Case history of labor. History of presenting illness. Obstetric history

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SACHINKUMAR

Group LA1 172(2)

Case history of labor

— An unbooked case of a 28 year old,Reshma Anjum W/O Nadeem,resident of Sangareddy belonging to SEC-3 is a housewife is G3P1L1A1 with 9 months amenorrhoea came with chief complaints of pain abdomen since 2 hours — LMP-19-11-2014 — EDD-26-8-2015

HISTORY OF PRESENTING ILLNESS

— G3P1L1A1 presented with complaints of pain abdomen since 2 hours — No H/O decreased perception of fetal movements — No H/O leaking P/V — No H/O bleeding P/V

— No H/O burning micturition — No H/O swelling of legs — No H/O headache — No H/O blurring of vision — No H/O of epigastric pain — No H/O frequency of micturition — No H/O of fever and vomitings — No H/O of trauma

OBSTETRIC HISTORY

 — Marital life-5years — non consanguinous marriage — No h/o usage of OCP’S or ovulation induction drugs — Conceived spontaneously 1 year after marriage — LMP-19/11/2014 — EDD-26/8/2015

1st Pregnancy: — Antenatal period was uneventful — Full term, LSCS (indication-CPD), female baby, 2years — Birth weight was 2.9kg,at narayankhed govt hospital — Postpartum period was uneventful (no h/o puerperal fever, wound discharge) — Exclusive breast feeding for 6 months — Developmental milestones were normal and baby immunized till date

2nd Pregnancy: — Conceived spontaneously 1 year after 1st pregnancy — Spontaneous abortion in 3rd month followed by dilatation and curettage. Present pregnancy: — Conceived spontaneously 1year after 2nd pregnancy. — Regular antenatal check ups in outside hospital.

— 1st Trimester ü No H/O excessive nausea and vomiting ü No H/O of pain abdomen and bleeding P/V ü Folic acid prophylaxis taken — No H/O radiation exposure — No H/O drug intak

— 2nd Trimester: — Quickening felt in 5th month — Iron and calcium supplementation taken — Two doses tetanus toxoid taken

 — 3rd Trimester: — No H/O bleeding or leaking P/V — No H/O pedal edema

MENSTRUAL HISTORY

 — Attained menarche at 13years of age — 4-5/30, regular, normal flow, no clots, no dysmenorrhea

PAST HISTORY

— No H/O Hypertension, Diabetes mellitus, Epilepsy, Tuberculosis, Asthma or Heart disease and — No H/O Blood transfusions.

 SURGICAL HISTORY

 — No significant surgical history except for previous caesarean and dilatation and curettage done in the past.

FAMILY HISTORY

 — No h/o multiple pregnancy,congenital anomalies

 PERSONAL HISTORY — Diet-mixed, Appetite-good — Sleep-adequate — Bowel & Bladder- Regular — No addictions

GENERAL EXAMINATION

 — Patient is conscious and coherent, moderately built and nourished. — Ht-148cms — Wt-64kgs — Pallor-present — No icterus, cyanosis, clubbing, lymphadenopathy and pedal edema — Spine, Breast and Thyroid – NAD

— Vitals-Temperature-Afebrile PR-82/min, normal volume BP-110/70mm of Hg in right arm supine position

 — CVS Examination: S1 and S2 heard, No murmurs

 — RESPIRATORY SYSTEM: Bilateral air entry-present, clear and equal on both sides, No adventitious sounds

PER ABDOMEN:

 — Uterus uniformly enlarged to size corresponding to 36wks gestational age.

 — On palpation fundal height was corresponding to 36wks GA

 — Fundal grip: broad, soft and irregular mass suggestive of breech

 — Lateral grip: back felt on left side, limb buds felt on right side — 1st pelvic grip: cephalic and head was ballotable

 — Uterus was irritable and scar tenderness was present

 — Symphysio fundal height was 34cms

 — Abdominal girth-94cms — Clinically liquor was adequate —

AUSCULTATION:

 — FHS heard,at left spino umbilical line, regular,142/min

 — P/S-cervix and vagina healthy

 — P/V-cervix was 50% effaced, os admitting 1 finger membranes+ presenting part vertex at -2 station pelvis gynecoid

 — Single live intrauterine fetus with longitudinal lie and cephalic presentation, head ballotable and fetal heart sound heard on left spino-umbilical line and was 142/min.

 SUMMARY

 — A 28year old unbooked case,G3P1L1A1 with 9months amenorrhoea with prev LSCS with complaints of pain abdomen since 2hrs — On examination uterus was corresponding to 36wks GA with single live fetus with cephalic presentation with scar tenderness

DIAGNOSIS:

— G3P1L1A1 with 36 weeks GA with 1 previous LSCS with scar tenderness in early labour

INVESTIGATIONS

 — Hb-10.8gm%

 — T.W.B.C-7200cells/cumm

 — Neutrophils-53%

 — Eosinophils-3%

 — Lymphocytes-37%

 — Monocytes-6%

 — Platelet count-1.8 lakhs/cumm

 — CUE-Normal

 — RBS-70mg/dl

 — HIV-NR

 — HBsAg-NR

 — VDRL-NR

 — B/G/T-B+ve

 — BT-1min 20 seconds

 — CT-3min 30 seconds

 — Patient was admitted

 — High risk consent was taken

 — Emergency LSCS was planned

Operation perfomed: Emergency LSCS with bilateral tubectomy under spinal anaesthesia

Operative Procedure Under complete aseptic conditions abdomen cleaned and draped.Pfannensteil incision was given over abdomen Abdomen opened In layers Lower uterine segment identified and incised LUS was thinned out Kehrs incision given over lower segment of uterus

 — A single live preterm male baby of birth weight 2.5kg and APGAR 1-8/10,5-9/10 was delivered on   26th july at 2.30pm.

 — Placenta was located in fundal anterior position

 — Placenta with membranes was removed in toto

 — Uterine suturing done and hemostasis secured.

 — Total blood loss was estimated to be 750ml.

 — Bilateral tube ligation was done

 — Abdomen was closed in layers

 — Patient condition was stable and was shifted to post operative ward.

 — Baby was admitted to NICU for observation and was discharged after 5days.

 — Post-operative period was uneventful

 — Suture removal done on 7th post operative day and wound was healthy.

 — Patient was discharged on 8th postoperative day and was reviewed in OP after 1 week

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