Madam Sarah, a 37 year-old obese clerk in her second pregnancy was admitted for

induction of labour at 38 weeks gestation in view of hypertensive disease in pregnancy on

treatment

Her first pregnancy was complicated by Caesarean delivery delivery at 37 weeks of

gestation for fetal distress.

1. What risk factors you could identify in this case?

Obese, Maternal hypertensive disease,History of Fetal Distress,Previous C
section,Advanced maternal age

2. Give two options of induction of labour for this patient, and its advantage and
disadvantage

1. Prostaglandins (e.g., Misoprostol or Dinoprostone)

Advantages:
 Effectiveness: Prostaglandins are effective in ripening the cervix and initiating
labor, particularly in women with an unfavorable cervix (Bishop score <6).
 Non-invasive: Administered vaginally or orally, reducing the need for initial
invasive procedures.
 Flexibility: Multiple forms available (gel, insert, or oral tablet), providing options
based on patient-specific factors.
Disadvantages:
 Risk of hyperstimulation: Can cause uterine hyperstimulation, leading to
excessive uterine contractions that may compromise fetal oxygenation.
 Side effects: May cause nausea, vomiting, diarrhea, and fever.
 Previous Cesarean Section: Increased risk of uterine rupture in women with a
previous cesarean delivery, requiring careful monitoring.
2. Oxytocin Infusion
Advantages:
 Control: Infusion rate can be adjusted based on uterine response, allowing for
precise control of contractions.
 Quick onset: Induces contractions relatively quickly once the infusion is started.
 Established use: Widely used and well-studied, with protocols in place for its
administration.
Disadvantages:
 Need for continuous monitoring: Requires continuous fetal and uterine
monitoring, typically necessitating hospitalization.
 Risk of hyperstimulation: Similar to prostaglandins, oxytocin can cause uterine
hyperstimulation, increasing the risk of fetal distress.
 Limited effect on cervical ripening: Less effective for cervical ripening
compared to prostaglandins, particularly in women with an unfavorable cervix.
Additional Considerations:
Given Madam Sarah's previous cesarean delivery and hypertensive disease, careful
monitoring and a multidisciplinary approach are essential to manage potential
complications. Prostaglandins should be used with caution due to the increased risk of
uterine rupture in patients with a history of cesarean section. Oxytocin may be preferred,
with close monitoring for hyperstimulation and fetal distress.

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3. How would you assess this patient’s suitability for induction of labour?
To confirm indication for IOL: Risk Factors
Confirm gestation date amd antenatal history via pink book and Transabdominal scan
CTG to monitor fetal heartbeat if suspicious perform ARM
Contraction -present (IOL with mechanical induction only)
- Absent (IOL with medical and mechanical induction (transcervical balloon
cathether))
TVS Scan for placental location ( Contraindicted in placenta previa)
EFW (4kg or lesser -IOL),>4kg (D/W HO/Specialist)
Fetal lie- induce only if longitudinal lie
Bishop score

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The patient was found suitable for induction of labour with estimated fetal weight of 3.4
kg. She was induced with PGE2 (Prostin) and developed regular contractions after 4
hours. Vaginal assessment shows cervical os of 5 cm with a fully effaced cervix. Upon
arrival in labour room she complained of severe headache. Her blood pressure was
150/110 mmHg with pulse rate of 88 bpm. The head was already deeply engaged (not
palpable) with cervical os of 8 cm with intact membrane. Her urine dipstick shows
proteinuria 3+.

4. What is her current diagnosis?

Severe Preeclampsia: This is suggested by her severe headache, high blood pressure
(150/110 mmHg), and proteinuria (3+ on urine dipstick). Severe preeclampsia can lead to
complications such as eclampsia, which is characterized by seizures.

5. What other symptoms and signs that you should enquire and look for?

Symptoms:
Visual disturbances (e.g., blurred vision, seeing spots)
Epigastric or right upper quadrant pain
Nausea or vomiting
Shortness of breath (due to pulmonary edema)
Sudden weight gain or swelling (due to fluid retention)
Signs:
Reflexes: Check for hyperreflexia or clonus, which can be signs of severe preeclampsia.
Signs of impending eclampsia: Seizures or altered mental status.
Signs of HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelet count):
Bruising, jaundice, bleeding tendencies.
6. How should the patient be managed now?
 Stabilization:
 Administer Magnesium Sulfate (MgSO4): To prevent seizures.
 Antihypertensive Therapy: Medications like labetalol, hydralazine,
or nifedipine to control blood pressure.
 Monitor Vital Signs: Continuous monitoring of blood pressure,
pulse, and respiratory rate.
 Labor Management:
 Expedite delivery due to the severity of preeclampsia and fetal
engagement.
 Fetal Monitoring: Continuous fetal heart rate monitoring to assess
fetal well-being.
 Analgesia and Anesthesia: Epidural anesthesia might be
considered to control pain and potentially lower blood pressure.

[Link] planned for forceps delivery how do you decide the suitability for
her forceps delivery?

 Fetal Position: The fetal head should be engaged and in an appropriate position
for forceps delivery (e.g., occiput anterior).
 Cervical Dilation: The cervix should be fully dilated.

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  Membranes: The membranes should be ruptured.
 Pelvic Adequacy: The pelvis should be assessed to ensure it is adequate for vaginal
delivery.
 Maternal Consent and Cooperation: The mother should consent to the procedure and
be able to cooperate during delivery.
8. Role of MgSO4 in This Patient
 Seizure Prophylaxis: MgSO4 is administered to prevent seizures in patients with
severe preeclampsia.
9. Other Uses of MgSO4
 Tocolysis: To delay preterm labor in certain situations.
 Severe Asthma: As a bronchodilator in severe asthma exacerbations.
 Arrhythmias: To treat certain types of cardiac arrhythmias (e.g., Torsades de
Pointes).
 Hypomagnesemia: To correct magnesium deficiency.
10. Monitoring for MgSO4 Toxicity
 Clinical Monitoring:
o Reflexes: Regularly check deep tendon reflexes; loss of reflexes may
indicate toxicity.
o Respiratory Rate: Monitor respiratory rate; <12 breaths per minute may
indicate toxicity.
o Urine Output: Ensure adequate urine output (>25-30 mL/hr) to prevent
accumulation of MgSO4.
o Mental Status: Monitor for confusion or lethargy.
 Laboratory Monitoring:
o Serum Magnesium Levels: Therapeutic range is usually 4-7 mg/dL; levels
above this can indicate toxicity.
11. Risks Associated with Retained Placenta
 Postpartum Hemorrhage: Increased risk of significant bleeding.
 Infection: Risk of endometritis or sepsis.
 Uterine Atony: Uterus may not contract properly, increasing bleeding risk.
 Surgical Intervention: May require manual removal or surgical intervention, with
associated risks.
12. Medications Post-Delivery
 Oxytocin: To promote uterine contractions and reduce the risk of postpartum
hemorrhage.
 Antibiotics: To prevent or treat any infection due to retained placenta or
instrumentation.
13. Handling the Baby Posthumously
 Documentation: Complete and accurate documentation of the events and time of
death.
 Support: Provide emotional support and counseling to the parents.
 Respectful Care: Handle the baby’s body with dignity, allowing parents time to say
goodbye.
 Autopsy: If consented by the parents, an autopsy can help determine the cause of
death and provide closure.
 Follow-Up: Offer follow-up care and support services to the family, including grief
counseling and support groups.

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