Lscs obg

1. CASE PRESENTATION
JEEVIGA.T

2. DEMOGRAPHIC DETAILS:
● Mrs Aysha 27 year old wife of Mr Yousuf Ali studied upto BBA is a housewife
belonging to middle class according to modified BG Prasad scale and residing
at Parangipettai
● Nearest health facility : Parangipettai PHC
● Obstetric score : G2P1L1
● LMP : 18/11/2021
● EDD : 25/08/2022
● Period of gestation : 39 weeks
● Booked and immunized at Cuddalore GH
● Blood group : A+ve

3. CHIEF COMPLAINT:
Admitted for safe confinement
Fetal movements perceived well
No h/o intermittent lower abdominal pain
No h/o bleeding or leaking per vaginum

4. PRESENT OBSTETRIC HISTORY:
● FIRST TRIMESTER:
Spontaneous conception
Pregnancy was confirmed by UPT at home after 40 days of Amenorrhoea
Folic acid supplementation taken
No h/o excessive vomiting
No h/o fever with rash
No h/o bleeding PV or white discharge
No h/o radiation exposure or drug intake
Dating scan was done at 12 weeks and was told to be normal

5. ● SECOND TRIMESTER:
Quickening felt at 20 weeks
Received two doses of Td (16 weeks and 20 weeks)
Iron, folic acid and calcium supplements taken
OGTT was done and said to be normal
No h/o epigastric pain, blurring of vision, headache, vomiting
No h/o excessive weight gain, swelling of legs, decreased urine output
No h/o leaking / bleeding PV
Anomaly scan done at 20 weeks and told to be normal

6. ● THIRD TRIMESTER:
Fetal movements perceived regularly
Iron and calcium supplements taken
No h/o swelling of legs
No h/o bleeding or leaking PV
No h/o pain abdomen
No h/o headache, blurring of vision, epigastric pain, vomiting
Growth scan done at 28 weeks and told to be normal

7. PAST OBSTETRIC HISTORY:
Spontaneous conception at the age of 23
ANTENATAL EVENTS: Uneventful
PERINATAL EVENTS: Institutional delivery by Emergency C-section at term done 4 years ago,
indication being fetal distress due to oligohydramnios
Intraoperative period- uneventful
Duration and stage of labour, duration between induction and caesarian section
OUTCOME:
● 4 year old baby boy, alive, weighing 2.8 kg at birth, cried immediately after birth on 2/5/2018
● Exclusively breastfed for 6 months
● No NICU admission
● Currently healthy, immunized upto date and doing well

8. POSTNATAL EVENTS:
Uneventful
Suture removed on 7th day after the surgery
Urine catheter removed after 24 hours of surgery
No h/o blood transfusion
Discharged on 5th day of postoperative period

9. MENSTRUAL HISTORY:
Menarche attained at 13 years of age
Regular 28 days cycle with 7 days flow
Changes 3 pads per day
No passage of clots
No dysmenorrhoea
LMP : 18/11/2021
EDD : 25/08/2022

10. MARITAL HISTORY:
Nonconsanguineous marriage
Age at marriage - 22 years

11. PAST HISTORY:
No h/o diabetes, hypertension, tuberculosis or bronchial asthma
No h/o surgery in the past
No h/o blood transfusion

12. PERSONAL HISTORY:
Mixed diet
Adequate sleep, normal appetite, normal bowel and bladder movements
No h/o addictions
No h/o drug intake or allergy

13. FAMILY HISTORY:
No h/o diabetes mellitus, hypertension
No h/o congenital anomalies

14. GENERAL EXAMINATION:
Patient is conscious, cooperative and well oriented to time, place and person
Moderately built and nourished
Height: 161 cm
Weight: 87kg (Current weight)
73kg (Pre-pregnancy weight)
BMI : 28.5
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema

15. VITALS:
Temperature: Afebrile
Pulse rate: 82 beats/min, regular rhythm, normal character
Respiratory rate: 18 breaths per minute
Blood pressure: 130/90 mmHg measured in the Right upper arm in sitting posture

16. ABDOMINAL EXAMINATION:
INSPECTION:
Abdomen longitudinally distended, flanks full
Umbilicus - Central and everted
Linea nigra, stria gravidarum present
No sinuses or engorged veins
Hernial orifices are free
A transverse curvilinear scar measuring 15cm seen above pubic symphysis has
healed by primary intention
SPT scar is healthy

17. PALPATION:
Symphysio-fundal height: 32cm
Fundal grip : Broad, soft, irregular, non-ballotable part suggestive of breech
Right lateral grip : Uniformly curved smooth resistance suggestive of spine
Left later grip: Irregular knob like structures suggestive of limb buds
First pelvic grip : Hard, globular, ballotable part suggestive of fetal head
Second pelvic grip: Fingers converging
No scar tenderness
Estimated fetal weight : 3100 grams

18. AUSCULTATION:
Fetal heart rate: 140 beats/min, regular, good tone heard at Right spinoumbilical
line
SYSTEMIC EXAMINATION:
CVS: S1, S2 heard; no murmurs
RS: Normal vesicular breath sounds heard
CNS: No focal neurological deficit

19. SUMMARY:
A 27 year old Mrs Aysha who is G2P1L1 with LMP- 18/11/2021, EDD-25/08/2022,
period of gestation 39 weeks with previous LSCS and last child birth 4 years ago
came for safe confinement. She is booked and immunized with regular antenatal
care
She is perceiving normal fetal movements
No h/o bleeding PV or labor pain
Examination revealed a singleton live fetus in cephalic presentation with good fetal
heart

20. DIAGNOSIS:
A 27 years old, G2P1L1 at 39 weeks of gestation, previous LSCS,last child birth 4
years ago with a singleton live fetus in longitudinal lie and cephalic presentation
with good fetal heart.

21. THANK YOU