Name: Siti Sara Mat NorR/N: 33549Gravida 8 Para 8 Age: 41 Sex: Female Race: MalayReligion: IslamOccupation: HousewifeEducational level: Form 3 Address: Kg. Lubok Rotan Tawar, Tanah Merah, Kelantan.Husband's name: Rahim Mat OpinHusband's Occupation: Bus DriverEstimated Date of Delivery: 28th October 2015Last Normal Menstrual Period: 7th February 2015Date of Admission: 2nd November 2015Date of Clerking: 2nd November 2015 Date of Delivery: 2nd November 2015 (7.43pm)

Chief Complaint Admitted due to contraction pain since 8.00pm on the 1st November 2015. There is also white fluid discharge.

History of Presenting Illness Siti Sara Mat Nor is a 41 years old Malay women of Gravida 8 Para 7 at 40 weeks + 5 days period of gestation. According to patient, she was doing her house chores when she felt the first contraction pain. She gave a pain score of 4/10 and it occurred every 10 minutes. She claimed that the pain was at the suprapubic region. Subsequently, her husband brought her to Hospital Tanah Merah. Upon admission to the labour room, patient was alert and conscious. The frequency and intensity of pain occurred more often. She undergo emergency lower section Caesarean section at 6.30pm and delivered a healthy baby girl with a weight of 3.35kg. No complication following surgery.

Antenatal History Patient is at Gravida 8 Para 7 at 40 weeks + 5 days period of gestation. Her last menses was on the 7th of February 2015 and estimated date of delivery is on the 28th October 2015. The current pregnancy is an unplanned but wanted pregnancy. Her dating scan was on the 26th May 2015, in which she is at 15 weeks of gestation. When she first came for her antenatal checkup, her weight was 91kg and height was 150cm. Her BMI is 40. Blood pressure reading during the first antenatal checkup was 100/70.

Follow ups:

26th May 2015At 15weeks,Hb: 11.9Weight: 91kgBP: 100/70VDRL: non-reactive

10th June 2015At 17 weeks, Weight: 91kgBP: 110/80MOGTT: FBS- 4.86mmol 24hours- 5.81mmol

7th July 2015At 23 weeks, Weight: 91kgBP: 110/70

4th August 2015At 27 weeks,Hb: 11.6Weight: 90.5kgBP: 100/60

18th August 2015At 29weeks,Weight: 92kgBP: 100/73

2nd Sept 2015At 32weeks, Hb: 10.0Weight: 91BP: 103/64

15th September 2015 At 34weeks,Hb: 10.5Weight: 94BP: 110/70

29th September 2015At 35weeks,Weight: 94kgBP:109/72

4th October 2015At 36weeks, Hb: 11.1Weight: 94kgBP: 100/66

13th October 2015At 37weeks + 6 days, Weight: 95kgBP: 104/69

20 October 2015At 39 weeks, Hb: 10.8Weight: 93kgBP: 95/64

28th October 2015At 40 weeks,Weight: 94kgBP: 100/70

She has taken her immunization for anti-tetanus toxoid once during her antenatal checkup. Her blood group is A+ and positive Rhesus. She doesn't have any history of hospitalization for the current pregnancy.

Past Obstetric History

No. Gestation Place of Delivery

Labour Complication Wt Sex Breastfeed

1. Term Hospital SVD NIL 3.7 Male Yes2. Term Hospital SVD NIL 3.2 Female Yes3. Term Hospital SVD NIL 3.0 Male Yes4. Term Hospital SVD NIL 3.3 Female Yes5. Term Hospital SVD NIL 3.3 Female Yes6. Term Hospital SVD NIL 3.1 Male Yes7. Term Hospital SVD NIL 3.4 Male Yes

Past Gynaecological History

Patient mentioned that her menarche was at the age if 13. The cycle was always regular around 28-35 days. There are no interval bleedings and she uses 1-2 pads per day. She doesn't have any dysmenorrhea. She claims that there are no vaginal discharge before but stated that sometimes she feels itchy at her vagina. She doesn't experience zny dyspareunia and post-coital bleeding. She did pap smear once in 1995 and the result was normal. She took contraceptive pills in 2006 up until 2011.

Past Medical Surgical History There is no significant past medical illness and she has never been hospitalized or undergo surgery before.

Drug History

Patient denied taking any over-the-counter drugs or other supplement pills.

Allergy

Patient claimed that she is allergic to seafood.

Family History

Patient's father died due to sickness. She doesn't remember the exact disease. Her mother died due to renal failure. Her siblings are well. There is no malignancy history running in the family.

Social History

Patient claimed that she doesn't smoke but her husband does. She eats a well-balanced diet and exercises occasionally. She currently lives with her husband and kids.

Physical Examination

On general examination, the patient is alert, conscious and no pallor. She is lying in a left lateral position. She is experiencing contraction pain. Patient is obese. She is well-aware of the time, place, person and responsive to questions.

Vital signs1) BP: 132/782) Pulse Rate: 1003) Temperature: 37 degree Celcius4) Respiratory Rate: 22/min There is no evidence of clubbing and peripheral cyanosis seen in this patient. Her facial

appearance was pink (well-perfused). The conjunctiva was pink and sclera was white. There was no discharge from the ear, eye, and nose. Oral hygiene is good and the tongue was pink, moist and has a normal contour. There is no pre-tibial, sacral and periorbital edema seen. Besides that, the lymph nodes at the cervical and supraclavicular are not enlarged or swollen.

On Inspection: Patient's abdomen is distended with gravid uterus. The linea nigra and striae gravidarum can be seen. The umbilicus is flat and centrally located. It is not deviated to the left or right. There are no surgical scars or Pfannenstiel scar seen.

On Palpation: During superficial palpation, the abdomen is soft and non-tender. After doing deep palpation, the uterus can be palpated and it is at term size, soft, non-tender and not irritable. The measurement of the symphysio-fundal height is 40cm.

On doing Leopold's maneuver, singleton with cephalic presentation. The head is hard, ballotable and small. As for the buttocks, it is soft, wider and non-ballotable. The fetus is at longitudinal lie and the head engagement is 3/5. No fetal movement noted at the time of doing the maneuver. Estimated fetal weight is around 3.4-3.6kg.

Vaginal examination showed os opening is 7cm. The cervix is effaced and membrane is intact. Station at -2. No cord and no placenta felt.

Differential Diagnosis

Differential diagnosis that may occur due to prolonged second stage is cervical dystocia.

Cervical dystocia is defined as difficult labor and delivery caused by mechanical obstruction at the cervix. This happens when the cervix fails to dilate properly and remains at the same position for more than 2 hours after the latent phase of labour. The sequelae that may happen to the baby is that the baby may develop brachial plexus injury and intra-uterine death may occur due to hypoxia and acidosis.

Investigations

Maternal: FBC-Hb, platelet : RBS : BUSE : GSH 2 Unit : GXM 4 unitFetal: CTG : Ultrasound

Management and Progress

Due to prolonged second stage of labour, patient was counseled for the need to do Emergency Lower Segment Caesarean Section. The doctor on duty also explained on the risk of bleeding, adjacent organ injury and the possibility of infection to occur. The patient understood and agreed. She also requested for bilateral tubal ligation (BTL).

Patient was sent to the operation theatre at 6.05pm. At the operation theatre, she was given spinal anaesthesia. Surgery started and the baby was born at 7.43pm. Once the baby was born, the baby did not need any resuscitation. Oral and nasal suction done on baby.

She delivered a baby girl. The weight of the baby was 3.35kg with an Apgar score of 9 in 1 minute and 10 in 5 minutes. The baby was placed under radiant warmer.

Discussion

Antenatally, the mother did not experience any complication. She did not develop gestational hypertension, gestational diabetes mellitus or asthma. Despite that, she experienced prolonged second stage of labor.

Prolonged second stage of labor is considered as abnormal labor. A normal second stage is supposed to be lasting no longer than 2 hours in a primiparous woman and 1 hour in a woman that has delivered vaginally before. If the second stage of labour lasts for more than 3 hours, this can cause an increased maternal and fetal morbidity. For this patient, she has been induced for labor and artificial rupture of membrane has been done but, the prolonged second stage is due to the fetal head is not engaged at the pelvic brim. The causes of prolonged second stage are:

1) Passenger (infant size, fetal presentation [occiput anterior, posterior, or transverse])

2) Pelvis or passage (size, shape, and adequacy of the pelvis)3) Power (uterine contractility)

Due to the prolonged second stage, the fetus was delivered and managed via Emergency Lower Segment Caesarean Section. There are four types of Caesarean Section. They are:

1. Classical Caesarean- The upper portion of the uterus is opened by an incision and the baby is extracted. There is high incidence of complications if this is used, hence it is not performed anymore.

2. Lower Segment Caesarean Section- The uterus is opened in the lower segment and the baby’s head or breech as the case may be is delivered.

3. Emergency C Section- When there is suspected danger to the mother's or baby’s condition an emergency section is resorted to.

4. Elective Caesarean Section (Planned C-Section)- The caesarean is planned and done on a specific date chosen by the patient and the doctor after assessing the maturity of the baby.

The indications for the Emergency Lower Segment Caesarean Section are:

1) Fetal distress- In this case, if the baby is having bradycardia or irregular heartbeat, these are

signs that the baby is under distress. The baby might also pass meconium signifying that there is leaking of amniotic fluid. It becomes worst if the umbilical cord slips out during labor and this can cause disturbance of blood supply to the baby. The baby has to be delivered immediately in case this happens.

2) Maternal distress- In case there is excessive bleeding or sudden surge of blood pressure happens,

an emergency caesarean section has to be performed.3) Mechanical impedance on the progress of labor

- The conditions that are associated includes mother’s birth passage being too small, macrosomic baby and failure of contractions to progress to deliver the baby. These conditions necessitates for the mother to undergo Emergency Lower Segment Caesarean Section.

The complications that may be associated with Emergency Lower Segment Caesarean Section include:

1) post-surgery infection or fever2) too much blood loss3) injury to organs4) emergency hysterectomy5) blood clot6) reaction to medication or anesthesia7) emotional difficulties8) scar tissue and difficulty with future deliveries9) death of the mother10) harm to the baby

Not all mothers will experience these complications. The mothers that are at risk for these complications include:

1) obesity2) large infant size3) emergency complications that necessitate a C-section4) long labor or surgery5) having more than one baby6) allergies to anesthetics, drugs, or latex7) maternal inactivity8) low maternal blood cell count9) use of an epidural10) premature labor

Complications that might be experienced by the baby include:

1) cuts or nicks from the surgery tools2) breathing problems3) low Apgar scores4) premature birth from an incorrect gestational age

Reference:

1) Obstetrics by Ten Teachers. Second Stage of Labour Page 191-192.2) Abnormal Labour. Saju Joy, MD, MS Associate Director, Division Chief of

Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Carolinas Medical CenterSaju Joy, MD, MS is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, Society for Maternal-Fetal Medicine, American Medical Associationhttp://emedicine.medscape.com/article/273053-overview

3) Caesarean Section. http://www.medindia.net/surgicalprocedures/caesarean-section-types-and-indications.htm

4) Caesarean Section Complications http://www.healthline.com/health/pregnancy/complications-cesarean-section#Complications0