UNIVERSITY OF ESWATINI

Faculty of Health Sciences

Department of Nursing Sciences

COURSE : Field Attachment (Introduction to

Midwifery)

COURSE CODE : GNS 330

LECTURER : Sr.A.R.DZIKO

TOPIC : ANC Case Report

DUE DATE : 16 October 2020

STUDENT’S NAME : Mkhonta Temahlungwane - 161667

ANC Case Report

COMPREHENSIVE HEALTH HISTORY

1. Biographic Data

Name: Hlengiwe Dludlu

Age: 24

Cellphone number: 76459132

Physical Address: Malanda

Education Level: High School

Occupation: Unemployed

Next of kin: Ncamsile Tsabedze

Cellphone number: 76389552

Physical Address: Maphalaleni

2. History of Present Concern

The patient reported that she was experiencing occasional series of nausea and vomiting mostly
in the morning. She reported that she then performed a pregnancy test a week ago and discovered
that she is pregnant.

Obstetric History

 Past

The patient was gravida 2 para 1. Her period was a regular 30 day cycle. Her last form of
contraception was noristerat. On her previous pregnancies she delivered naturally without
complications. There was neither antepartum hemorrhage nor postpartum hemorrhage in
her previous pregnancies. She received two doses of Tetanus diphtheria (Td). On her
 previous pregnancy she delivered on full term which was at 40 weeks. The interval since
her last birth is 6 years.

 Present

The patient last known menstrual period was on 5 June 2020. Calculating from her LMP, her
expected date of delivery is on 12 March 2021. Her gestational age was 18 weeks. She reported
that she experiences nausea in the morning with small amounts vomiting with dry heaves.

3. Past health/ surgical history

The patient has no history of chronic illnesses such as cancer or HIV. She also doesn’t have a
history of surgery or admission at hospital. She has no known drug allergies.

4. Family history

Her grandmother is hypertensive and on treatment. There is no one in the family who has a
history of diabetes, tuberculosis and heart diseases.

5. Lifestyle and health practices

The patient reported that she exercises three to five times week. She also reported that she eats a
diet consisting of three meals a day and snacks (primarily meats, vegetables, fruits, bread, water).

Observations and Screening tests

Vital Signs

The findings on her vitals were as follows;

Blood pressure- 117/78 mmHg Temperature - 36.5 degrees Celsius

Pulse- 87 beats per minute Respirations- 18 breaths per minute

Measurements

MUAC – 25 cm

Weight – 54.8 kg
Height- 172 cm

Screening Tests

I performed screening tests on the woman and the findings were as follows;

Hb- 10.4 g/dl

Urinalysis- Ketones-Negative ; Proteins- Negative; Glucose- Negative ; Leukocytes- Negative

HIV – Non reactive

Syphillis – Non reactive

Blood Group- O+

TB – Negative

Covid- 19- Negative

Head to Toe Examination

Skin: no hyperpigmentation.

Hair/nails: soft, smooth, clean.

Eyes – No pallor

Mouth – No pallor in tongue

Ears: No discharge noted

Thyroid: No masses or enlargement noted

Peripheral Vascular: There is no oedema in the face and extremities. Pulses are equal
bilaterally .Homans’ sign negative
Physical Examination

1. Breasts
 Inspection- Breast size is increased and nodular. The areola is also darkening, which
were normal findings for a pregnant woman.
 Palpation – There was no lumps on palpation

2. Abdomen
A. Inspection- The linea nigra was present and prominent which is normal in pregnant
women. Silvery striae gravidarum from her previous pregnancy was visible as well as
pinkish one from her current pregnancy. The size of the abdomen was corresponding with
the number of weeks pregnant. She didn’t have any scars on her abdomen. The shape of
the abdomen was oval. I observed that there were also fetal movements. All the findings
were normal for a pregnant woman.

B. Palpation
I. Symphysis Fundal Height : The symphysis fundal height was 19 cm which was a
normal findings since the patient’s gestational age was 18 weeks.

II. Leopold’s maneuvers

1. Fundal Palpation
On palpation, the fetal buttocks occupy the fundus. The fetus is lying longitudinally
which is a normal finding in a pregnant woman.

2. Lateral Palpation
The fetus’s back was on the left side and the front on the right side of the woman.
Such findings were used to locate the fetal heart rate.

3. Deep pelvic palpation

The fetus presenting part was cephalic presentation which is a normal finding in
pregnancy. It has not yet engaged since it early in the pregnancy.
 4. Pauwlik’s manoeuvre
The fetus attitude is flexion which is a normal finding in pregnancy.

5. Walking
The fetus is lying longitudinally with cephalic presentation. The back of the fetus is
located at the left side of the mother while the front is located at the right side of the
mother.

C. Auscultation- The fetal heart rate is 132 beats per minute which is within the normal
range which is 120 beats per minute to 160 beats per minute.

D. Genitalia

The patient reported that there was no abnormal discharge from the vagina. I also confirmed
through inspection of the genitalia

Health education

I educated the patient on the importance of couple testing for HIV and also emphasized on using
a condom when having intercourse to protect herself and the unborn baby from contacting STIs
such as HIV and syphilis. I also emphasized on eating a balanced diet with a lot of greens. I
explained to her that since she is now pregnant, she has to be cautious on what she eats since
whatever she eats will have an effect to the growing fetus. Lastly I educated her on pregnancy
danger signs such as severe headache, fever and bleeding and I advised her to immediately come
to the facility in case such arises.

Supplements and immunizations

I supplied her with iron supplements which were ferrous sulphate and folic acid. Both
supplements were 30 in each packet whereby she takes them every morning. I explained to her
that folic acid will help in the absorption of iron in the body while ferrous sulphate will help in
preventing iron deficiency anemia. I also administered albendazole 400 mg to prevent worm
infections. I also immunized her for tetanus and diphtheria since her last immunization was 6
years back and she had received only 2 immunizations which according to the tetanus-diphtheria
schedule she was eligible for the vaccine.

Return Date

Her next return is on 12 November 2020.