Preterm Labour And Delivery Grand Round

DELIVERY OF PRETERM INFANT J. Siekei O’Mogire V. Maloba Awori

Patient Data • • • •

M. S. T. 22 yr old lady from Huruma Date of Admission:06/07/2009 LNMP 12th Jan, 2009 –reliable?? Para 1+2 with no living child, Gravida 4 • EDD 19th October, 2009 • Gestation By Dates 25 weeks

History of presenting condition • Complained of spotting for I day prior to admission • Patient on routine antenatal follow up @ the HRC • No History of lower abdominal pain, no drainage of liquor. • ? Fetal movements

• Was first seen 4 months ago @ GBD 10 weeks – Blood group B+ve, Hb 12g/dl – VDRL & PITC negative – Urinalysis normal

• Impression of BOH due cervical incompetence was made • Plan then: Patient advised for McDonald’s stitch @ 16/40 • She did not come back for booked appointment

Obstetric history •Para 1+2 with no living child, Gravida 4 •EDD 19th October, 2009 •Gestation By Dates 25 weeks Year

Place of delivery

1st pregnancy 2nd pregnancy

2007

Hospital

2008

Hospital

@ 18 weeks

-

Abortion

3rd pregnancy

2008

Hospital

@ 21 weeks

-

Abortion

• Puerperium normal

Gestatio Mode Outcome n of deliver Term SVD Female FSB y

Gynecological history • LNMP 12th Jan, 2009 • ?

PMHx/FSHx/Personal Hx • • • • •

PMSHx – Family HxMarried with no living children Form 4 leaver, housewife Husband 29 year old, businessman

Summary • MTS, a 22yr old married lady, para 1+2 with no living child, Gravida 4,LNMP 12th Jan 09,EDD 18th October 09, GBD 25 weeks, presenting with spotting for 1 day PTA.

EXAMINATION • General exam recorded as normal • BP 100/70mmHg ABDOMINAL EXAM • No scars, striae gravidarum present • Fundal height @ 24 weeks, presentation cephalic, engagement 5/5, position LOA • No contractions felt • FHR 150/min

VAGINAL EXAM • Digital exam – Cervix dilated at 3 cm – Bulging membranes

• Speculum exam – Cervical Os open – Membranes bulging

Other system exam findings not recorded, probably normal

• Impression made: – Inevitable early pregnancy loss with – Bad obstetric history

Plan on 6 @ 10:30am th

• Admitted to RMBH – Nurse in the delivery room with resuscitation eqpt

• • • • • •

IV fluids 1.5 litres N/saline MgSO4 1g/hour Buscopan 40 mg TDS Dexamethasone 20mg IM stat IV Ceftriaxone 2g OD Salbutamol infusion 1mg in N/saline, run for 6-8hrs • Monitor FHR quarter hourly • Inform neonatologist

• Patient stable • Fetal heart rate reassuring (142 – 158/minute) • No contractions felt

2

nd

day/7 July @ 8:30am th

• FHR 164/min • MO review – Suggested Obstetric U/S to • Confirm fetal status • Gestation • Determine state of cervix

– Patient given warm fluids to take & discouraged from voiding

• @ 10:40am – mild contractions, taken for U/S

Investigations • U/S – “single Intrauterine fetus, in cephalic presentation, cervix wide open with bulging membranes, gestation by femur length and bi-parietal diameter approximately 24 weeks” – Impression: sonographic features of inevitable abortion

• Urinalysis – Normal

• @ 11:30 am – Mild contractions noted – Neonatologist informed – Consultant review • Manage as inevitable abortion @ 24 weeks • Allow natural labour • Manage 3rd stage actively

• @ 1:30 pm – Moderate contractions – Fetal heart sound spresent

• @ 3:15pm – Strong urge to push – Delivered SVD – Live male infant did not cry immediately – APGAR score 4/1 ,5/5 ,8/10 ,8/20 – Suctioned, ambubagged, kept warm – Admitted to NBU, Weighed in NBU 870g – Placenta and membranes delivered – Minimal PV loss, about 100mls

Labor & delivery ctd • No drugs given to the mother • Perineum intact • Duration of labor (as recorded) – 1st stage 12 hours 30 minutes – 2nd stage 5mins – 3rd stage 5mins – TOTAL = 12hours 40 mins

• Fundus below umbilicus, mother stable, placenta not weighed

• • • •

Baby progress

Baby was given 0.25mg vitamin K IM Respiratory rate 52breaths/min Heart rate 132 beats/min Noted to be in respiratory distress,with grunting. • Had Flaring of alae nasi,severe chest wall indrawing,with reduced air entry bilaterally. • In cardiovascular exam,had peripheral cyanosis. • PLAN

•Start IVF at 120mls/kg •Monitor vitals •Patient needs surfactant •Placed on CPAP

• 8th July – Patent (mother)stable – ? Lochia, Fundal Height – Patient declined IV medications

10th July • Neonate had several apneic attacks • Resuscitation done,with ambubag • Aminophylline at 5mg IV

– Stopped breathing – No cardiac activity – Neonate certified dead at 5pm – Neonate passed away in NBU – Mother counseled – Discharged