1st Case Presentation Tuesday, April 17th 2012

Cephalopelvic Disproportion Diagnostic on G2P1A0 Term Parturien at Second Stage, with History of First Child Birth Weight of 3500gr
Presented by : Desmy Adelia Resource Person : Mulya Nusa A R, dr.SpOG. M.Kes

FETAL HEAD

PELVIS
DISPROPOTION

CPD

Impey and OHerlihys :

68% successful vaginal delivery rate in women who had previous caesarean sections for CPD Diagnosing CPD is an imperfect activity and it should be accepted that many women whose labour is terminated for CPD may only have relative disproportion or simply inadequate uterine contractions.

What is CPD The Baby is too big for your pelvic

But my second was bigger..?

Identity
Name Age Address Education : Mrs. L : 29 years old : JL. Cisarua 01/05 Lembang : Elementary school

Occupation
Medical Record

: House Wife
: 1204 xxxx

Date of admission: February 09th, 2012 , 21.25

ANAMNESIS
Referred by Notes Hypertention Chief complaint : Garuda Primary Health Care : G2P1A0 Term Pregnancy; Gestational : Labour pain

G2P1A0 term pregnancy Labour pain (+) Amniotic fluid membrane (-) Fetal movement (+) Hypertension (due to delivery date) Hypertension history (-)

Impending eclampsia sign (-)

OBSTETRIC HYSTORY

1. Traditional Birth Attendant, Term, 3500 gram, spontaneus delivery, , 13 y.o; Alife 2. This pregnancy

 Marrital status Contraseption LMP EBD Prenatal care

:, 14 y.o, Elementary school; Housewife , 20 y.o ,Elementary school; Blue collar :DMPA, 2002 - 2008 : 20th May 2011 : 27th February 2012 : Midwife/ 8x

Identity
2 month; Test Pack(+) Midwife S Not pregnant 4month; Midwife S Not pregnant USG; Restu Ibu; 4 month pregnancy

Garuda PHC

Traditional Birth Attendant

BPS E; Midwife 4x; SpOG 3x

RSHS

HOME VISIT

House size 8 x 5 m2 Live with husband and 1 child 1 Living room, 2 bedroom, 1 store, 1 kitchen, 1 bathroom Family income was about Rp.25.000/day

Age 14 d, cough

Age 17 d, midwife

Age 20 d, GP

Home

RS IMC

Peditrician

04.00

Status Present
General condition : compos mentis Blood pressure Pulse : 150/100mmHg : 88 x/minute

Respiration
Temperature

: 20
: 36,7

x/minute
OC

EXTERNAL EXAMINATION

Fundal High AC Fethal Lie

FHR UC EBW

:35 cm :109 cm : Head, 3/5 Back at the Left side : 144-148x/minute :3-4x/10/40 strong : 3500 gram

INTERNAL EXAMINATION

V/V P

: In normal limit : Soft and thin

: 3-4 cm Amniotic membrane : (-),clear amnion Head : ST -1; SS transverse

Laboratorium

Hemoglobin Lekosit Hematokrit Trombosit Protein urine

: 13 gr% : 17.600/mm3 : 34% : 316.000/mm3 :(-)

Diagnosis G2P1A0 term parturien first stage active phase; Gestational Hypertension Therapy : Admission test P/ Spontaneus Delivery Methyldopa 3x500 mg Observe GC, vital sign , contraction, FHR

Observation
Time
21.25-22.25 22.25-23.25 23.25-00.25 00.25-01.20

Contractio n
3-4 x/10'/40 K 3-4 x/10'/40 K 3-4 x/10'/40 K 3-4 x/10'/40 K

FHR (Bpm)
144-148 140-144 132-136 144-148

BP(mmHg)
150/100 150/100 150/100 150/100

HR (Bpm)
88 88 92 96

R (Bpm)
22 22 24 24

Note
Admission test Baseline rate 140150 bpm VariabilitY > 5 bpm Accellerati on (+) Decelerati on (-)

01.20
Time :01.20 Patient want to bear down Internal examination: V/V AM Head : In normal limit : complete :(-), clear fluid :St -1, ss transverse, caput (+)

WD/ G2P1A0 term parturien second stage II; Gestational Hypertension Th/ Lead the patient to bear down Contact perinatology Obeserve GC, Vital sign, contraction, fetal heart rate

Second Stage

Time 01.20-01.50

Contractio n 3-4x/10/40 K

FHR (bpm) BP(mmHg) 132-136 150/100

HR (Bpm) 92

R (Bpm) 24

Note

hour without progress Internal Examination

V/V AM Head

: In normal limit : complete :(-), clear fluid :St -1, ss transverse, caput (+)

Dk/ G2P1A0 term parturien second stage II; gestational hypertension, cephalopelvic disproportion

P/ C-section due to cephalopelvic disproportion Informed consent Consult anestesiology Contact OT, perinatology Observe GC, vital sign, FHR, contraction Advice from Onsite Consultant agree with diagnosis and therapy

Operating Theater

Time
01.50-02.15

Contractio n
2-3/10/30 KK

FHR (b/m) BP(mmHg) HR (Bpm)

136-140 150/100 100

R (Bpm)
24

Note
Preparation Waiting for OT

02.20 Go to the OT 02.25 Arrived at the OT External Eamination:

Contraction : 2-3x/10/30 LS FHR : 132-136 Bpm

Internal Examination :

V/V AM Head

: In normal limit : complete :(-), clear fluid :St -1, ss across, caput (+)

 03.00 03.05

03.08

04.00

Operation began A Baby was delivered BW: 3480 gram, BL 51 cm, Apgar 7/9 caput (+) 5x4 cm, at occiput, Contraction adequate Born placenta with mild umbilical cord traction W : 500 gram, Size 23x21x2 cm Operation finished Bleeding during operation 500cc Diuresis during operation 200cc

WD/ BS :G2P1A0 Term parturien at second stage I; gestational hypertension , cephalopelvic disproportion WD/ AS :P2A0 Term C-Section delivery due to cephalopelvic disproportion; gestational hypertension OT :SCTP ; IUD Insertion

III. Problems

How to diagnosed Cephalopelvic disproportion in this patient? Was the management appropriate? What is the prognosis for the next delivery?

How to diagnosed Cephalopelvic in this patient?

Causes of CPD : Increased Fetal Weight Fetal Position Problems with the Pelvis Problems with the Genital tract

Pelvimetry:
Manuver Muller Manuver Osborn X-ray pelvimeter, USG sefalometer

Pelvimetry:

Manuver Muller Manuver Osborn MRI, CT Scan, X-Ray ; pelvimeter, USG sefalometer

Oops... I should have remember the accuracy of pelvimetry only 28 %

How to diagnose CPD in this patient :

Head was at 3/5, station 1, not engaged Second staged and still in station 1; Delivery hystory with > 2500gr birth weigh baby. Adequate contraction caput Unborn baby after the patient led to bear down.

Was the management appropriate

Was the management appropriate ?

Spontaneus delivery, traditional birth attendant

3480 gr
C-Section, RSHS

3500 gr

Caput at Occiput ?

Caput at Occiput ?

Admission Test

Can we do Augmentation ?
21.25 3-4 X/ 10/ 40 S 22.25 3-4 X/ 10/ 40 S 23.25 3-4 X/ 10/ 40 S 00.25 3-4 X/ 10/ 40 S

01.20
3-4 X/ 10/ 40 S

Lead to bear down

01.50
3-4 X/ 10/ 40 S

C-section

02.15 2-3 X/ 10/ 30 S

02.25 2-3 X/ 10/ 30 S

03.05 Baby was born

Correlation between Position Changing and Pelvic Diameter

Michel, S.C.A., et al (2002). MR Obstetric Pelvimetry: Effect of birthing position on pelvic bony dimensions. American Journal of Roentgenology 179, 1063-1067

Median Duration of the Second Stage :

Nulliparas median duration of the second Stage

Multiparas

50 minute

20 minute

Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap LC, Wenstrom KD. William obstetrics. Edisi ke-23. New York: McGraw Hill; 2010

2 hours

Second stage : Nulliparas

Second Stage

3 hours with regional analgesia 1 hour

Multiparas 2 hour with regional analgesia

Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap LC, Wenstrom KD. William obstetrics. Edisi ke-23. New York: McGraw Hill; 2010

What is the pronosis for the next delivery ?

Impey L, OHerlihy C :
> 68% women diagnosed with CPD delivered spontaneusly, 47 % with bigger baby

> 65% women diagnosed with CPD delivered spontaneusly

American Journal of Public Health,

SUMMARY

CPD Diagnostic in this patient was to early because the patient was only led to bear down for Hour

The management of this patient is not adequate

The patient may delivered spontaneusly for the next delivery

SUGGESTION

Perform Muller Maneuver for this patient Change the position from supine to squatting and knee down position to enlarge the outlet Augmentation for inadequate contraction if possible

Lead multipara to bear down for at least 1 hour

3rd Case Presentation Friday, April 20th 2012

Uterine Rupture in Multiparous Woman with Hystory of Hysteroraphy

Presented by : Erfan Kharisma B Resource Person : Hartanto Bayuaji, dr.SpOG (K)