 80 beats per minute with regular rhythm and strong volume. Respiratory rate was
22 breaths per minute. No abnormalities detected for systemic examination.
On obstetric examination, the engagement was 2/5th palpable and was not engaged. Fetal heart
rate was heard at 140 beats per minute, strong and regular.
Vaginal examination:
Vulva

: No abnormalities detected

Cervical Os

: 6 cm

Cervical position

: Anterior

Station

:0

Cervix

: 75% effaced, soft

Presenting part

: Cephalic

Membrane

: Ruptured, clear fluid (spontaneous)

CTG tracing:
Baseline

: 142 beats per minute

Variability

: More than 5

Acceleration

: Present

Deceleration

: Absent

Uterine contraction

: 3 in 10 minutes for 30 seconds

Comment:
Maternal vital signs was within normal range. As for vaginal examination, cervical os was 6 cm
dilated with spontaneous rupture of membrane with clear fluid. CTG tracing was also reactive.
Uterine contraction is 3 in 10 minutes for 30 seconds.

Management:
1. Continuous maternal vital signs and CTG monitoring
2. Vaginal examination 2 hourly
3. Look out for signs of poor progress of labour

Physical examination at 12.00 am (14th December 2014)

General examination revealed no abnormalities. Her blood pressure was 120/76 mmHg. Her
pulse rate was 80 beats per minute with regular rhythm and strong volume. Respiratory rate was
22 breaths per minute. No abnormalities detected for systemic examination.
On obstetric examination, the engagement was 2/5th palpable and was not engaged. Fetal heart
rate was heard at 138 beats per minute, strong and regular.
Vaginal examination:
Vulva

: No abnormalities detected

Cervical Os

: 6 cm

Cervical position

: Anterior

Station

:0

Cervix

: 75% effaced, soft

Presenting part

: Cephalic

Membrane

: Ruptured, clear fluid (spontaneous)

CTG tracing:
Baseline

: 138 beats per minute

Variability

: More than 5

Acceleration

: Present

Deceleration

: Type 1 early deceleration

Uterine contraction

: 3 in 10 minutes for 45 seconds

Comment:
Maternal vital signs was within normal range. There was no other abnormalities detected. As for
vaginal examination, cervical os was 6 cm dilated and cervix is 75% effaced only. CTG showed
early deceleration. Uterine contraction was 3 in 10 minutes for 45 seconds.

Management:
Despite the strong contractions and the spontaneous ruptures of membranes, the head descent
was still poor at station 0. The progress of labour was poor as the partograph showed cervix
dilatation that moves to the right. CTG also shows suspicious tracing of early deceleration.

Thorough assessment was carried out thus resulted in Emergency Lower Segment Caesarian
Section (EMLSCS).
1.
2.
3.
4.
5.

Monitor maternal vital signs

Continuous CTG monitoring
Inform consent from patient
Pre-operative assessment
Anesthesia team review

Reasons for EMLSCS

Emergency Lower Segment Caesarian Section (EMLSCS) was done on Madam Rabaiyah is due
to poor progress of the active phase of labour that was because of obstructed labour and
suspicious CTG.

Post-delivery summary
Madam Rabaiyah delivered a healthy male baby with birth weight of 2.33 kg on 14th December
2014 at 1.17 am via emergency lower segment caesarian section.

Post-operative management
1.
2.
3.
4.
5.
6.
7.
8.
9.

Transfer out to post-natal ward once patient is stable

Allow orally
Vital signs every hourly until patient is stable
Strict pad charting
Intravenous drip of 5% dextrose until patient can tolerate orally
Subcutaneous Heparin, 5000U BD until patient ambulating well
IV cefobid 1g BD
Wound inspection on day 2 post-operative
IV Pitocin 40U for 6 hours

DISCUSSION

Normal labor is defined as uterine contractions that result in progressive dilation and effacement
of the cervix. Meanwhile, dystocia of labor is defined as difficult labor or abnormally slow
progress of labor. Other terms that are often used interchangeably with dystocia are dysfunctional
labor, failure to progress (lack of progressive cervical dilatation or lack of descent), and
cephalopelvic disproportion (CPD).
Below are the 3 stages of labor:
1. The first stage starts with uterine contractions leading to complete cervical dilation and is
divided into latent and active phases. In the latent phase, irregular uterine contractions
occur with slow and gradual cervical effacement and dilation. The active phase is
demonstrated by an increased rate of cervical dilation and fetal descent. The active phase
usually starts at 4 cm cervical dilation and is subdivided into the acceleration, maximum
slope, and deceleration phases.
2. The second stage of labor is defined as complete dilation of the cervix to the delivery of
the infant.
3. The third stage of labor involves delivery of the placenta
In general, abnormal labor is the result of problems with one of the 3 P' s:
1. Passenger (infant size, fetal presentation [occiput anterior, posterior, or transverse])
2. Pelvis or passage (size, shape, and adequacy of the pelvis)
3. Power (uterine contractility)
A prolonged latent phase may result from oversedation or from entering labor early with a
thickened or uneffaced cervix. It may be misdiagnosed in the face of frequent prodromal
contractions. Protraction of active labor is more easily diagnosed and is dependent upon the 3 P:
1. The first P, the passenger, may produce abnormal labor because of the infant's size (eg,
macrosomia) or from malpresentation.
2. The second P, the pelvis, can cause abnormal labor because its contours may be too small
or narrow to allow passage of the infant. Both the passenger and pelvis cause abnormal
labor by a mechanical obstruction, referred to as mechanical dystocia.
3. With the third P, the power component, the frequency of uterine contraction may be
adequate, but the intensity may be inadequate. Disruption of communication between
adjacent segments of the uterus may also exist, resulting from surgical scarring, fibroids,
or other conduction disruption. Whatever the cause, the contraction pattern fails to result
in cervical effacement and dilation. This is called functional dystocia. For uterine
contractile force to be considered adequate, the force produced must exceed 200 MVUs
during a 10-minute contraction period. Arrest disorders cannot be properly diagnosed
until the patient is in the active phase and had no cervical change for 2 or more hours
with the contraction pattern exceeding 200 MVUs. Uterine contractions must be
considered adequate to correctly diagnose arrest of dilation.