[Year]

CASE WRITE-UP
OBSTETRICS & GYNAECOLOGY
POSTING
SESSION 2021/2022

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Contents
HISTORY...............................................................................................................................3
Identification Data..............................................................................................................3
Chief Complaint..................................................................................................................4
History of Presenting Illness...............................................................................................4
History of Presenting Pregnancy........................................................................................5
Past Obstetrics History........................................................................................................6
Gynaecological history.......................................................................................................6
Past medical and surgical history........................................................................................6
Family history.....................................................................................................................7
Social history......................................................................................................................7
Drug history........................................................................................................................7
Diet history.........................................................................................................................7
Systemic Review.................................................................................................................8
Summary.............................................................................................................................9
PHYSICAL EXAMINATION.............................................................................................10
General Inspection............................................................................................................10
Vital Signs....................................................................................................................10
Specific Examination........................................................................................................11
Abdominal Examination...................................................................................................11
Inspection.....................................................................................................................11
Palpation.......................................................................................................................11
Vaginal examination.........................................................................................................11
Modified Bishop Score................................................................................................11
Summary of Physical Examination...................................................................................12
INVESTIGATIONS.............................................................................................................13
Maternal Monitoring.........................................................................................................13
Fetal Monitoring...............................................................................................................14
MANAGEMENT.................................................................................................................15
DISCUSSION.......................................................................................................................17
1. Gestational Diabetes Mellitus..................................................................................17
Definition.....................................................................................................................17
Risk Factors..............................................................................................................17
Preconception care.......................................................................................................17

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 Screening and Diagnosis of Diabetes in Pregnancy.....................................................18
Self-monitoring of blood glucose (SMBG)..................................................................18
Metformin Therapy......................................................................................................18
Insulin Therapy............................................................................................................19
Fetal Surveillance.........................................................................................................19
Timing and Mode of Delivery......................................................................................19
2. Induction of Labour (IOL).......................................................................................20
Definition.....................................................................................................................20
Indication......................................................................................................................20
Contraindication...........................................................................................................20
Complication and Risks...............................................................................................21
Preparation of Induction...............................................................................................21
Monitoring....................................................................................................................21
Method of IOL.............................................................................................................22
3. Contraception...........................................................................................................22
Methods of contraception.............................................................................................22
References................................................................................................................................23

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HISTORY

Identification Data

Name
Registration No. :
Age : 26 years old
Gender : Female
Race : Malay
Marital Status : Married
Address : Kota Bharu, Kelantan
Occupation : Housewife
Date of admission : 22/05/2022
Date of clerking : 23/05/2022
Informant : Patient herself
Gravity & Parity : Gravida 3 Para 2 Abortion 0
Last Menstrual Period : 28/08/2021 (sure of date, regular menses, not breastfeeding, on
Yasmin after second pregnancy since December 2020 until July
2021)
EDD : 4/6/2022
Revised EDD : First scan was done on 8/11/2021, at 10 weeks 2 days of POA,
with fetal parameters and crown-rump length (CRL)
corresponding to the period of gestation. Thus, estimated
delivery date calculated from last menstrual period is 2/6/2022
Period of Amenorrhea : 38 weeks

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Chief Complaint

Patient was referred from Pejabat Kesihatan Daerah Bachok for Gestational Diabetes
Mellitus on subcutaneous Insulin for Induction of Labour at 38 weeks of Period of
Amenorrhea (POA)

History of Presenting Illness

Modified oral glucose tolerance test (MOGTT) was done on 10 weeks of POA due to
risk factor of Gestational Diabetes Mellitus (GDM) which is history of GDM in her previous
pregnancy, booking Body Mass Index (BMI) of 26.1kg/m2 and family history of GDM. The
result was 5.6 mmol/L for fasting plasma glucose (FPG) and 9.0 mmol/L two hours
postprandial (2-HPP). The FPG and 2-HPP value were exceeding normal range thus
diagnosis of GDM was established. Patient was then referred to a dietitian on proper diet
control. She claimed that she adhered to the principle of diabetic control but the Blood Sugar
Profile (BSP) on 12 weeks of POA was sub-optimized. The result was 5.5/6.9/6.5/6.4. She
claimed that BSP was done weekly because her BSP was not optimize. She started on
subcutaneous Insulatard 8U ON. At 21 weeks of POA, her BSP was still sub-optimized. The
result was 5.8/5.5/6.0/5.8. Insulatard dose was increased to 10U ON and subsequently was
increased to 12U ON, 14U ON and 16U ON because the BSP was still sub-optimized. At 34
weeks of POA, she had one episode of hypoglycaemic. The symptoms were giddiness and
sweaty. It was resolved after taking food. At 36 weeks of POA, her BSP was sub-optimized
and the Insulatard dose was increased from 16U ON to 18U ON. Latest BSP was done at 38
weeks of POA and the result was 5.4/4.4/4.4/4.7 which was optimized. Her HbA1c result was
4.8%. Patient denies of having any classical symptoms of hyperglycaemia such as
polyphagia, polydipsia, and polyuria.

Upon admission, patient is alert, conscious and afebrile. Patient was tested with Rapid
Test Kit Antigen (RTK-Ag) and the result was negative. Fetal movement was good and there
was no contraction pain, no leaking liquor and no show. She also denied having symptoms of
urinary tract infection (UTI) such as dysuria, foul smelling urine, or suprapubic pain. Patient
show no evidence of upper respiratory tract infection (URTI).

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History of Presenting Pregnancy

Currently, this is third pregnancy at 38 weeks of POA. She claimed that this is a planned
pregnancy and first suspected her pregnancy when she missed her period in late August 2021.
She did the urine pregnancy test (UPT) at her home and the result was positive. She then
confirmed her pregnancy at Pejabat Kesihatan Daerah Bachok, Kelantan at 9 weeks of POA.
Subsequently, she had her booking done too on the same day. Investigations were done and
the parameters were as followed:

Height : 167 cm
Weight : 73 kg
Body Mass Index : 26.1 kg/m2
Blood Pressure : 120/800 mmHg
Pulse Rate : 88 beats per minute
Blood Group : B+
VDRL : non-reactive
HIV/Syphilis : non-reactive
Hepatitis : non-reactive
She attends all subsequent antenatal check-up (ANC) at Klinik Desa Melor., she had
her ANC weekly and claimed she never missed her antenatal check-up. Blood sugar profile
was taken during the check up. Patient claimed that she gained weight but unsure of the exact
amount. Ultrasound was done at 10 weeks 2 days of POA, it showed good fetal growth, no
fetal anomaly, adequate liquor and placenta at the upper segment of uterus. Latest ultrasound
was done upon admission at 38 weeks of POA, showed an estimated fetal weight (EFW) of
3.44 kg and amniotic fluid index (AFI) of 17.17cm.

She experienced quickening at 18 weeks of POA with increased frequency and

intensity. She had pedal edema but denied of having nausea, vomiting, constipation,
frequency, backache, and breast engorgement. She completed her anti-tetanus toxoid (ATT)
booster injection but unsure of rubella and Hepatitis B immunization status. She completed
two doses of Covid-19 vaccine (Pfizer).

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Past Obstetrics History

This is the patient’s second marriage. Her first marriage was in 2012 and then got
divorced 2014. The second marriage was in 2020. The marriage is non-consanguineous.
Currently, she has 2 sons. The details of each pregnancy were as followed:

Year Place Method Gestation Sex Birth Breastfeeding Complication

of of Birth of Age Week Weight
Birth Delivery (Kg)
2012 HRPZI SVD Term L 3.4 1 Year No complication
I
2020 HRPZI SVD Term L 2.9 1 Year No complication
I

Patient has a history of GDM in her second pregnancy in 2020. The baby was born via
spontaneous vaginal delivery with weight of 2.9 kg, no extended term, no shoulder dystocia,
and no postpartum hemorrhage. She claimed that she had voluntary subfertility and taken
Yasmin since December 2020 until July 2021.

Gynaecological history

Patient attained menarche at the age of 12 years old. Before marriage, she had a regular
menstrual cycle of 28 to 30 days with 7 days of flow. Heavy flow occurred from the 2 nd to 3rd
day of menstruation which involved the usage of 3 fully soaked sanitary pads. Otherwise, she
had no dysmenorrhea, menorrhagia, dyspareunia, or post-coital bleeding. She claimed that
she never had pap smear done. Otherwise, patient has no dysmenorrhea, menorrhagia,
intermenstrual bleeding, postcoital bleeding and dyspareunia.

Past medical and surgical history

Patient has Gestational Diabetes Mellitus in her second pregnancy. Her last hospital
admission was during birth of her second child at HRPZII which was 2 years ago. She has no
history of having Patient has no known medical illness such as chronic hypertension, type 2

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diabetes mellitus, heart disease or asthma. This is the first hospitalization of the patient. There
was no history of surgical intervention done.

Family history

Patient’s father has Type 2 Diabetes Mellitus and patient’s mother has hypertension. The
patient is the second child out of 5 children. Otherwise, other siblings are healthy and has no
known medical illness. There is no history of malignancy within the family.

Social history

The patient is a housewife, and her education level is up to SPM. Her husband is a 38-year-
old security guard. Her husband is a smoker whilst the patient is a non-smoker. Both do not
consume alcohol and take any recreational drugs. She currently lives at Bachok in a house
with good water and electrical supply from the government and there is a total of 4 occupants
in the house. Father is the caretaker of the children when the mother was admitted.

Drug history

Patient is currently not on any regular medications. She claimed that at home she takes
multivitamins (Obimin) tablet daily since November 2021. Otherwise, she is not taking any
other over the counter drug or traditional medicine. She has no known drug allergy.

Diet history

Patient is on diabetic diet. She eats twice a day with a diet consisting of rice, fruits,
vegetables and fish or chicken.. Usually, patient is having bihun goreng with tea as a
breakfast (9 am) and ‘nasi berlauk’ with plain water in the afternoon. Otherwise, she has no
known food allergy

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8
Systemic Review

Cardiovascular system No shortness of breath

No palpitation

No chest pain

Respiratory system No shortness of breath

No hemoptysis

No night sweats

Gastrointestinal system No abdominal pain

No altered bowel habits

No dysphagia

Genitourinary system No changes in urine colour

No changes in urinary frequency

No dysuria

Nervous system No weakness

No altered sensation

No numbness

Endocrine system No heat or cold intolerance

No increased thirst

No skin or hair changes

Haematological system No rash

No bleeding tendency

No Pallor

Musculoskeletal system Swelling of ankle

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 No painful joint

No muscle pain

Summary

Faezah, a 26-year-old, Malay woman, gravida 3 para 2, currently at 38 weeks and 2 days of
POA, was admitted for induction of labour in view of Gestational Diabetes Mellitus on
Insulin. She has good foetal movement and does not have any signs and symptoms of labour.
Her blood sugar was well controlled.

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PHYSICAL EXAMINATION

General Inspection

Patient was lying comfortably in supine and supported with one pillow. She was alert, active
and oriented to time, place and person. Her hydrational and nutritional status were clinically
adequate. She was not in pain and showed no sign of respiratory distress with respiratory rate
of 20 breaths per minute. There was no muscle wasting and no involuntary movement were
noted.

Patient’s palm was pink, warm, and moist. There was no clubbing of fingers, leukonychia or
koilonychias and no peripheral cyanosis noted on both hands. Capillary refill time was less
than 2 seconds.

Patient’s conjunctiva was pink, and the sclera was not jaundice. Patient’s oral hygiene
was good with no angular stomatitis, glossitis, noted and no coated tongue and central
cyanosis.

There was no thyroid or lymph node enlargement. Her ankle was swollen. Patient
does not have varicose veins and all peripherals were palpable.

Vital Signs

Blood pressure : 119/75 mmHg

Pulse rate : 86 beats/min

Pulse character : Regular rhythm and good volume

Temperature : 37.0°C

SpO2 : 99%, ↓ RA

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Specific Examination

Abdominal Examination

Inspection
On inspection, the abdomen is distended with gravid uterus as evidenced by the presence of
linea nigra and striae gravidarum on the abdominal wall. The umbilicus was flat and centrally
located. There were no surgical scars or distended veins can be seen. The hernia orifices were
intact. The fetal movement can be appreciated.

Palpation
Upon superficial palpation, the abdomen soft and non-tender. On deep palpation, the uterus
was relaxed and there was no uterine contraction. The clinical fundal height was at 38 weeks
whereas the measured symphysiofundal height (SFH) was 38 cm, which was corresponds to
the date. On fundal grip, it was smooth, broad and not ballotable which indicate the fetal
buttocks. The fetal back was at the maternal right side and fetal parts was at the maternal left
side. On pelvic grip, it was four fifth palpable. The estimated fetal weight ranged from 3.2-
3.4 kg and the liquor was clinically adequate.

Fetal heart sound was inaudible during auscultation using pinard thus heart rate could not be
calculated.

Vaginal examination

 No cord and placenta

 No prostin inserted

Modified Bishop Score

Characteristics 0 1 2
1. Position Posterior Axial Anterior
2. Length 2cm 1cm <1cm
3. Dilatation <1cm 1cm 2cm 3cm
4. Consistency Firm Soft Soft &
Stretchable
5. Station of -2 -1 0

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 Presenting Part

Summary of Physical Examination

On general examination, the patient was generally well. There were no signs of
peripheral stigmata of cardiovascular and respiratory diseases. On specific abdominal
examination, the clinical fundal height and symphysiofundal height (SFH) correspond to the
date. There was a singleton fetus with longitudinal lie and cephalic presentation with the
presenting was four fifth palpable. The fetal back was palpable at the maternal right side
whereas the fetal parts at the maternal left side. Estimated fetal weight was 3.2 to 3.4 and the
liquor was clinically adequate.

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INVESTIGATIONS

Maternal Monitoring

1. Full blood count

This test is done to assess degree of infection and anemia if present. Also, to assess patient’s
hemodynamic status

Result (22/5/2022):

Test Results Normal Range Unit Interpretation

White blood cell 9.05 3.40-10.1 x109 /l Normal
Red blood cell 4.23 3.52-5.16 x1012/l Normal
Hemoglobin 10.5 11.6-15.1 g/dL Low
Hematocrit 32.6 31.8-42.4 % Normal
MCV 77.1 77.5-94.5 fL Normal
MCH 24.8 24.8-31.2 pg Normal
MCHC 32.2 29.4-34.4 g/dL Normal
Platelet 304 158-410 x109/L Normal

Interpretation: Patient does not have anemia, leukocytosis and thrombocytopenia. All the
parameters are within normal range

2. Blood Sugar Profile (BSP)

To make sure that the blood sugar level is optimized by insulin.

Result:

 Pre breakfast: 5.4

 Pre/post lunch: 4.4
 Pre/post dinner: 4.4
 Pre bed: 4.7

Interpretation: BSP is optimized

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Fetal Monitoring

1. Transabdominal Sonography (TAS)

• To assess fetal biometry parameters

• To assess fetal growth if the fetus is macrosomic or IUGR
• To exclude polyhydramnios which is the complication of GDM

Investigation Result
Pole, lie, presentation Singleton baby with longitudinal lie and cephalic presentation
Head circumference 32.76
Abdominal circumference 34.1 cm
Femur length 7.4 cm
Amniotic fluid weight 17.17 cm
Estimated fetal weight 3.4 kg
Interpretation: femur length, head circumference and abdominal circumference correspond to
gestational age. Estimated fetal weight of 3.2-3.4 kg. No polyhydramnios or multiple
pregnancy noted on ultrasound.

2. Cardiotocography

• To assess for signs of fetal compromise

• To monitor fetal heart rate and fetal wellbeing
• To detect uterine contraction

Baseline heart rate 130 beats per minute

Beat to beat variability 5-15 beats per minute
Acceleration +ve
Deceleration -ve

Interpretation: the CTG was reactive

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MANAGEMENT
1. Vital sign, fetal heart rate and fetal kick chart monitoring

2. Capillary blood sugar 4 times daily

3. Continue SC Insulatard 18u ON

4. Watch out for hypoglycaemic symptoms

5. Diabetic diet

In meal planning strategies, there are few factors that have to be taken into consideration. The
basic nutrition advice is as below:

 Timing of meals and snacks (no more than 4 hours without eating)
 Limiting refined carbohydrates and added sugars
 Get a variety of healthy food choices :
a. Complex carbohydrates such as whole grain bread
b. Fibre, which is found in beans, whole grains, fruits and vegetables
c. Lean protein, such as chicken (without skin) or fish
d. Lots of vegetables – especially the green, leafy ones
e. A limited amount of heart-healthy fats, such as olive, peanut or canola oil,
walnuts, almonds and flax seed
 Watch portion sizes and read labels, follow plate method
 Keep a food journal
 Learn to make lifestyle changes and not diet for a short period of time
 Healthy Plate Method. One way is to change the amount of food you are already
eating.
a. Breakfast : a balance of half starchy foods, one-fourth fruit and one-fourth
protein.
b. Lunch and dinner : fill ½ the plate with non-starchy vegetables (such as: green
leafy vegetables, beans, cabbage); ¼ should contain meat or other protein
(fish, lean meat, skinless chicken); ¼ contains starch (such as rice, chapatti).
On the side, you can have a serving of fruit.

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 c. choose whole grain food items over refined grain items, choose lean meat over
fatty cuts of meat and non-fat or low-fat dairy products over whole-fat dairy
products

6. Prepare for IOL with prostin if cervix not favourable.

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DISCUSSION

1. Gestational Diabetes Mellitus

Definition
Impaired glucose tolerance resulting in hyperglycaemia which first develops or becomes
diagnosed during pregnancy.

Risk Factors
 Body mass index > 27 kg/m2
 Previous history of GDM
 First degree relative with dia betes mellitus
 History of macrosomia (birth weight > 4 kg)
 Bad obstetric history
 Glycosuria ≥2+ on two occasions
 Current obstetric problems (essential hypertension, pregnancy-induced
hypertension, polyhydramnios and current use of corticosteroids)

Preconception care
Provided by a multidisciplinary team, consists of:

 discussion on timeline for pregnancy planning

 lifestyle advice (diet, physical activities, smoking cessation and optimal
body weight)
 folic acid supplementation
 appropriate contraception
 full medication review (discontinue potentially teratogenic medications)
 retinal and renal screening
 relevant blood investigations

Women with pre-existing diabetes should be informed of the glycaemic control

targets and empowered to achieve control before conception. They are also counselled
on the risk and expected management approaches during pregnancy

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Screening and Diagnosis of Diabetes in Pregnancy

Self-monitoring of blood glucose (SMBG)

• Should be done in diabetes in pregnancy.

The blood glucose targets should be as the following:

 fasting or preprandial: ≤5.3 mmol/L

 1-hour postprandial: ≤7.8 mmol/L
 2-hour postprandial: ≤6.7 mmol/L.

The frequency of SMBG should be individualised based on mode of treatment and glycaemic
control

Metformin Therapy
 In GDM, metformin should be offered when blood glucose targets are not met by
modification in diet and exercise within 1–2 weeks.
 Metformin should be continued in women who are already on the treatment before
pregnancy

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Insulin Therapy
Insulin should be initiated when:

• Blood glucose targets are not met after MNT and metformin therapy
• metformin is contraindicated or unacceptable
• FPG ≥7.0 mmol/L at diagnosis (with or without metformin)
• FPG of 6.0-6.9 mmol/L with complications such as macrosomia or
polyhydramnios (start insulin immediately, with or without metformin).

Human insulins are the preferred choice in pregnant patients who need insulin
therapy. Both rapid and long acting (basal) insulin analogues are as efficacious as
human insulin in pregnant women with pre-existing diabetes and GDM. Insulin
analogues are associated with fewer incidences of hypoglycaemia

Fetal Surveillance
• At 11-14 weeks of gestation, early scan is performed to: confirm gestational
age using crown-rump length measurement assess for major structural
malformation including acrania and anencephaly
• At 18-20 weeks of gestation, detailed structural anatomy scan which includes
the spine and heart (four-chamber, outflow tract and three-vessel views)
• At 28-36 weeks of gestation, serial growth scan is performed every four weeks
to assess fetal growth and amniotic fluid volume. The rate of fetal growth
should be used to facilitate decisions with treatment, and timing and mode of
delivery

Timing and Mode of Delivery

 In pregnant women with pre-existing diabetes with:
a. no complications, deliver between 37+0 and 38+6 weeks
b. maternal or fetal complications, deliver before 37+0 weeks
 In women with GDM:
a. on diet alone with no complications, deliver before 40+0 weeks
b. on oral antidiabetic agents or insulin, deliver between 37+0 and 38+6 weeks
c. with maternal or fetal complications, deliver before 37+0 weeks
 Mode of delivery should be individualised, taking into consideration the estimated
fetal weight and obstetric factors.

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2. Induction of Labour (IOL)

Definition
Intervention designed to artificially initiate contractions leading to progressive dilatation and
effacement of the cervix and birth of the baby.

Indication
Maternal:

Urgent Elective/ non-urgent

Escalation of pre-eclampsia Post term pregnancy
Significant maternal disease Gestational diabetic at term
 Infection: chorioamniotis Logistic Problem (residence is too far
 PPROM & PROM from hospital)
 Isoimmune disease near term

Fetal

Urgent Elective/ non-urgent

Fetal compromise (marked Intrauterine fetal demise
oligohydramnios)

Severe IUGR
Unstable lie

Contraindication
• Placenta Previa
• Cord presentation
• Active genital herpes
• Prior classical c-section
• Abnormal lie
• Previous uterine surgery involving full thickness of myometrium
• Invasive cervical carcinoma

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Complication and Risks
a. Uterine hyperstimulation

Management:

 Perform vaginal examination

 Flush posterior fornix with normal saline to remove remaining prostin
 CTG is mandatory to exclude fetal distress
 Treat by IV ritodrine or IV/SC Terbutaline
b. Failed Induction- Failure to establish labour after one cycle of treatment,
consisting of the insertion of two vaginal PGE2 tablets (3 mg) or el (1-2 mg) at 6-
hourly interval, or one PGE2 pessary (10 mg) within 24 hours. C-section should
be advised
c. Cord Prolapse
d. Uterine rupture

Preparation of Induction
 Thorough evaluation of mother and fetus before induction to exclude the
contraindication and assess the need for induction abdominal examination, vaginal
examination for bishops score
 Confirm period of gestation- USG
 Fetal wellbeing: CTG
 Maternal well-being vital signs
 Explain the anticipated outcome, benefits and risks of induction of labour with
oxytocin to the woman and obtain verbal consent

Monitoring
Monitoring after PGE2 :

 Continuous electronic fetal heart rate and uterine contraction monitoring. Bishop
score should be reassessed 6 hours after vaginal PGE2 tablet or gel insertion, or 24
hours after vaginal PGE2 controlled release pessary insertion, to monitor progress

Monitoring after oxytocin infusion:

 Continuous cardiotocography (CTG) is indicated with commencement of oxytocin

(Syntocinon) infusion

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 Uterine contractions should be assessed carefully for a 10-minute period at 30-minute
intervals. Contraction frequency and duration should be reconciled with uterine
activity recorded on the CTG
 Strength of contraction is a subjective assessment requiring manual palpation

Method of IOL
 Membrane sweep is offered weekly from 40 weeks
 Prostaglandin gel, tablet or pessary to ripen cervix and initiate contractions
 Artificial rupture membrane (ARM), to do this, cervix must be favourable
 Oxytocin infusion which is done after rupture of membranes either spontaneous or
artificial
 Mifepristone and misoprostol for intrauterine death

3. Contraception

Methods of contraception
1. Barrier methods
 condoms
2. Daily methods
 combined oral contraceptive pill
 progesterone only pill
3. Long-acting methods of reversible contraception (LARCs)
 implantable contraceptives
 injectable contraceptives
 intrauterine system (IUS): progesterone releasing coil
 intrauterine device (IUD): copper coi

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References
1. Kenny, L.C., & Myers, J.E. (2017). Obstetrics: by Ten Teachers (20th ed.). CRC Press.
https://doi.org/10.1201/9781315382401
2. Nalliah S & Sachithanantham, Clinical Protocols in Obstetrics and Gynecology for
Malaysian Hospital, 2015
3. Clinical Practice Guidelines, Management of Diabetes in Pregnancy, Ministry of Health
Malaysia, 2017
4. Reethiya Letchumanan, Rokeshwar Hari Dass, Doctrina Perpetua: Guides on Obstetrics,
R & S Publishing House, 2015

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