Tutorial 1 Step 1 Mrs .

Partina, a 30-years-old P0 A0 visited the Maternal and Neonatal Health Clinic (MNHC) in the Primary Care Health Center where you were the assistant of the doctor in charge. She said that she had missed 3 periods, which normally comes on date 10th of the month. The first day of her last menstrual period was on 10 August 2007 last. She has also been suffering from nausea and vomiting. The latter had become worse that she vomitted almost everything she ate. She complained of painless frequent-voiding, fatigue, breast discomfort and increased skin pigmentation especially on her face, nipple, and abdominal skin. She was worried about losing weight 3 kg since her last period.

The doctor has perform physical examination to Mrs. Partina, and the finding were as follows:

Physical examination: Height : 160 cm tall Weight : 50 kg

Vital signs : within normal limit Skin torgor : normal Heart and lungs are normal.

Obstetricexamination: External examination Speculum examination Vaginal examination : Vagina : fundal height 2 fingers above symphysis : bluish portio, normal size Vulva : normal : normal

Portio

:soft, ostium is closed

Uterine corpus : enlarged, equals to 12 weeks pregnancy Douglas pouch Parametrium : normal : normal

Laboratory result: Laboratory result: Hb : 11,5 mg%,

Hematocrit : 35 % Platelet : 250.000/cc

Liver function test : normal Kidney function test Urinalysis Urine hCG test : normal

: within normal limit : positive

A. Identify the patient problems. B. Generate a list of hypothese for each problem. C. What further information would you like to know from Mrs. Partina? Explain your answers!

Tutorial 1 Step 2

The doctor reffered Mrs. Partina for an Ultrasonography (USG) scanning in the Feto Maternal clinic. Result of USG examination was as follow: Uterus is enlarged filled with a singleton fetus, actively moves, HR 160 bpm, regular, CRL 5.5 cm, nuchal translucecy 2 mm, amniotic fluid normal, chorion frondosum at the anterior uterine wall. Both adnexa within normal limits, no abnormal mass found.

D.Does the information change your hypothesis? Why? E. Identify the patients problems. F. Can you explain your management plans for this patient? Please describe the details. Tutorial 2 Step 1

Mrs. Partina was sent home, given some prenatal vitamins and antiemetics. She was also adviced to have regular prenatal visit, scheduled once a month up to 28 weeks of pregnancy and more frequent there after. She went to widwife for prenatal care as scheduled. In the 38th week of pregnancy, Mrs. Partina returned to the hospital, complaining that she had been having a regular contractions for 8 hours. She knew the baby was still moving, no water broke.

Physical diagnosis : Vital signs : within normal limits Obstetric examination :

Fundal height : 35 cm Leopold 1 : soft mass was palpated in the funus, larger resistance on the

left side of the fundus Leopold 2 Leopold 3 Leopold 4 : small fetal parts were palpable on the right : on the area above symphisis, a globular, round mass detected : acute angle was found between the two examining palms : revealed FHR 150 bpm, regular

Fetal auscltation Contraction

: once in every 6 minutes, lasting 20 second weak

Admision test (cardiotocography) result was consulted to feto-maternal consultant and the result was as follows: Baseline Variability : 145-150 bpm : 5-10 bpm, presence of 2 acceleration without deceleration

during 20 minute period Contraction : once in every 6 minute, amplitude 25 mmHg. Conclusion : fetal in good condition

Vaginal examination : Vulve/vagina Portio : no abnormalities : axial position, soft, effacement 80 %

Cervical dilatation : 4-5 cm Amniotic membrane Presenting part : intact

: occiput on the left anterior position, station +2

Mrs. Partina was informed about her and her babys condition, and the doctors plan to have labor augmentation. She wanted to know if she could have spontaneuos delivery and also about the risks and benefit of having labor augmentation.

The doctor explained everything about his plan and about the risk of having labor augmentation. After a while, Mrs. Partina and her husband agreed to the doctors plan. G. What have you learnt so far ? What is your current diagnosis ? H. What would be your management plan for this patient ?

Tutorial 2 Step 2

A few moment later augmentation commenced. A few hours has passed, her water broke spontaneuosly, and she started urging to bear down. When your checked her, the perineum is already crowning Here is the copy of Mrs. Partinas partogram I. J. What is Mrs. Partina problem now ? Explain the finding in the partograph !

K. What should you do now ? Tutorial 3 Mrs. Partina gave birth to a healthy girl of 3000 grams, 51 I length. She was crying out loud. Both parents looked happy with their offspring.