MENSTRUAL FUNCTION. Regular menstruation from the beginning. CLINICAL EXAMINATION. EXTERNAL EXAMINATION. SPECIAL OBSTETRICAL INVESTIGATION. Pelvimetry. Palpation of abdomen. Calculation of pregnancy’ term

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MENSTRUAL FUNCTION

Date/age of menarche: 13years of age

Regular menstruation from the beginning

Duration of flow: 5days

Menstruation occurs every 28 days

Volume of blood loss: about 50ml

CLINICAL EXAMINATION

EXTERNAL EXAMINATION

Her skin colour is normal. There are no any rashes, pigmentation, hemorrhage and external tumors.

Mucous membrane is moist and pinkish red.

Joints are regular in shape, not painful during movement.

Darkening of skin on white line can be seen, linea nigra and little pigmentation on face is present as the signs of pregnancy.

Temperature of body - 36. 7 º C

Height - 155 cm

Weight - 70kg

BMI - 29. 1

SPECIAL OBSTETRICAL INVESTIGATION

AC (Abdominal Circumferences): 95cm

SFH (Symphysis-Fundal Height): 35cm

Wrist circumferences: 16 cm

Expected body weight of fetus: 3. 5 kg

Pelvimetry

Distantia spinarum: 27cm

Distantia cristarum: 28cm

Distantia trochanterica: 32cm

External conjugate: 18cm {norm= 20-21cm}

Diagonal conjugate: 11cm {norm= more than 12cm}

Obstetric conjugate: 9cm (external conjugate-9) {norm= 11cm}

Anterior posterior diameter of the inlet: 9cm (diagonal conjugate-2)

{norm= 11cm}

Palpation of abdomen

The 1^st obstetrical grip: Longitudinal lie of the fetus

The 2^nd grip: fetus back is corresponding to the right side of the mother

The 3^rd grip: presentation is cephalic

The 4^th grip: convergence possible

Calculation of pregnancy’ term

By the first day of LNMP: February 14^th 2020

By the 1^st fetal kick: July 4^th 2020 (2^nd trimester) (21 week)

By the 1^st US: march 14^th 2020 (week 5) gestation sac visible

march 28^th 2020 (week 7) (heart beat detectable by ultrasound)

Estimated date of delivery: November 21^th 2020

Auscultation of the fetus heart sound :

Heart rate: 140 bpm

Heart sound: rhythmic

The most audible sound: right side of the mother’s abdomen

Clinical Diagnosis:

The main diagnosis:

The fetus is a term baby having rhythmic normal heart sound with the heart rate of 140 bpm.

Pregnancy is in the 2^nd stage of labor since there is rupture of bag of water and there is occurrence of expulsive pain

According to the pelvimetry of the mother we can see that the internal pelvis is small for the fetus head to pass through.

The fetus head is pressed on to the internal pelvis which is the 1^st plane of the pelvis.

Since the forewater is broken and the maternal pelvis is small for the fetal head to pass through cesarian section must be performed or else it might cause an injury to the fetal head

Complications:

The complication of C-section is infection of the wound causing redness, swelling of the endometrium.

Post-partum hemorrhage is to be seen due to excessive loss of blood after giving birth because of uterine atony.

Accompanying disease: None

Management

1. Listening to the heart sound every 2-3 min

2. Observing the rules of sepsis and antisepsis

3. Preservation of fetus

4. Monitoring of blood pressure of the mother

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