Case number 001

ARREST OF DESCENT WITH MALPOSITION.

Lira Regional Referral Hospital

Biodata

Mother’s initials: A.J

Date of admission: 18/10/2020 Time of admission: 09:30 hours

Inpatient number: 2069

Age: 21 years

Address: Village: Ober, Anai ward, Ojwina Division, Lira District

Religion: PAG

Tribe: Lango

Occupation: Teacher

Next of kin (N.O.K): O.B

Occupation: Driver

Relationship: Husband

LNMP: 15/01/2020.

EDD: 21/10/2020.

W.O.A: 39weeks 4days

Gravida: Prime gravida

PRESENTING COMPLAINT (PC): Labor-like pains & Uterine contractions since 03:00hrs
HISTORY OF PRESENT COMPLAINT: 21 y/o PG with an intrauterine pregnancy at 39 4/7
weeks of gestation, well dated by LNMP (15/01/2020) and no Ultra Sound scan performed
throughout pregnancy, who presented to Maternity with PC of uterine contractions. Antenatal care
(ANC) attended at LRRH (5 visits, first visit at 10 weeks GA), uterine size corresponds to dates,
ANC Blood Pressure range (100–126)/ (64–83) mmHg. Patient admitted in active labor.
STUDENTS REPORT ON PREGNANCY

MEDICAL HISTORY

A.J reported no history of any chronic medical diseases like Essential Hypertension, Diabetes
Mellitus, mental illness, Asthma, Epilepsy, sickle cell anemia, kidney disease, rheumatic fever, no
history of any sexually transmitted infections like HIV/AIDS, syphilis, gonorrhea, Genital herpes
simplex, cancroid, chlamydia infection ,Genital warts, candidiasis and no trichomonas, no history
of any childhood illnesses like poliomyelitis, and rickettsia which can bring complications to her
pelvis, no history of other infections like active pulmonary tuberculosis, Hepatitis B, cervical
cancer and no recurrent malarial infections which can complicate or be complicated by pregnancy,
labor and puerperium.

SURGICAL HISTORY

A.J reported no history of any surgical operations like caesarean section and no operations on the
pelvic floor muscles, she has never been involved in any accidents, involving the spines, pelvis
and lower limbs and no skeletal deformity. No history of any blood transfusion.

SOCIAL HISTORY

Mother said she’s happily married. She earns as a teacher and also gets financial support from her
husband. A.J reported that she neither smokes nor drinks alcohol. Their house is well ventilated
and currently spacious with clean toilets and bath rooms. They fetch their water at the borehole.

FAMILY HISTORY

A.J reported that both her parents are alive and healthy. No history of any familial diseases like
Diabetes Mellitus, hypertension, asthma, mental illness, epilepsy sickle cell and no history of any
twins in the family, which can complicate or be complicated by pregnancy, labor, delivery and
puerperium.

GYNAECOLOGICAL HISTORY

Conditions: She reported no history of abortion or ectopic pregnancy, no history of ovarian cyst.
Operations: no history of dilatation and curettage done, no history of myomectomy done. No
history of fistula and no history of repair of 3rd degree tear.

PAST OBSTETRICAL HISTORY

Not applicable
 MENSTRUAL AND CONTRACEPTIVE HISTORY:
Menarche: 16 years
Length of bleeding: 5 days
Length of cycle: 30days
Remarks: Normal menstrual cycle.
Family planning Methods used: Condoms
Indication for use: To prevent conception.
When she stopped: impromptu
Why she stopped: To conceive her first baby.

QUICK REVIEW OF OTHER SYSTEMS

Reported having good appetite, good sleep pattern and normal bowel and micturition habits.

PRESENT OBSTETRICAL HISTORY

LNMP:15/01/2020, EDD: 21/10/2020, W.O.A: 395/7 Weeks, Prime Gravida.

Mother has attended ANC 5 times her first visit being at 10 weeks. She reports no complaints like
fever, cough, diarrhea, excessive vomiting, weight loss, bleeding and no hospitalization in the past
one month.

ANTENATAL EXAMINATIONS

Date Fundal presen Engag Position Fetal Blood Weight/ Nipple Notes
height tation ement and lie heart pressure Height
rate (mmHg) (Kgs)/cm
(b/m)
25/03 PALPABLE MASS 100/64 65/157 Normal 1st IPT, T.T 1,feso4+
/2020 folic acid
06/05 16/40 PALPABLE MASS Heard 120/72 66/157 Normal 2nd
/2020 IPT,T.T,meb,feso4+f
olic acid
01/07 24/40 Cephal Free L.O.A, 136 110/70 68/157 Normal 3rd IPT,2nd
/2020 ic Long T.T,meb,feso4,folic
acid
12/08 30/40 cephali Free R.O.A, 140 118/83 68/157 Normal Feso4, folic acid
/2020 c long

23/09 36/40 Cephal Free R.O.P, 132 126/80 70/157 Normal Feso4, folic acid
/2020 ic long
BLOOD TESTS:

Date Blood group Rhesus factor

A Positive (+)

Date HB (g/dL) Bs/MPs VDRL RCT

12.6 Negative Non-reactive Negative

Not done Not tested Not tested Not tested

12.0 Not tested Not tested Negative

NOTES;

Any special examinations, like: x-ray , health education talks given.

i. Danger signs during pregnancy, labor and puerperium

ii. Signs of true labor
iii. Diet in pregnancy and lactation
iv. Preparation for the coming baby and good hygiene

STUDENTS REPORT ON LABOUR

ADMISSION

A.J, a 21 y/o PG with an intrauterine pregnancy at 39 4/7 weeks of gestation, well dated by LNMP
(15/01/2020) and no Ultra Sound scan performed throughout pregnancy, who presented to
Maternity with presenting complaint of labor-like pain and uterine contractions since 03:00hrs.
Antenatal care (ANC) attended at LRRH (5 visits, first visit at 10 weeks GA), uterine size
corresponds to dates, ANC Blood Pressure range (100–126)/ (64–83)mmHg. Mother admitted in
active labor.

General examination:

On general examination, there was no sign of anemia, jaundice, edema, dehydration, cyanosis and
clubbing. Breasts are normal with no abnormal discharge, nipples are well protruded. No varicose
veins seen.

Vital observations

Temperature: 36.2 0C, Pulse: 80b/m, Blood pressure: 120/80mmHg, Respiration: 18b/m
ABDOMINAL EXAMINATION

On inspection, abdomen was enlarged and ovoid in shape. Linea nigra present below and above
the umbilicus, Striae gravidarum present and fetal movements observed.

On superficial palpation, there’s no tenderness elicited, On deep hypochondriac palpation, no

enlargement of the spleen on the left, and no enlargement of the liver on right side.

Fundal height is 39/40 weeks.

Deep pelvic palpation: A smooth hard round mass was felt and was engaged (4/5 palpable
abdominally), presentation is cephalic.

Fundal palpation: A soft mass was felt to be the breech and lie was longitudinal

Lateral palpation: A continuous curved mass was felt and position was Right occipito- posterior

Auscultation: Fetal heart heard at a rate of 136b/m

Contractions: 3 moderate contractions in 10 minutes lasting less than 40 seconds

Fetus feels big, estimated weight 4kgs by Leopold’s.

VAGINAL EXAMINATION

Time: 09:30 hours 0n 18/10/2020

Mother re-assured, privacy provided and done under aseptic technique.

Vulva: on inspection, vulva clean, no warts, no sores and no varicose veins observed,

Vagina; warm and moist,

Cervix; soft and thin, posteriorly positioned and 8cm dilated, anterior fontanelle felt, LOP position
confirmed vaginally

Membranes intact, presentation is vertex, not well applied to the cervix, level of presenting part
above the pelvic cavity.

Internal pelvic assessment

Sacral promontory: not tipped at 12cm, sacral curve: not well curved, Ischial spines not
prominent, Sub- pubic arc admits 2 fingers, Intertuberous diameter accommodates 4 knuckles
Diagnosis

A prime gravida in active stage of labor with inadequate pelvis.

Plan of care

I encouraged mother to have enough rest, eat frequent light meals and drink plenty of fluids to
conserve energy and maintain hydration in preparation for second stage of labor.

I encouraged her to empty bladder frequently.

PROGRESS OF FIRST STAGE OF LABOR

Fetal heart monitored ½ hourly (every 30 minutes) and ranged from 136-150b/m

Temperature monitored 4 hourly and ranged from36.0-37.2 degree Celsius

Pulse monitored ½ hourly and ranged from 82-90 b/m

Blood pressure monitored 2 hourly and ranged from (100-120)/(80-90)mmHg

Respirations monitored 2 hourly and ranged from 18-20 breaths per minute

Urine monitored 2 hourly and ranged from 100-500mls

Descent monitored 2 hourly and remained 2/5 palpable abdominally

Cervical dilatation monitored 4 hourly and dilated fully.

Contractions monitored ½ hourly and ranged from 3 moderate to 4 strong contractions.

Uterine contractions increased progressively but there was no progress in descent of the head.

PROGRESS OF SECOND STAGE OF LABOR

At 13:30 hours on 18/10/2020

Abdominal examination, 3 moderate contractions in 10 minutes lasting 35 seconds. Fetal heart

heard and regular at a rate of 150b/m, descent 2/5.

Vaginal examination repeated, membranes still intact, cervix still soft and thin. Cervical os 10cm
dilated, presenting part is vertex, not well applied to the cervix, and in lower uterine cavity.

At 15:30 hours

Abdominal examination repeated, 4 strong contractions in 10 minutes each lasting 50-60 seconds,
fetal heart heard and regular at 160 b/m, descent 2/5
Vaginal examination repeated, membranes found ruptured and meconium stained liquor draining.
No cord prolapse. Cervix is soft and thin, fully dilated, presenting part vertex in the lower cavity
but not well applied to cervix

Diagnosis

Prolonged second stage due to cephalon-pelvic disproportion.

I re-assured the mother and explained to her that she needed to undergo cesarean section since the
labor was not progressing and meconium stained liquor is a sign that the fetus is getting distressed.
I called the doctor to review her who instructed me to prepare her for theater and informed the
theater staff.

Preparation of mother for theater

I sought her consent and she signed a written consent form.

I took off blood sample for Hb, grouping and cross matching, and booked 2 units of blood.

I put an I.V line and rehydrated her with 2 liters of fluid (normal saline)

I administered I.V Ceftriaxone 2g stat and I.V gentamycin 160mg for prophylaxis 30 minutes
before operation commenced.

I inserted a Foley catheter with urinary bag attached.

I removed hair pins, wedding ring and necklace and kept them safely.

I dressed mother in theater gown and rolled her to theater.

I assisted in positioning the mother by instructing her to bend forward as the anesthetist officer
administered the spinal anesthesia.

We positioned mother in Trendelenburg position with right hip tilted towards the left.

I scrubbed, wore sterile gown and assisted the doctor in the operation.

A live term male infant was delivered at 16:03 hours. I clamped the cord after 1 minute, cut it and
handed the infant to the receiving midwife. Baby had an Apgar score of 9/10 at 1st minute and
10/10 at 5 minutes and weighed 4.1Kgs.
ACCOUNT OF THIRD STAGE OF LABOR

The abdomen palpated for the presence of another baby. Pitocin 10 IU given on the outer aspect
of the right thigh intramuscularly to stimulate uterine contractions.

Placenta and membranes expelled by controlled cord traction abdominally at 16:05 hours. A quick
examination of the placenta done for completeness and was complete and normal

Fundus rubbed for contractions, blood mopped, and uterus repaired using vicryl 2, rectus sheath
using vicryl 2/0 and skin using vicryl 2

Estimated blood loss was approximately 450mls.

EXAMINATION OF PLACENTA AND MEMBRANES:

Placenta examined on a flat surface, with adequate light. Placenta held under running water to
remove blood clots, using protective wears.

The membranes: placenta held by the cord and membranes allowed to hang, a hole through which
the fetus passed was identified and a hand inserted and membranes inspected and was normal.

Amnion peeled from the chorion and was complete, and membranes complete.

The maternal surface: placenta laid on a flat surface, lobes was complete since they easily fit
together, cotyledons was complete.

The maternal surface appeared healthy, no infarcts seen.

The fetal surface: the cord was normally and centrally inserted. The amnion peeled right up to
the cord insertion.

The cord: long cord observed, normal without true or false knot.

Blood vessels: 2 arteries and 1 vein examined

Placenta placed in a kidney dish and disposed in the placenta bucket waiting for final disposal.
SUMMARY OF PROGRESS OF LABOR

Labor Bega Membranes Cervix fully Baby Placenta Duration of labor

n ruptured dilated born expelled

Date 18/10 18/10/2020 18/10/2020 18/10/20 18/10/2020 1st stage latent:

/2020 20 10hrs:30mins

Time 03:00 15:30hrs 13:30hrs 16:03hrs 16:05 hrs 2nd stage

hrs 2hr 33minutes

3rd stage
2 minutes
Total:13hrs 05 mins

IMMEDIATE POSTPARTUM CARE OF MOTHER (fourth stage of labor; 0-1hr)

I cleaned mother, put for her a sterile pad and rolled her to recovery room.
Immediate vital observations were:
Temperature: 36.8 degree Celsius
Pulse: 92b/m
Blood pressure: 120/80mmhg
Respiration: 20b/m
Bleeding was minimal.
These were monitored every 30 minutes for 1st 2 hours, 2 hourly for next 6 hours and 6 hourly for
24 hours.
I checked Uterus every 15 minutes and was contracting well.
I administered I.V normal saline 2 liters alternated with 1 liter of 5% dextrose in 24 hours and
urine output was monitored in color and amount. The color was amber (normal), and urine output
was sufficient.

Patient recovered from spinal anesthesia and transferred to postnatal ward.

I administered 100mg of I.V pethidine stat and continued with I.M diclofenac75mg 8houlrly for
24 hours.
Patient had nothing orally for 6 hours, bowel sounds returned and was given sips of warm tea and
had a soft meal after 24 hours.

I instructed her not to touch the operation site and not to wet the incision site.
I monitored the genital area and incision site for bleeding every after 15 minutes.
BABY:

Immediately the baby’s head was born, the airway was cleared and the face with clean baby’s
towel to enable the newborn to breathe effectively. Tetracycline eye ointment was applied to both
eyes for prophylaxis against eye infection.

The receiving midwife dried the baby with dry sheets to keep baby warm and showed the baby to
the mother to identify the sex, placed in a baby’s coach.

Baby and mother were taken back to the ward and on the ward, I took the baby’s vitals and were
as follows:

Respiration: 45b/m

Heart rate/ apex beat: 141b/m

Temperature: 36.5degree Celsius

Vitamin K given 1mg in the outer aspect of the thigh intramuscularly to prevent intracranial
hemorrhage
Baby placed on mother’s breast and had good sucking reflex with in 1 hour of birth
Cord checked every 30 minutes and was well ligatured and not bleeding.

EXAMINATION OF THE NEW BORN.

This was done on day 0 of birth.

Head to toe.

Head: Head circumference was 36.5cm.

on inspection, the baby’s head was even in shape with no caput, no hematoma and no bruise,
Anterior fontanelle flat and diamond in shape, while posterior fontanelle triangular in shape, flat
and on gentle palpation, both fontanelles felt soft and open. ; Hair fairly distributed on the head;
the face, ears, eyes, and nose normal and intact with no abnormal discharges. Baby’s bones felt
symmetrical on both sides. Baby was able to suck my gloved fingertip properly showing good
sucking reflex.

Neck: skin was intact, clavicles symmetrical, no abnormality seen.

Chest: on inspection, skin intact, breasts normal, on percussion, resonant sound heard; on
auscultation clear and normal breath sounds with respiration 52blm, no extra sounds.
Abdomen; on inspection, skin intact, abdomen round in shape and moved with respiration,
umbilical cord clean, well tied and not bleeding, no redness, no swelling; On palpation, abdomen
felt soft , no organometallic.

Back; no openings, swelling, or defects found when a baby was gently turned over and a finger
gently run down the spine, no sacral dimple between the buttocks.

Limbs; both upper and lower limbs present, two in number, 5 fingers on each hand and 5 toes on
each foot, no extra digits, normal palmar creases, no talipes on feet.

Genitalia; skin was intact, no abnormality seen, vagina was open, urethral opening present, anus
patent. Baby passed urine 2 hours from birth and meconium after 5 hours of birth.

Barlow’s Test was done to detect dislocation of the fetus’ hip and was found to be normal.

Neurological Assessment

The baby’s reflex response was tested within 24 hours of birth to confirm normal neuromuscular
development as follows.

Rooting Reflex

The cheek of the baby was stroked and the baby turned towards the source of the stimulus and
opened the mouth ready to suckle.

The Moro reflex

This was done by holding the baby in a semi sitting position and allowing the head to drop about
2cm on to the examiners open hand. The infant responded by abducting and extending the arms
with fingers open thus normal Moro reflex.

Grasp Reflex.

I places my finger in the baby’s hand and it grasped it thus normal grasp reflex.

Walking and stepping reflex

I supported the baby up right on a flat surface and it made a stepping movement thus normal
walking and stepping reflex.

Baby’s length was 51cm long.

I recorded my findings on the baby’s chart and gave feed back to the mother.

I thanked her for the cooperation and gave back the baby to her.

I places my finger in the baby’s hand and it grasped it thus normal grasp reflex.
ADVICE TO THE MOTHER AND BABY

• Eat well balanced diet for proper healing and lactation

• Begin ambulating on post-operative day one to enhance healing and prevent deep venous
thrombosis.
• Care for baby’s cord using boiled cool water and keeping it dry.
• Keep baby warm and dry all the time
• To exclusively breast feed her baby for the first 6 months
• Not to leave the incision site wet, It should be left clean and dry
• Should not apply anything on the umbilical cord and stump.
• To visit postnatal clinic at six weeks for postnatal checkup and immunization of the baby.
• To have enough rest and sleep
• To do self vulva swabbing three times a day, keep it dry, frequently change vulva pads
• To take plenty of fluids to avoid constipation.
• Hand washing before and after vulva cleaning, before handling and breast feeding the baby.
• To clean from front to back to avoid contaminating the perineum with faces
• To avoid sexual intercourse until at least 6 weeks
Delivered/Assisted by: IRAHUKA CLIFTON ………………
Supervised by: ………………

Acen Joy ………………….

Head of department signature &stamp
Nursing &midwifery,
Lira University.