GRAND CASE PRESENTATION

In
Polyhydramnios

A Clinical Case Study

Presented to
The GCP Committee and Faculty of Bachelor of Science in Nursing
and School of Midwifery
City University of Pasay (Formerly Pamantasan ng Lungsod ng Pasay)
In Partial Fulfillment of the Requirements in
Related Learning Experience
By:
Midwifery II-I
Rofan Rosachany I. Suaifan
Team Leader
Mary Jane F. Cambangay
Madelyn B. Castro
Hidaya c. Hadji Omar
Analyn M. Labadan
Maria Rose A. Odulana
Analiza D.Sevilla

I. INTRODUCTION
Polyhydramnios is a medical condition describing an excess of amniotic
fluid in the amniotic sac. It is seen in about 1% of pregnancies.It is typically
diagnosed when the amniotic fluid index (AFI) is greater than 24 cm.There are
two clinical varieties of polyhydramnios:

Chronic polyhydramnios where excess amniotic fluid accumulates

gradually
Acute polyhydramnios where excess amniotic fluid collects rapidly

The opposite to polyhydramnios is oligohydramnios, a deficiency in amniotic

fluid.
In most cases, the exact cause cannot be identified. A single case may have one
or more causes, including intrauterine infection (TORCH), rh-isoimmunisation,
or chorioangioma of the placenta. In a multiple gestation pregnancy, the cause of
polyhydramnios usually is twin-to-twin transfusion syndrome. Maternal causes
include cardiac problems,kidney problems, and maternal diabetes mellitus, which
causes fetal hyperglycemia and resulting polyuria (fetal urine is a major source of
amniotic fluid).
A recent study distinguishes between mild and severe polyhydramnios and
showed that Apgar score of less than 7, perinatal death and structural
malformations only occurred in women with severe polyhydramnios.In another
study, all patients with polyhydramnios, that had a sonographically normal fetus,
showed no chromosomal anomalies.
Fetuses with polyhydramnios are at risk for a number of other problems
including cord prolapse, placental abruption, premature birth and perinatal death.
At delivery the baby should be checked for congenital abnormalities.

II. OBJECTIVES OF THE CASE STUDY

General Objective:
This case presentation seeks to enhance the students knowledge with
patients general health and disease condition, and its possible complications
treatment plan and medical regimen. This also seeks to assimilate the students
skills through application of midwifery intervention and medical management.
Furthermore, This case presentation intends to improve the students attitude by
conveying open-mindedness and utilizing therapeutic communication all through
the activity.
Specific
This study aims to:

Perform maternal health assessment and plan maternal care related to

patient condition.

Apply the role and responsibilities of midwife in implementing interventions

with polyhydramnios.

Familiarize with the anatomy and physiology of the disease.

III.SCOPE AND LIMITATION

This study is being prepared by Midwifery Level II-I as a requirement for the
subject Clinical Practicum 102 B.

I. PERSONAL DATA

Name

PASTILLAS

Address

# 2 Deciembre St. Brgy 195 Sun Valley Village,

NAIA Road, Pasay City

Age

33 years old

Sex

Female

Civil Status

Married

Religion

Roman Catholic

Birthday

May 19, 1982

Birth Place

Sorsogon

Room and Bed No:

OB WARD 1

Hospital No

399148

Case No

:
:

399148

Admitting Physician: Dr. Al R. Tanyag

Chief Complaint/Reason for Seeking Health Care:
Labor Pain
Medical Diagnosis : G2P2 (1102) Pregnancy Uterine 35 4/7 wks AOG by MUTZ,
Cephalic in Labor, Polyhydramnios

II.Medical History
A.History of Present Illness
2 Weeks Prior to Confinement
August 07,2015 (9:30 AM)
Patient Pastillas went to Airways Health Center for her pre-natal check up
and she complained for edema on her lower extremities.She felt her legs
restless.She stated that maybe it is because of sitting and prolonged standing
when shes at work.After taking her vital signs,she was told to have her Ultra
Sound and directly referred to Donya Martha Lying In due to incomplete facilities
such as laboratories and ultra sound of the health center.
August 13, 2015 (10:00 AM)
Patient Pastillas had her laboratories and ultrasound in Doa Marta lying in.
Her ultrasound result shows Pregnancy Uterine 37 5/7 wks by fetal biometry,Live
singleton in cephalic presentation,Placenta Anterior Gr.2,Polyhydramnios doctor
advised her to have complete bed rest but the patient insisted to go to work.
AUGUST 19 2015
Prior to admission patient pastillas experience uterine contraction with a
painscale of 5/10 at work but still do her work at the office
The night of admission the patient experience severe abdominal pain radiating to
the back with pain scale of 8\10. the family decided to bring her to hospital. The
patient is admitted to the labor room at around 9:49 pm with 4cm dilatation.

B.Past Medical History

Patient Pastillas was never confined in any hospital facility before.During her
first pregnancy (2006),she gave birth on her first child via home delivery and was
assisted by unlicensed midwife (manghihilot).Whenever she feels sick,she used
to take herbal medicines as alternatives.

C.Family Medical History

Family has no history of diabetes milletus,hypertension on the both side.

D.Social History
Patient Pastillas is the 1st child of 6 siblings.Married for 9 years and has two
children.She is a college graduate of Bachelor of Science in Criminology and has
been working as Aviation Security for (5) five years.
Born in Sorsogon City,Patient Pastillas is known as friendly,good person and
knows how to get along with different types of people.Despite of being away from
her husband,Pastillas can still manage to raise her children well.She is currently
living with her 1st child and new born baby, She has a good relationship with her
husbands family member most especially with her Mother-in-law, who helped her
in taking good care of her children whenever shes at work.
Patient is not a cigarette smoker but drinks alcohol occasionally
(approximately 2 glasses). The patient is not picky when it comes to food,She
usually eat vegetables, meat and fruits as part of her diet. She drinks less than
10 glasses of water a day.

E.Environmental History
Patient Pastillas resides at # 2 Deciembre St. Brgy.195, Sun Valley Village,
Naia Road, Pasay City. Their house is made up of cement, light material but still
unfinished. The floor is approximately 16 x 9 sq. Meter with one window and
door.Their bed is situated near the entrance door which also serves as their living
room. The house is well ventilated and has a source of electricity. Breeding sites
of mosquitoes, flies, cockroaches and rodent are inevitable due to poor
sanitation. Their toilet facility is located in front of their kitchen. Electric Water
Pump was their source of water supply. They pay P2,500 for their home rental,
P200 for water bill and P500 for electric bill.
Patient Pastillas used to segregate their waste (Biodegradable, NonBiodegradable and Recyclable materials) in a plastic container located at the
back of their house. Garbage truck roam around in their place every day around
6am-7am to collect their trash.
There are sari-sari stores available in the vicinity.Public utility vehicle such
as Jeepneys and Tricycle serves as their mode of transportation.They used
cellular phones as their means of communication.

F. OB Score/ OB History
The patients menarche experienced when she was 14 years old. She
consumed (4) four pads of sanitary napkins 3x a day, regular and doesnt
experienced any difficulty like dysmenorrhea when she had her menstruation.Her
first coitus was when she was 24 years of age with her first husband and got
pregnant. She delivered her first child via home birth at La Union Province while
her second child was delivered via Normal Spontaneous Delivery at Pasay City

General Hospital.G2P2
(1-1-0-2).

G. Immunization History
During her first pregnancy, Patient Pastillas did not received any
vaccination/ immunization because she doesnt have any pre-natal or regular
check up.She doesnt visit any nearest health center in their place to seek
consultation.During her second pregnancy, Patient Pastillas decided to visit MIA
Health Center to have her self checked-up. She receives Tetanus Toxoid twice.
Patient Pastillas was admitted at Pasay City General Hospital and gave
birth to her second child.Her child was given Hepatitis B, Vitamin K, BCG (Bacille
Calmette Guerin) at time of birth.
H. Developmental History
GROWTH AND DEVELOPMENTAL

ERIKSONS THEORY
Developmental Stage
Infancy
Age: 0 to 1 1/2
Virtue: Hope
Early Childhood
Age: 1 1/2 to 3
Virtue:
Will
Pre-School

Developmental Task
Trust
vs.
Mistrust

Implication
Patient Pastillas was
breastfed at this age.

Autonomy
Vs.
Doubt and Shame

Patient Pastillas was not

toilet rained when she was
on this age.She always
insist what she wants.

Iniatiative

Patient Pastillas stated that

Vs.
Guilt

Age: 3 to 5
Virtue:
Purpose

School Age

Industry
Vs.
Inferiority

Age: 5 to 12
Virtue:
Competency
Adolescence
Age: 12 to 18
Virtue:
Fidelity

she wants to do many

things on her own like
sweeping the floor and
bathing, but her mother
refused to let her do this
alone.
Patient Pastillas was an
active student.She
wants to participate in
any school activity on
her own.

Ego Identity
Vs.
Role Confusion

Patient Pastillas doesnt like

to hangout with her
friends.She stated that
she liked to stay at
home and mingle with
her brother, sister and
cousins.She claimed
that she did not get
confused of her identity
being female.

Intimacy
Vs.
Isolation

Patient Pastillas decided to

apply for work away
from her family.She
stated that her family
was supportive to her
when they knew shes
already pregnant.

Young Adulthood
Age: 18 to 40
Virtue:
Love

III. Patterns of Functioning-Altered System

Gordons Functional Pattern
Patterns of
Functioning
Health
Preparation &
Health
Management

Before
Hospitalization

During
Hospitalization

Analysis/
Interpretation
Patient build up
her awareness
about her
health.

NutritionalMetabolic

Elimination

Activity & Exercise

Coping Stress
Tolerance

Value-Belief

Patient E.D.B
loves to eat
fish,vegetable
and fruits. She
eats her meals
(3) times a day.
She can drink
up to 8 glasses
of water per day
Patient voids (5)
five times a day
and she moves
her bowel
(2)twice a day.
Doing house
hold chores
every day is the
form of exercise
being done by
the patient
before going to
work.
When she has
problem,Patient
E.D.B used to
communicate &
share her
problems to her
family and
friends.She
makes herself
busy like
watching
television or
listening to
radio.
Patient E.D.B was
a Roman Catholic.
She go to church
regularly.She does
praying before
eating and every

Patient E.D.B
was advise to
lessen her
water intake
because of her
condition.

Patients
urinates
regularly 3-4 x a
day with
difficulty and
defecated
yellowish stool.
Patient activity
is limited.She
usually lies
down or talk to
the neighbor
whenever she
feels bored.

Patients finds
difficulties of
bowel
movements.

During
hospitalization,
the patient
coped stress by
talking to her
neighbor and
family through
phone.

The patient has

outlet to let her
feeling of stress
out by
interacting with
the family
neighbor during
visitation hours.

Patient E.D.B
cannot attend the
mass because of
her hospitalization
but she always
prays and

Patient believes
that every thing
has a reason and
that present
situation is a
challenge.

Patients daily
activity was
affected.
She was
difficulties on
moving.

night before
sleeping.

believes that God

will always bless
and help her.

PHYSICAL ASSESSMENT
PHYSICAL ASSESSMENT
Body Parts
SKIN

Normal Findings

Actual Findings

Interpretation/An
alysis
Inspection
Inspection
Presence
of
stretch mark in the
Skin color varies Skin color was abdomen due to
from light to dark brown
previous
and
brown.
complexion.
No present
abrasions
or pregnancy.
lesion
found.
Temperature was
warm, dry, rough
elastic turgor and
mobile.
Abdomen
has
stretch marks.
Palpation

NORMAL
Palpation

Skin temperature
is warm to touch.
Skin is warm to
touch.

HEAD
SCALP

Inspection

Inspection

White, clean and Scalp is white, NORMAL

no scars, nits, clear and there is
dandruffs
and no presence of
lesions.
lice,
scars,
dandruff
and
lesions.
Palpation

Palpation

Free from masses

Free from masses

NORMAL

HAIR

and lumps.

and lumps.

Inspection

Inspection
NORMAL

Black and evenly

distributed
that
covers the whole
scalp, shiny, free
from split ends.
Inspection

Color of hair was

black and evenly
distributed
that
covers the whole
scalp, shiny, free
from split ends.
Inspection

EYES

Oblong,
oval,
square or heartshaped,
symmetrical.
Facial expression
depends on the
mood
or
true
feelings,
no
wrinkles,
no
involuntary
movements.
Inspection

Wrinkles
Face is oblong her age.
symmetrical,
expression
depends on the
patients mood or
feelings, has little
bit of wrinkles on
the side of both
eyes,
no
involuntary
movements.
Inspection

SCLERA

Parallel
and
evenly
placed
symmetrical, nonprotruding
and
clear.There
is
scant amount of
secretions,
both
eyes are black
and clear.
Inspection

PUPILS

Pinkish and Clear

Inspection

FACE

Eyes
are NORMAL
black,symmetrical,
not protruding and
clear.There
is
scant amount of
secretions.

Inspection
NORMAL
Inspection
NORMAL

Round,Symmetric
al,constrict
with
increasing
light
and
accommodation.

Round,Symmetric
al,constrict
with
increasing
light
and
accommodation.

due

to

EYE
MOVEMENTS

EARS

Inspection

Inspection

Able to move eyes

in full range of
motion
in
all
directions.

Able to move eyes

in full range of
motion
in
all
directions.

Inspection

Inspection

Parallel,
symmetrical
proportional to the
size of the head,
bean
shaped,
helix is in line with
the outer canthus
of the eye, skin
color is the same
as the surrounding
area, clean.

Parallel,symmetric NORMAL
al,proportional to
the size of the
head,bean
shaped, helix is in
line with the outer
canthus of the
eye, skin color is
as the same as
the
surrounding
area, clean.

Palpation

Palpation

Firm cartilage.

Ear cartilages are

firm.
Inspection
NORMAL

NORMAL

NOSE

Inspection

MOUTH

Clean,pinkish with Clean, pinkish with

few cilia, airways few cilia and both
are clear.
nasal airways are
patent.
Inspection
Inspection

A.LIPS

B.TEETH
NECK

Pinkish,
symmetrical,
lip
margin
welldefined.
Inspection

Inspection

Proportional to the Proportional to the

size of the body size of the body

NORMAL

and
head, and
head,
symmetrical and symmetrical and
straight.
straight.

THORAX

Palpation

Palpation

NORMAL

No
palpable
masses, lumps or
area
of
tenderness.
Inspection

No
palpable
masses, lumps or
areas
of
tenderness.
Inspection

The chest contour

is
symmetrical.
The
spine
is
straight.There is
no
bulging
or
retraction of the
ICS
during
breathing.
The
chest wall moves
symmetrically
during respiration.

The chest contour NORMAL

is
symmetrical.
The
spine
is
straight.There is
no
bulging
or
retraction of the
ICS
during
breathing.
The
chest wall moves
symmetrically
during respiration.

Palpation

Palpation

NORMAL

No lumps,masses, No
lumps,
areas
of masses,areas of
tenderness.
tenderness.
HEART

Auscultation

Auscultation

ABDOMEN

Cardiac
rate Cardiac rate is 80.
ranges from 60- Beats per minute
100 beats per
minute.
Inspection
Inspection

NORMAL

Skin
is Skin has presence
unblemished, No of
striae
scars,
flat, gravidarum.
rounded
(concave),
There is
scaphoid
(+)
abdominal
(concave),
distension.
symmetrical

movements
Abdominal Girth:
caused
by
respiration,
umbilicus is flat or
concave,
positioned midway
between
the
xiphoid
process
and the symphisis
pubis, color is the
same
as
the
surrounding skin.
Palpation

EXTREMITIES

Soft abdomen, no
tenderness,
no
muscles guarding,
no
lamps
or
masses.
Inspection
Inspection

Edema is brought
up
by
fluid
No
scars,
No No
scars,
(+) retention in the
edema,skin is as edema on both body.
the same as the lower extremities.
surrounding area.

ANATOMY AND PHYSIOLOGY