COMPETENCY APPRAISAL- OB/GYNE

AY:2017-2018; CASE SCENARIO’S

LEVEL – 4

INTRAPARTUM
This is the case of M.R. , a single 17 y/o , Roman Catholic, resident of Tondo Manila, who came in last
September 15,2018 due to watery vaginal discharge.
History of present illness:
Two hours prior to admission, patient experienced sudden watery vaginal discharged which was described
as clear non-foul smelling.
She was brought to Tondo MC-ER and was subsequently admitted.
Past medical history and family history is unremarkable. Obstetrical history, Gravida 1 Para 0 with last
menstruation period March 5,2018.
Menarche at age 14 with regular menstruation every 28-30 days, 4-5 days in duration. Patient had her prenatal check
up done in the clinic with irregular intake of FeSO4 and Multivitamins and 1 shot of Tetanus Toxoid.
Her first sexual contact was at age 15, no dyspareunia noted.
On physical examination, patient is awake, ambulatory with VS: BP 110/80, CR 88/min, RR 19, T 37.C;
anicteric sclerae, pink palpebral conjunctiva, symmetrical chest expansion, clear breath sounds;
adynamic precordium, apex beat at 5th LICS MCL; globular abdomen, fundic height at 35 cms, estimated fetal weight
of 3988 gms, based on ultrasound findings ,fetal heart tone 140/bpm.
Uterine Contraction: Mild-Moderate 2-3x/10 minutes lasting for 30 secs/contraction;
LM1: nodular, non-mobile structure, LM2: Firm smooth resistant structure on the Left, Small nodular part on the Right,
LM3: Mobile nodular structure, LM4: Unengaged; Internal examination: cervix- soft 2 cms dilated, 50% effaced,
cephalic, ruptured bag of water, clear, station -3.

At the labor room, fetal heart tone, maternal VS and progress of labor were monitored. After 4 hours, repeat
internal examination was done revealing cervix soft, 6 cms dilated, 70% effaced, cephalic, ruptured bag of water, clear,
station -3.
Uterine contraction at this time is 4 strong UC in 10 minutes lasting for 30-40 secs. Fetal Heart Rate at 140-150 bpm,
maternal VS: Bp 110-120/min, HR 100-110/min, RR 20, T 37.9C.
After 2 hours of labor there was no progress in contractions with fetal heart rate of 100-110 bpm. at the end of each
contraction, (+) thinly stained meconium discharge/vagina.
Maternal VS: 120-130/70-80, HR 110-120/min, RR 24, T: 38.C. Patient was scheduled for “E” CS with pre-operative
antibiotics of Piperacillin Tazobactam at 2.25 mgs/iv given stat and then every 8 hours.

Admitting Diagnosis: G1P0, Cephalic in labor, Prelabor rupture of membrane. Arrest in cervical Dilatation
secondary to Inlet Contraction vs CPD secondary to Large for gestational age baby.

Guide questions:
1. Review the 4 P’s of labor, relate these factors to the possible cause/s that brought about the problem of
Dystocia in this case”.)
2. Enumerate the risk factors that are present in our patient. (Related to dystocia)
3. Determine the relationship of the laboratory and diagnostic tests that helped establish the medical diagnosis
and the interventions that are appropriate for this case
 4. .Review the concept of the partograph and determine why this is not applicable to this case
5. Present the pathophysiology of this case utilizing a diagrammatic format..
6. Prepare a comprehensive nursing care plan that will address the priority problems of our client