INTRODUCTION

Fetal death in utero (stillbirth) is defined in most states as a demise at 20 weeks of gestation
and/or weight of 500 grams The fetal death rate in the United States varies among races, but
overall it is 6.8/1,000 total births and accounts for approximately half the perinatal mortality
(fetal and neonatal deaths). Management of fetal death in utero has changed dramatically from
earlier recommendations that regarded the event as a medically innocuous condition to be
managed conservatively except under life-threatening circumstances, with 75% of women
delivered within 2 weeks after fetal demise. After coagulopathy was observed in pregnancies
complicated by fetal death in utero and with newer agents to effect cervical ripening and uterine
contractions, the management of stillbirth has become more proactive.
Investigations have evaluated the significance of a previous stillbirth maternal serum
biochemical markers, genetic causes, maternal complications of pregnancy, infective agents,
intrapartum events, usefulness of autopsy examinations,and placental findings in the cause of
fetal death. The one material complication frequently evaluated after the diagnosis of a fetal
demise is the development of disseminated intravascular coagulopathy (DIC). Numerous
publications have evaluated the causes of fetal death in utero, but except for the rarely
encountered case of DIC, other maternal complications associated with the management and
delivery of a stillbirth have not been assessed in a large investigation. The purpose of this
investigation was to evaluate the maternal morbidity associated with IUFD.

PATIENTS PROFILE
A. GENERAL DATA
Name: San Pedro, Noimy Mendoza
Address: NA, Villa de Calamba, Calamba Laguna
Religion: Christian
Occupation: housewife
Nationality: Filipino
case no.: 09-1085
sex: Female Civil status: Married
birthdate: December 31, 1980
Age: 28 Y6M1
Birth place: Nueva Ecija
B.CHIEF COMPLAINT
cc: hypogastric pain for 1 day actively moderate
C. HISTORY OF PRESENT ILLNESS
Present illness: G3 P2
Last menstrual period: Febuary 24, 2009
Expected date of confinement: December1, 2009
Age of Gestation: 21 weeks

ANATOMY AND PHYSIOLOGY

The female reproductive system is designed to carry out several functions. It produces the female
egg cells necessary for reproduction, called the ova or oocytes. The system is designed to
transport the ova to the site of fertilization. Conception, the fertilization of an egg by a sperm,
normally occurs in the fallopian tubes. The next step for the fertilized egg is to implant into the
walls of the uterus, beginning the intitial stages of pregnancy. If fertilization and/or implantation
does not take place, the system is designed to menstruate (the monthly shedding of the uterine
lining). In addition, the female reproductive system produces female sex hormones that maintain
the reproductive cycle.
During menopause the female reproductive system gradually stops making the female hormones
necessary for the reproductive cycle to work. When the body no longer produces these hormones
a woman is considered to be menopausal.
The Mammary Glands
The mammary glands are accessory organs of the female reproductive system that are specialized
to secrete milk following pregnancy. They are located in the subcutaneous tissue of the front
thorax within the elevations which are called breasts. A "nipple" is located near the tip of each
breast, and it is surrounded by a circular area of pigmented skin called the "areola." A mammary
gland is composed of fifteen to twenty irregularly shaped lobes, each of which includes alveolar
glands, and a duct (lactiferous duct) that leads to the nipple and opens to the outside. The lobes
are separated by dense connective tissues that support the glands and attach them to the tissues
on the underlying pectoral muscles. Other connective tissue, which forms dense strands called
"suspensory ligaments," extends inward from the skin of the breast to the pectoral tissue to
support the weight of the breast. The breasts are really modified sweat glands, which are made
up of fibrous tissues and fat that provide support and contain nerves, blood vessels and lymphatic
vessels.
Cervix
The lower one-third of the uterus is the tubular "cervix," which extends downward into the upper
portion of the vagina. The cervix surrounds the opening called the "cervical orifice," through
which the uterus communicates with the vagina.
Fallopian Tubes
The fallopian tube extends from the uterus to the ovary. This tube carries eggs and sperm and is

where fertilization of the egg, or "ovum" takes place. The fallopian tubes lie in the pelvic portion
of the abdominal cavity and each tube reaches from an ovary to become the upper part of the
uterus. This funnel-shaped tube is about three inches in length. The larger end of the funnel is
divided into feathery, finger-like projections which lie close to the ovary. These beating
projections, along with muscle contractions, force the ovum down the funnel's small end, which
opens into the uterus. After sexual intercourse, sperm swim up this funnel from the uterus. The
lining of the tube and its secretions sustain both the egg and the sperm, encouraging fertilization
and nourishing the egg until it reaches the uterus. If an egg splits in two after fertilization,
identical or "maternal" twins are produced. If separate eggs are fertilized by different sperm, the
mother gives birth to un-identical or "fraternal" twins.
Labia Minor
The labia (singular, labium) minor are flattened lengthwise into folds located with the cleft
between the labia major. These folds extend along either side of the vestibule. They are
composed of connective tissue that is richly supplied with blood vessels, causing a pinkish
appearance. In the back, near the anus, the labia minor merge with the labia major, while in the
front they converge to form a hood-like covering around the clitoris.
Ovary Ligaments
Each ovary is attached to several ligaments that help to hold it in position. The largest of these,
formed by a fold of peritoneum, is called the "broad ligament." It is also attached to the uterine
tubes and to the uterus. At its upper end, the ovary is held by a small fold of peritoneum, called
the "suspensory ligament," which contains the ovarian blood vessels and nerves. At its lower end,
it is attached to the uterus by a rounded, cord-like thickening of the broad ligament, called the
"ovarian ligament." The "peritoneum" is a two-layered membrane that supports the abdominal
organs, produces lubricating fluid that allows the organs to flow smoothly over each other, and
protects against infection.
Ovaries
The ovaries are a pair of oval or almond-shaped glands which lie on either side of the uterus and
just below the opening to the fallopian tubes. In addition to producing eggs or "ova," the ovaries
produce female sex hormones called estrogen and progesterone. The ovaries produce a female
hormone, called estrogen, and store female sex cells or "ova." The female, unlike the male, does
not manufacture the sex cells. A girl baby is born with about 60,000 of these cells, which are
contained in sac-like depressions in the ovaries. Each of these cells may have the potential to
mature for fertilization, but in actuality, only about 400 ripen during the woman's lifetime.
Pregnant and prenatal both come from the same Latin roots. "Prae" means "before" and "nascor"
means "to be born". Nascor is also the derivative of nature, innate and native. Only a few years
ago, the word, "pregnant" was seldom used in mixed company. Polite society referred to a
pregnant woman as "expecting" or "being in the family way."
Uterus
The uterus or "womb" is a hollow, muscular organ in which a fertilized egg, called the "zygote,"
becomes embedded and in which the egg is nourished and allowed to develop until birth. It lies
in the pelvic cavity behind the bladder and in front of the bowel. The uterus usually tilts forward
at a ninety degree angle to the vagina, although in about 20%% of women, it tilts backwards. The
uterus is lined with tissues which change during the menstrual cycle. These tissues build under
the influence of hormones from the ovary. When the hormones withdraw after the menstrual
cycle, the blood supply is cut off and the tissues and unfertilized egg are shed as waste. During
pregnancy, the uterus stretches from three to four inches in length to a size which will

accommodate a growing baby. During this time, muscular walls increase from two to three
ounces to about two pounds and these powerful muscles release the baby through the birth canal
with great force. The womb shrinks back to half its pregnant weight before a baby is a week old.
By the time the baby is a month old, the uterus may be as small as when the egg first entered.
Superstition, myth or ignorance have surrounded the menstrual period since the beginning of
time. This is largely due to a primitive fear of blood. The word, "taboo," may stem from the
Polynesian word for menstruation, but not all legends are negative; a girl's first menses is
celebrated in some societies, because it is a sign that she can bear children.
Vagina
The vagina is a muscular passage which forms a part of the female sex organs and which
connects the neck of the uterus (called the "cervix") with the external genitals. The vagina, which
is approximately two and one-half to four inches long, has muscular walls which are supplied
with numerous blood vessels. These walls become erect when a woman is aroused as extra blood
is pumped into these vessels. The vagina has three functions: as a receptacle for the penis during
love-making; as a outlet for blood during menstruation; and as a passageway for the baby to pass
through at birth. According to The Guiness Book of World Records, a Russian peasant woman
who lived in the 18th Century holds the record for the most children born to one mother. She had
sixty-nine children within forty years. She produced sixteen pairs of twins, seven sets of triplets,
and four sets of quadruplets!
Vulva
The vulva is made up of several female organs which are external. These include a small,
rounded pad of fat which protects the pubic bone. Reaching down almost to the anus are two
folds of fatty tissue, called the "larger lips," to protect the inner genitals. Just inside are two
"smaller lips," which enclose the opening of the urethra (which comes down from the bladder)
and the vagina. At the upper end, are small projections, called the "prepuce," that protect the
clitoris. The clitoris is a very small, sensitive organ with numerous nerve endings that, like the
penis, contain tissues which fill with blood when sexually aroused.

NEUROLOGIC ASSESSMENT:

CATEGORY
Mental status:
Level of
consciousness

NORMAL
FINDINGS
Conscious and
coherent

Orientation

Time, place and

person oriented

Language test

Expressive language,
receptive language

Recall

Could explain recent

and past events in
their personal history

ACTUAL FINDINGS

ANALYSIS AND
INTERPRETATION

Conscious and coherent Patient must be able to state

alert
their name, location and date or
time easy to understand and
Oriented in time, place response
and person
Patient must be aware of the
three dimension, patient knows
people and can recognize the
Receptive language,
role
difficulties finding
words
Patient must be able to
comprehend questions but has
difficulty knowing what to say
Patient is aware of the
next
IUFD, patient has no
Patient must recall three
problem of recalling
words(spoon, red and Toyota)
immediately after two
rehearsals and then again five
minutes later
Patient must recall my name
after 3O minutes.

Cranial Nerves:
CN I
Olfactory
CN II
Optic

Must have no
abnormalities in
smell
Visual acuity 20/20
Pupillary light reflex
Visual fields

CN III, IV, VI

Patient has no difficulty Air moves freely as the client

in smell
breaths through the nares

Patient can read

progressively smaller
lines on the near card
(20/20)
Direct and consensual
response are elicited

Direct and consensual response

are elicited when the light
shines on the eye. Dilation
occur during the swing
between

Occulomotor
Trochlear
Abducens

PERRLA
Accommodation
reflex

CN V
Trigeminal
Normal and
symmetrical
Masseters feels firm
and strong

PERRLA
As eyes converge
pupils constricted

Normal and
symmetrical
Masseters feels firm
and strong
Contracting temporalis
is felt

CN VII
Facial

Symmetrical facial
features
CN VIII
Vestibulocochlear

CN IX, X
Glossopharyngeal

Patient must hear the

numbers whispered
with the other ear
covered

Vagus
Gag reflex
CN XI
Accessory (spinal)

Normal swallowing

Patient must be able

to move certain body
parts against resistant
CN XII
Hypoglossal

Pupils equally round and

reacting to light and
accommodation

With the touch on the face, w/

a piece of cotton, patient feels
it. Normal and symmetrical
Patient is asked to clench her
teeth
Contracting temporalis is felt

The grin is symmetrical

and full
Furrows of the
Face is symmetrical and does
forehead is
not involve involuntary
symmetrical
movements

Patient is able to hear

and repeat the numbers
whispered

Patient gag when

pharynx is stroked
Patient has no problem
swallowing

Patient is able to raise

shoulders against
resistant
Patient is able to turn to
the side and back
against resistant

Patient is able to hear and

repeat the numbers whispered

Patient should gag when the

pharynx is stroked
Patient may cough or choke
when swallowing

Accessory nerves sends motor

fibers to the trapezius and
sternocleiodomastoid muscles.
Damage to the nerves produce
weakness in head rotation and

Patient passed the

ligual speech test
Patient has no tremor,
atrophy and
fasciculations

shoulder elevation

The left arm must be

able to move.

Patient can alternately

supinate and pronate
rapid pace

Right arm

The right arm must

be able to move.

Left leg

Patient must be able

to move both legs

Patient can alternately

supinate and pronate
rapid pace
left and right leg are
strong
can maintain stance

Perform with slow, clumsy

movements and irregular
timing has difficulty moving
the arm
Perform with slow, clumsy
movements and irregular
timing has difficulty moving
the arm

Patient must be have

no atrophy in the
mouth

Muscle strength:
Left arm

Right leg

Patient must be able

to move both legs

left and right leg are

strong
can maintain stance

Hypoglossal supplies motor

fibers to all of the muscles of
the tongue . loss of function
will point the tongue to the
affected side

The patient with strong muscle

leg strength is normal

The patient with strong muscle

leg strength is normal