Angeles University Foundation

School of Medicine
Department of OB-GYN

Obstetrics Preceptorship 1
Normal Labor & Delivery

Group 1
MD – 3

Angeles, Joel R.

December 7, 2017
Dr. Casciple
Date of Admission:
Time of Admission: 8:30 AM
Source of History: patient
Reliability: 100%

I. IDENTIFYING DATA
o Patient MR is a 24, female, married, a Filipino, a Roman Catholic, and a housewife from
Marisol, Angeles City.

II. CHIEF COMPLAINT

o Vaginal spotting

III. HISTORY OF PRESENT ILLNESS

o 3 days PTC, patient noted on and off pain in the hypogastric area which was described as
sharp, 6/10 pain scale, occurring every 20 minutes. This prompted her to seek consult. Upon
examination: FHT = 130 bpm, FH = 30 cm, IE: 1 cm dilated, 50% effaced, cervix is soft, mid-
position, station -3. She was then sent home.
o 3hours PTC, patient felt the same type of pain described from 3 days ago but was now
radiating to the back, more frequent (occurring every 5 minutes) and with a pain scale of
9/10. There was also noted vaginal discharge which she described as mucus-like and brown,
filling her underwear. Due to the persistence of symptoms, the patient opted consultation.

IV. OBSTETRICS HISTORY

o G1P0 (0000)
o LMP: Feb. 16, 2017
o EDC: Nov. 29, 2017
o Fundic height at 30cm
o Ante-partum History
₋ Pre-natal check-up: regular until 28/weeks
₋ Takes Iron, Ca, Vitamins
₋ Ultrasound done at 8 weeks; due at Nov. 29, 2017 (normal results)
₋ CBC, OGTT, Hepa B titer (normal values)
₋ At 14 weeks AOG, diagnosed w/ uncomplicated UTI. Prescribed with Cefalexin 500mg BID
x 7 days
₋ At 28 weeks AOG, diagnosed w/ uncomplicated UTI given same medication
₋ Speculum exam was not done

V. GYNECOLOGICAL HISTORY
o Menarche at 12 yrs old
o Menstrual cycle: every 28-30 days, 5 days duration, consumes 3pads/day moderately soaked,
no associated dysmenorrhea
o No history of STI
o No contraceptions
o Coitarche at 20 years old
o 1 sex partner (husband)

VI. PAST MEDICAL HISTORY

o No congenital abnormalities
 o Complete immunization history
o Had chicken pox and mumps during childhood; No measles
o No history of HPN, DM, Liver diseases, Allergies
o No history of hospitalization
o No history of previous surgery
o No history of psychiatric illness

VII. FAMILY HISTORY

o Father is 60 yrs w/ no comorbids
o Mother is 59 yrs w/ no comorbids
o Has 3 siblings w/ no comorbids
o No history of DM, HPN, TB, Hepatitis

VIII. PERSONAL & SOCIAL HISTORY

o High school graduate
o Non use of alternative medicine practices
o Sleeps approx. 9 hrs/day (8pm-5am)
o ADL’s serves as exercise

IX. DIET & ENVIRONMENTAL HISTORY

o Includes fish and vegetables in diet
o Drinks 8 glasses of water/day (purified water)
o Lives with husband in a concrete bungalow w/ 1 bedroom, 1 bath room w/ flush
o The house is well lit and ventilated
o No hazardous exposures
o Garbage collection once a week

X. REVIEW OF SYSTEMS
o (+) weight changes (pre-pregnancy: 120 lbs, now: 145 lbs)
o (+) heartburn during night time since 28 weeks of pregnancy
o (+) regular self-breast exam
o (-) anemia, edema
o (+) nocturia

XI. PHYSICAL EXAMINATIONS

o Vital signs
₋ BP = 120/80
₋ HR = 89
₋ RR = 17
₋ Temp = 36.8C
o Abdomen: globular
₋ LM 1 = cephalic, FH: 30 cm
₋ LM 2 = FHT = 140-145
₋ LM 3 = ballotable
o Pelvic exam
₋ External: (-) lesions, masses, rashes
₋ Speculum: smooth, violaceous, minimal mucoid, brownish, odorless discharge, (-) lesions,
pulling of fluid
 ₋ IE: 4 cm dilated, 100% effaced, cervix soft, anterior position, station -1, intact BOW
o NST
₋ Baseline FHT = 140-145
₋ Variability = moderate

XII. ANCILLARY PROCEDURES

o Electronic Fetal Monitoring
₋ Internal (Direct) Electronic Monitoring
₋ External (Indirect) Electronic Monitoring: ultrasound Doppler principle
₋ Baseline Fetal Heart Activity
o Other Intrapartum Assessment Techniques
₋ Fetal Scalp Blood Sampling
₋ Scalp Stimulation
₋ Vibroacoustic Stimulation
₋ Fetal Pulse Oximetry
₋ Fetal Electrocardiography
₋ Intrapartum Doppler Velocimetry
o Intrapartum Surveillance Of Uterine Activity
₋ Internal Uterine Pressure Monitoring
₋ External monitoring

XIII. SALIENT FINDINGS

Pertinent Positives Pertinent Negatives
24 years old, female No history of HPN, DM, congenital abnormalities
G1P0 (0000) 38 weeks AOG No history of hospitalization/surgery/trauma
LMP: Feb. 16, 2017 No history of intake of medications/illegal drug use
EDC: Nov. 29, 2017 Non-smoker and non-alcohol drinker
History of uncomplicated UTI at 14 & 18 weeks No history of measles during pregnancy
AOG- resolved by antibiotics No history of miscarriages/threaten abortions
Wt gain from 120 lbs to 145 lbs No anemia/edema

XIV. INITIAL IMPRESSION

o G1P0 pregnancy uterine, 39 weeks AOG, cephalic presentation, in true labor.

XV. DIFFERENTIAL DIAGNOSES

Criteria True Labor False Labor
Regularity/Interval Irregular, longer, variable Gradual increase
Intensity Gradually increases Unchanged
Duration Longer Short
Effacement Absent Present & progresses
Dilatation Absent Present & progresses
Location of pain Lower abdomen, non-radiating Lower abdomen, radiates to the
back
Effect on sedation Relieved Not relieved
Bloody show Absent Present

XVI. COURSE IN THE WARD

 o Upon admission: Hooked to D5LRS 1L x 30 gtts/min, given HNBB 2 amps IV.
o 2 hours post admission: IE—same results; with mild to moderate, irregular, 5-7mins interval
contractions.
o 4 hours post admission: IE—4-5cm fully effaced; -1 station; intact BOW; incorporated
Oxytocin 4-6 mU/mL to current IVF regulated at the same rate.
o 5 ½ hours post admission: IE—6cm fully effaced; -1 station; intact BOW; w/ regular and
strong contraction at 200 MV; given IV sedation to minimize pain.
o 7 ½ hours post admission: IE—8cm fully effaced; -1 station; spontaneous rupture BOW; clear
amniotic fluid.
o 9 hours post admission: IE—fully effaced and dilated; +2 station; (-) BOW; presenting part
triangular fontanel (occiput) at the left side of the mother (LOA)
o 12 hours post admission: Delivered a live baby boy, BW of 2.5kg, with a APGAR score of 8-9,
clear amniotic fluid; Placenta is delivered 10 mins after

XVII. FINAL DIAGNOSIS

o G1P1 1001 uterine pregnancy, term cephalic via NSD alive baby boy, BW of 2.5kg, APGAR 8-9,
NMR: 39 weeks appropriate for gestation age.

XVIII. DISCUSSION
o Background
₋ Labor is the process that leads to childbirth. It begins with the onset of regular uterine
contractions and ends with delivery of the newborn and expulsion of the placenta.
₋ The natural culmination of second-stage labor is controlled vaginal delivery of a healthy
neonate with minimal trauma to the mother. Vaginal delivery is the preferred route of
delivery for most fetuses, although certain clinical settings may favor cesarean delivery.
₋ Labor is characterized by brevity and considerable biological variation. Active labor can
be reliably diagnosed when cervical dilatation is 3 cm or more in the presence of uterine
contractions. Once this cervical dilatation threshold is reached, normal progression to
delivery can be expected, depending on parity, in the ensuing 4 to 6 hours. Anticipated
progress during a 1- to 2-hour second stage is monitored to ensure fetal safety. Finally,
most women in spontaneous labor, regardless of parity, if left unaided, will deliver within
approximately 10 hours after admission for spontaneous labor. Insufficient uterine
activity is a common and correctable cause of abnormal labor progress.
₋ Therefore, when the length of otherwise normal labor exceeds the expected norm,
interventions other than cesarean delivery—for example, oxytocin administration—must
be first considered.
o Plan of management options
₋ The initial assessment of labor should include a review of the patient’s prenatal care,
including confirmation of the estimated date of delivery. Focused history taking should
elicit the following information:
 Frequency and time of onset of contractions
 Status of the amniotic membranes (SROM? Amniotic fluid clear or meconium-
stained?)
 Fetal movements
 Presence or absence of vaginal bleeding
₋ Physical examination should include documentation of the following:
 Maternal vital signs
 Fetal presentation
 Assessment of fetal well-being
 Frequency, duration, and intensity of uterine contractions
 Abdominal examination with Leopold maneuvers
 Pelvic examination
₋ First stage of labor
 Assume the following positions that patient finds most comfortable: walking,
lying supine, sitting, or resting in a left lateral decubitus position
 Periodic assessment of frequency and strength of uterine contractions and
changes in cervix and in the fetus’ station and position
 Monitoring the FHR at least every 15 minutes, particularly during and
immediately after uterine contractions
₋ Second stage of labor
 With complete cervical dilatation, the FHR should be monitored or auscultated at
least every 5 minutes and after each contraction.
₋ Delivery of the fetus
 Positioning of the mother for delivery can be any of the following:
 Supine w/ her knees bent (dorsal lithotomy position)
 Lateral (Sims) position
 Partial sitting or squatting position
 On her hands and knees
₋ Episiotomy used to be routinely performed at this time, but current recommendations
restrict its use to maternal or fetal indications:
₋ Delivery maneuvers are as follows:
 The head is held in mid position until it is delivered, followed by suctioning of the
oropharynx and nares
 Check the fetus’s neck for a wrapped umbilical cord, and promptly reduce it if
possible
 If the cord is wrapped too tightly to be removed, the cord can be double clamped
and cut
 The fetus’ anterior shoulder is delivered with gentle downward traction on its
head and chin
 Subsequent upward pressure in the opposite direction facilitates delivery of the
posterior shoulder
 The rest of the fetus should now be easily delivered w/ gentle traction away from
the mother
 If not done previously, the cord is clamped and cut
  The baby is vigorously stimulated and dried and then transferred to the care of
the waiting attendants or placed on the mother’s abdomen
₋ Third stage of labor
 The following 3 classic signs indicate that the placenta has separated from the
uterus
 The uterus contracts and rises
 The umbilical cord suddenly lengthens
 A gush of blood occurs
₋ Delivery of the placenta usually happens within 5-10 minutes after delivery of the fetus,
but it is considered normal up to 30 minutes after delivery of the fetus.
₋ Pain control
 Agents given in intermittent doses for systemic pain control include the
following:
 Mepreidine 25-50 mg IV q 1-2 hours or 50-100 mg IM every 2-4 hours
 Fentanyl, 50-100 mcg IV q hour
 Nalbuphine, 10 mg IV or IM q 3 hours
 Butorphanol 1-2 mg IV or IM q 4 hours
 Morphine 2-5mg IV or 10 mg IM q 4
 As an alternative, regional anesthesia may be given. Anesthesia options include
the following:
 Epidural
 Spinal
 Combined spinal-epidural
XIX. REFERENCES
o Williams Gynecology 2nd ed.
o Medscape: Normal Labor & Delivery