Arrest of descent oi CPD

Patients ID
Name Age Address MR Number Time of admission : : : : : Mrs. RY 30 years old Kel. Indarung 83 23 98 June 19th, 2013

Anamnesis

A 30 years old patient was admitted to the Emergency Room of Dr. M. Djamil Central General Hospital on June 19th, 2013 at 6.00 am with chief complain feeling pain from waist region which referred to the groin since 2 hours ago

Present Illness History

Pain from waist region which referred to the groin was felt since 2 hours ago Bloody show from the vagina was (+) since 2 hours ago There was no fluid leakage from the vagina There was no massive vaginal bleeding Amenorrhea since 9 months ago First date of last menstrual period was forgotten Estimation date of delivery was hard to determine

 The fetal movement was felt since 5 months ago. No complain of nausea, vomitus, or vaginal bleeding during early nor late pregnancy Prenatal care to midwife 3 times(2,4 and 8 month) pregnancy age Menstruation history: Menarche at 13 years old, the cycle was irreguler, once a month, 5-7 days in duration with 2-3x pad change/day, menstrual pain (-)

Previous Illness History

There was no history of cardiac disease, lung disease, liver disease, renal disease, diabetes mellitus, hypertension, nor allergy.

Familial Illness History

There was no history of any hereditary, contagious, or psychiatric disorder.

Marriage history: married once in 2002 Educational history : senior high school graduate Occupational history : housewife
Obstetric history : Pregnancy/Abortion/Delivery: 3/0/2 1. In 2008, male, 2600g, term, spontaneous, midwife, alive 2. In 2006, male, 2500g, term, spontaneous, midwife, alive 3. Present History of family planning : (-) Immunization : (-)

Physical Examination
GA Cons BP HR RR T BW BH BMI 155 22,4(normoweight)

Mdt CMC 110/70 80 20 36.7 50 BW after pregnancy: 62 kg Eyes Neck Thorax

: conjunctiva was not anemic, sclera was not icteric : JVP 5-2 cmH2O, no enlargement of thyroid gland : Heart & lung were in normal limit

Extremity: oedema -/-

Obstetric Record
Abdomen

Inspection : Seemed enlarged in accordance with term pregnancy, cicatrix (-) Palpation : L1 : Uterine fundus was palpated at 3 fingers bellow proccesus xyphoideus, a large soft nodular mass was palpated L2 : The hardest resistance was felt on the right side, Small multiple structures were felt in the left side L3 : A Round hard mass was palpated, not fixated L4 : Convergen

Fundal height : 32 cm, EBW : 2945 gr, Uterine contraction : 2-3x/ 30/ S Percussion : tympany Auscultation : peristaltic sound was normal FHR : 140-146 bpm

Genitalia
Inspection : V/U was normal, Vaginal bleeding (-) Vaginal Touche 2-3 cm, effacement 80% Amnionic sac was (-) clear residue Head was palpated tranverse sagitalis sutura HI-II Inner and Outer Pelvic Size Examination: no contracted pelvis

Laboratory Finding
Parameter Result Normal

Haemoglobin Leukocyte Thrombocyte Hematocrit Eritrocyte

10.6 7600 224 32 3.7

9,5-14 5000-15000 150-400 x103 37-43 4-5 jt

USG

CTG

Diagnosis : G3P2A0L2 Term parturient First stage Laten phase Fetal alive, singleton, intrauterine, head presentation tranverse sagitalis sutura HI-II
Management : Control general condition, vital signs, FHR, uterine contraction Informed consent Routine blood check Examine 4 hours later

Plan: Vaginal Delivery

Progress of Labour
10.00 am (4 h after)
Anamnestic feeling pain from waist to groin with increase in intensity , fetal movement (+). VS Abd : normal limit : His 3-4/42/moderate, FHR 128-136 bpm : : v/u normal : 5-6 cm Amniotic sac (-), clear residu Head was palpated tranverse sagitalis sutura HI-II

02.00 pm
feeling pain from waist to groin with increase in intensity , fetal movement (+). VS : normal limit Abd : His 4-5/50/strong, FHR 126-134 bpm Gen : I : v/u normal VT : complete Amniotic sac (-), clear residu Head was palpated left tranverse occiput HI-II G3P2A0L2 term parturient 2nd stage Fetal live singleton intrauterin head presentation left tranverse occiput HI-II Control general condition, vital signs, FHR, uterine contraction lead to bare down , lying to left side Examine 1 hours later Vaginal delivery

03.00 pm
Finished lead to bare down. feeling pain from waist to groin with increase in intensity ,fluid leakage (+) fetal movement (+). VS Abd : normal limit : His 4-5/50/strong, FHR 130-138 bpm : : v/u normal : complete Amniotic sac (-), clear residu Head was palpated left tranverse occiput HII-III

Physical Examination

Gen I VT

Gen I VT

Diagnostic

G3P2A0L2 term parturient 1st stage active phase Fetal live singleton intrauterin head presentation left tranverse occiput HI-II Control general condition, vital signs, FHR, uterine contraction Examine 4 hours later

G3P2A0L2 term parturient 2nd stage Fetal live singleton intrauterin head presentation left occiput tranverse HII-III + Arrest of Descent due to CPD Control general condition, vital signs, FHR, uterine contraction Informed consent Antibiotic Councelling contraception Emergency Cesarean Section

Advice

Planning

Vaginal delivery

June 19th, 2013 03.30 p.m. TPPCS was performed A male baby was born by TPPCS, with : 3600g of body weight, 50 cm in height, APGAR score 7/8 Placenta was born with a slight pull on the umbilical cord, it was born intact, single, & weighing 500 gr with a size of 17x17x3 cm. The umbilical cord length was 60 cm with paracentral insertion. Insertion IUD was performed. Bleeding during procedure was 250 cc

Diagnosis :
P3A0L3 post TPPCS on indication arrest of descent due to CPD Mother & Baby in care

Management :
Post surgery observation

Thank You..