WH Case Write Up Obstetric

History Taking
Venue: Hospital Sultan Ismail Ward 4A (obstetrics ward)
Date: 10/3/2016
Patients identification: A 32 years old Malay female, who is G4P1+2 and currently
with 37w+6d period of gestation. She works as a nurse and married for 5 years.

Gestation
LMP
EDD by dates
EDD by scan

6 / 6 / 2015
25 / 3 / 2016
12 / 3 / 2016

Presenting complaint
This is a referred case from Hospital Kota Tinggi for elective lower segment
caesarean section due to persistent transverse lie.

History of Presenting Complaint

The first ultrasound scan was done at week 9 of pregnancy and a transverse lie was
noted. She was referred to family medicine specialist for 2-weekly monitoring of
fetal lie. However, the fetal lie was remained at transverse position throughout the
whole pregnancy. At gestation of 37w+1d, she was admitted to Hospital Kota Tinggi
and had a counselling regarding the mode of delivery with the O&G specialist. She
has been requested for elective Caesarean section in view of involuntary subfertility
for 8 years and had persistent transverse lie. She was not keen for external cephalic
version and decided to accept Caesarean section. Postoperative Caesarean section
risk was explained and she understood. At gestation of 37w+4d, she was then
referred to Hospital Sultan Ismail and the date of operation was scheduled.

History of pregnancy
She suspected pregnancy because of the missed period for 2 weeks. A urinary
pregnancy test was done by herself and the result was positive. The pregnancy was
confirmed by ultrasound scan in the Klinik Kesihatan. At that time, it was week 7 of
pregnancy. There was no any symptoms of early pregnancy such as morning
sickness, tiredness, breast tenderness and frequent urination. However, she has
developed bilateral lower leg oedema without calf tenderness at gestation week of
32. The fetal movements were started from week 20 of pregnancy and well
perceived by her. There were no episodes of abdominal pain and any vaginal
bleeding or discharge throughout the pregnancy. All the booking investigation
showed normal result except for mild anaemia. Her blood group is A+.

Past obstetrics history

No
.

Year

Gestation
al age

Antenatal
complication

Mode of
delivery,

Birth
weigh

Sex

WH Case Write Up Obstetric

s
1

200
8

38w

200
9
201
2

4w

Breech
presentation
with success
external
cephalic
version
Miscarriage

8w

Miscarriage

Postnatal
complication
s
Vaginal
delivery

t
3.5kg

Male

Past gynaecological history

Menarche: 12 years old

Usual menstrual cycle: 3/30

Experience dysmenorrhea occasionally on the first day of menstruation

IMB/PCB: No

UTI (vaginal discharge): No

Contraception: No

She has annual cervical smear since her marriage. The last cervical smear
was done in last year and the result was normal.

No history of sexually transmitted disease.

She has 8 years of subfertility problem without taking any medications.

Dilation and curettage was done twice for the previous miscarriage.

Past medical history

No significant past medical history

1. Absence of any chronic medical conditions (diabetes, hypertension,
cardiac disease)
2. No previous admission to hospital other than the first child delivery
3. No history of blood transfusion

Drug history

Folic acid & vitamins (at booking)

Ferrous fumarate for anaemia

2

WH Case Write Up Obstetric

No allergy to drug or food

Not on any long term medication

Social history

She is living with her husband and son with adequate family support

Not smoking/alcohol/drug abuser

Family history

Both parents are fit and well

No history of diabetes, hypertension, gestational diabetes
Absence of multiple pregnancy and Downs syndrome

System review

No fever

No SOB

No chest pain

No UTI symptoms

No URTI symptoms

ICE
Ideas
She thinks that the persistent transverse lie might be related to the previous
miscarriage.

Concerns
She was worried for the persistent transverse lie that requires Caesarean section
which may associate with several risks to her baby and herself.

Expectations
She hopes that she can deliver a healthy baby.

Physical examination
General examination

Comfortable under room air

Medical adjuncts: IV assess on both hands and urinary catheter

Temperature 37.2C

Pulse 84bpm

Capillary refill time <2s

WH Case Write Up Obstetric

Blood pressure 135/81mmHg

Conjunctival pallor

Good hydration

No symptoms of labour (uterine contraction pain, rupture of membrane)

Fetal movements are well perceived
No other active complaints

Abdominal examination
Inspection

Distention of abdomen consistent with pregnancy

Linea nigra and striae gravidarum
No previous surgical scars
No visible fetal movements
Symphysiofundal height is 40cm

Palpation
Abdomen is soft and non-tender
Transverse lie and breech presentation
Adequate liquor volume

Auscultation

Bowel sounds are present

Fetal heart sounds are heard

Lower limb inspection

Mild bilateral lower limb oedema

No calf tenderness
No varicose vein

Management
Preoperative management
Nil by mouth for 12 hours with IV drip
2 large bore branula to operating theatre
Gastric prophylaxis on operating theatre
Glucuronoxylomannan and 2 pints packed red blood cell

Postoperative management
Monitor vital signs for half hourly X2, hourly X2, 2hourly X2, if stable then 4hourly
4

WH Case Write Up Obstetric

Keep the continuous bladder drainage until ambulatory well

Spinal care for 6 hours
Allow oral intake as tolerated
Strict I/O chart
Strict pad chart (to inform if more than 2 fully soaked pad within 1 hour)
IV cefuroxime 750mg tds for 2 days then switch to tablets for 5 days
S/C heparin 7500 units bd until discharge
Continue IV Pitocin 80U for 12 hours
Analgesia as per required by anesthetist order

Basic neonatal information

Number of babies delivered: 1
Date and time of delivery: 10/3/2016; 1110h
Sex: Female
Birth weight: 3.4kg
Apgar score: 9@ 1min