Name: Siti Sara Mat Nor

R/N: 33549
Gravida 8 Para 8
Age: 41
Sex: Female
Race: Malay
Religion: Islam
Occupation: Housewife
Educational level: Form 3
Address: Kg. Lubok Rotan Tawar, Tanah Merah, Kelantan.
Husband's name: Rahim Mat Opin
Husband's Occupation: Bus Driver
Estimated Date of Delivery: 28th October 2015
Last Normal Menstrual Period: 7th February 2015
Date of Admission: 2nd November 2015
Date 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 2015
At 15weeks,
Hb: 11.9
Weight: 91kg
BP: 100/70
VDRL: non-reactive
10th June 2015
At 17 weeks,
Weight: 91kg
BP: 110/80
MOGTT: FBS- 4.86mmol
24hours- 5.81mmol
7th July 2015
At 23 weeks,
Weight: 91kg
BP: 110/70
4th August 2015
At 27 weeks,
Hb: 11.6
Weight: 90.5kg
BP: 100/60
18th August 2015
At 29weeks,
Weight: 92kg
BP: 100/73
2nd Sept 2015
At 32weeks,
Hb: 10.0
Weight: 91
BP: 103/64
15th September 2015
At 34weeks,
Hb: 10.5
Weight: 94
BP: 110/70

29th September 2015

At 35weeks,
Weight: 94kg
BP:109/72
4th October 2015
At 36weeks,
Hb: 11.1
Weight: 94kg
BP: 100/66
13th October 2015
At 37weeks + 6 days,
Weight: 95kg
BP: 104/69
20 October 2015
At 39 weeks,
Hb: 10.8
Weight: 93kg
BP: 95/64
28th October 2015
At 40 weeks,
Weight: 94kg
BP: 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

1.
2.
3.
4.
5.
6.
7.

Term
Term
Term
Term
Term
Term
Term

Place of
Delivery

Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital

Labour

Complication

Wt

Sex

SVD
SVD
SVD
SVD
SVD
SVD
SVD

NIL
NIL
NIL
NIL
NIL
NIL
NIL

3.7
3.2
3.0
3.3
3.3
3.1
3.4

Male
Female
Male
Female
Female
Male
Male

Breastfeed

Yes
Yes
Yes
Yes
Yes
Yes
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 wellaware of the time, place, person and responsive to questions.
Vital signs
1) BP: 132/78
2) Pulse Rate: 100
3) Temperature: 37 degree Celcius
4) 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 unit
Fetal: 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
babys head or breech as the case may be is delivered.
3. Emergency C Section- When there is suspected danger to the mother's or babys
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 mothers 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 fever
2) too much blood loss
3) injury to organs
4) emergency hysterectomy
5) blood clot
6) reaction to medication or anesthesia
7) emotional difficulties
8) scar tissue and difficulty with future deliveries
9) death of the mother
10) harm to the baby
Not all mothers will experience these complications. The mothers that are at risk for these
complications include:
1) obesity
2) large infant size
3) emergency complications that necessitate a C-section
4) long labor or surgery
5) having more than one baby
6) allergies to anesthetics, drugs, or latex
7) maternal inactivity
8) low maternal blood cell count
9) use of an epidural
10) premature labor
Complications that might be experienced by the baby include:
1)
2)
3)
4)

cuts or nicks from the surgery tools

breathing problems
low Apgar scores
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 Center
Saju 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 Association
http://emedicine.medscape.com/article/273053-overview
3) Caesarean Section.
http://www.medindia.net/surgicalprocedures/caesarean-section-types-andindications.htm
4) Caesarean Section Complications
http://www.healthline.com/health/pregnancy/complications-cesareansection#Complications0