Chinese General Hospital & Medical Center Department of Obstetrics &

Gynecology

OB Audit
June 8, 2011

Yuzhen G. Segarra, MD

General Data
M.G.B. 31 y/o G3P2 (2002) 38-39 weeks AOG

Chief Complaint
Hypogastric pain

History of Present Illness

Few hrs PTA

Occasional hypogastric pain radiating to the lumbosacral area Minimal bloody mucoid discharge No watery vaginal discharge Good fetal movement

Admission

 LMP: September 1st week, 2010 EDC: June 1st week, 2011 AOG: 38-39 weeks

Pre-natal Care
Private physician
Starting at 3 months AOG 8-10 visits 1st, 2nd, 3rd trimester: unremarkable

CBC, BT Urinalysis UTZ 50 g OGCT HBsAg - reactive

Review of Systems
No fever, no headache, no dizziness No dyspnea, no cough, no colds No vomiting No dysuria, no diarrhea No palpitations

Past Medical History

No previous operation No blood transfusion (+) HBsAg reactive No hypertension No diabetes mellitus No thyroid problem No PTB No asthma No allergy

Family History
No hypertension No diabetes mellitus No thyroid problem No cancer No asthma No allergy

Personal & Social History

Non-smoker Non-alcoholic beverage drinker Denies illicit drug use

Menstrual History
Menarche: 12 y/o Interval: 28-30 days Duration: 3-4 days Amount: 2-3 pads/day, moderately

soaked Symptoms: no dysmenorrhea

Sexual History
First coitus at 25 y/o to a 30 y/o

present partner No dyspareunia No postcoital bleeding No family planning method used

Obstetrical History
G1 2006, full term, boy, NSD, CGH, ~6

lbs G2 2008, full term, girl, NSD, CGH, ~6 lbs G3 present pregnancy

Physical Examination
Conscious, coherent, not in

cardiorespiratory distress BP=100/70 PR=80 RR=20 T=37 Warm, moist skin, no active dermatoses Pink palpebral conjunctiva, anicteric sclerae, no cervical lymphadenopathy Adynamic precordium, AB at 5th LICS MCL, S1>S2 at the apex, S2>S1 at the base, no murmurs Symmetrical chest expansion, no retractions, clear breath sounds

Physical Examination
Globular abdomen, FH=35cm, FHT=150

bpm, LM1 breech, LM2 fetal back right, LM3 cephalic, UC q 4-5 mins, 40-50secs, moderate Normal external genitalia, parous vagina Cervix : 3-4cm dilated, 70% effaced, soft, anterior, station -3, cephalic, (+) BOW Uterus: enlarged to age of gestation

Physical Examination
Clinical Pelvimetry
Sacral promontory not accessible Ischial spines not prominent Pelvic sidewalls not convergent Subpubic arch wide Sacrum curve MH Station: -3

No edema, no cyanosis Pulses full and equal

Assessment
G3P2 (2002) Pregnancy 38-39 weeks

AOG, cephalic, in labor

Plan
CBC Urinalysis Monitor progress of labor For vaginal delivery

Friedmans Curve
10 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 -5 -4 -3 -2 -1 0 +1 +2 +3 +4 +5 Hours of labor

Final Diagnosis
Gravida 3 Para 3 (3003) Pregnancy

Uterine 38-39 weeks AOG, cephalic, delivered via low transverse cesarean section I secondary to arrest in cervical dilatation to a live full term baby boy, BW 3558g, BL 50cm, AS 8,9 AF clear

DISCUSSION

NORMAL LABOR & DELIVERY

Vertex presentation Occiput anterior No operative obstetrics Term pregnancy

Duration 24 hours

ABNORMAL LABOR

Abnormal presentation Abnormal position Operative obstetrics Pre- or post term pregnancy Abnormal labor progression

Abnormal presentation

Abnormal position

Operative obstetrics

Pre- or post term pregnancy

Abnormal labor progression

NORMAL LABOR & DELIVERY

Vertex presentation Occiput anterior No operative obstetrics Term pregnancy

Duration 24 hours

Mechanisms of labor
Effacement Dilatation Three Ps
Powers Uterine activity Passage Passenger

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POWER

Active segment Passive segment

Powers
Uterine contractions
Normal labor Duration 30-60 seconds Q 2-5 minutes 3-5 contractions / 10 minutes Montevedeo units (intrauterine catheter) Baseline to peak, sum of contractions in 10 minutes Adequate: >200-250 MVU

Interventions
Induction Augmentation Oxytocin AROM
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POWER

PASSAGE

Passage

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POWER

PASSENGER

PASSAGE

Passenger
Size
4500gram =

macrosomia

Lie Presentation
5% not vertex

Attitude Position Station

Engagement Widest diameter passes inlet 0 station, vertex
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POWER

PASSENGER Active segment Passive segment

PASSAGE

Fetal descent Cervical progression

Cardinal Movements of Labor

Descent Flexion Internal rotation Extension External rotation Expulsion

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Labor stages
First stage onset of labor to

complete dilatation
Latent phase Active phase

Second stage Third stage

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Second stage of labor

First stage of labor

Stages of Labor
First stage
True labor pain

Prolonged latent phase

fully dilated Latent 1st - 20 Hr. >2nd - 14 Hr. Active 1st - 1.2 cm/Hr. >2nd - 1.5 cm/Hr.

Protracted active phase of dilatation Secondary arrest of dilatation

7 to 10 cm

Prolonged deceleration phase 1st : > 3 hr >1st : >1 cm

Stages of Labor
Second stage
Delivery of fetus 1st : < 2 hours > 2 nd : < 1 hour
Prolonged second stage

Arrest of descent Failure of descent

Stages of labor
Third stage
Delivery of

placenta < 30 minutes

Prolonged third stage

Labor Pattern Prolongation Disorder Prolonged Latent Phase Prolonged Second Stage

Diagnostic Criteria Nulliparas > 20 hrs Multiparas >14 hrs

> 3 hrs with > 2 hrs with regional anesthesia regional anesthesia > 2 hrs without > 1 hr without regional anesthesia regional anesthesia

Protraction Disorder Protracted Active Phase Dilatation Protracted Descent Arrest Disorder Prolonged Deceleration Phase Arrest of Dilatation Arrest of Descent > 3 hrs > 2 hrs > 1 hr
n d

< 1.2 cm/hr < 1 cm/hr

< 1.5 cm/hr < 2 cm/hr > 1 hrs > 2 hrs > 1 hr

Failure of Descent Practice Guidelines on Abnormal Labor and Delivery, POGS, Nov 2009 Lack of expected descent during Clinical

Friedmans Curve
10 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 -5 -4 -3 -2 -1 0 +1 +2 +3 +4 +5 Hours of labor

-3

-3

-3

-3

-3

-3

-3

-3

-3

-3

-3

-3

-3

-3

Labor Pattern Prolongation Disorder Prolonged Latent Phase Prolonged Second Stage

Diagnostic Criteria Nulliparas > 20 hrs Multiparas >14 hrs

> 3 hrs with > 2 hrs with regional anesthesia regional anesthesia > 2 hrs without > 1 hr without regional anesthesia regional anesthesia

Protraction Disorder Protracted Active Phase Dilatation Protracted Descent Arrest Disorder Prolonged Deceleration Phase > 3 hrs > 1 hrs < 1.2 cm/hr < 1 cm/hr < 1.5 cm/hr < 2 cm/hr

Arrest of Dilatation

> 2 hrs

> 2 hrs

Clinical Practice Guidelines on Abnormal Labor and Delivery, POGS, Nov 2009

MANAGEMENT
disciplined approach to the diagnosis

of labor, assessment of maternal and fetal well-being, and careful monitoring of labor progress

YUZHEN
Hanap ka ng current ACOG

recommendation regarding management of active phase disorders. Wala kc aq book nun, la din aq mahanap sa internet. Lam ko meron kyo jan sa DR =) ok? Ill be @ MCos clinic pa naman till 5pm. Pag naguguluhan ka d2 punta ka na lang dun. K?

Recommendations For Arrest Disorders

Before an arrest disorder can be diagnosed in the first stage of labor,
the

latent phase completed, and

should be

the uterine contraction pattern

exceeds 200 Montevideo units for 2 hours without cervical change

Recommendations For Arrest Disorders

Cesarean delivery is NOT performed
for labor arrest until there were at least :

4 hours of a sustained uterine contraction

a minimum of

pattern of greater than 200 Montevideo units , or augmentation if the contraction pattern could not be achieved

6 hours of oxytocin

If we hope to create a non-violent world where respect and kindness replace fear and hatred We must begin with how we treat each other at the beginning of life. For that is where our deepest patterns are set. From these roots grow fear and alienation ~or love and trust. ~Suzanne Arms

If we want to create a less violent world, we must begin with birth