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WH Case Write Up OBS
WH Case Write Up OBS
History Taking
Venue: Hospital Sultan Ismail Ward 4A (obstetrics ward)
Date: 10/3/2016
Patients identification: A 32 years old Malay female, who is G4P1+2 and currently
with 37w+6d period of gestation. She works as a nurse and married for 5 years.
Gestation
LMP
EDD by dates
EDD by scan
6 / 6 / 2015
25 / 3 / 2016
12 / 3 / 2016
Presenting complaint
This is a referred case from Hospital Kota Tinggi for elective lower segment
caesarean section due to persistent transverse lie.
History of pregnancy
She suspected pregnancy because of the missed period for 2 weeks. A urinary
pregnancy test was done by herself and the result was positive. The pregnancy was
confirmed by ultrasound scan in the Klinik Kesihatan. At that time, it was week 7 of
pregnancy. There was no any symptoms of early pregnancy such as morning
sickness, tiredness, breast tenderness and frequent urination. However, she has
developed bilateral lower leg oedema without calf tenderness at gestation week of
32. The fetal movements were started from week 20 of pregnancy and well
perceived by her. There were no episodes of abdominal pain and any vaginal
bleeding or discharge throughout the pregnancy. All the booking investigation
showed normal result except for mild anaemia. Her blood group is A+.
Year
Gestation
al age
Antenatal
complication
Mode of
delivery,
Birth
weigh
Sex
s
1
200
8
38w
200
9
201
2
4w
Breech
presentation
with success
external
cephalic
version
Miscarriage
8w
Miscarriage
Postnatal
complication
s
Vaginal
delivery
t
3.5kg
Male
IMB/PCB: No
Contraception: No
She has annual cervical smear since her marriage. The last cervical smear
was done in last year and the result was normal.
Dilation and curettage was done twice for the previous miscarriage.
Drug history
Social history
She is living with her husband and son with adequate family support
Family history
System review
No fever
No SOB
No chest pain
No UTI symptoms
No URTI symptoms
ICE
Ideas
She thinks that the persistent transverse lie might be related to the previous
miscarriage.
Concerns
She was worried for the persistent transverse lie that requires Caesarean section
which may associate with several risks to her baby and herself.
Expectations
She hopes that she can deliver a healthy baby.
Physical examination
General examination
Temperature 37.2C
Pulse 84bpm
Conjunctival pallor
Good hydration
Abdominal examination
Inspection
Palpation
Abdomen is soft and non-tender
Transverse lie and breech presentation
Adequate liquor volume
Auscultation
Management
Preoperative management
Nil by mouth for 12 hours with IV drip
2 large bore branula to operating theatre
Gastric prophylaxis on operating theatre
Glucuronoxylomannan and 2 pints packed red blood cell
Postoperative management
Monitor vital signs for half hourly X2, hourly X2, 2hourly X2, if stable then 4hourly
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