ANTENATAL CASESTUDY OF

MRS POOJA

WITH

OLIGOHYDRAMNIOS

Submitted to, submitted by,

Mrs Smitha Jose Arathy unnithan

Associate professor 2nd year MSc nursing

TMMCON TMMCON

Thiruvalla Thiruvalla

Submitted on

06 -09 -2023
 IDENTIFICATION DATA

Name of the patient :

Age :

Address :

Religion :

Income :

Husband name :

Blood group of the mother :

Blood group of the father :

Date of admission` :

Date of discharge :

Date of study started :

Date of study ended :

Obstetrical score :

LMP : 4/01/2023

EDD : 11/10/2023

Reason for admission : For safe confinement

DIAGNOSIS : OLIGOHYDRAMNIOS
OBSTETRICAL HISTORY

 PRESENT OBSTETRICAL HISTORY

Mrs Pooja 27years/F primigravida mother got admitted in TMM hospital Thiruvalla and
consulted doctor Anu and doctor advised the patient to take obstetrical scan for the check up
after that the ultrasonography shows that decreased amniotic fluid level(AFI less than 6
cm) .On examination no pallor , per abdomen uterus is firm and relaxed, visible fetal
movements are perceived. Fetal heart rate is normal148 beats per minutes.

1st TRIMESTER

The pregnancy was planned and confirmed by the urine pregnancy test. Her first scan was
done on 5th week which should confirm the pregnancy. She started to take Tab.flovite 5mg
OD from the fidth week onwards.During the first trimester she had increased frequency of
micturition ,weakness and morning sickness such as nausea and vomiting. She completed
first dose of T.T on 12th week.

2nd TRIMESTER

Morning sickness was increased and frequency of micturition was decreased. The mother
was more active .She started Tab. shelcal 500 mg in the morning. She gained all the antenatal
checkups. Anomaly scan was performed at 20 th week of pregnancy, it was normal. She
completed her second dose of T.T at 18th week.

3rd TRIMESTER

She gained 5 kg weight. She had increased urinary frequency, mild itching, over the abdomen
and backache due to the overstretching of the abdomen. She underwent all the regular
antenatal checkups.

PAST OBSTETRICAL HISTORY

Mrs Pooja has no significant past obstetrical history

PAST MEDICAL HISTORY

Mrs Pooja has significant past medical history of bronchial asthma since 6 years and she was
taking medications from TMM hospital Thiruvalla.
PRESENT AND PAST SURGICAL HISTORY

Mrs Pooja has significant past surgical history of left breast excision since 2018 and no
present surgical history.

FAMILY HISTORY

Mrs Pooja belongs to a high-class family. Her husband is the bread winner of the family. All
the family members are healthy and are free from all the communicable diseases.

Name of the family Age Relation Education occupation Health

member status
Mr. Peethambaran 62 Father SSLC Nil Healthy
Mrs. Santha 59 Mother SSLC Nil Healthy
Mrs. Raji 32 Sister Degree Engineer Healthy
Mr. sarath 35 Brother on law Degree Engineer Healthy

Mrs. pooja 27 Patient Degree Accountant Healthy

peethambaran
Mr. Sanjay 30 Husband Degree Engineer Healthy
PEDIGREE CHART

Mr. Peethambaran ,62 years Mrs. Santha ,59 yrs

Mr. Sarath Mrs. Raji Mr.Sarath Mrs Pooja

Baby.Nivedhya

PERSONAL HISTORY

Mrs Pooja Peethambaran lives with her husband. She is well nourished and likes non
vegetarian food .She has adequate rest and sleep but sometimes sleeping pattern is disturbed
due to hospitalization.She maintains good personal hygiene.Her Bowel and bladder pattern
was regular . She have no any bad habits like smoking , chewing, etc.

MENSTRUAL HISTORY

Age of menarche : `15 Years

Frequency and duration : 28 days and 4-5 days

Amount of blood : 3-4 pads/ day

Any Abnormalities : no any abnormalities in menstruation

MARITAL HISTORY

Age of marriage : 26 years

Type of marriage : non consagenious marriage

Years of marriage : 2 years

Use of contraceptives : nil

SOCIO ECONOMIC STATUS

Place of housing : rural

Occupation : nurse

House : own

She is living in a pucca house with adequate supply of water, electricity and good sanitation
and maintenance a good relationship with all family members.
INVESTIGATIONS

Date Name of the Patient value Normal value remarks

investigations
Hemoglobin 12.9 11.5-16.5

PCV 37.9 35-45

WBC count 8900 5000-10000

RBC count 4.44 4.35-5.65

million cells

Poly 67 40-75%

Lymph 27 20-40%

Esino 3 0-6%

21/09/23 Mono 3 1-3%

Mcv 85 80-100

Mch 39 27-32

Mchc 34 32-36

RDW 16 11.5-14.5

Platelet count 224 100-400 Normal

URINE

EXAMINATION

Colour Light yellow

Apperence Clear

PH 5.5

specific gravity 1.030

glucose Neg

protein Neg

ketones +

bilirubin Negative
PHYSICAL EXAMINATION

General examination

Body build : good

Nourishment : moderate

Height : 164 cm

Weight : 80 kg

BMI : weight in kg/height in m2 * 100

80/1.64*1.64 = 30 kg/m2

VITAL SIGNS

Temperature : 98.6 degree F

Pulse : 78beats per minute

Respiration : 24 breaths per minute

Blood pressure : 110/70 mm of hg

Head

Scalp : clean and no dandruff

Hair : equally distributed

Color : normal

Pediculosis : absent

Face

Facial puffiness : present

Cholasma : present

Eyes

Eye brows : symmetrical

Eye lashes : symmetrical

Eye lids : no edema

Sclera : white

Conjunctiva : pink in color

Vision : normal

Ear

Pinna : equally distributed

Hearing : normal

Discharge : absent

NOSE

Nasal septum : midline

Nasal pathway : patent

Nasal pathway : absent

Rhinorrhea : absent

Mouth and Pharynx

Halitosis : absent

Dental caries : absent

Mucosal skin : not ulcerated

Gums : no bleeding

Tounge : not coated

Neck and axilla

Range of motion : possible

Thyroid gland` : not enlarged

Trachea : Midline
Lymph node : not enlarged

Breast

 Inspection

Size : enlarged

Symmetry : Symmetrical

Veins : not visible

Nipples : no abnormalities like cracked nipples or flat nipples

Areola : secondary areola

Montgomery’s tubercle : present

Discoloration : absent

 Palpation

Consistency : hard

Engorgement : absent

Colostrum : present

Extremities

 Upper extremities

Symmetry : symmetrical

Range of motion : possible

Edema : absent

Cyanosis : absent

 Lower extremities

Symmetry : symmetrical

Range of motion : possible

Edema : absent
Cyanosis : absent

Genitalia and back

Vulva : slight edematous

Genital warts : absent

Varicosities : absent

Discharge : leucorrhoea

Physical examination findings

 Facial puffiness present

 Chloasma present
 Edema present
 Leucorrhea present

ANTENATAL EXAMINATION

ABDOMEN

 INSPECTION

Size : appropriate for the gestational age

Contour : convexity of abdomen present

Shape : ovoid in shape

Fetal movements : visible

Umbilicus : protruded

Skin changes : linea nigra and straie gravidarum present

 PALPATION

Abdominal girth : 98 cm

Height of the fundus : 33 in weeksand 32 in cm

Fundal palpation : soft broad irregular mass suggestive of fetal

buttocks
Lateral palpation : Right –irregular knob like feel suggestive of
fetal limbs

Left – smooth curved resistant feel suggestive of

fetal spine

 PELVIC GRIP

At pelvis : smooth hard globular mass suggestive of fetal

head

Occipital pole : above the pelvic brim

Syncipital pole : above the pelvic brim

Converging/diverging : diverging

Descent of the presenting part : 5/5

 PAWLIK GRIP

Size : appropriate for the gestational age

Flexion : flexed

Mobility : movable

 COMBINED GRIP

At fundus : podalic

At pelvis : cephalic

 AUSCULTATION

FHS : 148 beats per min

FINDINGS

Gestational age : 33 weeks

Lie : longitudinal lie

Presentation : cephalic

Position : LOA

Attitude : flexion

Descent of the presenting part : 5/5

Engagement : not engaged

FHS : 148 beats per minute

 ANATOMY OF UTERUS

The uterus is a thick walled, pear shaped hollow muscular organ situated in the pelvic cavity
with the urinary bladder infront and the rectum behind. It has thick muscular walls and the
small central cavity.

Dimensions

The uterus is 7-8 cm long,5-7 cm wide and 2-3 cm thick and its weighs 30-40 grams

Parts of uterus

The uterus has 2 major parts

 1. the expanded superior two third is known as the body
2. the cylindrical lower one third is called the cervix

A slight constriction called the isthmus marks the junction between the body and the cervix.

 FUNDUS

The fundus of the uterus is the rounded upper part of the body. It is located superior to a line
joining the point of entry of the fallopian tube. The site of entry of the uterine tube is called
the cornua.

 CERVIX

The cervix or neck of the uterus is the lowest portion, part of which projects like an inverted
cone in to the vault of the vagina. Thus the cervix divided in to vaginal and supra vaginal
parts.

 WALLS OF THE UTERUS

The uterine wall has 3 layers

1. Serous coat or perimetrium

2. The middle muscular coat or myometrium.it is 12-15 mm thick. Myometrium consist
of smooth muscle fibers. The main branches of blood vessels and nerves are situated
in the layer. During pregnancy the thickness of myometrium increases greatly.
3. The inner mucous coat or endometrium .it is highly specialized, mucus membrane
which varies in thickness according to the phase of menstrual cycle except its basal
layer. The endometrium is shed off during menstruation it regenerate after
menstruation.
 POSITION

In nulliparous women uterus is completely with in the pelvis.it is normally anteverted and
anteflexed in position. The long axis of the cervix is bent forwards over the long axis of
the vagina and this is anteversion.

The body of the uterus is bent forwards over the cervix. This is known as anteflexion.

 RELATION

 Anterior surface or vesical surface

 The urinary bladder is situated anterior to the uterus. The uterovesical pouch of
peritoneum seperates the fundus and the body of uterus from the anterior 2/3rd of the
superior surface of the bladder.

 The posterior surface

The posterior surface of the fundus body and supravaginal cervix areconverted to
peritoneum, which separate’s the uterus from the rectum.

 SUPPORTS OF UTERUS

The uterus is a mobile organ which undergoes extensive changes in size and shape during
pregnancy.it is supported and prevented sagging down by a number of factors.

 Muscular support
 Fibromuscular ligaments
 Peritoneal ligaments
Muscular support
o The pelvic diaphragm
o The perineal body
o Thr urogrnital diaphragm

Fibromuscular ligaments
o Pubocervical ligament
o Transverse cervical ligament
o Uterosacral ligament
o Round ligament of uterus
Peritoneal ligaments: broad ligaments

 BLOOD SUPPLY OF UTERUS

 Arterial supply
The uterus is supplied chiefly by two uterine arteries and partly by ovarian
arteries.The uterine artery is a branch of the internal iliac artery. It runs medially
towards the cervix 2cm lateral to the cervix.
 Venous drainage
The corresponding uterine veins drain into the internal iliac veins

 Lymphatic drainage
To external iliac ,internal iliac and aortic nodes,some lymphatic from the fundus
accompany the round ligaments and in the superficial inguinal node.

 Nerve supply
By autonomic nervous system- sympathetic (T12,L1) and
parasympathetic(S2,S3,S4).
 Amniotic fluid
ORIGIN OF AMNIOTIC FLUID:
The precise origin of the liquor amnii is still not well understood. It is probably of
mixed maternal and fetal origin.
CIRCULATION
The water in the amniotic fluid is completely changed and replaced in every 3 hours
as shown by the clearance of radioactive sodium injected directly into the amniotic
cavity. The presence of lanugo and epithelial scales in the meconium shows that the
fluid is swallowed by the fetus and some of it passes from the gut into the fetal
plasma (vide scheme).
VOLUME
Amniotic fluid volume is related to gestational age. It measures about 50 mL at 12
weeks, 400 mL at 20 weeks and reaches its peak of 1 liter at 36–38 weeks. Thereafter
the amount diminishes, till at term it measures about 600–800 mL. As the pregnancy
continues post term, further reduction occurs to the extent of about 200 mL at 43
weeks.
PHYSICAL FEATURES
The fluid is faintly alkaline with low specific gravity of 1.010. It becomes highly
hypotonic to maternal serum at term pregnancy. An osmolarity of 250 mOsmol/L is
suggestive of fetal maturity. The amniotic fluid’s osmolality falls with advancing
gestation.

Color

In early pregnancy it is colorless, but near term it becomes pale straw colored due to
the presence of exfoliated lanugo and epidermal cells from the fetal skin. It may look
turbid due to the presence of vernix caseosa.

Abnormal color

Deviation of the normal color of the liquor has got clinical significance.
 Meconium stained (green) is suggestive of fetal distress in presentations other
than the breech or transverse. Depending upon the degree and duration of the
distress, it may be thin or thick or pea soup (thick with flakes). Thick with
presence of flakes suggests chronic fetal distress.
  Golden color in Rh incompatibility is due to excessive hemolysis of the fetal
RBC and production of excess bilirubin.
 Greenish yellow (saffron) in post maturity.
 Dark colored in concealed accidental hemorrhage is due to contamination of
blood.
 Dark brown (tobacco juice) amniotic fluid is found in IUD. The dark color is
due to frequent presence of old HbA.

COMPOSITION:

In the first half of pregnancy, the composition of the fluid is almost identical to a transudate
of plasma. But in late pregnancy, the composition is very much altered mainly due to
contamination of fetal urinary metabolites. The composition includes—(1) water 98–99% and
(2) solid (1–2%). The following are the solid constituents.

(a) Organic: Protein–0.3 mg% NPN–30 mg% Total lipids–50 mg% Glucose–20 mg%
Uric acid–4 mg% Hormones (prolactin, insulin and renin) Urea–30 mg% Creatinine–
2 mg
(b) Inorganic—The concentration of the sodium, chloride and potassium is almost the
same as that found in maternal blood. As pregnancy advances, there may be slight fall
in the sodium and chloride concentration probably due to dilution by hypotonic fetal
urine, whereas the potassium concentration remains unaltered.
(c) Suspended particles include—Lanugo, exfoliated squamous epithelial cells from the
fetal skin, vernix caseosa, cast off amniotic cells and cells from the respiratory tract,
urinary bladder and vagina of the fetus.

FUNCTION

Its main function is to protect the fetus.

During pregnancy:

 It acts as a shock absorber, protecting the fetus from possible extraneous

injury
 Maintains an even temperature
  The fluid distends the amniotic sac and thereby allows for growth and free
movement of the fetus and prevents adhesion between the fetal parts and
amniotic sac
 Its nutritive value is negligible because of small amount of protein and salt
content; however, water supply to the fetus is quite adequate

During labor

 The amnion and chorion are combined to form a hydrostatic wedge which helps in
dilatation of the cervix
 During uterine contraction, it prevents marked interference with the placental
circulation so long as the membranes remain intact
 It guards against umbilical cord compression
 It flushes the birth canal at the end of first stage of labor and by its aseptic and
bactericidal action protects the fetus and prevents ascending infection to the uterine
cavity.

CLINICAL IMPORTANCE

 Study of the amniotic fluid provides useful information about the well being and also
maturity of the fetus
 Intra-amniotic instillation of chemicals is used as method of induction of abortion
 Excess or less volume of liquor amnii is assessed by amniotic fluid index (AFI)
 Maternal abdomen is divided into quadrants taking the umbilicus, symphysis pubis
and the fundus as the reference points. With ultrasound, the largest vertical pocket in
each quadrant is measured. The sum of the four measurements (cm) is the AFI. It is
measured to diagnose the clinical condition of polyhydramnios or oligohydramnios
respectively
 Rupture of the membranes with drainage of liquor is a helpful method in induction of
labor
 DISEASE CONDITION
OLIGOHYDRAMNIOS
INTRODUCTION

Oligohydramnios refers to amniotic fluid volume (AFV) that is less than the minimum
expected for gestational age. It is diagnosed by ultrasound examination, preferably based on
an objective measurement such as amniotic fluid index (AFI) ≤5 cm or single deepest pocket
(SDP) <2 cm, but a subjective assessment of reduced AFV is also acceptable. Some cases
have an identifiable maternal, fetal, or placental cause ; the remainder are considered
idiopathic.

The fetal prognosis depends on several factors, particularly the underlying cause, severity
(reduced versus no amniotic fluid), and gestational age at occurrence. Because an adequate
AFV is critical to normal fetal movement and second-trimester lung development and for
cushioning the fetus and umbilical cord from uterine compression, pregnancies complicated
by oligohydramnios from any cause are at risk for pulmonary hypoplasia (if second-trimester
oligohydramnios), fetal deformation (if prolonged oligohydramnios), and umbilical cord
compression. Oligohydramnios is associated with an increased risk for fetal or neonatal
death, which may be related to the underlying cause of the reduced AFV, the sequalae of
reduced AFV, or both.

DEFINITION:

It is an extremely rare condition where the liquor amnii is deficient in amount to the extent of
less than 200 mL at term. Sonographically, it is defined when the maximum vertical pocket of
liquor is less than <2cm or when amniotic fluid index is less than 5 cm. With AFI less than or
more than 24cm was considered abnormal at gestational age from 28-40 weeks. Absence of
measurable pocket of amniotic fluid is defined as anhydramnios. AFI between 5 and 8 is
termed as borderline AFI or borderline oligohydramnios.

Book picture Patient picture

ETIOLOGY A.
Fetal conditions:
(i) Fetal chromosomal or structural
anomalies
(ii) Renal agenesis
(iii) Obstructed uropathy
(iv) Spontaneous rupture of the
membrane
 (v) Intrauterine infection
(vi) Drugs: PG inhibitors, ACE
inhibitors
(vii) Post maturity
(viii) IUGR
(ix) Amnion nodosum (failure of
secretion by the cells of the amnion
covering the placenta).

B. Maternal conditions: Etiology is idiopathic

(i) Hypertensive disorders

(ii)Uteroplacental insufficiency
(iii) Dehydration
(iv) Idiopathic

DIAGNOSIS:
(1) Uterine size is much smaller than the period
of amenorrhea
(2) Less fetal movements Usg done in my patient
(3) The uterus is “full of fetus” because of AFI less than 6 cm in single deepest pocket
scanty liquor
(4) Malpresentation (breech) is common
(5) Evidences of intrauterine growth retardation
of the fetus
(6) Sonographic diagnosis is made when
largest liquor pool is less than 2 cm. Ultrasound
visualization is done following amnioinfusion
of 300 mL of warm saline solution
(7) Visualization of normal filling and
emptying of fetal bladder essentially rules out
urinary tract abnormality.
(8) Oligohydramnios with fetal symmetric
growth restriction is associated with increased
chromosomal abnormality
COMPLICATIONS
Fetal:
(1) Abortion
(2) Deformity due to intra-amniotic adhesions
or due to compression. The deformities include
alteration in shape of the skull, wry neck, club Patient have no complications
foot, or even amputation of the limb
(3) Fetal pulmonary hypoplasia (may be the
cause or effect)
(4) Cord compression
(5) High fetal mortality.
Maternal:
(1) Prolonged labor due to inertia
(2) Increased operative interference due to
malpresentation. The sum effect may lead to
increased maternal morbidity.
TREATMENT:
Presence of fetal congenital malformation
needs referral to a fetal medicine unit. When Doctor advised to take more fluids
decision for delivery is made, it should be done
irrespective of the period of gestation. Isolated
oligohydramnios in the third trimester with a
normal fetus may be managed conservatively.
Oral administration of water increases amniotic
fluid volume. In labor, cord compression is
common. Amnioinfusion (prophylactic or
therapeutic) for meconium liquor is found to
improve neonatal outcome.
PROBLEM IDENTIFIED AND NURSING DIAGNOSIS

Problem identified Nursing diagnosis

Risk for injury Risk for injury related to possible preterm
labor secondary to oligohydramnios

Risk for effective thermoregulation Risk for effective thermoregulation related

to low-birth-weight secondary to
oligohydramnios

Risk for infection Risk for infection related to loss of

protective barrier secondary to
oligohydramnios

Knowledge deficit Deficit knowledge related to misinformation

secondary oligohydramnios as evidenced by
inaccurate execution of the given task.

Anxiety Anxiety related to a perceived threat to self

and the fetus secondary to oligohydramnios
as evidenced by verbalization of feeling
helpless.
 HEALTH EDUCATION

 ANTENATAL ADVICES

 A balanced diet to meet the demand of increased calorie requirement

 Rest and sleep to ensure that the mother is not having discomfort.
 Bath to be taken regularly and avoid slipping in the bathroom
 Loose clothes to be worn and avoid the high heels shoes.
 Dental hygiene to be maintained and dentist to be consulted earlier.
 Care of the breast to be done by checking any problem in the mothers’ nipples and
treat the same.
 Coitus to be avoided during first and third trimesters of pregnancy
 Drug should be taken with caution as almost all the drug cross placenta and reach the
fetus.
 Travelling by vehicles having jerks should be avoided in the first and the last
trimesters.
 Immunization with tetanus toxoid is given to give protection to the mother as well as
the fetus.
 Avoid smoking and alcoholism as it affects the health status of the mother.
 Regular antenatal checkups positively on the schedule date of visit
 She is instructed to report on the physician even at an early date if some untoward
symptoms arise such as intense headache, disturbed sleep with restlessness, urinary
trouble epigastric pain vomiting and scanty urination.
 She is advised to come to hospital if there is
o Painful uterine contraction
o Sudden gush of watery fluid per vaginum
o Active vaginal bleeding

ANTENATAL DIET

 The increased calorie requirement is to extent of 300 over the no pregnancy state
during second half of pregnancy.
 Diet in pregnancy should be of women’s choices
 The pregnancy diet ideally should be light, nutritious, easily digestible and rich in
protein, minerals and vitamins.
 Half liter if not 1 liter of milk (contains about 1gm of calcium) plenty of green leafy
vegetables and fruits.
 Dietetic advice should be given with due consideration to the socioeconomic
condition, food habits and taste of the individual.
 Supplementary iron therapy is needed for all pregnant women from 16 weeks
onwards.
 1 table of ferrous sulphate contain 60 mg of elemental iron is enough
 Intake of protein 60 gm sources are meat fish, poultry and dairy product.
 Iron rich foods , vitamins,folic acid rich in leafy vegetablesand liver,additionally 1 tab
contains 5 mg.
PROGRESS NOTE

DAY -1 (20/9/23)

Mrs. Pooja Peethambaran, 27 years/female was admitted in TMM hospital for the treatment
for oligohydramnios. At the time of admission vital checked and recorded and the vitals are
normal. Doctor advised the patient to take rest. On the day of admission, the mother is
conscious and oriented.

Day-2(21/09/23)

Vitals checked and recorded foetal assessment also done. The fetal assessment also done the
fundal height is 35 cm and the abdominal girth is 100cm.She was stable was anxious about
the delivery process. Her sleeping pattern is disturbed due to anxiety.

Day-3(22/09/23)

Patient is anxious about the delivery process. The vital signs are checked and recorded also
checked the fetal heart rate is 146 beats/min. Patient is conscious and oriented.

Day-4(23/09/23)

The patient is conscious and oriented. Vitals signs and checked and recorded. Fetal heart rate
is 148 beats per min. Health education is given regarding the antenatal advices and about the
breast feeding.

CONCLUSION

Mrs. Pooja Peethambaran 27 years primigravida was admitted in TMM hospital on 20/09/23
for the safe confinement. At the time of admission vitals are checked and recorded. The
patient is conscious and oriented. I have a good opportunity to learn more about the antenatal
care.

BIBLIOGRAPHY

 .Sabaratnam Arulkumaran, V Sivanesaratnam. Essentials of Obstetrics. Second

edition, Jaypee brothers’ medical publishers (p) ltd. New Delhi
 .Jayne Marshall, Naveen Raynox, Wylex. Text book of Midwives.16th edition.
Elsevier publications
 .Hiralal Konor. D C Duttas book of Obstetrics. 9th edition. Jaypee publications
 .Annamma Jacob. A Comprehensive text book of midwifery. 2nd edition. Jaypee
publications
 .Lynna V Littleton, Jonac Engebretson Obstetric and gynaecological nursing care.
Thomson Delmer learning publications.
 . P R Ashalatha, G Deepa. Text book of anatomy and physiology. 3rd edition. Jaypee
publications
 Hiralal Konar “Dc Dutta’s textbook of Obstetrics”9th edition, Jaypee publishers, New
Delhi.
 Annamma Jacob “maternal and neonatal nursing careplan”3 RD edition, Jaypee
brothers and medical publishers, New Delhi.
 Shwetha Naik and Hannah Roseline “Procedure manual for obstetrics and gynecology
nursing” first edition (2019) CBS publishers and distributers, New Delhi