Things I learnt overnight

Before I start my entry, I'd like to say "Hi Dr. Laili!" ... she's one of my friend in O & G who had just found my blog... so I can no longer b*tch about friends at work... hehe.

Last night, I had one of the most amazing on calls, and this time, it doesn't involve getting a good long sleep... hehe! What I mean by amazing is the variety of cases that I got to see, unlike my previous calls, where most of them were either latent phase of labour or false labour. 

Here are some of the interesting cases I got to see:

1. Inadequate pelvimetry. 

2. Breech in labour. 

3. A few decelerations noted on CTG. 

4. About 3 cases of asthma during pregnancy! 

5. Antepartum hemorrhage secondary to cervical erosion.

And thank God... no perinatal asphyxia! Being part of the obstetrics team, our main goal is 0 % perinatal asphyxia, and this motto has been reminded to us by our head of department almost every morning. So whenever I am on call, I try be as alert as possible to prevent the worse complications, especially involving fetal asphyxia as it causes long-term effects. 

***

1. Inadequate pelvimetry

Anyway... the first unusual encounter was the inadequate pelvimetry. The patient is a gravida 2 para 1 at 39 weeks, she came in because of contraction pain. She also has 1 previous scar for breech, she refused external cephalic version and chose to proceed with elective C-section. I did vaginal examination on her, but to my surprise, the canal felt very weird, very 'sempit'! It was very difficult for me to put in my fingers in a little deeper as there was like a bony structure obstructing the outlet. So I confirmed my finding with my MO and he had the same impression, we thought that the pubic arch angle is relatively more acute than usual. So performing VE was little tricky. The patient did not want to take the risk of an obstructed labour, so she opted for semi-elective C-section, but the indication recorded was for maternal request rather than suspected CPD (cephalo-pelvic disproportion) or small pelvis. This is because to diagnose CPD, a proper pelvimetry (which includes the bi-ischial tuberosity diameter, curvature of the pelvic, spinous process is tipped or not and whether the pelvis can fit in 4 knuckles or not) must be done and the patient is not keen for such tests. Today, she had already given birth to a cute baby boy, birth weight 3.2 kg! 

2. Breech in labour

The patient presented with a strong contraction pain, she is an unmarried mother who had no ANC check-up. She claims that she is around 8 months, based on her LMP (last menstrual period) somewhere in May. These kind of cases have to be handled with precaution because they have no proper screening so the risk of the transmitted diseases are higher... and also they forget their LMPs, no early scans, which makes estimation of gestational age difficult, we need to differentiate whether she is term or preterm. As for this girl's case, I will just treat her as premature, it is better to safe then sorry, so I planned for Dexamethasone before delivery. While I was busy clerking other patients, the nurses alerted me telling that the patient is about to bear down, so I straight away palpated her abdomen and performed VE. Per abdomen, it just felt like any other abdomen, I thought it was an engaged cephalic presentation, but via VE the os felt very very weird! There were like to many structures all clumped together, not like the usual cephalic presentation. With my very little experience, I tried to feel for other structures, and what a surprise, I felt the heel of the baby! It was a footling breech, and I could feel both feet. So I told the nurse to call my MO and he came right away, by scan it was confirmed that it's a footling breech. The initial plan was to proceed with emergency C-section but before we even got to that, the patient delivered vaginally. It was also funny how I got to be in the scene because I was on call in PAC, not the labour room. But what happened was that I chased the patient to the maternal OT to get her signed consent for the C-section, so when the other MO on call who was about to the surgery arrived, she decided to reassess the patient... and she decided it's better to encourage the patient to bear down and just conduct the delivery. I felt privileged to assist in a breech delivery... my second breech delivery! The baby was fine, but a little small, 2.2 kg, most probably a premature baby. 

3. Fetal heart decelerations 

Well... this a common thing actually, nothing significant about this story. The patient complained of strong contraction pain, no history of rupture of membranes. The CTG was not so nice, it showed a few late decelerations which could indicate fetal hypoxia. Sadly my MO wasn't around in PAC, so I just decided to do an ARM (artificial rupture of membrane) to check for the liquor colour and to speed up the process of delivery. Luckily the liquor was clear, not meconium-stained... so we sent the patient straight to the labour room... and alhamdulillah, the baby was born alive and healthy! To do an ARM, we're supposed to get the permission of the MO first... later I informed my MO and he approved my action. Actually, I was scared to ARM because I am not good at it... like last week, I thought I had already ruptured the membrane with the amniotic hook, but as it turns out, I didn't, the membrane was still intact, so the baby was born with the membrane covering him... hehe. Alhamdulillah, I managed to ARM 2 patients successfully! 

4. Asthma during pregnancy

We just gave nebulizer to the patient, and discharged the patients as they were well after the nebulizer. All the cases were treated as AEBA (acute exacerbation of bronchial asthma) secondary to URTI. 

5. Anterpartum hemorrhage secondary to cervical erosion

This lady is a primigravida at about 30 weeks gestation. She complained to per vaginal bleed with no history of trauma or massage, but recent sexual intercourse about 2 days ago. The blood soaked about half of a pad, and I saw the pad, it looked like menses bleeding! The one thing everyone should remember is, whenever a pregnant patient comes with a PV bleed, always confirm where the location of placenta is because it could be placenta previae, so performing VE will just make the bleeding worse. I asked my MO to confirm via scan and thank God it was at the upper segment. So we did a speculum examination and saw that there were cervical erosions, and there were active bleeding. There was also multiple small growths, so we took a PAP smear too. The patient was admitted to the ward for further observation. I had never encountered any bleed like this one, because the usual ones I see are just spotting and not fresh blood. 

*** 

Ok, I am so tired because I didn't get to sleep at all last night, but the strange thing is, I don't feel like sleeping.. instead, I feel like 'lepaking'... cleaning up my room while listening to my iPod... one of the luxuries which I rarely get to feel lately. :-)