I.

AGE: 40

PATIENT PROFILE

NAME: Pilar Calipjo SEX: Female CIVIL STATUS: Widowed BIRTH DATE: October 21, 1972 BIRTH PLACE: Pagudpud, Ilocos Norte ADDRESS: Brgy. Nagbalagan, Bangui, Ilocos Norte NATIONALITY: Filipino RELIGIOUS AFFILIATION: Roman Catholic HIGHEST EDUCATIONAL ATTAINMENT: 3rd year high-school II. PATIENTS HISTORY Pilar is the only child of Mr and Mrs. Alejandro Condoy who both live a simple life as farmers though her mother stayed mostly at home for a housewife. She had experienced self-limiting viral illnesses like chicken pox and measles as a child. She did not have any vaccination as far as she knows because her parents werent too much concerned with it. She was short in accomplishing secondary education as she stopped after 3rd year in high school. She mostly stayed at home from then. She met her first husband, a farmer, at the age of 21. She got married shortly and relocated to Nagbalagan, Bangui where his husband permanently resides. They had their first child a year immediately after tying the knot. Given the limited income, they struggled to support and properly provide for the need of their seven children of which she delivered almost every other year successively. Her husband died early and lamentably left Pilar and their children fatherless. In the year 2004, a year after her husbands death, she met Hene cris Trinidad, a young carpenter, they eventually moved in together and had children of their own. She is currently pregnant for her 3rd child from Hene Cris. III. SIGNS AND SYMPTOMS: Amenorrhea Nausea and vomiting during the first trimester. Easy fatigability Fundic height large for gestational age Difficulty of breathing Fetal parts hard to appreciate during Leupolds maneuver. Pelvic Sonography reveals above normal amniotic fluid and breech position sustained up to 38 weeks of gestation.

IV.

PERTINENT FINDINGS A. RURAL HEALTH UNIT DATA 1st visit

Name: Pilar Calipjo Age: 40 Gender: F Birth date: October 12, 1972 Doctors Order: A> PU 37 5/7 weeks AOG G10P9 P> Advised Advised for laboratory exams: Pelvic Ultrasound Multivitamins 1 cap once a day For regular check up Maintain healthy lifestyle Address: Nagbalagan, Bangui RURAL HEALTH CENTER DATA: Clinic Visit Date: April 9, 2013 Chief Complaint: For prenatal check up LMP: ? EDC: May 2, 2013 AOG: 37 5/7 weeks G10P9 Admission Vital Signs: Blood pressure: 90/50 mmHg Body Temperature: 36.C Pulse Rate: 86 /min Respiratory Rate: 24 /min Wt. 60 kgs

B. RURAL HEALTH UNIT DATA Name: Pilar Calipjo Age: 40 Gender: F Address: Nagbalagan, Bangui RURAL HEALTH CENTER DATA: Clinic Visit Date: May 14, 2013

2nd visit

Birth date: October 12, 1972 Doctors Order: A> PU 31 2/7 weeks AOG G1P0 P> Advised Multivitamins 1 cap once a day For Pelvic Ultrasound Maintain healthy lifestyle Referred to BDH for delivery.

Chief Complaint: For prenatal check up LMP: ? EDC: May 2, 2013 AOG: G11P10 Admission Vital Signs: Blood pressure: 90/60 Body Temperature: 36.3C Pulse Rate: 86 /min Respiratory Rate: 24 /min Wt. 61 kgs. 34 2/7 weeks pelvic ultrasound estimation

V.

LABORATORY AND DIAGNOSTIC PROCEDURES

Complete Blood Count Examination Hemoglobin Hematocrit RBC count WBC count lymphocytes Neutrophils Urinalysis Color: Yellow Character: Clear Reaction: 6 Specific Gravity: 1025 White cells: 0-2 RBC: 0 CHEMICAL Protein: negative Sugar: negative Results 108 .36 3.85 20.3 .92 .08 Reference Male: 140-160, G/L Female: 130-150, G/L Male: 36-47 Female: 36-42 Examination ESR Platelet Ct.

Blood Type B+

Pelvic Ultrasound ( Dated May 10, 2013) Single live, female, intrauterine pregnancy in breech presentation. Sonar age of 37 weeks and 4 days. Placenta is posteriorly located mid-uterine, Grade III maturity. Moderate Polyhydramnios with AFI = 32. Estimated Fetal Weight 2508-2602 grams. BPS 7/8. VI. OBSTERIC HISTORY Elsa had her menarche very late at the age of 17 which came regular and usually last 2-3 days. When her menstruation comes, she experiences dysmenorrhea and usually treats it with herbal medicine. She delivered her first child at the age of 22 and at present pregnant with her 10th child. No history of abortion and all pregnancies were delivered viable and term thru spontaneous vaginal deliveries. VII. FINDINGS OF THE CASE Multiparity, Polyhamdramnios and Breech Presentation ASSESSMENT OF THE PHYSICIAN

VIII.

History and physical Assessment: (-) history of DM (-) history of hypertension HEENT pinkish palpebrae CHEST Clear Breath Sounds EXTREMITIES (-) Edema ABDOMEN globular, leupold maneuver reveals breech presentation.

IX. MEDICAL MANAGEMENT In this case presented a pregnant woman who is considered grand multiparous by definition, also carrying breech presentation and polyhydramnios management is directed towards reduction of potential risks. Early and regular prenatal check up is imperative and healthy lifestyle is a must. Maternal hemorrhage and fetal abnormalities if not stillbirth is highly possible. Prenatal care is crucial and a well established intrapartal care is indispensable. Things to consider throughout pregnancy to wit are: 1. 2. 3. 4. 5. 6. Iron and folate prophylaxis. Vigilance for abnormal fetal presentations from 36 weeks onward. Plan for possible rapid labour and delivery. Monitor strength of contractions and fetal presentation during delivery. Planning for the possibility of postpartum haemorrhage. Good physiotherapy and postnatal follow-up for urogynaecological problems. Cesarean section is very much imminent to reduce risk on both mother and baby. X. PREVENTION OF MULTIPARITY, BREECH PRESENTATION, AND POLYHYDRAMNIOS Patient education is crucial to maintain healthy pregnancy spacing so as to avoid multiparity. It takes two to tango as the health care provider can only do so much in encouraging patient. Information dissemination or specific counseling plays a vital role. Youd be surprised as to how effective it is. Contraception is the key. Providing all the possible information regarding birth control, natural and artificial method is presented, coupled with relevant discussion of maternal and fetal risk of multiparity. It is not possible to totally prevent breech presentation but knowing possible causes is a good start of prevention. There are ample amount of studies that would support the claim that multiparous women have greater risk to carry breech pregnancies as well as polyhydramnios pregnancies. Relatively in the case of pillar who is multiparrous and have a considerably high amniotic fluid index predisposed her higher. Sometimes, polyhydramnios are caused by genetic defects in the fetus, and as such there is not a lot the mother can do in terms of prevention besides getting frequent, quality prenatal care that will allow her doctor to treat the condition should it be detected. However, this condition is also associated with uncontrolled maternal diabetes, so treating the diabetes may assist in preventing the polyhydramnios. XI. SHORT DISCUSSION A. MULTIPARITY A grand multipara is a woman who has already delivered five or more infants who have achieved a gestational age of 24 weeks or more, and such women are traditionally considered to be at higher risk than the average in subsequent pregnancies. A grand multigravida has been pregnant five times or more. A great grand multipara has delivered seven or more infants beyond 24 weeks' gestation.

Obstetric histories should always record parity, gravidity and outcomes of all previous pregnancies as: Outcomes of previous pregnancies give some indication of the likely outcome and degree of risk with the current pregnancy. The number of previous pregnancies and deliveries will also influence the risks associated with the current pregnancy. What is considered normal labour varies according to parity:

Normal labour in a primagravida is significantly different to normal labour in multiparous women, as physiologically the uterus is a less efficient organ, contractions may be dyscoordinate or hypotonic. The average first stage in a primagravida is significantly slower than in a multip (primarily due to the rate of cervical dilation)[4] - so progress is expected to be slower but delay longer than expected should prompt augmentation in managed labour. Interestingly, grand multips have a longer latent phase of labour than either nulliparous or lower-parity multiparous women but then begin to dilate more rapidly. After 6 cm dilation, partogram curves for lower parity multips and grand multips are indistinguishable. Progress of labour does not appear to continue to improve with additional child-bearing.[5] Higher risk of developing pre-eclampsia (relative risk 2.91 with confidence interval 1.28-6.61). Delayed first stage of labour, though this could be considered normal in a primagravida. Dystocia (or difficult labour) was diagnosed in 37% primagravidae in one Danish study. A multiparous has an increased risk of: Abnormal fetal presentation Precipitate delivery Uterine atony Placenta praevia Uterine rupture Amniotic fluid embolism Obstetric haemorrhage Stress incontinence and urinary urgency symptoms Levator ani dysfunction

Increased parity is often associated with: Increasing maternal age Lower socio-economic and educational status Poorer prenatal care (more likely to be late bookers and poor attenders) Smoking and alcohol consumption Higher BMIs Higher rates of gestational diabetes B. BREECH PRESENTATION Most babies will move into delivery position a few weeks prior to birth with the head moving closer to the birth canal. When this fails to happen, the babys buttocks and/or feet will be positioned to be delivered first. This is referred to as "breech presentation." Breech births occur in approximately 1 out of 25 full-term births Frank breech: In this position, the babys buttocks are aimed at the birth canal with its legs sticking straight up in front of his or her body and the feet near the head. Complete breech: Here, the buttocks are pointing downward with the legs folded at the knees and feet near the buttocks.

Footling breech: In this position, one or both of the babys feet point downward and will deliver before the rest of the body.

The causes of breech presentations are not fully understood. However, the data show that a breech birth is more common: In subsequent pregnancies In pregnancies of multiples When there is history of premature delivery When the uterus has too much or too little amniotic fluid When there is an abnormal shaped uterus or a uterus with abnormal growths, such as fibroids. With women who have placenta previa

A few weeks prior to the due date, the health care provider will place his/her hands on the mothers lower abdomen to locate the babys head, back, and buttocks. If it appears that the baby might be in a breech position, they can use ultrasound to confirm the position. Special x-rays can also be used to determine the babys position and the size of the pelvis to determine if a vaginal delivery of a breech baby can be safely attempted. Even though most breech babies are born healthy there is a slightly elevated risk for certain problems. Birth defects are slightly more common in breech babies and the defect might be the reason that the baby failed to move into the right position prior to delivery. It is preferable to try to turn a breech baby between the 32nd and 37th weeks of pregnancy. The methods of turning a baby will vary and the success rate for each method can also vary. It is best to discuss the options with the health care provider to see which method he/she recommends. Medical Techniques: External Version: External version is a non-surgical technique to move the baby in the uterus. In this procedure, a medication is given to help relax the uterus. There might also be the use of ultrasound to determine the position of the baby, the location of the placenta and the amount of amniotic fluid in the uterus. Gentle pushing on the lower abdomen can turn the baby into the head-down position. Throughout the external version the babys heartbeat will be closely monitored so that if a problem develops, the health care provider will immediately stop the procedure. External version has a high success rate. However, this procedure becomes more difficult as the due date gets closer. Chiropractic Care: The late Larry Webster, D.C., of the International Chiropractic Pediatric Association, developed a technique that enabled chiropractors to reduce stress on the pregnant womans pelvis lead ing to the relaxation of the uterus and surrounding ligaments. A more relaxed uterus makes it easier for a breech baby to turn naturally. His technique is known as the Webster Breech Technique. The July/August issue of the Journal of Manipulative and Physiological Therapeutics reported and 82% success rate for the Webster Technique. Further, the results of the study suggest that it is preferable to perform the Webster Technique in the 8th month of pregnancy. Natural Techniques: The following risk-free techniques, often suggested by physical therapist, Penny Simkin, can be tried at home for free: The Breech Tilt: Using large, firm pillows, raise the hips 12 or 30cm off the floor for 10 -15 minutes, three times a day. It is best to do this on an empty stomach when your baby is active. In this technique, try to concentrate on the baby without tensing your body, especially in the abdominal area. Using Music: We know that babies can hear sounds outside the womb. Consequently, many women have used music or taped recordings of their voice to try to get their baby to move towards the sound! Placing

headphones on the lower part of your abdomen and playing either music or sounds of your voice can encourage babies to move towards the sounds and out of a breech position. Some homeopathic remedies have also been found to be successful in correcting breech positions. If interested, you can contact your local holistic practitioner about the possibility of using of Moxibustion or Pulsatilla to correct a breech position. Most health care providers do not believe in attempting a vaginal delivery for a breech position. However, some will delay making a final decision until the woman is in labor. The following conditions are considered necessary in order to attempt a vaginal birth: The baby is full-term and in the frank breech presentation. The baby does not show signs of distress while its heart rate is closely monitored. The process of labor is smooth and steady with the cervix widening as the baby descends. The health care provider estimates that the baby is not too big or the mothers pelvis too narrow for the baby to pass safely through the birth canal. Anesthesia is available and a cesarean delivery possible on short notice

In a breech birth, the babys head is the last part of its body to emerge making it more difficult to ease it through the birth canal. Sometimes forceps are used to guide the babys head out of the birth canal. Another potential problem is cord prolapse. In this situation the umbilical cord is squeezed as the baby moves toward the birth canal, thus slowing the babys supply of oxygen and blood. In a vaginal breech delivery, electronic fetal monitoring will be used to monitor the babys heartbeat throughout the course of labor. A cesarean delivery may be an option if signs develop that the baby may be in distress. Most health care providers recommend a cesarean delivery for all babies in a breech position, especially babies that are premature. Since premature babies are small and more fragile, and because the head of a premature baby is relatively larger in proportion to its body, the baby is unlikely to stretch the cervix as much as a full-term baby. This means that there might be less room for the head to emerge. C. POLYHYDRAMNIOS Polyhydramnios is a medical condition describing an excess of amniotic fluid in the amniotic sac. It is seen in about 1% of pregnancies.[1][2][3] It is typically diagnosed when the amniotic fluid index (AFI) is greater than 24 cm.[4][5] There are two clinical varieties of polyhydramnios: Chronic polyhydramnios where excess amniotic fluid accumulates gradually Acute polyhydramnios where excess amniotic fluid collects rapidly

The opposite to polyhydramnios is oligohydramnios, a deficiency in amniotic fluid. In most cases, the exact cause cannot be identified. A single case of polyhydramnios may have one or more causes. Some cases are due to maternal diabetes mellitus, which causes fetal hyperglycemia and resulting polyuria (fetal urine is a major source of amniotic fluid) and also rh-isoimmunisation can cause it. Few cases are associated with fetal anomalies that impair the ability of the fetus to swallow (the fetus normally swallows the amniotic fluid). These anomalies include: gastrointestinal abnormalities such as esophageal atresia, duodenal atresia, facial cleft, neck masses, tracheoesophageal fistula, and diaphragmatic hernias. An annular pancreas causing obstruction may also be the cause. Bochdalek's hernia, in which the pleuro-peritoneal membranes (especially the left) will fail to develop & seal the pericardio- peritoneal canals. This results in the stomach protrusion up into the thoracic cavity, and the fetus is unable to swallow sufficient amounts of amniotic fluid. fetal renal disorders that results in increased urine production during pregnancy, such as in antenatal Bartter syndrome.[6] Molecular diagnosis is available for these conditions. [7] neurological abnormalities such as anencephaly, which impair the swallowing reflex

chromosomal abnormalities such as Down's syndrome and Edwards syndrome (which is itself often associated with GI abnormalities) Skeletal dysplasia, or dwarfism. There is a possibility of the chest cavity not being large enough to house all of the baby's organs causing the trachea and esophagus to be restricted, not allowing the baby to swallow the appropriate amount of amniotic fluid.

It can also be caused by intrauterine infection. In a multiple gestation pregnancy, the cause of polyhydramnios usually is twin-twin transfusion syndrome. Other maternal causes include cardiac or kidney problems. Additionally, chorioangioma of the placenta can also cause this condition. A recent study distinguishes between mild and severe polyhydramnios and showed that Apgar score of less than 7, perinatal death and structural malformations only occurred in women with severe polyhydramnios. [8] In another study, all patients with polyhydramnios, that had a sonographically normal fetus, showed no chromosomal anomalies.[4] There are several pathologic conditions that can predispose a pregnancy to polyhydramnios. These include a maternal history of diabetes mellitus, Rh incompatibility between the fetus and mother, intrauterine infection, and multiple pregnancies. During the pregnancy, certain clinical signs may suggest polyhydramnios. In the mother, the physician may observe increased abdominal size out of proportion for her weight gain and gestation age, uterine size that outpaces gestational age, shiny skin with stria (seen mostly in severe polyhydramnios), dyspnea, and chest heaviness. When examining the fetus, faint fetal heart sounds are also an important clinical sign of this condition. Fetuses with polyhydramnios are at risk for a number of other problems including cord prolapse, placental abruption, premature birth and perinatal death. At delivery the baby should be checked for congenital abnormalities. Treatment Mild asymptomatic polyhydramnios is managed expectantly. For a woman with symptomatic polyhydramnios may need hospital admission. Antacids may be prescribed to relieve heartburn and nausea. No data support dietary restriction of salt and fluid. [citation needed] In some cases, amnioreduction, also known as therapeutic Amniocentesis, has been used in response to polyhydramnios.[9]

Prepared by:

Signed by:

Jeanette A. Ramos RHMPP

Dr. Evangeline R. De Guzman Municipal Health Officer

Noted By: Rosita A. De Guzman DOH representative

A CASE STUDY ON MULTIPARITY POLYHYDRAMNIOS & BREECH BIRTH

JEANETTE A. RAMOS, RM

RURAL HEALTH MIDWIFE PLACEMENT PROGRAM III RURAL HEALTH UNIT BANGUI ILOCOS NORTE