Case Presentation Obstestrics m 5 Pt ID 24732128

Case Presentation Obstestrics 성균관대학교 의과대학 m 5 손의영 Pt ID : 24732128 문 0희 38/F

Chief Complaint � Amenorrhea for 41 + 1 weeks

Present Illness � PN check at 봄빛, 마리아 병(의)원 � PN check at SMC OBGY since 10 + 5주 by Pf 노정래 � Routine OB Lab : 특이사항 (No) Hbs. Ab/Ag(+/-) Rubella Ig. G/Ig. M(+/-) AB+ � Last Pap : 2009 특이사항(No) � Serum screening test - Quad test 결과 : Down syndrome (+) � Amniocentesis : Karyotype ( ) not done – refused � 50 g oral GTT : 117 mg/d. L � CBC : 특이사항 (No) � Level II (2011. 2. 10, PA 22+5 wks) : WNL � Last USG (2011. 6. 16, PA 40+5 wks) : Vx. / decreased(deepest 2. 45 cm) / Post. / 3513(50 -75 P)

Ultrasonography (2011 -06 -19)

Other History �PMHx. �HTN/DM/Tb/hepatitis/Allergy (-/-/-) �약물력 : (No) �수술력 : (Yes) ; appendectomy, 1986 �FHx. �특이사항 없음 �SHx. �Marriage : 기혼 (30세) �smoking: no �alcohol: no

Physical Exam � 기본신체사항 및 활력징후 (2011 -06 -19 15: 07) �혈압 100/57 mm. Hg 신장 174. 6 cm 몸무게 79. 3 kg BMI 26. 01 kg/m 2 � General appearance �Not so ill looking �Mental status : Alert � Abdomen �Palpitation : Distended d/t pregnancy �Tenderness (No) �Rebound tenderness (No)

Physical Exam � 산과 진찰소견 �FHR : Normal by USG �Presenting part : Cephalic �Cervix dilatation : Fingertip �Effacement : Partial effacement �Station : Floating �Vaginal discharge : Normal �Rupture of membrane (No) �Vaginal bleeding (No)

Assessment � Pregnancy : 41 + 1 weeks �for IVP �elderly (amniocentesis refused) �oligohydramnios

Hospital Course � 2011 -06 -19 (41+4 weeks) � FT(0), PE(0), Floating(0), Posterior(0), Soft(2) � Bishop score 2점으로 Propess 투여 결정 � 2011 -06 -20 분만기록 - Baby 1 � Induction Augmentation(Yes) Prostaglandin (Yes) - Dinoprostone (Yes) Oxytocin (Yes) � 성별 : 여아 출생시 체중 (3. 13)kg � Apgar score : 1 min – (9), 5 min – (9) � MS (0) CN (1) GA (No) : cord p. H 7. 293 � NR

Hospital Course � 2011 -06 -21 PP#1 【검사명】【단위】【시행일】【결과】 ------------------------------Hb, Blood g/d. L 2011 -06 -19 12. 1 2011 -06 -21 ▼ 10. 9 3 WBC, Blood x 10 /u. L 2011 -06 -19 7. 81 2011 -06 -21 ▲ 12. 79 PLT, Blood x 103/u. L 2011 -06 -19 ▼ 124 2011 -06 -21 ▼ 115 ------------------------------ Dressing done : episiotomy site clear, no hematoma 익일 퇴원 예정

Mechanisms of Labor �Lie of fetus �Longitudinal, transverse �Presentation �Cephalic presentation (96%) �Breech presentation (3. 5%)

Mechanisms of Labor �Fetal position

Mechanisms of Labor w/ OA Presentation �Cardinal movement

Changes in Shape of the Fetal Head �Caput succedaneum (산류) �Molding (거푸집 현상)

분만의 관리 – Admission Procedures �Identification of labor �Vital signs and review of pregnancy record �Detection of ruptured membrane �FHR monitoring �Vaginal examination �Cervical examination �Lab studies

References �Williams Obstetrics, 23 rd Edition �Chapter 17. Normal Labor and Delivery