A 27-year-old woman living in Chandigarh is a third gravida at 37+4 weeks pregnant with a history of 1 previous cesarean section and 2 abdominal surgeries. She has been admitted to the hospital for a planned vaginal birth after cesarean. Her previous pregnancies and medical history were unremarkable except for a history of abdominal tuberculosis 3 years ago. On examination, she is stable and her pregnancy is progressing normally.

1. CLINICO-PSYCHOSOCIAL
CASE
Moderator:-
Dr. Vineeth Rajagopal
Assistant Professor
Deptt. Of Community Medicine
PGIMER
Presenter:-
Dr. Yogesh Kumar Arora
Junior Resident 5th Sem
Deptt. Of Community Medicine
PGIMER

2. Case Location
 This case has been taken from :-
 Gynecology Ward, 3-C, Nehru Hospital-PGIMER.
 Resident of- Sector-25 D,
 Chandigarh,
 Native of- Maloya, Sector-38
 Chandigarh.

3. Family Profile – Nuclear Family(4 Members)
S.
no
Name Age/
Sex
Relation
to HOF
Education Occupation Monthly
Income
Health
Status
1. Mr. S 28/M Head 8th Std HA in PGI
(Previously a Social
Worker in an NGO)
15k Apparently
Well
2. Mrs. N 27/F Wife 12th Std Housewife
(Previously a
receptionist in
VLCC.)
----- Index Case
3. Ms. P 6/F Daughter 2nd Std Student ----- Immunized
Up to date
4. Mas. T 1/M Son ------ ----- Immunized
Up to date

4.  Health Centers in order of its proximity to the case
are:-
 Public Health Dispensary (Under Dept. of
Community Medicine, PGIMER) -200 m
 GMSH, Sector-16 - 2.5 Kms
 PGIMER, Chandigarh 2.5 Kms

5. Housing & Environmental Condition
1) 2 Room Pakka house. Kitchen Separate. Toilet-
Covered-Indian Type.
2) Water through Municipal Water Supply.
3) Garbage Disposal In nearby Dumper.
4) Lighting/Ventilation- Adequate.
5) Overcrowding- Not Present.
6) Rodents/ flies infestation present.

6. Socio-economical Status

7. Total Score:-7
Class-IV (Upper Lower)
Source:- Saleem SM, Modified Kuppuswamy
socioeconomic scale updated for the year
2020,
Indian Journal of Forensic and Community
Medicine, January-March, 2020;7(1):

8. Chief Complaints
1) No Fresh Complaints.
2) Admitted in Gynae Ward(Maternity Ward closed
due to COVID) on 19/07/2020. She is G3 P2+0+0+2
with 37+4 weeks gestation with history of 1 LSCS
and a history of laparotomy, planned for VBAC on
19th of July 2020. (COVID test sent on 19/07/20.
Came Negative)

9. History of Presenting Illness
 After her last child birth, she regained her menses on Dec
2019.
 She was 2 months over due for the periods and had a
UPT +ve. She presented with complaint of pain in lower
abdomen soon after (in the month of march).
 Came to PGI and was diagnosed with SLIUF of POG 20+1
weeks (on 18th March 2020).
 LMP through USG came to be 20th Oct 2019.

10. History of Presenting Illness Contd.
 USG findings on 18th March 2020:-
Findings Conclusion
BPD- 4.7 cm Corresponds to 20+3 weeks
HC- 17.9 cm 20+3 weeks
AC- 15.7 cm 21 weeks
FL- 3.25 cm 20+1 weeks
Placenta Posterior, away from internal OS
Triple Vessel Cord
Identified
Advised for Level II scan for fetal CMF.

11. History of Presenting Illness Contd.
 Patient had irregular menstrual cycles till January
2020.
 She was due in February but delayed her UPT +ve
because she had a history of Irregular menstruation
for 3 years.
 Patient was Booked and supervised from here
onwards.

12. History of Presenting Illness Contd.
 Conclusion till now:-
1) Had her periods for 3 months:-
a) Spotting (BPV) due to Threatened Abortion
b) Luteal Phase Defect

13. History of Presenting Illness Contd.
 She wanted to terminate the pregnancy but
couldn’t do it because the maximum age for
termination is 20 weeks.
 In exceptional cases, a court may allow a
termination after 24 weeks.
 So she continued with the pregnancy.

14. 1st Trimester 2nd Trimester 3rd Trimester
Unnoticed.
Spontaneous Conception.
Not Sure of Dates
UPT at 5 months Overdue
Received Td booster/All ANC
Investigations WNL
Hb:- 7.9gm/dl
Visit at 20+1 weeks/USG Done
Felt Quickening at 24 weeks POG
Patient
admitted to PGI
i/v/o Pain
abdomen at
34+6POG
No intake of FA
H/o BVP
(Soaked 3-4 Pads /Day*3-4
Days)
No H/o Increased
BS/BP/Hypothyroidism
No H/o Itching over Palms and Soles
Level II Scan-WNL
NST done
(WNL)
Received Dexa
Cover and was
discharged
No H/o any other drug intake Advised Fe/Ca No H/o BPV/LPV
No H/o any radiation exposure No H/o BPV/LPV DFMC Adequate
No H/o any fever with rash DFMC Adequate

15. Menstrual History
 Menarche at 13-14 years of age. LMP-Not known
 By USG-29/10/2019. Irregular periods from 2017-2019.
5-6 days 30-32 Days
3-4 Pads/days No Dysmenorrhea
No clots

16. Past Obstetric History
Currently she is 3rd Gravida
Her obstetrics score is G3
P2Term+0Preterm+0Abortion+2Live

17. 1st Pregnancy 2nd Pregnancy 3rd Pregnancy
6 years ago
Spontaneous Conception
1 year ago
Spontaneous
Conception
Index Pregnancy
ANP-B/S at GMSH 16 ANP-B/S at PGI Conceived during
Lactational
Amenorrhoea
Emg LSCS i/v/o Breech @ 38 weeks SOL @ 36+1
weeks via NVD
with RMLE
LB/Girl/1.6 kgs
NICU stay*7 days
LB/Boy/1.85
kg/Apgar 8/9
Exclusively Breastfed for 6 months -do- Not Received Anti-D
yet.
Received Anti-D after delivery -do-

18. Contraception History
Knowledge Attitude Practice
Condoms Easy to use,
Good and convenient method
Used till date.
Cu-T Not a good option(Knows a
relative who was not happy
with it and complained of
heavy bleeding)
Never
Pills Easy to use but creates various
menstrual problems.
Tried 2-3 times but
discontinued due to
uneasiness and nausea.
Tubectomy (Operation) Good option but involves risks
of surgery.
Now thinking of it,
motivated to get it done
after 6 weeks.

19. Past History
• There is a H/o Abdominal Tuberculosis 3 years ago.
 Patient had medical treatment for approx 2 years.
 After she had an Ileal Resection i/v/o intestinal
perforation.
 There is no history of Hypertension/Diabetes
Mellitus/Hypothyroidism

20. Marital and Personal History
• Married for 9 years.
• Non- Consanguineous Marriage.
• Arranged Marriage.
• Never consumed alcohol/tobacco in any form.
• Physical activity- Daily walking of 1-1.5 kms for
groceries(Before Pregnancy).
• Sleep=8-9 hours.
• Likes to watch TV and want to become a beautician.

21. Dietary History
 Calculated by 24-hour dietary recall method
 Vegetarian. Oil used for cooking-Mustard/Soyabean Oil
 Daily Calorie Intake= 1680 Kcal (RDA is 2150) (1800 for
Sedentary lifestyle+ 350 Kcal)
 Deficit:-470 Kcal (21%) (Now RDA is 2400 and intake is 1940
Kcal, Deficit is 19 %)
 Daily Protein Intake=32 gms (RDA is 60 gms) (1.2-1.5
gm/kg/day)
 Deficit:-28 gms (46%)

22. Family History
 There was a history of Pulmonary TB in Brother-in-
law’s daughter and her mother’s sister at her native
place preceding her illness. Both received full
treatment and now healthy.
 There is no history of Hypertension, Diabetes Mellitus in the family.
 There is no history of any birth defects, twins or multiple abortions in
the family.

23. General Physical Examination:- Patient was lying comfortably on
bed in supine position.
Thin built, well oriented to time, place and person.
Wt.=58 Kgs. Wt. Gain= 10 kgs Approx.
Vitals:-
RR-18/min
PR-84/min
BP-124/80 mm of Hg in lying position
Temperature- Afebrile
Examination

24. Examination
 Pallor present, cyanosis, clubbing, icterus,
lymphadenopathy, edema not present.
 Oral cavity- No ulcer or visible lesion found.
 Breast- Non tender, no mass appreciated.

25. Per Abdomen Examination
 Inspection:-
 -Shape-ovoid
 -Abdomen uniformly distended.
 -Umbilicus everted.
 -Linea nigra/ Stria gravidarum present.
 -No dilated veins/ lump.
 -Laparotomy scar mark seen.
 -Movement with breathing, equal in all quadrants.

26. Per Abdomen Examination
 Palpation:-
 -Symphisio fundal height was 36cm, which indicates 36 weeks
POG or fetal head engagement.
 Superficial Palpation:-
1) Non tender
2) Uterus in midline position.

27. Per Abdomen Examination
 Palpation:-
a)Deep Palpation:-
1) Fundal Grip:- Smooth symmetrical structures palpated
suggestive of buttocks.
2) Umbilical Grip:- Firm broad mass palpated suggestive
of back on Right lateral surface.
 Small irregular structures palpated on Left Lateral surface
suggestive of fetal extremities.

28. Per Abdomen Examination
 Palpation:-
a)Deep Palpation:-
3) Second Pelvic Grip (Pawlick’s grip) :- Neck
appreciated on deep palpation.
4) First Pelvic grip (Leopard’s) :- Indication of Fetal
head engagement.

29. Per Abdomen Examination
 Auscultation:-
 Bowel sound heard.
 Fetal Heart sound heard on Right lateral side, 2 cm
from the umbilicus on the line joining umbilicus to
ASIS.
 Rate = 136 /min

30. Systemic Examination
• CVS Examination- S1S2 heard, No Murmur heard.
• RS Examination- B/L Normal Vesicular Breath Sound
Heard, Air entry equal B/L.
• CNS Examination- Both Sensory And Motor
Functions intact.

31. SUMMARY OF THE CASE
 Provisional Diagnosis:-
A 27 year old woman, living in a nuclear family
in Sec-25, belonging to Upper Lower class, is a
3rd gravida at 37+4 weeks POG with previous 1
LSCS with h/o 2 abdominal laparotomies &
Ileocecal resection with Rh –ve BG planned for
VBAC.

32. Flamm Model
 When to Use:- Women in Labor with h/o C-section delivery.
 Why to Use:-Determining which laboring patients are likely to
have successful of unsuccessful vaginal delivery.
 Limitations:-
1) Admission is required.
2) High Score predicts success but a low score doesn’t necessarily
predict failure.
(Source:- Flamm BL, Geiger AM. Vaginal birth after cesarean delivery: an admission scoring system. Obstet Gynecol.
1997;90:907-10)

33. Flamm Model- Components
Maternal Age Age < 40 (0) Age> 40 (+2)
Vaginal birth history Vaginal birth
before and after
1st C-section (+4)
Vaginal birth
after 1st C-
section(+2)
Vaginal birth
before C-section
(+1)
No
previous
Vaginal
Delivery
(0)
Reasons other than
failure to progress for
first cesarean delivery
No (0) Yes (+1)
Cervical effacement
At admission
>75% (+2) 25-75% (+1) <25% (0)
Cervical dilation > 4 cm
at admission
No (0) Yes (+1)

34. Flamm Model-Interpretation
VBAC Score % of Women with Successful
VBAC
0-2 49
3 60
4 67
5 Patient’s Score 77
6 89
7 93
8-10 95

35. Investigations
 BG:- O –ve
 Husband BG:- AB +ve
 Urine R/M, C/S:- WNL
 HIV/HCV/HBsAg/VDRL:- NR
 RFT:-16/0.66
 LFT:-0.56/0.19/39/26/278
 GTT/HPLC:- WNL
 HMG:-7.9/8600/237,000

36. Investigations
 Coagulation Profile:- 15.0/99%/1.01/28.4
 Vit. B12:- 2000(200-950pg/ml)
 Folate:- 1.53 (2-10ng/ml)
 S.Fe:- 38.6 (N=37-145 mcg/dl)
 S. Ferritin:- 18.32 (N=20-500 ng/ml)
 TIBC:- 709 (N=250-425 mcg/dl)
 % Iron Saturation:-5.1% (N=15-50%)
 S. Electrolytes:- 136.4/4.2/105.9

37. Investigations
 USG
0n 18/03/2020 Level II on
28/04/2020
28/06/2020
POG 20+1 weeks POG 26+2 weeks POG 34+6 weeks
Placenta Posterior SLIUF Wt 2.1 Kg
FCA+ Liquor Adequate Liquor Adequate
No GCMF FCA +
Placenta Posterior,
Upper Segment

38. Diagnosis OF THE CASE
 Final Diagnosis:-
A 27 year old woman, living in a nuclear family
in Sec-25, belonging to Upper Lower class, is a
3rd gravida at 37+4 weeks POG with previous 1
LSCS with h/o 2 abdominal laparotomies &
Ileocecal resection with Mixed Deficiency
anemia with Rh –ve BG planned for VBAC.

39. Consents
1) Consent for Cesarean Section(Emergency/Elective).

42. Consents
1) Consent for Cesarean
Section(Emergency/Elective)
2) Information and Consent for Patients with
previous cesarean section(s)
3) Patient care information and consent in view of
COVID-19 Pandemic
4) Information and Consent for High Risk Pregnancy

43. Intra-Partum
Non Stress Test was performed actively.
AOL with Pitocin 6ml/Hr (10Units/ml)
started at 2:00 PM on 20th July with dose
escalation of 3ml/30 min under active
monitoring with NST.
Dose escalated up to 33 ml/Hr till 11:30
PM.

44. Delivery Out Come
 Live Birth
 Via Normal Vaginal Delivery with Right
Medio-Lateral Episiotomy.
 At 12:07Am on 21st July.
 Sex-Female/ BG: A+ve
 Wt. 2767 gms
 No GCMF
 Apgar- 8/9

45. Follow up in Post Partum
 Mother and Child both doing fine.
 Exclusive breastfeeding.
 Visit done by ANM of PHD 25.
 Episiotomy Scar healed.
 BP Normal.
 No complaint of fever.

46. MANAGEMENT
 On Individual Level:- Currently She is Day 18 Post Partum
 Non-Pharmacological:-
1) Dietary Advises:- Iron and calorie dense foods.
2) Rest and Abstinence for 6 weeks and counseling for
contraception.

47. MANAGEMENT
• Pharmacological:-
1) Tab IFA 100mg BD for 3 months.
2) Syp. Calcium + Multivitamin (500mg+500IU+1500mcg )5ml OD

48. MANAGEMENT
• On Family Level:-
1) Husband motivated for NSV.
2) Husband counseled for financial planning and insurance
services.
3) Counseled for NB’s immunization.

49. MANAGEMENT
 On Community level:-
1) Counseled her for Anganwadi services.
2) Counseled her for services given at PHD-25.

50. MANAGEMENT
 On Community level:-
3) Programs and their benefits she received/is receiving:-

51. Program Benefits She is receiving
Integrated Child Development Services NO (Reason:-Not interested because of
safety issues and ignorance)
JSSK/MCCI Admission fees waiver benefits of Rs
700 in PGI.
Janani Suraksha Yojna NA
PM Matru Vandana Yojana NA
PM Surakshit Matritva Abhiyaan She visited PHD twice on 9th after being
diagnosed from PGI.
Intensified -NIPI She got Fe from PHD 25 but buying in
PGI
Home Based Post Natal Care (HBPNC) Receiving care form PHD 25

52. Thank You