CASE
Tutorial 1 step 1
Mrs. Amanda, a 29 year old G3P1A1, is referred to the MHC clinic in her 34week pregnancy because of mild discomfort at the upper left abdominalpart. She noticed that everytime her baby moves; somethink that she saidshe had never experienced before. She also complains a bit tense on herlower tummy and afraid of recurrent having preterm birth.When the doctor asked, mrs. Amanda had started some contraction, butthere is no water broke, no bloody or slimy discharge from her vagina.She admits that the baby is still moving now.
Previous obstetric history.
She knew that she had arcuate uterus from hysterosalphyngogram prior toher first pregnancy.Her first pregnancy ends with spontaneous miscarriage, but the secondone she had a spontaneous pre-term birt, weighing 2000grams. Her son isa healthy 3-year old now. She sad an incision of vaginal septum onprevious delivery. She had normal lab exams performed a few weeksbefore.
Tutorial 1 step 2Her physical diagnosis
is shown below:BP:120/80mmHg, PR:72/m, RR:20/m, T:36
o
CHeart and lungs: within normal limitOther: within normal limit
Obstetric examination
Uterin fundus 30 cm above symphisisLeopold 1 : a globular round hard mass is occupying the uterine fundus.Leopold 2 : small fetal part detected on the left abdominal wall, on therigh side a long flat area of mass with higher resistence is detected on theright side
Leopold 3 : some soft mass is palpable above the symphisis, and havesomehow entered the pelvic inlet.Contraction: once on every 10 minutes, weakAuscultation (laennec stethoscope) :Fetal heart breat could be easily and more clearly heard just above theumbilicus.Fetal heart rate : 144-152 beat per minuteSpeculum examination: Vulva/Vagina : no abnormalitiesCervical dilatation : nonePelvic examination : normal
Tutorial 1 step 3
She was referred to the feto-maternal clinic at the nearest district hospital.She came back, bringing the result of USG as follows:A singleton fetus, female, in brerch presentation, the back is on theright.Biometrical measurements are in accordance with a 34-36 weeks’pregnancy.Heart rate is normal.Estimated fetal weight is 2200 + 3000grm.No major congenital anomalies detected. The plasenta lies in the anterior body of the uterus not occupyingthe internal uterine ostium.
Amniotic fluid index
: 12cm.
Conclusion:
G3P1A1 34-35 weeks pregnancy, breech presentation. The doctor prescribed oral tocolysis and explained the alarming signs aswhen the patient should return prior to the scheduled follow up visit.
Tutorial 2
Mrs. Amanda returned three weeks later to the MCH clinic, complainingthat she has been having regular contractions for 8 hours. She knows thebaby is sill moving, no water broke.
Physical diagnosis
:
Vital signs
: within normal limits
Obstetric examination
Uterine fundus 30 cm above symphisis.Leopold 1 : a globular round hard mass is occupying the uterine fundus.Leopold 2 : small fetal part detected on the left abdominal wall, on therigh side a long flat area of mass with higher resistence is detected on theright sideLeopold 3 : some soft mass is palpable above the symphisis, and havesomehow entered the pelvic inlet.Estimated fetal weight 2700 grmContraction: once every 3 minutes, lasting 50 second, strong.Fetal heart rate: 152-160 beat per minute
Vaginal examination
Vulva/vagina : no abnormalitiesPortio: axial position, soft, effacement 80%Cervical dilatation: 9-10 cmAmniotic membrane : intactPresenting part: breect, sacrum on the right, station +2 no feet palpable
Admission test result with cardiotocography : fetal in concition.
An hour later full dilatation is reached and as the baby’s buttocckis bulgingin the perineum. She was lead to bear down. There was some difficultywhile delivering the shoulder, and an assisted breech delivery had to bedone.
A baby boy is born, emerging limph, pale, cyanotic and takes onegasping breath on the way to the open warmer.
His heart rate is noted to be 80 beath min.
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