GRAND CASE PRESENTATION

In

Polyhydramnios

A Clinical Case Study

Presented to

The GCP Committee and Faculty of Bachelor of Science in Nursing and School of Midwifery

City University of Pasay (Formerly Pamantasan ng Lungsod ng Pasay)

In Partial Fulfillment of the Requirements inRelated Learning Experience

By:Midwifery II-I

Rofan Rosachany I. SuaifanTeam Leader

Mary Jane F. CambangayMadelyn B. Castro

Hidaya c. Hadji OmarAnalyn M. Labadan

Maria Rose A. OdulanaAnaliza D.Sevilla

I. INTRODUCTION

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

Chronic polyhydramnios where excess amniotic fluid accumulates gradually

Acute polyhydramnios where excess amniotic fluid collects rapidly

The opposite to polyhydramnios is oligohydramnios, a deficiency in amniotic fluid.

In most cases, the exact cause cannot be identified. A single case may have one or more causes, including intrauterine infection (TORCH), rh-isoimmunisation, or chorioangioma of the placenta. In a multiple gestation pregnancy, the cause of polyhydramnios usually is twin-to-twin transfusion syndrome. Maternal causes include cardiac problems,kidney problems, and maternal diabetes mellitus, which causes fetal hyperglycemia and resulting polyuria (fetal urine is a major source of amniotic fluid).

A recent study distinguishes between mild and severe polyhydramnios and showed that Apgar score of less than 7, perinatal death and structural malformations only occurred in women with severe polyhydramnios.In another study, all patients with polyhydramnios, that had a sonographically normal fetus, showed no chromosomal anomalies.

Fetuses with polyhydramnios are at risk for a number of other problems including cord prolapse, placental abruption, premature birth and perinatal death. At delivery the baby should be checked for congenital abnormalities.

II. OBJECTIVES OF THE CASE STUDY

General Objective:

This case presentation seeks to enhance the student’s knowledge with

patient’s general health and disease condition, and its possible complications

treatment plan and medical regimen. This also seeks to assimilate the student’s

skills through application of midwifery intervention and medical management.

Furthermore, This case presentation intends to improve the student’s attitude by

conveying open-mindedness and utilizing therapeutic communication all through

the activity.

SpecificThis study aims to:

Perform maternal health assessment and plan maternal care related to

patient condition.

Apply the role and responsibilities of midwife in implementing interventions

with polyhydramnios.

Familiarize with the anatomy and physiology of the disease.

III.SCOPE AND LIMITATION

This study is being prepared by Midwifery Level II-I as a requirement for the

subject Clinical Practicum 102 B.

I. PERSONAL DATA

Name : PASTILLAS

Address : # 2 Deciembre St. Brgy 195 Sun Valley Village,

NAIA Road, Pasay City

Age : 33 years old

Sex : Female

Civil Status : Married

Religion : Roman Catholic

Birthday : May 19, 1982

Birth Place : Sorsogon

Room and Bed No : OB WARD 1

Hospital No : 399148

Case No : 399148

Admitting Physician: Dr. Al R. Tanyag

Chief Complaint/Reason for Seeking Health Care: Labor Pain

Medical Diagnosis : G2P2 (1102) Pregnancy Uterine 35 4/7 wks AOG by MUTZ,

Cephalic in Labor, Polyhydramnios

II.Medical History

A.History of Present Illness

2 Weeks Prior to Confinement

August 07,2015 (9:30 AM)

Patient Pastillas went to Airways Health Center for her pre-natal check up and she complained for edema on her lower extremities.She felt her legs restless.She stated that maybe it is because of sitting and prolonged standing when she’s at work.After taking her vital signs,she was told to have her Ultra Sound and directly referred to Donya Martha Lying In due to incomplete facilities such as laboratories and ultra sound of the health center.

August 13, 2015 (10:00 AM)

Patient Pastillas had her laboratories and ultrasound in Doña Marta lying in. Her ultrasound result shows Pregnancy Uterine 37 5/7 wks by fetal biometry,Live singleton in cephalic presentation,Placenta Anterior Gr.2,Polyhydramnios doctor advised her to have complete bed rest but the patient insisted to go to work.

AUGUST 19 2015

Prior to admission patient pastillas experience uterine contraction with a painscale of 5/10 at work but still do her work at the office

The night of admission the patient experience severe abdominal pain radiating to the back with pain scale of 8\10. the family decided to bring her to hospital. The patient is admitted to the labor room at around 9:49 pm with 4cm dilatation.

B.Past Medical History

Patient Pastillas was never confined in any hospital facility before.During her

first pregnancy (2006),she gave birth on her first child via home delivery and was

assisted by unlicensed midwife (manghihilot).Whenever she feels sick,she used

to take herbal medicines as alternatives.

C.Family Medical History

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

D.Social History

Patient Pastillas is the 1st child of 6 siblings.Married for 9 years and has two

children.She is a college graduate of Bachelor of Science in Criminology and has

been working as Aviation Security for (5) five years.

Born in Sorsogon City,Patient Pastillas is known as friendly,good person and

knows how to get along with different types of people.Despite of being away from

her husband,Pastillas can still manage to raise her children well.She is currently

living with her 1st child and new born baby, She has a good relationship with her

husband’s family member most especially with her Mother-in-law, who helped her

in taking good care of her children whenever she’s at work.

Patient is not a cigarette smoker but drinks alcohol occasionally

(approximately 2 glasses). The patient is not picky when it comes to food,She

usually eat vegetables, meat and fruits as part of her diet. She drinks less than

10 glasses of water a day.

E.Environmental History

Patient Pastillas resides at # 2 Deciembre St. Brgy.195, Sun Valley Village,

Naia Road, Pasay City. Their house is made up of cement, light material but still

unfinished. The floor is approximately 16 x 9 sq. Meter with one window and

door.Their bed is situated near the entrance door which also serves as their living

room. The house is well ventilated and has a source of electricity. Breeding sites

of mosquitoes, flies, cockroaches and rodent are inevitable due to poor

sanitation. Their toilet facility is located in front of their kitchen. Electric Water

Pump was their source of water supply. They pay P2,500 for their home rental,

P200 for water bill and P500 for electric bill.

Patient Pastillas used to segregate their waste (Biodegradable, Non-

Biodegradable and Recyclable materials) in a plastic container located at the

back of their house. Garbage truck roam around in their place every day around

6am-7am to collect their trash.

There are sari-sari stores available in the vicinity.Public utility vehicle such

as Jeepney’s and Tricycle serves as their mode of transportation.They used

cellular phones as their means of communication.

F. OB Score/ OB History

The patient’s menarche experienced when she was 14 years old. She

consumed (4) four pads of sanitary napkins 3x a day, regular and doesn’t

experienced any difficulty like dysmenorrhea when she had her menstruation.Her

first coitus was when she was 24 years of age with her first husband and got

pregnant. She delivered her first child via home birth at La Union Province while

her second child was delivered via Normal Spontaneous Delivery at Pasay City

General Hospital.G2P2

(1-1-0-2).

G. Immunization History

During her first pregnancy, Patient Pastillas did not received any

vaccination/ immunization because she doesn’t have any pre-natal or regular

check up.She doesn’t visit any nearest health center in their place to seek

consultation.During her second pregnancy, Patient Pastillas decided to visit MIA

Health Center to have her self checked-up. She receives Tetanus Toxoid twice.

Patient Pastillas was admitted at Pasay City General Hospital and gave

birth to her second child.Her child was given Hepatitis B, Vitamin K, BCG (Bacille

Calmette Guerin) at time of birth.

H. Developmental HistoryGROWTH AND DEVELOPMENTAL

ERIKSON’S THEORY

Developmental Stage Developmental Task Implication

Infancy

Age: 0 to 1 1/2 Virtue: Hope

Trustvs.

Mistrust

Patient Pastillas was breastfed at this age.

Early Childhood

Age: 1 1/2 to 3Virtue:Will

AutonomyVs.

Doubt and Shame

Patient Pastillas was not toilet rained when she was on this age.She always insist what she wants.

Pre-School Iniatiative Patient Pastillas stated that

Age: 3 to 5Virtue:Purpose

Vs.Guilt she wants to do many

things on her own like sweeping the floor and bathing, but her mother refused to let her do this alone.

School Age

Age: 5 to 12Virtue:Competency

IndustryVs.

Inferiority

Patient Pastillas was an active student.She wants to participate in any school activity on her own.

Adolescence

Age: 12 to 18Virtue:Fidelity

Ego IdentityVs.

Role Confusion

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

Young Adulthood

Age: 18 to 40Virtue:Love

IntimacyVs.

Isolation

Patient Pastillas decided to apply for work away from her family.She stated that her family was supportive to her when they knew she’s already pregnant.

III. Patterns of Functioning-Altered System

Gordon’s Functional Pattern

Patterns of Functioning

Before Hospitalization

During Hospitalization

Analysis/ Interpretation

Health Preparation & Health Management

Patient build up her awareness about her health.

Nutritional-Metabolic

Patient E.D.B loves to eat

Patient E.D.B was advise to

fish,vegetable and fruits. She eats her meals (3) times a day. She can drink up to 8 glasses of water per day

lessen her water intake because of her condition.

Elimination Patient voids (5) five times a day and she moves her bowel (2)twice a day.

Patients urinates regularly 3-4 x a day with difficulty and defecated yellowish stool.

Patients finds difficulties of bowel movements.

Activity & Exercise Doing house hold chores every day is the form of exercise being done by the patient before going to work.

Patient activity is limited.She usually lies down or talk to the neighbor whenever she feels bored.

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

Coping Stress Tolerance

When she has problem,Patient E.D.B used to communicate & share her problems to her family and friends.She makes herself busy like watching television or listening to radio.

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

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

Value-Belief Patient E.D.B was a Roman Catholic. She go to church regularly.She does praying before eating and every night before sleeping.

Patient E.D.B cannot attend the mass because of her hospitalization but she always prays and believes that God will always bless

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

and help her.

PHYSICAL ASSESSMENT

PHYSICAL ASSESSMENT

Body Parts Normal Findings Actual Findings Interpretation/Analysis

SKINInspection

Skin color varies from light to dark brown.

Palpation

Skin temperature is warm to touch.

Inspection

Skin color was brown complexion. No abrasions or lesion found. Temperature was warm, dry, rough elastic turgor and mobile.

Abdomen has stretch marks.

Palpation

Skin is warm to touch.

Presence of stretch mark in the abdomen due toprevious and present pregnancy.

NORMAL

HEADSCALP

Inspection

White, clean and no scars, nits, dandruffs and lesions.

Palpation

Free from masses and lumps.

Inspection

Scalp is white, clear and there is no presence of lice, scars, dandruff and lesions.

Palpation

Free from masses and lumps.

NORMAL

NORMAL

HAIR Inspection

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

Inspection

Color of hair was black and evenly distributed that covers the whole scalp, shiny, free from split ends.

NORMAL

FACEInspection

Oblong, oval, square or heart-shaped, symmetrical. Facial expression depends on the mood or true feelings, no wrinkles, no involuntary movements.

Inspection

Face is oblong symmetrical, expression depends on the patient’s mood or feelings, has little bit of wrinkles on the side of both eyes, no involuntary movements.

Wrinkles due to her age.

EYES Inspection

Parallel and evenly placed symmetrical, non-protruding and clear.There is scant amount of secretions, both eyes are black and clear.

Inspection

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

NORMAL

SCLERA Inspection

Pinkish and Clear

InspectionNORMAL

PUPILS Inspection

Round,Symmetrical,constrict with increasing light and accommodation.

Inspection

Round,Symmetrical,constrict with increasing light and accommodation.

NORMAL

EYE MOVEMENTS

Inspection

Able to move eyes in full range of

Inspection

Able to move eyes in full range of

NORMAL

motion in all directions.

motion in all directions.

EARS Inspection

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

Palpation

Firm cartilage.

Inspection

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

Palpation

Ear cartilages are firm.

NORMAL

NOSE Inspection

Clean,pinkish with few cilia, airways are clear.

Inspection

Clean, pinkish with few cilia and both nasal airways are patent.

NORMAL

MOUTH A.LIPS

B.TEETH

Inspection

Pinkish, symmetrical, lip margin well-defined.

Inspection

NECK Inspection

Proportional to the size of the body and head, symmetrical and straight.

Inspection

Proportional to the size of the body and head, symmetrical and straight.

NORMAL

Palpation

No palpable masses, lumps or area of tenderness.

Palpation

No palpable masses, lumps or areas of tenderness.

NORMAL

THORAX Inspection

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

Palpation

No lumps,masses, areas of tenderness.

Inspection

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

Palpation

No lumps, masses,areas of tenderness.

NORMAL

NORMAL

HEART Auscultation

Cardiac rate ranges from 60-100 beats per minute.

Auscultation

Cardiac rate is 80.Beats per minute

NORMAL

ABDOMEN Inspection

Skin is unblemished, No scars, flat, rounded (concave), scaphoid (concave), symmetrical movements caused by respiration, umbilicus is flat or

Inspection

Skin has presence of striae gravidarum.

There is (+) abdominal distension.

Abdominal Girth:

concave, positioned midway between the xiphoid process and the symphisis pubis, color is the same as the surrounding skin.

Palpation

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

EXTREMITIES Inspection

No scars, No edema,skin is as the same as the surrounding area.

Inspection

No scars, (+) edema on both lower extremities.

Edema is brought up by fluid retention in the body.

ANATOMY AND PHYSIOLOGY