Comment on the CTG
Fetal heart rate: 145 b.p.m
Baseline variability: 5-15 beat.
Acceleration: present
Deceleration: not present
Uterine contraction: present and strong.
Comment: active CTG
Outline of management
1) Confirmation of the date of pregnancy
a) Sure of date or not
b) First ante natal check up
c) Early ultrasound
2) Take vital sign of the mother and elicit any sign of infection.
3) Full history
a) To confirm the diagnosis of the leaking liquor and possibility of dealing with pre term labour
b) To see any complicated pregnancy (malpresentation, IUGR, medical condition that is exarcebated by pregnancy)
c) To exclude the differential diagnosis (genital tract infection, urinary incontinence)
4) Assesment of fetal well being
a) Abdominal examination to access fetal lie and position, abdominal contraction.
b) Pinard auscultation.
c) Non stress CTG
d) Ultrasound to measure the biophysical profile, amniotic fluid index of the baby
Notes: CTG shows the evidence of contraction pain, therefore premature delivery with ruptured membrane should be anticipated.
5) Vaginal examination for assessment of Bishop score
6) Speculum examination to confirm that patient leaks liquor
a) Pooling of clear fluid at posterior fornix
b) Alkaline fluid (change litmus paper from red to blue)
7) Set an IV access to the patient (at least 2 large bore needle)
8) Blood investigation (FBC, GSH)
9) Transfer the patient to the premature room
10) IM Pethadine 75 mg stat for pain management and continue with infusion. Plus Metoclopromide 10 mg IV stat.
11) IM dexamethasone 12 mg B.D, 12 hours apart.
12) Tablet Adalat 20 mg t.d.s (notes; Adalat is Nifedipine for tocolytic while the dexamethasone works)
13) Monitor the blood pressure, systolic >100 and diastolic > 60
14) IV ampicillin I g stat and continue B.I.D for prohylaxis against group B Streptococcus sp.
15) To book for a ventilator and inform paed team.
16) Strict pad chart
17) Monitoring of vital sign
18) If the labour progress, then expected management should be done. Can choose vaginal delivery if no contraindication.
19) If the labour is suppressed, then patient can be transferred to the ante natal wards.
20) After there is no more contraction for 3 consecutive days, then patient can be discharged home.
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