TEALE FENNING

EMAK · Century Club Joined: 26 Nov 2006 Posts: 572

30 years old lady in her 28 wks gestation , she is G2P1A0, her first baby delivered 3 years ago, per vaginum , she had epidural analgesia and she got prolonged second stage of labour, the fetus extracted by forceps. he baby can not sit till now. She think that the prolongation in the second stage is responsible for her baby condition and she requst Cs for this pregnancy.

A] What are the possible causes of her baby situation ?[5 Marks]
B] How you can reach to the diagnosis ?[ 5 Marks]
C] How would you councel her ?[10 Marks]

nilofar · Joined: 14 Jun 2007 Posts: 6

A] the possible causes of this condition in term babies could be related to various antepartum,intrapatum or early neonatal [<1 hr of delivery] complications leading to the acute hypoxic events so its imported to rule out cerebral palsy as cause related to brain damage.it is evident that in 90% of cases,the cause of brain damage do not relate to intrapatum hypoxic events.among the 10%of the antenatal,intrapatum & early neonatal causes can be implicated.antepatm causes includes maternal & fetal conditions as maternal metabolic,autoimmune disorder,IUI,fetal developmental abnormalities or coagulation disorder,IUGR,APH,breech presentation.a definitive sentinal events during intrapatum period has significant adverse effects on neurological conditions of a healthy term infant & includes a reputered uterus,abruptio placenta,cord prolapse,AFE& fetomaternal heamarrage.metabolic,coagulation disorder& acute infection at neonatal period is often responsible for significant brain damage.

nilofar · Joined: 14 Jun 2007 Posts: 6

B]national consensus statement proposed criteria for diagnosing CP dependng on metabolic acidosis,NN encephalitis,CP type,sentinal hypoxic events,FHR &NN brain imaging but all of these have problems in defining the cause & timing of neuropathlogy causng CP.thus it is difficult to have a definitive diagnostic evidence.complications occurring in antipatum period are common, imp cause of CP & evaluated from detail retrospective antpatm records.though intrpatm complications play an infrequent role in the causation of CP,should be evaluatd frm details intrpatm recods,in which FBSif taken for nonreassurng CTGor any sentinal hypoxc events is significnt.signs of mod to srvere HIE inclds hypotonia,seizure,coma& requiremnts of SBCU admission.CP type like spastic quadriplagia or dyskinetic CP is associatd with acute hpoxic intrpatm events &hemiplagic CP,spastc displagia & ataxia are not. NN brain imagng is imp for predctng signs of acute hpoximia using cranial USS,MRI or EEG.USS though available has less sensitivity & specificity than MRI, which is not widely available& expensive but can suggest long standing neurological changes& disfuntion predctng funtional neurological disability in NN or infants so currently use.

nilofar · Joined: 14 Jun 2007 Posts: 6

C] the couple should be counceld empathically & sensitivly. involving senior neunatologist & midwivs familiar with the case.after re evaluation of all the records,they should be givn detail information based on clinical & epidemiological stdies which indicats that majority of cases the events leadng to CP occur in fetus prior to onset of labor or in new born followng delivry. more than 75%cases have no clinical signs of intrpatm hpoxia. intrpatm complicaton are not responsible for CP.accurate diagnosis of the cause &timing of neuropathology can't ba predcted till now due to pitfall of diagnostic modilities available.acute intrpatm hypoxc events usually affects all the vital organs & not only the fetal brain but may rarely occur without major disfunction of othr organs.there is also no proven evidence that whether any early obstetric intervention could have preventd cerebral damage in any individual case of extensive intrpatm hypoxia where no detectable sentinal hypoxic events occur.the actual length of time & degree of hypoxia required to cause CP in a previously healthy fetus is not known.risk & benefit of c/s vs vaginal delivry shuold be explaind but her wishes must be respected.

nilofar · Joined: 14 Jun 2007 Posts: 6

please nick do give me a feedback on this answer.waiting eagerly for your reply.thanks.

nilofar · Joined: 14 Jun 2007 Posts: 6

comment on this from anybody is more than welcome thanks .

salihabduallah · Century Club Joined: 04 Sep 2007 Posts: 120

I send an E-mail to your adress, check it.

Nick Raine-Fenning · Posted: Mon Dec 03, 2007 12:44 pm Post subject:

No need to send private e-mails guys - just post stuff here.

Don't worry about the content - we can jointly correct it if necessary.

N

Xerxes I · Posted: Sun Jan 13, 2008 1:08 pm Post subject:

The question is obviously targetting our knowledge on CP but thinking laterally, the baby can't sit at 3 YO. She doesn't necessatrily have CP. I think we should say a sentence like:

Congenital abnormalities (eg musculoskeletal etc) rendering a three year old unable to sit should be considered through consultation with paediatricians and geneticists. A thorough examination and history should pay specific attention to other developmental milestones, including speech etc.

(can the mother sit? considering the difficult forceps and requesting CS! Wink

sorry, couldn't help it.)

Xerxes I · Posted: Sun Jan 13, 2008 1:17 pm Post subject:

And also, in the third question, I think we are not being enough feely touchy. She is obviously anxious about the risk of this happening again. requesting CS being just one sign.

We can say something like:

The parent's anxiety regarding the possibility of recurrence should be fully addressed and discussed. They should be reassured that the baby will be closely monitored both antenatally and intrapartum. ....CS does not eliminate the possibility of CP for the reasons you just said.... was the forceps traumatic.... did she have a bad tear .... fecal faltulence continence etc

or will it make the essay too long?

Nick Raine-Fenning · Posted: Mon Jan 14, 2008 11:56 am Post subject:

Xerxes I · Posted: Mon Jan 14, 2008 1:33 pm Post subject:

That' exactly why I m coming to your ourse this weekend. how do you put it so neatly?

Nick Raine-Fenning · Posted: Tue Jan 15, 2008 11:39 am Post subject:

Years of practice Smile

That's the paln this weekend - to turn those years into a weekend. Sounds ridiculous but we manage pretty well Wink