ANC Module

DEBRE TABOR UNIVERSITY
COLLEGE OF HEALTH SCIENCES

DEPARTMENT OF MIDWIFERY
ANC MODULE PBL CASES FOR REGULAR MIDWIFERY STUDENTS
Prepared and Edited by:

 Mulugeta Dile
 Punithalakshmi
 Yitayal Ayalew
 Shemeles Biru
 Habtamu Abie
JUNE, 2016 G.C

DEBRE TABOR UNIVERSITY
DEBIRE TABOR, ETHIOPA
Table of Contents
Week One: Tutor Guide for Pelvic Organ Prolapse..................................................................3
ANC Module: Week One................................................................................................................4
Week Two: Tutor Guide for Infertility.......................................................................................9
ANC Module: Week Two..............................................................................................................10
Week Three: - Tutor Guide for Intra Uterine Fetal Growth Restriction (IUGR)................16
ANC Module: - Week Three.........................................................................................................17
Week Four: - Tutor Guide for Prolonged Pregnancy..............................................................23
ANC Module: Week Four.............................................................................................................24
Week Five: - Tutor Guide Hyperemesis Gravidarm................................................................30
ANC Module: - Week Five............................................................................................................31
Week Six: Tutor Guide Intra Uterine Fetal Death(IUFD)......................................................36
ANC Module: Week Six................................................................................................................37
Week Seven: Tutor Guide for Malaria in Pregnancy..............................................................43
ANC Module Week Seven............................................................................................................44
Week Eight: Tutor Guide Multiple Pregnancies......................................................................49
ANC Module: Week Eight............................................................................................................50
Week Nine: - Tutor Guide Severe Pre-eclampsia.....................................................................56
ANC Module: Week Nine.............................................................................................................57
Week Ten: Tutor Guide Placenta Previa..................................................................................63
ANC Module: Week Ten...............................................................................................................64
Week Eleven: Tutor Guide for Abruptio Placenta...................................................................70
ANC Module: Week Eleven..........................................................................................................71
Week Twelve: Tutor Guide for Gestational Diabetes Mellitus...............................................76
ANC Module: Week Twelve.........................................................................................................77
Week Thirteen: Tutor Guide for Oligohydramnious...............................................................83
ANC Module Week Thirteen.........................................................................................................84
Week Fourteen: Tutor Guide for Breech presentation............................................................90
ANC Module: Week Fourteen.......................................................................................................91
Week Fifteen: Tutor guide for Pre Mature Rupture of Membrane.......................................97
ANC Module: Week Fifteen.......................................................................................................98
Week One: Tutor Guide for Pelvic Organ Prolapse
Objectives: At the end of this session, students will be able to:

 Identify relevant structures involved in Pelvic Organ Prolapse.
 Analyze the functions of organs involved in Pelvic Organ Prolapse.
 Explain the causes that contribute to Pelvic Organ Prolapse (POP).
 Discus the risk factors of Pelvic Organ Prolapse.
 Explain sign and symptoms of Pelvic Organ Prolapse.
 Discus the management approaches of the patient with Pelvic Organ Prolapse
Presenting problems:
 Heaviness around the perineum, back pain and pain during sexual intercourse.
Predicted Hypothesis:
 Enterocele (bowel herniation at top of vagina), Cystocele, Rectocele
Differential Diagnosis
 Endopelvic fascia damage (cardinal ligament, uterosacral ligaments) causing uterine prolapse
 Pelvic floor damage (levator ani muscles)
 Increased abdominal pressure
 Sacral/diabetic neuropathy
 Chronic cough--(smokers)
 Congenital damage/intrinsic weakness
 Multiparity
Learning issues
 Which structures are involved in Pelvic Organ Prolapse and why?
 How and why POP causes heaviness around the perineum, back pain, pain during sexual
intercourse and involuntary urine leakage ?
 How to assess and manage heaviness around the perineum, back pain, pain during sexual
intercourse and involuntary urine leakage?
Assessment Criteria:
 Contribution, flow of idea/ knowledge, communication skills, cooperation team building and
reasoning skills
Key readings
 Up-to-date 20.3
 Williams’s Gynecology
 Current obs & gyne 2007

ANC Module: Week One
Patient information
 Name: Beletech Mamo
 Age: 55 years
 Sex: Female
 Address: Gasaye
 Site of visit: Gyn OPD
Patient Presentation
Presenting at GYN OPD W/ro Beletech Mamo reported that “she has heaviness around the
perineum, back pain and pain during sexual intercourse.”
Discussion questions one
1. List Mrs. Beletech’s presenting problem?

2. Define your hypotheses as a leading mechanism to Beletech’s problems?
3. Which systems (Structure and Function) are involved?
4. What aspects of history would you like to obtain that help you to narrow your hypotheses?
Present history
W/ro Beletech Mamo who is P4A1, arrived at Gyn OPD of Debretabor General hospital said that
she experienced heaviness before a year and worsen late in day, after lifting and while standing.
In addition, she mentioned that the problem is associated with back pain, pain during sexual
intercourse, involuntary urinary leakage, difficulty in emptying the bladder.
Past history: She was treated for pulmonary tuberculosis before 3 years and now she is on
chronic follow up for diabetes mellitus.
Risk factors:
She is a farmer who carries heavy things for a long distance.
Environmental factors
She is living by selling potato and tomato after carrying to the market three times per week.
In addition, she has regular activities in her house.
Behavioral: She drinks alcohol sometimes on holiday and cup of coffee ones a day.
She is using implanon as contraceptives, douching with soap frequently, no smoking and no drug
addiction.
Dietary: she is eating enjera with wot regularly and egg or milk sometimes.
Sexual: she enjoys with her monogamous husband 3 times per week.
Disease Associated: She Is Diabetic
Education: Can read and write
Partnership status: Married and her husband is a farmer
Financial status: 1000 Ethiopian birr per month is a family income
Discussion Question two
1. Summarize the new information you obtained.
2. How does this new information help you re-rank your hypothesis or suggest new
hypothesis?
3. What data do you require in physical examination?
4. How does it help you to refine your hypothesis?
Physical examination
General Appearance: Comfortable
Vital sign: Temperature = 37.8c, Pulse = 110bpm, Respiratory = 24bpm, BP = 100/60 mmHg,
Weight = 62 kg, Height = 1.69cm
HEENT: Pale conjunctiva and icterus sclera
LGS: No any discharge on the breast, no lump tenderness, symmetry and dark areola
Respiratory System: Has crepitation at left lower lobe of the lung
CVS: S1 & S2 well heard
Abdomen: no scar, localized tenderness on pubic symphysis and mild to moderate supra pubic
discomfort. There is depression below the umblicus.
GUS: The labia and external genitalia Erymanthos patches.
: Speculum examination whitish non offensive discharge.
: Ulcerated and indurated mass protruding per vagina.
: The mass is associated with the anterior and posterior vaginal wall.
: Cannot be reduced by hand.
Integumentary: Pale, hot extremities
CNS: Conscious to TPP
Dissection Question three
1. What additional history would you like to take after doing the PE that helps in your
hypothesis?
2. How does the PE help you?
3. Do you want to change the ranking of your hypothesis based on the PE? Why?
4. How would you explain to Mrs. Beletech that you are going to take samples for
investigation?
Axillary Investigations
Tests Result Normal value

HCT 30 36-48%
BG A+ve
RBC 4500cell/mm3
Uretheral smear 5lucokocyte/oil immersion No leukocytes
1st voided urine specimen 10WBC/hpf on microscope Non mid-stream specimen
VDRL Negative
Urinalysis No leukocytes
Discussion Question four

1. Interpret the results and re-evaluate your hypothesis
2. What would be her concern? How do you counsel her?
3. Based on your hypothesis what intervention do you consider?
4. Explain to Mr. Beletech’s in languages she understands what the findings are and what
you will do?
Case Summary
The possibility of Precedentia (Complete utero-vaginal prolapse) + cystocele+ rectocele was
entertained. She was sent to gynecology ward and admitted on bed No 6 and put on
Metronidazole 500mg iv TID for three days + Ceftriaxone 1gm Iv BID for three days + COC
Powder was applied on the ulcerated protruded mass. After that cross matched blood was
prepared and sent to the operation room. Finally, Vaginal hysterectomy anterior colporahaphy
+Posterior Colporahaphy was done. After she went out of the OR, gauze with uracil was
maintained for 72 hours and she took metronidazole 500mg IV+ Ceftriaxone 1gm IV for 5 days
and Heam up 5ml Po Bid for a month and catheter was maintained for o5 days. At last she was
discharged with a relatively good condition.
Mini Case
1. What if she is 30 years old?
2. What if it is a delivered Myoma?

Week Two: Tutor Guide for Infertility

1. Explain physiology of menstrual cycle
2. Explore the physiology of fertility
3. Identify the requirements for fertility
4. Discuss the role of hypothalamus for female fertility
5. Explain the role of pituitary on female infertility
6. Identify causes of female infertility
7. Counsel patient with infertility
Presenting Problem:
1. Failure to conceive
Hypotheses:
1. Infertility
2. Menopause
3. Premenarche
Learning Issues:
1. How stress cause infertility?
2. Why weight loss cause infertility
3. How women’s immunologic responses affect fertility?
4. How pituitary and fertility related?
Assessment criteria:
1. Participation and communication skills
2. Cooperation/Team- building skills
3. Comprehension/Reasoning skills
4. Knowledge/ Information skills
References
 Novak gyn-obs
 Williams’s text book
 Current obstetrics
ANC Module: Week Two
Patient information
 Name: Ruth Ayele
 Age: 25 years
 Sex: Female
 Address: Woreta
 Site of visit: Gyn OPD
Presenting problem
Arriving at Debre Tabor hospital emergency OPD and said," Despite I have been married for
three years’ duration, I couldn’t conceive”.
Discussion Questions One
1. List Ruth’s problem
2. Define your hypothesis as the mechanism leading to the problem. Which system might
be involved?
3. What aspects of history, would you want to obtain that help you test your hypothesis of
the problem?
History of presenting illness
This is a nulliparous woman coming to Debre Tabor Hospital with a complaint of failure to
conceive for three years’ duration. She had never used any types of contraceptive methods and
she had 5 sexual contacts per week for three years’ duration. She had started her menses by the
age of 13. She had irregular menstrual cycle which came every two to three months, stays for 1
day and it never wet 1 pad. Her husband had a seven-year-old son from his ex-wife.
Past history
She had no history of diabetes mellitus, and obesity. But she had a history of 10% weight loss
secondary to loss of appetite. She had no any associated gynecological problems before.
Fixed factors
 Family history: she has lost her mother five years ago. Her mother had primary
amenorrhea, but she had six children.
Acquired factors
 Environmental: she had no history of chemical and radiation exposure as she was a
housewife.
 Behavioral:
- Alcohol: she Drinks social amounts of “tela” On holidays
- Tobacco: she has no history of smoking
- Caffeine: she drinks 3 cups of coffee per day.
- Illegal drugs: none.
- Sexual: she enjoys with her monogamous husband
- Dietary habits: she eats injera with wot regularly.
- Emotional state: as she has lost her mother, she has very worried about her elder
brothers and sisters. She even lost her appetite as a result; she lost her weight by
10%.
 Treatment associated:
- Surgery: None
- Allergies: None.
Social history
- She lives with her husband; she is a housewife and completed grade 12.
Review of system
- No other pertinent positive history
Discussion question Two
1. Summarize the new information you obtained. How does these new information
contribute to your hypothesis? How do you re- rank your hypothesis?
2. Tell Ruth you would like to examine her. What physical examination should be looking
for? How does it help with your hypothesis?
General: Healthy looking
Vital sign: PR- 80bpm, BP- 120/80mm Hg, Temp- 37 .1oc, RR-20bpm, Weight = 42, Height =
1.68cm
HEENT: Pink conjunctiva, NIS
LGS: No Lymphadenopathy,
Lung: Clear and resonant
CVS: S1 and S2 well heard, no murmur and gallop
Abdomen: flat abdomen moves with respiration
: No sign of ascites
: No sign of organomegally
GUT: No Costovertebral angle tenderness
-normal hair distribution, inverted triangle vulva
-no visible vaginal defect
MSS- no fracture, no deformity
IGS- no rash, no pallor
CNS _conscious and oriented
Discussion question Three
1. What more history would like to take after doing the physical examination that helps in
your hypothesis?
2. How does the physical examination help you? Do you want to change the ranking order
of the hypothesis based on the physical examination? How?
3. How would you explain to Ruth what investigation you do test your hypotheses? Justify
each test ordered?
Ancillary Investigations and Laboratory results
Sr, No Item Result Normal value
1 HCT 40% 36-48%
2 PLT 300,000 150-400,000
3 Ultra sound Normal uterus, fallopian tube, ovary
4 FSH 0.11IU/L 5-20 IU/L
4 LH 0.001IU/L 5-25 IU/L
5 TSH 3.6mu/l 0.5-5mu/l
6 Free Thyroxin 18pmol/ml 11-23pmol/ml
7 Estradiol 80pmol/ml 70-510pmol/ml
8 Prolactin 101mcg/L 5-20mcg/L
Discussion question Four

1. Interpret test results and re-evaluate your hypotheses.
2. What investigations would you like to do?
3. Based on your hypotheses, what intervention do you consider?
4. Explain to Ruth in the language she understands what your findings are and what you
will do
5. What could be her concern
Case summary
The possibility of primary infertility secondary to hyperprolactinemia was considered as the
values of prolactin, FSH and LH are below the normal range. She was given 2.5mg
bromocriptine per day for 7 days followed by 5mg per day for 14 days. She worried about not
giving a live birth after treatment and divorce as her husband has more desire for children.
Follow up
She was appointed to come after three weeks.
Mini cases
1. What if she had hypothyroidism?
2. What if she had hypothalamic dysfunction?
3. What if she had ovary problem?
Week Three: - Tutor Guide for Intra Uterine Fetal Growth Restriction
(IUGR)
Explain normal fetal growth patterns.

Analyze causes and risk factors of Intra Uterine Growth Restriction (IUGR).
Diagnose a patient with Intra Uterine Growth Restriction (IUGR).
Manage a patient with Intra Uterine Growth Restriction (IUGR).
Analyze magnitude of Intra Uterine Growth Restriction (IUGR).
Presenting Problems:
Failure of abdominal growth

Psychological stress of the mother
Hypotheses;
1. Intra Uterine Growth Restriction 3. Wrong Dating

(IUGR) 4. Oligohydramnios
2. Intra Uterine Fetal Death (IUFD) 5. Transverse lie
Learning Issues
How do maternal causes like DM, HTN and nutritional status leads to the development of IUGR?
How does obstetric u/s help to diagnose IUGR?
How do you differentiate symmetric and assymetric IUGR?
Assessment criteria: Skills on
Participation and communication Comprehension/Reasoning

Cooperation/Team- building Knowledge/ Information
References:
Gyn-obs lecture note

Williams’ text book of gyn obs
Myles text book of midwifery
Novak gyn
ANC Module: - Week Three
Patent information
- Name: Almaz Alemu

- Age: 30 years Old
- Sex: Female
- Address: Debre Tabor Kebele 03
- Site of visit: Debre tabor Hospital ANC Clinic
Patient presentation
Arriving at ANC Clinic, W/ro Almaz said, “My abdomen is not growing when I compare it to
the previous pregnancy; as a result of this I am worried too much about it.”
Discussion question one
1. List Almaz’s presenting problem(s).

2. Define your hypothesis and describe the mechanisms of each problem.
3. Identify the systems involved in each problem?
4. What aspect s of history would you like to obtain to test your hypothesis?
Patient History
History of Present Pregnancy
After arriving at ANC unit, w/ro Almaz said, “My abdomen is not growing well when I compare
it to my previous pregnancy, as a result, I am worried too much”. She is a 30 years old para II,
gravida III mother whose LNMP was on _______ E.C with a calculated gestational age of 36
weeks. She reported that she has regular menstrual cycle which comes every 28 days and has no
history of contraceptive use.
Past history
She delivered two of her babies at health center with Spontaneous Vaginal Delivery (SVD) and
the outcomes were 2.8 and 3 kg male and female neonates, respectively.
Fixed factors
Family history: Her parents are both alive and well. She has no family history of DM or HTN,
but her mother was having similar problem while she gave birth of her last baby.
Acquired Factors
Behavioral
- Alcohol: she drinks social amount of “tela” On holidays
- Caffeine: she drinks about two cups of coffee every day.
- Dietary habits:
She usually eats ijera made of teff with shiro wot three times a day.
She also eats meat about three times a week.
- Emotional state: she has no history of any psychological or physical stress.

- Health maintenance: she has regular ANC follow up.
Social history
- She lives with her 2 children and husband, she has graduated from AAU with BA
in accounting and she is currently working as an accountant in Commercial Bank
of Ethiopia (CBE).
Review of system
- GIT: she has no diarrhea
- GUS: she has no vaginal bleeding
Discussion question two
1. Summarize the new information you obtained. How does this new information contribute
to your hypothesis?
2. How do you re- rank your hypothesis?
3. Tell to Almaz that you would like to examine her.
4. What physical examination should be looking for? How does it help with your
hypothesis?
General Appearance: Depressed
Vital sign: PR= 90bpm, BP=110/70mm Hg, Temp= 37 C, RR=18bpm

O
HEENT: Pink conjuctiva, NIS,
LGS: No LAP, no thyroid enlargement
Lung: Clear and Resonant
CVS: S1 and S2 well heard, no murmur and gallop
Abdomen: Darkness of linea nigra, strae gravidarm, but no scar
: Ux is 30 weeks sized by fundal height
: Fundus is occupied by an irregular, soft, and non –ballotable mass
: Longitudinal lie
: Fetal heart beat is 130 bpm
GUT: Inspection: - normal hair distribution, inverted triangle vulva
: Speculum: - closed and firm cervix
: Bimanual examination: - No cervical motion tenderness, no adnexal tenderness
CNS: Conscious and oriented
your hypothesis?
3. How would you explain to Almaz what investigation you do test your hypotheses? Justify
each test ordered?
Sr. No Item Result Normal value

1. HCT 38% 36-48%
2. Blood group A+
3. VDRL NR
4. PICT NR
5. Obstetric U/S GA = 29wks
AFI= 4

3. Explain to Almaz in the language she understands what your findings are and what you
will do
4. How would you counsel her?
5. What could be her
Case summary
The possibility of IUGR plus mild oligohydramnios were entertained as her gestational age by
LNMP was 36 wks (the LNMP was reliable) but the gestational age by fundal height was 30
weeks and the ultrasound finding was also supportive of this. Moreover, the AFI on ultra sound
was 4.
She was admitted to the labor ward and advised on bed rest. IV line was secured and she was
resuscitated with normal saline. The pregnancy was then terminated by medical induction.
Follow up
She was discharged after six hrs of delivery and appointed after 6 days.
Mini cases
1. What if she is HIV +ve?

2. What if she is VDRL reactive?
3. What if she will refuse medical induction?
Week Four: - Tutor Guide for Prolonged Pregnancy
1. Define prolonged pregnancy.

2. Discuss the risk factors of prolonged pregnancy.
3. Describe the clinical manifestations of dysmaturity syndrome.
4. Discuss the maternal and fetal complications of prolonged pregnancy.
5. Manage mothers with prolonged pregnancy.
1. Absence of onset of labor by the expected date of delivery

Hypotheses:
1. Prolonged pregnancy
2. Wrong date
Predicted learning Issues:
1. How does oligohydramnios occur in prolonged pregnancy?

2. Why does dysmaturity syndrome occur in prolonged pregnancy?
3. Why does macrosomia occur in prolonged pregnancy?
4. How are mothers with prolonged pregnancy managed?

References:
- Gyn-obs lecture note
- Williams’ text book of gyn obs
- Myles text book of midwifery
- Selected obs national management protocol

ANC Module: Week Four
Patient and visit Information
 Name: W/o Marta Bitew
 Age: 36yrs
 Sex: Female
 Address: D/Tabor, Kebele 04
 Site of vist: ANC unit
Presenting problem
Appearing at the ANC unit, w/o Fasika said, “My pregnancy has passed 9 months but I have no
labor pain.”
1. List Marta’s presenting problem(s)
2. Define your hypothesis and describe the mechanisms of each problem.
3. Identify the systems involved in each problem?
4. What aspect s of history would you like to obtain to test your hypothesis?
Patient History
Patient history of present pregnancy
W/o Marta, a 36yrs old gravida V para IV mother, appeared at the ANC unit and said, “My
pregnancy has passed 9 months but I don’t feel labor pain.” Her LNMP was on 03/01/06 E.C
with a calculated GA of 42+4wks. She has a regular menses that comes every 28 days and has no
history of contraceptive use for the last two years. She started to feel her fetal movement since
the 5th month of pregnancy and she still feels it. She has no history of diabetes mellitus or HTN.
She has no prior history of similar problem.
Past medical history
Occupational exposure: She is shop keeper.
Behavioral: She doesn’t have history of alcohol use.
: She doesn’t have history of smoking.
: She had history of sexual contact with her monogamous husband.
Health maintenance: she has regular ANC follow up.
Disease associated: She had no history of any disease.
Social History
Family history: her mother had similar problem while giving birth of her 1st child.
Education: she completed grade 10.
Review of system
HEENT: no headache, or bleeding per nose.
GIT: She had no vomiting, abdominal cramp.
GUT: I had no vaginal bleeding, Bleeding related with urination.

No pertinent positive history.
Discussion question two
2. Tell Marta you would like to examine her. What physical examination findings are you
looking for? How does it help with your hypothesis?
General Appearance: Healthy looking

Vital Sign: BP = 100/60 mmHg, PR= 86, RR= 20, To= 37
HEENT: pink conjunctiva & non-icteric sclera;
LGS: no LAP or thyroid enlargement
RS: Vesicular breath sound; no added sound
: Resonant to percussion
CVS: S1 & S2 are well heard; no murmur or gallop
Abdomen: Ux is term-sized by fundal height
: Fundus is occupied by an irregular, soft, non-ballotable mass
: The lie is longitudinal
: FHB is 134 bpm
GUS: Normal hair distribution in pubic area
: Cervix is closed, medium in consistency and anterior
: No bleeding or abnormal Vx discharge
Integumentary sys: no rash or skin color change
MSS: no swelling or visible muscle wasting.
CNS: conscious but worried.
Discussion question three
your hypothesis?
3. How would you explain to Marta what investigation you do to test your hypotheses?
Justify each test ordered?
Test Result Normal Value

HCT 36% 34-44%
BG B+ve
PITC NR
VDRL NR
Obstetric U/S with BPP:
 Singleton with a GA of 42wks
 Cephalic presentation
 FHB = 140 bpm;
 AFI= 14
Discussion question four

3. Explain to Marta in the language she understands what your findings are and what you
will do?
5. What could be her concern?
Case summary
The possibility of prolonged pregnancy has been entertained. The mother was advised on
termination of pregnancy and after receiving her consent, she was admitted to labor ward, the
cervix was ripened and induction of labor was done.
Mini cases
1. What if she is HIV +ve?

2. What if she is VDRL reactive?
3. What if the mother refuses induction of labor?
Week Five: - Tutor Guide Hyperemesis Gravidarm
1. Explain the cause/risk factor hyperemesis gravidarm

2. Describe prevalence of hyperemesis gravidarm
3. Describe investigation methods of patient with hyperemesis gravidarm.
4. Describe the management option of hyperemesis gravidarm
Nausea and vomiting
Hypotheses;
1. Hyperemesis gravidarm 4. Sever esophageal reflux

2. Gastroenteritis 5. PUD
3. Appendicitis
Learning Issues:
1. How hyperemesis gravidarm occur?
2. Explain major clinical presentation of hyperemesis gravidarm
3. What are diagnostic modality of hyperemesis gravidarm
4. Describe clinical sign of improvement
References:
1. Williams’ text book of obstetrics 24th edition
2. Current Obstetrics and Gynecology Diagnosis and Treatment, 12th ed

ANC Module: - Week Five
Patient and visit information
 Name: Birke Alemu

 Age: 32 years’ old
 Sex: Female
 Address: Abaregay
 Site of Visit: ANC Clinic
Presenting problem
Arriving at emergency OPD, Mrs. Birke said, “I have nausea and vomiting for the last three
days”
Discussion Questions one
1. List Mrs. Birke’s presenting problems

2. Which systems might be involved and define your hypothesis as a mechanism leading to her
problem?
3. What aspects of history would you take that will help you to test your hypothesis?
Patient History
History of presenting illness (HPI)
Asked about how it started, she said that “it started before three weeks as nausea without
vomiting. With increased time, nausea was associated with vomiting as an early morning
sickness. She also said that I have 4-5 vomits and feel sick throughout the day and unable to keep
down any food or drinks. I urinate less often than usual and I have also abdominal pain. For these
problems, I visited our traditional healer, Merigeta Adamu and gave me herbal medication but
not got improvements”. She also said; “It is more than a month that my period should have come
and getting body weight loss”. Asked if she feels dizziness, she said, “I do have when standing
up”
Risk factor assessment
 Family history: She has no family history of similar illness

 Occupation: Merchant in semi-urban area
 Education: completed primary school
 Behavioral: - she drinks local beer occasionally
: - No smoking,
: - No drug abuse
: - Sexually active and do not use contraceptives
 Health maintenance: - No regular medical checkup
 Disease associated: - none
 Social history: - 28 years old, married and has 2 children (a female & a male)
Review of systems (ROS): - no pertinent positive findings

Discussion Questions two
1. What new information did you get and how this information helped you for your
hypothesis?
2. Re-evaluate your hypothesis
3. You inform Mrs. Birke that you would like to perform physical examination. What
information do you need and how will help you with your hypotheses?
General appearance: acutely sick looking
Vital sign: - Ht=1.6m, weight = 55 kg, Temp= 36.5 0C, PR= 115 bpm, BP=80/60 mmHg,
RR=26
HEENT: - dry ducal mucosa and tongue, pink conjunctiva, non-icteric sclera
LGS: - No Lymphadenopathy
Chest: - clear and resonant
CVS: - S1 and S2 well heard, No murmur and gallop
Abdomen: - flat abdomen, no flank fullness
No organomegally, no tenderness
Uterus is not palpable
Genito-urinary system: - normal vaginal wall, no abnormal discharge, No cervical motion

tenderness
CNS: conscious and oriented
Discussion questions Three
1. How the physical examination does help you in testing your hypothesis?
2. What more history would you like to take after doing the physical examination and why?
3. How could you explain to Mrs. Birke what investigations you do to test your hypothesis and
why?
Laboratory investigation
Tests Results Reference range

Hematocrit 52% 34-44
Blood group AB+
HCG Positive
RBS 126 gm/dl
Stool exam No ova or parasite seen
Urinalysis Ketone; +2; no WBCs or RBCs seen
PITC Non-reactive
VDRL Non-reactive
Discussion questions Four
1. Interpret test results and & re-evaluate your hypotheses

2. Based on your hypotheses what interventions do you consider?
3. Explain to Mrs. Birke in languages she understands what the findings are and what you will
do?
4. What would be her concern? Counsel Birke as a role play
5. What additional investigations would you like to do and why?
Case summary
The possibility of hyper emesis gravidarum has been entertained as she is having excessive
nausea and vomiting during the first trimester of her pregnancy. She was then admitted and
resuscitated with 1 bag of ringer’s lactate. She was also managed with Vit B complex, IV fluid,
metoclopramide, and consecutive urine ketone body determination was done.
Mini case
1. What if hyperemesis gravidarum Persists?

Week Six: Tutor Guide Intra Uterine Fetal Death(IUFD)
1) Analyze causes and risk factors IFUD

2) Diagnose patient with IUFD
3) Manage patient with IUFD
4) Analyze magnitude of IUFD
- Decrement of Fetal Movement
Hypotheses:
1) IUGR
2) IUFD
3) Oligohydramnios
Learning Issues:
1) How do maternal causes like DM, HTN and nutritional status lead to IUFD?
2) How does obstetric u/s help us to diagnose IUGD?
3) Explain complication of IUFD
1) Participation and communication skills
2) Cooperation/Team- building skills
3) Comprehension/Reasoning skills
4) Knowledge/ Information skills
References:
1) May, Katharyn A., and Mohlmeister; Comprehensive Maternity,
2) Mays text book for Midwives 11th ed.1988
ANC Module: Week Six
 Name: Tamralech Debalkie
 Age: 35
 Sex: Female
 Address: Debre Tabor, Kebele 01
 Site of Visit: ANC Unit
Presenting problem
Arriving at Debre Tabor hospital Gyni OPD Mrs. Tamralech said, “My fetal movement was
decreased for the last one week.
1. List Mrs. Tamralech’s presenting problems?

2. Define your hypothesis?
3. What aspects of history would you ask Mrs. Tamralech?
Client history
Present history
Mrs. Tamralech who is gravid II Para I mother whose LNMP was on --------A of 32 weeks was
coming with the complaint of loss of fetal movement for the last three days. She has no history
vaginal bleeding or gush of fluid. She had no history of trauma. She has ANC follow up, VDRL
and PITC was done and non-reactive for both. Her blood group is A+. She had history of using
implanon as a contraceptive method before she became pregnant. Her menstrual cycle was
regular, on every 30 days. she has no blurring of vision or Right upper quadrant pain.
Her previous pregnancy was completed without fetal or maternal complication.
Risk factor
Fixed factors: both of her parents are alive and live together, she has no family history of
chronic illness.
Acquired factors: Environmental: No exposure to pollution, dust or others
Behavioral: Alcohol- she takes social amount of alcohols; Exercise- activities of daily living,
smoking; no drug addiction; no, Dietary- she is taking enjera with wot.
Health maintenance: she has regular ANC follow up
Social history
Education: unable to read and write
Partnerships status: currently married and her spouse is a farmer
Financial status: The husband is the source of subsistent family income
ROS
 No pertinent history other than mentioned above.

2. How does this new information help you re-rank your hypotheses or suggest new
hypothesis?
3. What data do you require in physical examination? How does it help you refine your
hypothesis?
General appearance- healthy looking

Vital sign: HT =170cm, Wt. = 60 kg T=37.2 C 0, pulse =96bpm bounding, Respiration, 24bpm,
BP=100/70mmHg
HEENT- pink conjunctiva, NIS
LGS - breast: no discharge, symmetry, dark areola, no lump & tenderness
Respiratory system- no pertinent finding
CVS: s1$s2 well heard, no murmur or gallop
Abdomen-symmetric, move with respiration, has stretch marks, No scar
o 28 weeks sized gravid uterus
o Presentation - Cephalic
o Lie- longitudinal
o Fetal heart beat – not heard by fetoscope
o No area of tenderness,
o No mass or fluid collection
Urogenital area-no discharge, no lesion,
MSS: no edema
Integumentary: no rash or pallor
CNS: she is conscious & oriented to TPP.
Discussion Questions three
1. What more history do you like to take after doing the PE that helps in your hypotheses?
2. How the PE does help you? Do you want to change the ranking of your hypotheses based
on the PE? How?
3. How would explain to Mrs. Tamralech that you are going to take samples for
investigations?
Ancillary investigations and results
Tests Result Normal value

PITC NR
BG B+ve
VDRL Negative
HCG Negative
Ultrasound:
 Singleton
 AFI-5
 Absent cardiac activity.
 Absent fetal movement.
 Collapsed cranial bones
Discussion Questions Four
1. Explain to Mrs. Tamralech in languages she understands what the findings are and what
you will do?
2. What would be her concern? And how do you counsel her?

5. Treatment/case summary
The possibility of IUFD is considered and if once suspected IUFD is confirmed by ultra sound,
the management could be either expectant or active intervention as determined by HCP-patient
discussion. She preferred to be terminated and Induction of labor was done after checking of
cervical status. We informed her to advise the HCP before she decides to become pregnant.
Mini case
1. What if there is DIC?
2. What if it is associated with APH?

Week Seven: Tutor Guide for Malaria in Pregnancy
1. Take history for pregnant women with malaria

2. Identify the risk factors of malaria in pregnancy
3. Identify complication of malaria in pregnancy
4. Counsel women about prevention and control of malaria
5. Identify signs and symptoms of malaria to the pregnant women
6. Perform basic lab investigation for ANC clients and interpret findings/results
7. Describe the magnitude of malaria globally and locally
Presenting Problems
- Fever, inability to perform daily activity
Expected hypotheses
 Malaria, typhoid, typhus, meningitis, pneumonia, UTI, PID

Expected learning issues
1. Signs and symptoms of malaria in pregnant women occur
2. Why pregnant women are prone to malaria than non-pregnant women?
3. How complications of malaria in pregnant women occur
References
1. Up to date
2. WHO, 2003: ANC in developing countries: Promises, achievements and missed
opportunities
ANC Module Week Seven
Patient Information
Name: Nitsuh Abere
Age: 32 years Old
Sex: Female
Address: Debre Tabor, Kebele 03
Presenting problem
Mrs. Nitsuh living in Woreta appeared at Debre Tabor Hospital adult OPD said, “I have fever
and inability to perform my daily tasks for the last three days”
1. List Mrs. Nitsuh’s presenting problems

2. Which systems might be involved and define your hypothesis as a mechanism leading to
her problem?
3. What aspects of history would you like to take that will help you to test your hypothesis?
Patient history of presenting illness (HPI)
Asked about how it started, she said that “the fever started before three days and it is high grade
and intermittent associated with inability to perform daily tasks”. Moreover, she has global
headache, joint pain, chills and rigors. She is Gravida V, Para IV mother whose LNMP was on
05/02/06 E.C with calculated gestational age of 32 weeks. She has regular menses that comes
every 28 days and has no history of contraceptive use over the last two years.
She has no history of loss of consciousness, abnormal body movement, and neck pain/stiffness.
She has no history of abdominal pain, nausea or vomiting.
Her all children were home delivered without any complication
Risk factor assessment
 Behavioral: she drinks tella occasionally

 No smoking and chat chewing
 No drug abuse
 Sexually active and do not use contraceptives
o Occupation: farmer
o Education: read and write
o Health maintenance: No regular medical checkup
o Disease associated: none
o Social history: 32 years old, married and has 4 children (two females & 2 males)
Review of systems (ROS): no pertinent positive history
1. What new information did you get and how this information helped you for your
hypothesis?
2. Re-evaluate your hypothesis
3. You inform Mrs. Nitsuh that you would like to perform physical examination. What
information do you need and how will help you with your hypotheses?
General appearance: acutely sick looking
Vital sign: Ht; 1.6M, weight: 60 kg, Temp; 38.6 0c PR: 110 bpm BP: 100/70 mmHg RR: 22
HEENT: Pink conjunctiva, non- icteric sclera
 No bleeding from nose or other sites
LGS: No Lymphadenopathy
Chest: clear and resonant
CVS: S1 and S2 well heard, No murmur and gallop
Abdomen: Spleen and liver are not palpable
o Uterus is 32 weeks’ size; fundus is occupied by an irregular, soft, non-ballotable

mass
o The lie is longitudinal
o Fetal heart beat = 128 bpm
Integumentary: No rash
Genito-urinary system: normal vaginal wall, no abnormal discharge
o No cervical motion tenderness
CNS: Conscious and oriented
Discussion questions Three
1. Does the physical examination help you in testing your hypothesis?

2. What more history would you like to take after doing the physical examination and why?
3. How could you explain to Mrs. Nitsuh what investigations you do to test your hypothesis
and why?
Laboratory investigations and results
Test Result Reference range

Blood film P. Falciparum, ++
Hemoglobin 11mg/dl 12-16 mg/dl
Platelet count 175,000/mm3 150,000-450,000/mm3
WBC count 5,000/mm3 4,500-10,500/mm3
PITC Non-reactive
VDRL No-reactive
Widal test Non-reactive
Weil flex Non-reactive
Blood group O+
Urinalysis 0-2 WBC and RBC/LPF
Stool exam No ova or parasite seen
2. Based on your hypotheses what interventions would you consider?
3. Explain to Mrs. Nitsuh in her own language what the findings are and what you will do?
4. What would be her concern?
5. What is the magnitude of your hypotheses globally and locally?

Case summary
The possibility of malaria was entertained. She was put on Quartem PO four tabs BID for three
days. She was also given a piece of advice to use insecticide treated bed nets and to flood burned
oils on insect breeding sites and let to flow stagnant water sources as she came from malaria
endemic area.
Mini case
1. What if the cause of fever is not malaria?

Week Eight: Tutor Guide Multiple Pregnancies
1. Explain cause and risk factor of multiple gestation
2. Discuss difference between monozygotic and dizygotic twin
3. Describe diagnostic methods of multiple gestation
4. Explain management option for multiple gestation
1. Fast abdominal growth
2. Fast breathing
Hypotheses:
1. Multiple gestation 3. Ascites with pregnancy
2. Fibroid or ovarian tumor with 4. Big baby
pregnancy 5. Hydramnios
Learning Issues;
1. What are the cause and risk factor of multiple gestation?

2. How do you differentiate between monozygotic and dizygotic twin?
3. How can we diagnose multiple Gestation?
4. How can we manage twin pregnancy?
5. What are the complication of multiple gestation?
References
 Myles text book of midwifery

 William’s text book obstetrics 24th edition
 DC Dutta’s text book of obstetrics 7E edition
ANC Module: Week Eight
Patent information
 Name: Solome Dires
 Age: 35 years
 Sex: female
 Address: Debre Tabor town
 Site of visit: Antenatal care clinic
Patient presentation
Mrs. Solome present in ANC clinic with complain of “fast abdominal growth and shortness of
breath.”
Discussion question One

1. Describe Mrs. Solome’s presenting problem.
2. Define your hypothesis as mechanism leading to the problem.
3. Which system might be involved?
4. What aspects of history would you want to obtain that help you test your hypothesis?
This GIVPIII lady which has been amenorrhic for the past 7 months presented at ANC clinic
with complains of fast increment of abdominal height, Excessive fetal movement, shortness of
breath and intermittent headache since 2 wks. She also has back pain and urinary frequency and
urgency. She denied blurring of vision, epigastric pain and vaginal bleeding.
Past medical History
She has no hypertension, diabetes mellitus, epilepsy and other chronic illness.
Past obstetric history
All the past pregnancies were completed without any complication (spontaneous vaginal
Delivery).
Family history
She is a twin of her 20 min elder sister. There is no family history of DM, HTN and other
chronic disease.
Health Maintenance: This is her 2nd ANC follow up
Socio-economic status: she has adequate income to fulfill her basic needs and also her husband
is civil servant
Behavioral: no Alcohol, no Tobacco, a cup of coffee per day, sexual contact only with her
husband
1. Summarize the new information you obtained. How does these new information?
2. contribute to your hypothesis? How do you re- rank your hypothesis?
3. Tell solome you would like to examine her. What physical examination should be
looking for?
4. How does it help with your hypothesis?

Physical Examination
General Appearance: Healthy Looking
Vital Sign: BP=100/70mmhg PR=85Bt/Min RR=22Br/min T=ATT wt.=60kg
HEENT: Slightly pale conjunctiva
LGS: No mass or lymphadenopathy
Chest: Clear and resonant
CVS: S1 and S2 well heard
ABD: Asymmetric (shifting to left side), barrel shaped
: 34 weeks sized gravid uterus
: Palpation of too many fetal parts
: Two distinct fetal heart sounds with each10 beats per minute difference
GUS: No CVAT
: Female like pubic hair distribution
: No visible external genitalia abnormality
: PV not deferred
MSS: Bilateral leg edema
INT: No skin rash
CNS: Conscious and well oriented

your hypothesis?
3. How would you explain to solome what investigation that you went to do? Justify each
test ordered?
Laboratory Investigation
Item RESULT
BG/RH A+ve
VDRL NR
HCT 30%
UA No leucocyte
Obstetric U/S Twin A
 BPD= 28wks
 FL=29wks
 AC=29wks
 Breech presentation
 Dichorionic, Diamniotic placenta
 Amniotic fluid volume = 5cm
Twin B
 BPD=28wks
 FL=28wks
 AC=29 wks
 Transverse lie
 Dichorionic, Diamniotic placenta
 Amniotic fluid volume = 5cm

2. What additional investigations would you like to do?
3. Explain to solome in the language she understands what your findings are.
5. What could be her concern?
Case summery
Twin pregnancy was entertained and she was advised to have adequate nutrition like calories,
protein, minerals, vitamins, and essential fatty acid provided two times that of singleton
pregnancy. Every visit fetal assessment was advised in order to identify abnormal fetal growth
or discordances. In addition, she categorized under special care and visit schedule was given
accordingly. Finally, she was told to come back if she detects any of the danger signs.
Mini case
1) What do you do if the pregnancy is Quadruplets?
2) What do you do if the pregnancy is conjoined?

Week Nine: - Tutor Guide Severe Pre-eclampsia

 Discuss the pathophysiology of Hypertensive disorders of Pregnancy.
 Explain the cause of severe headache and blurring of vision.
 Identify relevant history and physical examination issues for woman with complaining
severe headache and blurring of vision.
 Explain classification of hypertension in pregnancy.
 Differentiate mild preeclampsia from sever preeclampsia.
 Discuss the public health importance of hypertensive disorders of pregnancy.
 Severe headache, blurring of vision
Hypothesis:
 Preeclampsia, anemia, malaria
Learning issues
 Why preeclampsia causes severe headache &blurring of vision?

 How to approach the patients with preeclampsia?
 Why fluid restriction is recommended for hypertensive patients?
 Contribution, flow of idea/ knowledge, communication skills, cooperation team building
and reasoning skills
Key readings
Up-to-date 20.3
Williams’s obstetrics 22nd edition
Current obstetrics and gynecology 2007th edition

ANC Module: Week Nine
a) Patient name: Melat

b) Sex: Female
c) Age:30 years
d) Site of visit: Gynecology OPD, Debre Tabor Hospital
e) Nature of the problem: Acute
Presenting problem
Arriving at the gynecological OPD, Ms Melat said, “I have severe headache and difficulty of
vision for 01-week duration.
Discussion Question One
1. List Melat’s presenting problems
2. Define your hypothesis and describe the mechanisms.
3. Which systems might be involved?
Patient history
Present history
Melat who is a primigravida lady whose NLMP was on ………with GA of 32 weeks, asked how
it started, she said, “I have sever globalized headache which is persistent and I took PCM but did
not improve. I have also associated blurring of vision. She has no previous history of headache.
she has nausea and vomiting. She has no epigastric pain. she has no urgency, frequency, dysuria
or vaginal discharge. She had ANC visit at 10th week but she missed the second visit because of
inadequate information provided by the health care provider.
She has no history of hypertension or DM
Risk factors
Fixed factors: her mother is a known hypertensive patient on medication.
Acquired factors:
Occupational exposures: her husband is smoker
Behavioral: Alcohol-no history; Caffeine- she is using coffee and cola; Illegal drugs- no;
Sexual- she has no risky sexual behavior.
Health maintenance: had one ANC visit
Treatment associated: No history of surgery, allergy
Social history
Education: she completed grade 10
Partnerships status: married
Financial status: she is merchant who gets adequate income
ROS:
Chest-no dyspnea, retrosternal chest pain
Gut – no vaginal bleeding, no complaint other than mentioned above
Discussion Questions Two

hypotheses?
3. What pertinent findings would you expect on physical examination? How does it help
you refine your hypotheses?
General appearance: acute sick looking

Vital sign- Ht = 160cm, Wt. = 70Kg, Temperature = 37.2 0C, Pulse =76 bpm, Respiration
=24bpm, B/P=160/120 mmHg
HEENT: Pink conjunctiva
LGS: No LAP
CVS: S1 & S2 well heard, no murmur, no gallop
Abdomen
symmetric distended abdomen,
30 week sized gravid uterus
FHB +ve(134b/min)
Lie-longitudinal
No scar
No area of tenderness,
no mass or fluid collection
Urogenital area-no discharge or lesion
o PV-non prominent ischial spine
o Straight side wall
o Diagonal conjugate 13 cm
MSS: slight pedal edema
Integumentary: no rash or pallor
CNS: she is conscious & oriented to TPP.
Discussion Questions Three
2. How does PE help you?
3. Do you want to change the ranking of your hypotheses based on the PE? How?
4. What investigation would you do for Melat?
5. Ancillary investigations and results
Test Result Normal value

PITC; Non-reactive Non-reactive
Protein urine +3
HCT 40% 34-44%
Platelet 200,000 150,000-400,000
Serum creatinine 1.4mg/dl 0.6-1.2
AST 40
ALT 35
1. Interpret test results. Considering the test re-evaluate your hypotheses.

2. Explain to Melat in languages that she understands what the findings are. Counsel and
advise the lady using role play.
Treatment/case summary
The possibility of sever preeclampsia is considered and magnesium sulphate was given as per
protocol which is 20% of 4 gm iv plus 10 gm 50% IM loading dose and maintenance dose of 5
gm IM every 4 hrs. Hydralazine 5 mg IV every 20 min until the diastolic blood pressure is
<110mmhg. After all, the definitive management of sever pre-eclampsia, termination of
pregnancy was done. 300 mg feSo4 daily for one month also given.
Week Ten: Tutor Guide Placenta Previa
 List risk factors and causes of placenta previa
 Describe diagnostic methodologies of placenta previa
 List diferential diagnosis and administer appropriate treatment.
Problems:
Flow of blood through my vagina
Hypotheses:
1. Placenta previa 4. Vasa previa

2. Abruptio placenta 5. Local lesions
3. Cervical carcinoma
Learning Issues;
1.Describe cause and risk factor of placenta previa
2.What are clinical manifestation of patient with placenta previa
3.How to differentiate placenta previa from other cause of APH
4.Explain management option of placenta previa
Reference
 May, Katharyn A., and Mohlmeister; Comprehensive Maternity, Mays text book for
Midwives 11th ed.1988.
ANC Module: Week Ten
Patent information
 Name: Sinkinesh Abate
 Age: 34 years
 Sex: female
 Address: Gahsay
 Site of visit: emergency OPD
Presenting problem
Arriving at Debre Tabor hospital emergency OPD and said," there is flow of blood through my
vagina.
Discussion questions one
1. List Sinkinesh’s problem

2. Define your hypothesis as mechanism leading to the problem. Which system might be
involved?
3. What aspect s of history would you want to obtain that help you test your hypothesis of
the problem?
When she asked how and when the problem was started said, “I am appreciated vaginal bleeding
before three days after I was lifting a Jerica which is full of water. When it starts the bleeding
was minimal but it is multiplying date by date and I decided to come to the health facility as this
is not healthy condition. Following this I am also experience tiredness when I am doing my
regular work. I have a regular menstrual cycle which comes every 30 days, wets 1 pad, dark and
non-clotted. I am a para III, gravida IV mother whose LNMP was on 15/02/06 E.C with a
calculated gestational age of 33weeks plus 4 days. I have ANC follow up at this hospital and
have a blood group of A+. I was screened for HIV and Syphilis the results were NR.”
Past history
She gave two female neonates at her home, and one 3.4kg male neonate at Debre tabor Hospital
with SVD and without any complication. She has no history of any associated disease and
hospital admission.
Fixed factors
 Family history: her parents are both alive and well. She has no family history any
associated disease
Acquired factors
 Environmental: she is a farmer and has work activities that may expose to trauma
 Behavioral
- Caffeine: she drinks coffee.
- Dietary habits: she eats ijera with wot regularly.

- Emotional state: she has no history of any stress.
 Health maintenance: - she has regular ANC follow up

 Treatment associated:
 Surgery: None
 Allergies: None.
 Social history:- She lives with her 3 children and husband, she is able to read and
write and she is a farmer.
Review of system
 GIT-she has no vomiting, abdominal pain
 Hematologic- no nasal or other site of bleeding
 No other pertinent positive history
2. Tell Sinkinesh you would like to examine her. What physical examination should be
General Appearance: - acutely sick looking
Vital sign: PR- 120bpm but weak, BP- 80/50mm Hg, Temp- 36 .4oc, RR-24bpm
HEENT: Slightly pale conjuctiva, NIS, dry mouth
LGS: No LAP, enlarged but non-tender breast
Lung: Clear and resonant
CVS: S1 and s2 well heard, no murmur and gallop
Abdomen: Distended abdomen, darkness of linea nigra, strae gravid arum but no scar.
Fundal height 32 wks, fetal heart beat 180bpm, longitudinal lie
An irregular, soft, and non ballotable mass is occupying fundus.
No ux tenderness, no palpable uterine defect
GUT – Inspection_ normal hair distribution, inverted triangle vulva
your hypothesis?
3. How would you explain to Sinknesh what investigation you do test your hypotheses?
Sr. No Item Result Normal value

1 HCT 32% 36-48%
2 PLT 300,000 150-400,000
3 Ultra sound GA 34 wks, placental edge implanted anteriorly
at her cervix
4. Explain to Sinknesh in the language she understands what your findings are and what
you will do
Case summary
The possibility of placenta previa is considered as ultra sound finding indicates anterior grade II
placenta previa. She worried about she cannot give alive birth after this. She was admitted and
resuscitated with normal saline. After she was received 6mg betamethasone IV bid for two days,
she was induced and delivered with SVD after 5 days of her admission. She was discharged after
six hours of deliver and full checkup of her health status.
Follow up
She is appointed to come if there is any problem other wise to the first post-partum visit.
Mini cases
1. What if she has painful bleeding?

2. What if she is term?
3. What if there is PP totalis?
Week Eleven: Tutor Guide for Abruptio Placenta
 Explain causes of bleeding before delivery

 Discuss how to differentiate each cause
 Explain investigation modalities
 Discuss anticipated complications of abruption and placenta previa
 Discuss management principles for abruption and placenta previa
 Vaginal bleeding
 Abdominal pain
Hypothesis
1. Abruption placenta 4. Trauma

2. Placenta previa 5. Bloody show
3. Vasa previa
Learning issue:
1. What are causes for abruptio placenta?

2. What is the mechanism of bleeding in abruptio?
3. How do you grade abruption placenta?
4. What are complications of abruption placenta?
Reference:
1. Williams obstetrics 22nd edition

2. Up-to-date 20.3
ANC Module: Week Eleven
 Patient name: Halima
 Sex: Female
 Age:35 years
 Site of visit: Emergency Gynecologic OPD, Debre Tabor Hospital
Presenting problem
Ms. Halima came to emergency gyn OPD and said “I have vaginal bleeding and abdominal pain
of 3 hours’ duration.”

1. List Halima’s presenting problems?
2. Define your hypothesis and describe the mechanisms. Which systems might be involved?
Patient history
Patient history at presentation
This G6P4A1 lady whose LNMP was on ----------making GA by date of 33 weeks, came to
emergency gyn OPD and said “. I have vaginal bleeding which is frank red and moderate in
amount associated with mild lower abdominal pain but no pushing down pain.” She has
appreciated increased fetal movement for the last two hours. she had similar episode one year
back which end up with still birth. She had no ANC follow up for the last pregnancies but for the
current. she has no history of previous surgery, trauma, smoking or hypertension.
Past medical history. Has no any history of illness other than mentioned above.
Occupational exposures: None
Behavioral: Alcohol-no history; Tobacco- no; Caffeine- she is using coffee and cola; Illegal
drugs- no; Sexual- has sexual history with her husband only. Exercise and Dietary habits-
ambulates for about 5 hours daily and gets balanced diet.
Health maintenance: Had no ANC follow up for the previous px but for the current.
Treatment associated: taking iron tablets.
Social history
Education: She is a merchant.
Financial status: has adequate income to support her family.
ROS: She has no complaint other than mentioned above.

hypotheses?
6. What findings would you expect on physical examination? How does it help you refine your
hypotheses?
General appearance- Acutely sick looking

Vital sign- Ht 163cm, Wt,70Kg, Temperature- 37.1 C0, Pulse-114bpm, Respiration, 20bpm, B/P-
100/60-mmHg
HEENT- NAD
CVS: s1 and s2 well heard, no mummer or gallop
Abdomen- symmetrically full abdomen
Mild tenderness over the lower abdomen
34 weeks gravid ux
Fundus occupied by hard ballotable mass
Longitudinal lie
FHB +ve (190 bpm)
No scar
no organomegally or fluid collection
Urogenital area-blood soaked vulva, active bleeding.
Pv-differed
Mss.-slight pedal edema
Intg-no rash or pallor
CNS-conscious and oriented
2. Would you re-rank or change your hypotheses based on the PE? How?
3. How would you investigate this patient?
Test Result Normal Value

HCT 32
Platelet 180,000
PTT Normal
Fibrinogen 200
Ca-125 Elevated
PITC NR
VDRL NR
Blood Group O +ve
Abdominal ultrasound shows hyperechoic retroplacental region and fundal placentation,

singleton, +ve fetal heartbeat.
1. Interpret test results. Considering the test re-evaluate your hypotheses

2. Explain to Halima in languages she understands what the findings are and what you will do?
4. What complications would you anticipate?
The possibility of grade 3 abruptio placenta with non-reassuring fetal heart rate was considered.
Iv line secured, 3 units of x-matched blood prepared. Emergency c/s was done to effect a
2800gms of male alive neonate. Transfused two times and is in good post op condition.
Week Twelve: Tutor Guide for Gestational Diabetes Mellitus
1. Explain types of Diabetes mellitus
2. Describe cause and risk factor diabetes mellitus
3. Determine investigation method of diabetes mellitus
4. Express management and complication of diabetes mellitus
Problems:
:I am worried b/c my abdomen is larger than the previous pregnancy
:My weight is increasing significantly
Hypotheses;
1. Gestational diabetes mellitus 3. Multiple gestation

2. Polyhydraminos 4. macrosomia
Learning Issues;
1. Explain different types of diabetes mellitus
2. How gestational diabetes mellitus occur?
3. What are major work up/investigation of diabetes mellitus
4. How to manage patient with gestational diabetes mellitus
References:
Gyn-obs lecture note, Myles text book of midwifery, Williams text book of obstetrics
ANC Module: Week Twelve
a. Patient name: Sara

b. Sex: Female
c. Age:31 yrs.
d. Fogera
e. Site of visit: Regular ANC OPD, Debre Tabor Hospital
Presenting problem
Mrs. Sara came to regular ANC follow up on her appointment and was asked if there is any
problem, said “I am worried b/c my abdomen is larger than the previous pregnancy and my
weight is increasing significantly.”
Discussion Questions one
1. List Sara’s presenting problems

2. Define your hypothesis and describe the mechanisms. Which systems might be involved?
Patient history
Patient history at presentation
This G2P1A0 lady whose LNMP was on----------making GA by date of 26 weeks, come to her
2nd ANC follow up appointment and said “my abdominal size is increasing faster than the
previous pregnancy and my weight is increasing significantly (80kg-94kg) after the pregnancy”.
She has nausea but not vomiting or diarrhea. She has frequency but no dysuria, urgency or foul
smelling vaginal discharge. She has no vaginal bleeding. She appreciates fetal movement. She
gave birth 2yrs back by cesarean section to effect a 4.3 kg female alive neonate.
At her first visit blood group AB+, PICT and VDRL was non-reactive.
Past medical history. No history of hypertension
Environmental: No exposure to pollution, dust or others
Behavioral: Alcohol-no history; Tobacco- no; Caffeine- she is using coffee and cola; Illegal
drugs- no; Sexual- has sexual history with her husband only. Exercise and Dietary habits-
ambulates for about 20 minutes daily and gets balanced diet.
Health maintenance: Had no ANC follow up for the previous Px but for the current.
Disease associated: No known associated disease
Treatment associated: taking iron tablets.
Social history
Education: She is a high school teacher
Financial status: has adequate income to support her family.
ROS
 She has no complaint other than mentioned above.
hypotheses?
3. What findings would you expect on physical examination? How does it help you refine
your hypotheses?
General appearance- stable

Vital sign- Ht 160cm, Wt. = 94Kg, Temperature- 37.1 C 0, Pulse-88bpm, Respiration, 20bpm,
B/P-120/80-mmHg
HEENT- NAD
CVS: s1 and s2 well heard, no murmur or gallop
Abdomen- symmetrically full abdomen

 30 weeks gravid ux
 FHB +ve (136 bpm)
 No scar
 No organomegally or fluid collection
Urogenital area-no vaginal discharge or bleeding.
Mss.-slight pedal edema
Intg- no rash or pallor
CNS-conscious and oriented
2. Would you re-rank or change your hypotheses based on the PE? How?
3. How would you investigate this patient?
U/A –non revealing
Oral glucose tolerance test (50gm glucose given orally)
After 1-hour blood glucose was 160mg/dl

Then she was told to come the next morning after fasting for 8 hours. When she comes the
next morning, blood sample taken for FBS then, given 100gm glucose and blood glucose was
determined. The results were as follow:
 FBS (110mg/dl)
 1 hour (210mg/dl)
 2 hours (180mg/dl)
1. Interpret test results. Considering the test re-evaluate your hypotheses

2. Explain to Sara in languages she understands what the findings are and what you will do?
Counsel and advise the lady using role play
4. What life modifications would be your advice?
The possibility of gestational diabetes mellitus was considered and put on insulin therapy after
dietary advice.
Follow up
1. Appointed to come after 2 weeks

Week Thirteen: Tutor Guide for Oligohydramnious
PBL objectives: At the end of this session, students will be able to:
1. Explain the cause that contribute to failure of fetal growth.
2. Identify relevant history and physical examination issues for woman with failure of fetal
growth
3. Understand the function of amniotic fluid
4. Explain sign and symptoms of oligohydramnios
5. Discus the risk factors of oligohydramnios
6. Discus the management approaches of the patient with oligohydramnios
Failure of uterine growth, decreasing fetal movement
Hypothesis:
oligohydramnios, IUFD, IUGR, wrong date,
Learning issues
1. Explain the causes that contribute to failure of fetal growth.

2. Why oligohydramnios causes IUFD&IUGR?
3. How to assess amniotic fluid volume?
Contribution, flow of idea/ knowledge, communication skills, cooperation team building and
reasoning skills
Key readings
 Up-to-date 20.3
 Williams’s obstetrics 23nd edition
 Current obs & gyne 2007

ANC Module Week Thirteen
 Name: Nardos Kurabachew  para I
 Age: 35  number of live birth I
 Sex: Female  Site of visit: Gyne- obs OPD
 Address: - Debretabor  marital status: married
 Gravida II
Presenting problem
Arriving at Debre Tabor hospital Gyni OPD, Mrs. Nardos said, “I feel that failure to
grow my abdomen with advancing gestational age .my fetal movement is also decreasing for 1
week’s duration.
1. List Ms Nardos’s presenting problems

2. Define your hypothesis and describe the mechanisms.
Client history
Present history
Asked how it started, she said, “even if my gestation is around 8 months, my pregnancy does not
grow with gestational age. Also the fetal movement has been decreasing since last week. I told to
my husband the condition yesterday and he informed me to go to the health institution. The
health care provider asked her that when her NLMP was and she said “my NLMP was on…with
gestational age of 35 weeks”. she has no history of vaginal bleeding or discharge. she had no
history of abortion. She had history of using implanon as a contraceptive method before she
became pregnant. Her menstrual cycle was regular, on every 30 days. she has no blurring of
vision.
Risk factor
Fixed factors: both of her parents are alive and live together, she has no family history of
chronic illness.
Acquired factors: Environmental: No exposure to pollution, dust or others
Behavioral: Alcohol- she takes social amount of alcohols; Contraceptives- do not use
contraceptives, Exercise- activities of daily living, smoking; no, drug addiction; no.
Dietary- she is taking enjera with wot, and occasionally rice, milk and meat,
Health maintenance: she has one follow up visit for her ANC
Disease associated: no
Treatment associated: no
Social history
Education: Able to read and write

Partnerships status: currently married and have one child, the spouse is a car driver
Financial status: The husband is the source of subsistent family income
ROS
 She said that she has headache,

 No other pertinent

hypothesis?
3. What data do you require in physical examination? How does it help you refine your
hypothesis?
General appearance- anxious, emotionally disturbed
Vital sign- Ht 165cm, Wt,70Kg, Temperature- 37.2 C0, Pulse-96bpm which is bounding,
Respiration, 24bpm, B/P-120/70-mmHg
HEENT- slightly pale conductive,
LGS - breast: no discharge, symmetry, dark areola, no lump tenderness
CVS: s1&s2 well heard, no murmur or gallop
Abdomen-symmetric, move with respiration, has stretch marks, No scar
30 sized gravid uterus
presentation - Cephalic
lie- longitudinal
fetal heart beat – +ve (148)
No area of tenderness,
no mass or fluid collection
Urogenital area-no discharge, no lesion,
MSS- no edema
Integumentary- no rash or pallor
CNS- she is conscious & oriented to TPP.
1. What more history do you like to take after doing the PE that helps in your
hypotheses?
2. How the PE does help you? Do you want to change the ranking of your hypotheses
based on the PE? How?
3. How would explain to Mrs. Nardos that you are going to take samples for
investigations?
Blood group B-ve
PITC NR
VDRL -ve
HCG Test -ve
Ultrasound: - Singleton, 33 weeks, AFI=3, Positive cardiac activity No fetal anomalies

1. Explain to Mrs. Nardos in languages she understands what the findings are and what
you will do?
2. What would be her concern? And how do you counsel her?
The possibility of idiopathic oligohydramnios is considered and there is no treatment of
oligohydramnios that has been proven to be effective long-term. However, short-term
improvement of amniotic fluid volume is possible and may be considered under certain
circumstances, such as Amnioinfusion, Maternal hydration. The patient was followed with serial
nonstress testing and biophysical profiles until term and she was advised to take more fluid. And
after all, we suggest delivery at 36 to 37 completed weeks of gestation.
Week Fourteen: Tutor Guide for Breech presentation
1. Explain the different forms of fetal malpresentations.

2. Explain the incidence and risk factors of breech presentation.
3. Diagnose breech presentation clinically.
4. Explain relevant investigations to diagnose breech presentation.
5. Manage pregnant mothers with breech presentation.
1. Previous delivery of baby with abnormal presentation

2. Psychological stress
Hypotheses;
1. Breech presentation
2. Face presentation
3. Brow presentation
4. Shoulder presentation
Expected learning Issues:

1. How do you differentiate among the different types of breech presentation?
2. How is breech delivery associated with adverse perinatal outcome?
3. How do polyhydramnios and oligohydramnios lead to breech presentation?
4. How do you manage pregnant mothers with breech presentations?
References:
 Gyn-obs lecture note
 Williams’ text book of gyn obs
 Myles text book of midwifery

ANC Module: Week Fourteen
Patient and visit Information
 Patient name: Alemitu Bitew
 Age: 37 yrs.
 Sex: Female
 Address: D/Tabor, kebele 03
 Site of visit: ANC unit
Presenting problem
Arriving at a DTH ANC unit, Alemitu said “I have a history of delivery of my last baby whose
presentation was abnormal and am now worried about the current pregnancy.”

1. List Alemitu’s problem
2. Define your hypothesis as mechanism leading to the problem.
the problem?
Patient History
Patient history of presenting illness
Arriving at DTH ANC unit, Alemitu said, “the presentation of my last baby whom I delivered
vaginally was abnormal and am now worried about the current pregnancy. “she is a gravid VI
para V mother whose LNMP was on 10/02/06 E.C with a calculated gestational age of 34+3wks.
She had regular menses that comes every 28 days and did not use contraceptive for the last 1yr &
6mo. She started to feel her fetal movement about the 5 th month of pregnancy and she still feels
it.
She has no history of DM or HTN. She has no pushing down pain or history of passage of gush
of fluid per vagina.
Past medical history_ Risk assessment
Occupational exposure_ I am a merchant.
Behavioral: Alcohol _ I don’t use alcohol.
Smoking_ I don’t smoke.
Sexual_ I have sexual contact with my monogamous husband.
Health maintenance_ I have regular ANC follow up.
Disease associated_ I have no history of any disease.
Social History:
Family history- I have no family history of DM, HTN or similar problem.
Education _ I have completed grade 10.
Review of system
GIT_I have no vomiting, abdominal cramp.
GUT_ I have no vaginal bleeding,
No other pertinent positive history.

2. Tell Alemitu you would like to examine her. What physical examination should be
Vital sign; PR- 90 bpm, BP- 110/70mm Hg, Temp- 36.7 oC, RR-18bpm
General- well-looking
HEENT-pink conjuctiva, NIS
LGS –no LAP
Lung -clear and resonant
CVS- s1 and s2 well heard, no murmur and gallop
Abdomen –uterus is 34wks sized
- the fundus is occupied by a hard, round, ballotable mass
-longitudinal lie
-FHB =130 bpm, heard above the umbilicus (Rt. Side)
GUT – Inspection---no vaginal ulcer, no chancre
CNS _mood- worried

1. How does the physical examination help you?
your hypothesis?
3. Do you want to change the ranking order of the hypothesis based on the physical
examination? How?
4. How would you explain to Alemitu what investigation you do test your hypotheses?
HCT 36% 34-44%
PITC NR
VDRL NR
Blood Group AB+ve
Obstetric U/S with BPP: Singleton, Breech presentation, longitudinal lie, GA =34wks, FHB
=126; AFI =16

3. Explain to Alemitu in the language she understands what your findings are and what
you will do
Case summary
The diagnosis of 3rd TM pregnancy + Breech presentation was entertained. The mother was
reassured that there is a high chance for spontaneous version to cephalic presentation up to the
GA of 36 wks. moreover, she was told to come back to hospital if danger signs like vaginal
bleeding, leakage of liquor, severe headache, epigastric pain or decrement in fetal movement
occur. She was then appointed after 2 wks.
Follow up
She was appointed after 2 wks.
Week Fifteen: Tutor guide for Pre Mature Rupture of Membrane
Objectives;
1) Explain physiologic effect fetal membrane

2) Discuss types of PROM
3) Analyze causes and risk factors of PROM
4) Diagnose patient with PROM
5) Manage patient with PROM
Presenting Problem
1. Flow of fluid per vagina

Hypotheses
1) PROM
2) Normal labor
3) STI
Learning Issues;
1. How PROM causes PPH?

2. Why pv is not necessarily for PROM patient?
3. How can you differentiate PROM from chorioamnitis?
1) Participation and communication skills

2) Cooperation/Team- building skills
3) Comprehension/Reasoning skills
4) Knowledge/ Information skills
References
 Myles text book foe midwifery

 Williams’s text book
 Current obstetrics
 Selected obstetrics national protocol
ANC Module: Week Fifteen
Patent information
 Name- Tihun Zeleke
 Age-28 years
 Sex-female
 Address- Gahsay
 Site of visit-gyn emergency OPD
Presenting problem
Immediately presenting at gyn emergency OPD Tihun said, the reason why I came to this is there
is flow of discharge through my vagina.
Discussion questions One
1. List Tihun’s problem

2. Define your hypothesis as mechanism leading to the problem. Which system might be
involved?
the problem?
A para III, gravida IV mother whose LNMP was on 15/02/06 E.C with a calculated gestational
age of 34 weeks came to this and stated that she felt wetness of her thighs and under wear when
she was taking her regular shower eight hours back. Moreover, she saw flow of fluid through her
vagina while she stood up after taking shower. The fluid had not bad odor and she has no history
of fever and abdominal pain. She has no history of blurring of vision or sever head ache. She has
regular ANC follow up at this hospital and has a blood group of A+. In addition, she was
screened for HIV and Syphilis the results were NR.
Past history
She delivered three of her children at home vaginaly and there was no any complication.
Fixed factors
 Family history: - her parents are both alive and well. She has no family history any
associated disease
Acquired factors
Environmental: - she is a house wife and has no hobbies or work activities that may
expose to trauma.
 behavioral
- Caffeine: she drinks an occasional cup of coffee.
- Dietary habits: she eats ijera with wot regularly.
- Emotional state: she has no history of any stress.
 health maintenance —she has regular ANC follow up

 treatment associated —
- Surgery: None
- Allergies: None.
Social history
- She lives with her child and husband; she was completed her college education
but she still not got her own job
Review of system
GIT-she has no vomiting, diarrhea
GUT- she has no history of vaginal bleeding, she has regular menstrual cycle
No other pertinent positive history
2. Tell Almaz you would like to examine her. What physical examination should be looking
for? How does it help with your hypothesis?
General- healthy looking
Vital sign; PR- 90bpm but weak, BP- 120/80mm Hg, Temp- 37.2oc, RR-18bpm
HEENT-pink conjuctiva, NIS
LGS – no LAP, enlarged but non-tender breast
Lung -clear and resonant
CVS- s1 and s2 well heard, no murmur and gallop
Abdomen – distended abdomen, darkness of linea nigra, strae gravid arum but no scar.
Fundal height 32wks, fetal heart beat 140bpm, longitudinal lie
An irregular, soft, and non ballotable mass is occupying fundus.
GUT – Inspection_ normal hair distribution, washed out vagina
Speculum _ fluid pooling in a posterior fornix, no cord seen
your hypothesis?
3. How would you explain to Tihun what investigation you do test your hypotheses? Justify
each test ordered?
No Item Result Normal value

1 HCT 38% 36-48%
2 WBC 9000cells/mm3
2 Nitrazine test Blue color of nitrazine paper yellow
3 Ultra sound Gestational age 28 weeks AFI 5-25
AFI 3
Discussion question 4
4. Explain to Tihun in the language she understands what your findings are and what you
will do

Case summary
The possibility of PROM is considered, as there was rupture of membrane before the onset of
labor. She was admitted to labor ward and advised to bed rest and complete pelvic rest. She
received 6mg dexamethasone IV bid for two days and 500mg amoxicillin po for seven days.
After all of this, the fetus was being matured she was induced and delivered with SVD after
7days of her admission. She was discharged after six hours of deliver and full checkup of her
health status.
Follow up
She is appointed to come if there is any problem other wise to the first post-partum visit.
Mini cases
1. What if she is febrile?

2. What if she is in labor?

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DEBRE TABOR UNIVERSITY

COLLEGE OF HEALTH SCIENCES

ANC MODULE PBL CASES FOR REGULAR MIDWIFERY STUDENTS

Prepared and Edited by:

JUNE, 2016 G.C

Week One: Tutor Guide for Pelvic Organ Prolapse

Objectives: At the end of this session, students will be able to:

 Enterocele (bowel herniation at top of vagina), Cystocele, Rectocele

 Which structures are involved in Pelvic Organ Prolapse and why?

 Current obs & gyne 2007

Discussion questions one

1. List Mrs. Beletech’s presenting problem?

Tests Result Normal value

Discussion Question four

1. What if she is 30 years old?

2. What if it is a delivered Myoma?

Objectives: At the end of this session, students will be able to:

Discussion question Four

Objectives: At the end of this session, students will be able to:

Explain normal fetal growth patterns.

Failure of abdominal growth

1. Intra Uterine Growth Restriction 3. Wrong Dating

Assessment criteria: Skills on

Participation and communication Comprehension/Reasoning

Gyn-obs lecture note

- Name: Almaz Alemu

Discussion question one

1. List Almaz’s presenting problem(s).

History of Present Pregnancy

- Tobacco: she has no history of smoking

- Caffeine: she drinks about two cups of coffee every day.

- Illegal drugs: none.

- Sexual: she enjoys with her monogamous husband

She also eats meat about three times a week.

- Emotional state: she has no history of any psychological or physical stress.

- GIT: she has no diarrhea

- GUS: she has no vaginal bleeding

Discussion question two

2. How do you re- rank your hypothesis?

3. Tell to Almaz that you would like to examine her.

General Appearance: Depressed

Vital sign: PR= 90bpm, BP=110/70mm Hg, Temp= 37 C, RR=18bpm

HEENT: Pink conjuctiva, NIS,

LGS: No LAP, no thyroid enlargement

Lung: Clear and Resonant

CVS: S1 and S2 well heard, no murmur and gallop

Abdomen: Darkness of linea nigra, strae gravidarm, but no scar

: Ux is 30 weeks sized by fundal height

: Fundus is occupied by an irregular, soft, and non –ballotable mass

: Fetal heart beat is 130 bpm

GUT: Inspection: - normal hair distribution, inverted triangle vulva

: Speculum: - closed and firm cervix

: Bimanual examination: - No cervical motion tenderness, no adnexal tenderness

CNS: Conscious and oriented

Discussion question Three

Ancillary Investigations and Laboratory results

Sr. No Item Result Normal value

Discussion question Four

1. What if she is HIV +ve?

Objectives: At the end of this session, students will be able to:

1. Define prolonged pregnancy.

1. Absence of onset of labor by the expected date of delivery

1. How does oligohydramnios occur in prolonged pregnancy?

1. Participation and communication skills