Spontaneous Vaginal Delivery IN Post Term Pregnancy
Spontaneous Vaginal Delivery IN Post Term Pregnancy
Spontaneous Vaginal Delivery IN Post Term Pregnancy
DELIVERY
IN
Presented by
POST
TERM
PREGNANCY
Jane A. Djianzonie
100 100 128
R. Pavin Vikneshwaran
Advisor
dr. Fadjrir, M.Ked (OG), Sp.OG
Mentor
dr. Rina Sinta Dhanu
SMF ILMU OBSTETRI DAN
GINEKOLOGI
RSU DR. PIRNGADI MEDAN
2015
INTRODUCTION
INTRODUCTION
INTRODUCTION
INTRODUCTION
INTRODUCTION
In postterm pregnancy there are changes in
placenta, amniotic fluid and fetal
circumstances oligohydramnios,
meconium aspiration, asphyxia fetus and
shoulder dystocia increase the risk of poor
perinatal outcome increased perinatal
mortality
Risk for mothers with postterm pregnancy
consist of postpartum bleeding and
increased obstetric action.
THEORY
Spontaneous
Vaginal
Duration:
o primigravida = 8-12 h
o multigravida = 6-8 h
Phases of the first stage:
Latent phase: started when the cervix
dilatated slowly and reached to about
3cm.
A. in primigravida = 8h
B. in multigravida = 4h
. - Active phase: rapid dilatation of the
cervix to reach 10cm
A. in primigravda = 4h
B. in multigravida =2h
Cardinal sign of
delivery
Engagement
Descent
Flexion
Internal rotation
Extension
External rotation
Delivery of the fetal's
shoulder (expulsion)
Delivery of Shoulder
After
Rotation
external
2.
3.
4.
THEORY
POST - TERM
DEFINITION
The international definition of prolonged
pregnancy, endorsed by the American
College of Obstetricians and Gynecologists
(2004), is 42 completed weeks (294 days)
or more from the first day of the last
menstrual period. It is important to
emphasize the phrase 42 completed
weeks. Pregnancies between 41 weeks 1
day and 41 weeks 6 days, although in the
42nd week, do not complete 42 weeks until
the seventh day has elapsed.
POST - TERM
INSIDENCE
Approximately 7% of the 4 million
babies born in the United States in
2001 is estimated to have been born at
42 weeks or more. Analysis of 27 677
women born in Norway, an increase of
10% to 27%, if the first birth postterm
and to 39% if the twice-born postterm.
POST - TERM
Etiology
Effects of Progesterone
progesterone sensitivity of uterus to oxytocin
Uterus Neural
Hereditary
POST - TERM
Diagnosis
Menstrual history
History of antenatal care
Pregnancy test
Fetal movement
Fetal heart rate
Radiological examination
Examination of amniotic fluid
Levels of Lecithin / spingomielin
Amniotic fluid Tromboplastin activity (AFTA)
Amniotic fluid cytology
POST - TERM
POST - TERM
POST - TERM
Postmaturity Syndrome
POST - TERM
POST - TERM
Postmaturity Syndrome
POST - TERM
Management
POST - TERM
Treatment
POST - TERM
CASE REPORT
CASE REPORT
PATIENTS
IDENTITY
Name
: DR
Age
: 23 years old
Religion
Race
: Christian
: Batak
Occupation
: Housewife
: 11 August 2015
CASE REPORT
History Taking
Mrs DR, 23 yo, G1P0A0, Christian, Batak, Housewife, wife from
Mr.H, 33yo, private servant, came to ER with :
Chief complaint : exited expected date of delivery (EDD).
Strain on labor (-), History of bloody show (-), Histoy of amniotic
Fluid Leakage (-)
History of previous disease : History of previous med : Menstrual History
LNMP : 19/10/2014
EDD
: 26/07/2015
ANC
History of Labor
1. This pregnancy
CASE REPORT
Status Present
Sens : CM
BP
Anemis : -
: 120/80mmhg
Icteric : -
HR
: 90 times /second
Cianoteic
:-
RR
: 20 times /second
Dyspneu
:-
Temp : 36,5C
Oedem : -
Obstetrics Status
Abdomen
: asymetric enlargement,
Fundal height
Tension Part
: Left
Lowest Part
: head presentation
: (+)
Uterine Contraction
: (-)
CASE REPORT
: Concave
: not prominent
: Blunt
: mobile
CASE REPORT
USG TAS
- Single Fetus, Head Presentation, Alive Fetus
- Fetal Movement (+)
- Fetal Heart Rate (FHR) (+)
- Biparietal Diameter : 96mm
- Femur Length : 84mm
- Abdominal Circum. : 342mm
- Placenta Anterior Corpus, Calcification (+)
- Amniotic fluid (+) normal range (150mm)
- Estimated Fetal Weight : 3000-3200
Conclusion :
Single Fetus + Intra uterine pregnancy (42-43
CASE REPORT
Results
Normal Values
4,10 g%
12-14
Erytrocyte
2,78 x106/mm3
4,5-5,5
Leucocyte
12.8 x103/mm3
4.000-10.000
16,3 %
36-42
164 x103/mm3
150-440 x 103
MCV
58,60 fL
80-97
MCH
14,70 pg
27-33,7
25,20 g/dL
31,5-35
22,90 %
10-15
Hb
Ht
Thrombocyte
MCHC
RDW
Protrombin time
-
Patient
Control
INR
APTT
-
Patient
Control
13,0 detik
15,5 detik
1,03
32,3 detik
AST/SGOT
33,4 detik
22,00 U/L
0-40
SGPT
12,00 U/L
0-40
Glucose Ad Random
92,0 mg/dL
<140 mg/dL
Ureum
20,0mg/dL
10-50 mg/dL
Creatinin
0,66mg/dL
0,60-1,20 mg/dL
Total Bilirubin
0,50
0,00-1,20 mg/dL
Direct Bilirubin
0,17
0,05-0,30 mg/dL
CASE REPORT
Diagnosis
Primi Gravida + Intrauterine Pregnancy (42 weeks
2days) + Head presentation + Alife Fetus + Non
Inpartu + Anemia
Therapy
- IVFD RL 20 drips/i
Planning
Improved general condition of the patient.
Transfusion 3 bag (PRC) , a routine blood test is
done 6 hours post-transfusion.
Consult Internal Medicine for Anemic diagnostic
confirmation and tolerance of transfusion.
Date
CASE REPORT
11
2015
Date
12
2015
August S O Sens: compos mentis
BP : 120/80 mmHg
BP : 120/80 mmHg
HR : 82x/I reguler
HR : 82x/I reguler
RR : 20x/I reguler
RR : 20x/I reguler
T : 36,5C
T : 36,7C
Dyspnea:- Edema: -
Dyspnea:- Edema: -
Obstetric Status
Obstetric Status
P IVFD RL 20 gtt/i
Planning :
-
Monitor
Vital
Sign,
FHR,
Uterine
Contraction
Transfusion PRC 2-bag, remainder 1bag.
Internal Medicine Consultation :
Screening blood test on Fe Serum
and TIBC test.
CASE REPORT
Date
13
August S
2015
RR : 20x/I reguler
HR : 88x/I regular
T : 36,6C
Fe Serum/ TIBC
: 23.00 / 619.000
A
P
Primi Gravida + IUP(42 weeks, 4days) + HP + AF + non inpartu + Iron Deficiency Anemia
IVFD RL 20 gtt/i
Planning :
-
CASE REPORT
Date
14
August S
2015
0900
WIT
RR : 21x/i reguler
HR : 88x/i, regular
T : 36,6C
Obstetric Status
Abdomen : Enlarged, Asymmetry
Fetal Movement : (+)
Uterine Contraction : (+), 2 x 10/10
Fetal Heart Rate : 148 x/i, regular
Vaginal Bleeding : (-)
Defecation and urination (+) normal.
Vaginal Toucher
Cervix : Axial, Dilation : 5cm, Effacement : 100%, occiput ??, Station of vertex (H II-III),
Amnion Sac : (+) Bulging
Glove: bloody show (+), Amnion fluid (-).
Primi Gravida + IUP(42 weeks, 4days) + HP + AF + non inpartu + Iron Deficiency Anemia
IVFD RL 20 gtt/i
Planning :
Monitor Vital Sign, FHR, Uterine Contraction
Spontaneus Vaginal Delivery
Partography Assessment on the progress of the delivery process.
CASE REPORT
0930
c c c c c
- - - - -
R
L
R
L
R
L
36 37 3737 37
DR
14 /08/ 15
23 tahun 1
0900
CASE REPORT
CASE REPORT
Neonatal
Assessment
Post Term
Syndrome
Skin
wrinkles
(+),Dominant Palm
and Soles
1130 WIT
circumstances of birth : Alive baby,
spontaneous cry.
Skin color
: (+), Pale
Sex
Lenugo
: female
: (-)
: 33cm
: not found
Long hair
: (+)
Skin maceration
: (-)
CASE REPORT
Planning
Transfusion 1 bag PRC
Routine blood test is done 6 hours post-transfusion.
Monitoring Vital Sign, Uterine Contraction and Post
partum haemorrhage.
CASE REPORT
Time
(hours) WIT
Heart Rate
Blood
14.15
14.45
15.15
84
80
90
82
Pressure
(mmHg)
Respiratory
80
0
88
13.45
22
22
20
20
20
20
20
Kuat
Kuat
Kuat
Kuat
Kuat
Kuat
Kuat
10
Rate
Uterine
Contraction
Bleeding
( in cc)
CASE REPORT
Date
15
August S
2015
RR : 21x/i reguler
HR : 88x/i, regular
T : 36,6C
Localized Status
Abdomen
Fundus height
Vaginal Bleeding
Urination
: (+) normal.
Defecation
Post Vaginal Delivery on the indication of occiput anterior position + post partum day 1
Cefadroxil
2 x 500mg
Mefenamat Acid 3 x 500mg
Methargin
3 x 1 tab
B- Complex Vitamin
2 x 1 tab
CASE REPORT
Date
16
August S
2015
RR : 20x/i reguler
HR : 80x/i, regular
T : 36,5C
Localized Status
Abdomen
Fundus height
Vaginal Bleeding
Urination
: (+), normal.
Defecation
: (+), normal
Post Vaginal Delivery on the indication of occiput anterior position + post partum day 2
2 x 500mg
Cefadroxil
Mefenamat Acid 3 x 500mg
2 x 1 tab
B- Complex Vitamin
Planning :
Discard today. Control Obstetric Polyclinic as outpatient on the 20th August
2015.
TIME LINE
CASE
DISCUSSION
CASE DISCUSSION
Theory
In this Case?
Menstrual History
2. USG TAS
Gestational Age
AFI <10cm
Calcification of
Placenta
LNMP
: 19/10/2014
EDD: 26/07/2015
Patient came to ER on the
11th August 2015
Gestational Age :
(42weeks, 2days)
CASE DISCUSSION
Theory
In this Case?
CASE PROBLEMS
CASE
PROBLEMS ?
Whether the treatment in this case
was appropriate ?
The extent of general practitioners
can do, to handle the post term
pregnancy ?
Terima Kasih!