Faculty of Medicine and Health Sciences, UTAR

Score sheet for CASE write-up

OBSTETRICS & GYNECOLOGY

Year 5 MBBS

Student name : Ng Chiew Min

ID No. : 13UMB04368 Year : 5

Name of lecturer: Dr. Khine Pwint Phyu

Marks allocation of case write-up

Chief complaints /5 Clear report on management (postop /15

History chronologically clear with /15
relavant positive & negative findings,
systemic review, personal
Physical Examination findings are clearly /15
and comprehensively documented, with
relevant positive and negative findings
included
Summary of case clear and concise /5
Clear and logical discussion of diagnosis /10
/Differential diagnosis , supported by
clinical evndence
Investigations on day of admission (with /5
appropriate indications results and correct
interpretation)
gyne / post-delivery)
& progress of patients in the ward
Subsequent investigations: indications /10
appropriate, results reported and
interpretations correct
Appropriate final diagnosis at discharge /5
or death (including clinical and
laboratory evidence to support this
diagnosis)
A MOCK discharge summary to GP and /5
a MOCK prescription to patient at
discharge, if relevant
Clear and critical discussion of case /10
(learning issues, evidence-based
management, prognosis and ethical
issues of this patient, professionalism
Total score /100
 Faculty of Medicine and Health Sciences, UTAR

Case Write-Up III

OBSTETRIC AND GYNAECOLOGICAL POSTING

Year 5 MBBS

PATIENT IDENTIFICATION

Patient’s Initial: Madame A R/N: AM00584975 Age: 32 years old

Gender: Female Ethnic group: Malay

Date of admission: 24/10/2017 (8.00 a.m.) Date of Discharge: 27/10/2017

Date of clerking: 25/10/2017 (9.30 a.m.)

Source of History: Patient

Presenting Complaints (PC):

 Electively admitted for induction of labour due to oligohydramnios, presented with one
day history of blood stained vagina discharge.

History of Presenting Illness (HOPI):

LMP: 27/1/2017 EDD: 3/11/2017

Madame A, Gravida 3 Para 1+1, currently at 39 weeks of period of gestation, with a background
history of gestational diabetes mellitus, presented with one day history of blood stained vagina
discharge. This was an unplanned but wanted pregnancy. Urine pregnancy test was tested
positive at 5 weeks of period of amenorrhea (POA). She also had her dating scan done on the
same day as she went to a private clinic to confirm her pregnancy; dating scan was corresponded
to date.
The early part of pregnancy was not associated with excessive nausea and vomiting or back pain.
No history of urinary tract infection. There was history of vaginal discharge throughout the
whole pregnancy, she did not notice this before she was pregnant. The discharge was yellowish
in colour, no blood associated and it was not foul smelling. She went Hospital Ampang for a
treatment. High vaginal swab was done and the result came back negative. Therefore, no
treatment was given.
Initial booking was done at 17 week of period of gestation at Klinik Kesihatan Sentul. Her
weight at that time was 65kg, height was 153cm and therefore the body mass index (BMI) was
27.8 kg/m2 (overweight). She gained a total weight of 10kg throughout her pregnancy, which is
appropriate. Her blood pressure was 97/62mmHg, Haemoglobin 11.1g/dL and her blood group
was O positive. Infection screening was done and they were all negative for Hepatitis B, HIV
and syphilis. No glycosuria or proteinuria. Modified glucose tolerance test (MGTT) was done on
the same day of booking. Fasting blood glucose is 5.2 mmol/L and 2 hour post-prandial was 8.1
mmol/L. Therefore, she was being diagnosed with Gestational Diabetes Mellitus at that time. She
was referred to dietician for diet control. No oral hypoglycaemic medications or insulin injection
needed.
She was being asked to perform Blood Sugar Profile (BSP) every two weeks the day before she
came for antenatal follow-up to monitor her blood glucose control. She had a 4 points BSP
monitoring, including fasting blood glucose and 3 one hour post-prandial blood glucose. All the
fasting blood glucose ranged from 4.9 mmol/L to 5.2 mmol/L and the post-prandial blood
glucose ranged from 4.7mmol/L to 7.0mmol/L. Her blood glucose was well controlled. No other
abnormality detected, no anaemia or hypertension in pregnancy. HbA1c was done once at 23
weeks period of gestation with a reading of 4.7% indicating she has good blood glucose control
for the past three months. No detailed scan of the fetus done. Yet, the ultrasound scans in the
antenatal follow-up were all normal. No congenital abnormalities detected and fetus was
growing well. Amniotic fluid was adequate, no polyhydramnios or oligohydraminios noted. Fetal
movement was good until now.
On the day of admission, she noticed she has vagina discharge in the morning and she had sexual
intercourse the night before. She noticed the discharge has blood stained and it soaked partial of
sanitary pad. No blood clot or fresh blood seen. No contraction pain, no leaking liquor, no fever,
no signs and symptoms of urinary tract infection. No previous history of antepartum
haemorrhage. Vaginal examination done at PAC Hospital Ampang showed that cervical os was
opened at 1cm. No cord or placenta seen. Membrane was intact. Cervical length was 2cm, firm
in consistency in axial position.
The latest scan done was at Hospital Ampang before admission to the ward (at 38 weeks of
gestation) showing parameters equal to date, singleton, cephalic presentation, longitudinal lie and
placenta at the posterior upper segment. Amniotic fluid index (AFI) was 6.1 cm which indicating
oligohydramnios and estimated fetal weight was 3201g. Fetal heart activity was seen. Therefore,
she was admitted to the ward for induction of labour.
No previous medical history of diabetes mellitus, hypertension or Thalassemia. No medication
history of ACE inhibitors or NSAIDs.
Systemic Review:

 General: No fever, no lethargy, no loss of appetite or loss of weight

 CVS: No chest pain, no palpitation, no orthopnea, no paroxysmal nocturnal dyspnea
 CNS: No headache, no blurring of vision, no seizures
 RESP: No cough, no sputum, no shortness of breath
 GIT: No nausea or vomiting no changed of bowel habit.
 GUT: No dysuria, no urgency, no frequency, no incontinence.
 MSK: No bone or joint pain, no deformity

Past Medical History (PMH) and Past Surgical History (PSH):

She has no history of diabetes mellitus, hypertension, asthma, coronary artery disease, stroke or
malignancies. No past surgical history.

Past Obstetric History:

This was Madame A third pregnancy. The first pregnancy was in 2009, baby girl, born via
spontaneous vagina delivery at term with a birth weight of 2.8 kg at Hospital Kuala Lumpur. She
is currently alive and well. She used IUCD for two years after that delivery and she has been
subfertility until the year 2015, she conceived again. Unfortunately, she had complete
miscarriage at 12 weeks of gestation. No dilatation and curettage done. She went for subfertility
investigation and she was being advised to reduce her body weight before considering other
method for assistive conception. She followed the advice and she successfully reduced a body
weight of 10kg before this pregnancy. There was no previous history of gestational diabetes
mellitus, pregnancy induced hypertension and also anaemia in pregnancy.

Past Gynaecological History:

Madame A attained her menarche at the age of 12. Since then, her menses has been regular with
a 28 days cycle, normal flow of 6 to 7 days. She stated that she used 3 to 4 pads per day for her
menses. No history of dysmenorrhea, menorrhagia or intermenstrual bleeding, post-coital
bleeding or dyspareunia. No history of urinary tract infection or sexually transmitted diseases.
She married 10 years ago and she was currently sexually active. She did not use any
contraceptive method. No PAP smear done before.

Family History (FH):

Madame A’s father has diabetes mellitus and hypertension while her mother has bronchial
asthma. Otherwise, all other family members were well healthy. No family history of malignancy.

Medication History:

Madame A did not take traditional medications. She is only taking T. Zincofer 1/1 OD and also
Allergy:

No known allergy to medications or food.

Social History (SH):

Madame A is a housewife and she married 10 years ago. Her husband is a soldier. Both of them
did not smoke or drink alcohol. She is currently staying with her husband and the family in
Bandar Mahkota Cheras. She wishes to have 4 children however she only planned to use natural
method as contraception.

Physical Examinations:
General Examination:

Anthropometric measurement:

Weight 75 kg
Height 153 cm

BMI 32.0 kg/m2

BMI of Madame A is overweight.

Vital Signs:

Blood Pressure 110/65 mmHg Normal

Temperature 37.1oC Afebrile
Pulse Rate 80 beats/ min, good volume, normal rhythm Normal
Respiratory Rate 20 breaths/ min Normal
SpO2 100% Normal

 Madame A was alert, conscious, cooperative and lying on the bed. She was not in pain or
respiratory distress.
 Upon examination of her hand, there was no pallor, no clubbing, no peripheral cyanosis,
no leukonychia, no koilonychias, no palmar erythema and no dupuytren contracture is
noted. Capillary refill time was less than 2 seconds.
 On examination of the eye, there was no subconjunctival pallor or yellowing of the
sclera.
  On examination of the mouth, there was no angular stomatitis, glossitis, jaundice or
central cyanosis. Oral hygiene was poor. The tongue was coated.
 Hydration status and nutritional status was good.
 No generalised lymphadenopathy.
 No pedal edema or calf tenderness.

Systemic Examinations:

Abdominal Examination:

 On inspection, the abdomen was distended by a gravid uterus as evidenced by linea nigra
and striae gravidarum. Abdomen moved with respiration. Umbilicus was centrally
located and flat. No dilated veins, no scar, no abnormal hyperpigmentation or fetal
movements seen.
 On superficial palpation, the abdomen was soft and non-tender. Uterus was not irritable.
 On deep palpation, the clinico-fundal height was at 34 weeks with flank fullness.
Symphysio-fundal height was 36cm.
 There was a singleton, cephalic presentation in longitudinal lie. Fetal back is a maternal
left side and fetal head is 3/5 palpable. Liquor volume was adequate. Estimated fetal
weight was 2.8kg.

Pelvic Examination (Done by doctor-in-charge)

 Speculum examination:
o Vulva and vaginal were normal. Cervix was healthy, minimal stale of blood seen.
No pooling of liquor. No cord or placenta seen. High vaginal swab was taken.
 Vaginal examination:
o Cervix was 2cm and cervical os is 1cm, it was firm in consistency in axial
position. Station of fetal head was -2. Membrane intact, no cord or placenta seen.
 Bishop score: 6/13

Cardiovascular Examination:

 On inspection of hands, no splinter haemorrhage, Janeway lesion or Osler node was

detected. The radial pulse was palpable at 80 beats/minute, good volume with regular
rhythm, no atrial fibrillation, no collapsing pulse or radial-radial delay. No xanthomata on
the palmar and extensor surfaces of the hands and no xanthelasmata or corneal arcus at
the eyes. No raised jugular venous pressure (JVP). No scars, no dilated veins, no visible
pulse and no deformities detected.
 On palpation, the apex beat was felt at the 5th intercostal space, mid-clavicular line. No
thrill or heave felt.
  On auscultation, first and second heart sound can be heard clearly with no murmur heard
on the mitral, tricuspid, aortic and pulmonary regions.

Respiratory Examination:

 On inspection, Madame A was not tachypnic or in respiratory distress. No stridor heard.

Respiratory rate was 20 breaths per minute. No flapping tremor. There was no chest
deformity such as pectus excavatum, pectus carinatum or Harrison’s Sulcus. There was
no scar on the chest region. No dilated veins seen on the chest.
 On palpation, chest expansion was symmetrical on both sides. Trachea was located
centrally. Vocal fremitus was resonant and symmetrical on both sides.
 On percussion, the percussion note was resonant and equal on both sides.
 On auscultation, normal vesicular breath sound was heard with no added sound.

Central nervous system:

 On inspection, there was no muscle wasting of all limbs. No fasciculation or abnormal

movement seen.
 The tone was normal for all limbs. The power was graded 5/5 for all the limbs.
 All reflexes are normal.
 There was no loss of sensation.
 Cranial nerves:
o Olfactory (I) nerve was not tested because patient has no problem with smell.
o Optic (II) nerve: Pupillary reflex is normal. Fundoscopy was not done.
o Other cranial nerves were intact.
 Coordination was intact.
 Gait was normal.

Musculoskeletal system:

 On inspection, all limbs were normal with no scar, no swelling or deformities.

 On palpation, there was no increase in temperature for all the limbs. No tenderness over
the joints.
 The ranges of movement of all joints tested were within normal range.
Summary of Case:

Madame A, Gravida 3 Para 1+1, currently at 38 weeks of period of gestation, with a background
history of gestational diabetes mellitus on diet control electively admitted for induction of labour
due to oligohydraminios presented with one day history of show. There was a history of vagina
discharged but there was no history of regular contraction pain, leaking of liquor, fever or signs
and symptoms of urinary tract infection. Her diabetes mellitus was well controlled. No other
medical disorder or fetal anomalies noted in antenatal follow up. Physical examination shows
gravid uterus smaller than date, singleton with a cephalic presentation, fetal head was 3/5
palpable, cervical os opened at 1cm with a Bishop Score of 6/13.

Provisional Diagnosis:
 Idiopathic Oligohydramnios
 Evidence support
o History:
 Oligohydramnios on ultrasound scan at 38 weeks of gestation (AFI 6.1cm)
 Uterus smaller than date
 No causes can be confirmed for oligohydramnios as the fetus are growing
well, no congenital deformities, no leaking liquor
 History of vaginal discharge during pregnancy.

Differential Diagnosis:
Differential Diagnosis
1. Oligohydramnios
secondary to
Prelabour Rupture of
Membrane at term
Evidence Support Evidence against
1. Madame A presented with 1. No leaking liquor
blood stained vaginal 2. No pooling of liquor
discharge 3. Oligohydramnios
2. Oligohydramnios on 4. Fetus with normal
presentation
ultrasound scan with an
AFI of 6.1cm
3. Uterus smaller than date
4. There is a possibility of
hindwater leaking where
the speculum examination
may show intact membrane.
5. No regular uterine
contraction pain indicated
that she is not in labour
Relevant Investigations:
Relevant Investigations
 Full Blood Count (FBC)
 C-Reactive Protein (CRP)
 Random Blood Glucose
 UFEME
 High Vaginal Swab
 Ultrasonography
 Doppler ultrasound
 Cardiotocography (CTG)
Justification
 Look for signs of infection
 To look for signs of infection and
inflammation
 To monitor her blood glucose as Madame
A has gestational diabetes mellitus
 To rule out urinary tract infection as the
risk for prelabour rupture of membrane.
 To rule out vagina infection
 To determine whether the patient need to
be treated with antibiotic prior to labour
 Determine the Amniotic Fluid Index
 To check for fetal lie and presentation
 To rule out intrauterine growth restriction
(IUGR)
 Non-specific. However, it can be used as
a baseline for future management
monitoring.
Results of Investigations Available and Interpretations:

Blood group: Blood Group O, Rhesus positive.

Full Blood Count (FBC):

Investigation Result Normal Range Interpretation

Red Blood Cell 4.55 x 106/uL 4.53-5.95 Normal
Haemoglobin 11.9 g/dL 11.5 - 16.0 g/dL Normal
Haematocrit 40.2 % 40.1 - 50.6% Normal
Mean Cell Volume 93.5 fL 80.6-95.5 Normal
(MCV)
Mean Cell Haemoglobin 30.7 pg 26.9-32.3 Normal
(MCH)
Mean Cell Haemoglobin 32.9 g/dL 31.9-35.3 Normal
Concentration (MCHC)
Platelet 291 K/uL 142-350K/uL Normal
Red Cell Distribution 14.6 % 12.0-14.8% Normal
Width
White Blood Cells 12.7 K/uL 4.0 - 11.4K/uL Raised
Interpretation: Presence of leukocytosis indicating presence of infection.

White Cell Differential Count:

Result Normal Range Interpretation

Absolute Neutrophil 8.6 K/uL 3.9 - 7.1 K/uL Raised
Absolute 3.2 K/uL 1.8 – 4.8 K/uL Normal
Lymphocyte

Absolute Monocyte 0.7 K/uL 0.4 - 1.1 K/uL Normal

Absolute Eosinophil 0.2 K/uL 0.0 – 0.8 K/uL Normal
Absolute Basophil 0.0 K/uL 0.0 -0.1 K/uL Normal
Interpretation: Raise in neutrophil count suggesting bacterial infection.

Cardiotocography (CTG)

 Baseline Fetal Heart Rate is at 130 beats per minute

 Good variability, more than 5
 Positive acceleration
 Absence of deceleration
 Conclusion: Normal CTG
Ultrasound:

 Singleton in cephalic presentation

 Parameters equal to dates, no signs of intrauterine growth restriction
 Placenta located at the posterior upper segment. No retroplacenta clot.
 AFI is 6.1cm suggesting oligohydramnios.
 Estimated fetal birth weight was 3.2kg.
 Fetal heart and fetal movements seen.
 Umbilical artery Doppler ultrasound: normal waveform.

Management & Follow Up:

Madame A was admitted to ward 4C in Hospital Ampang. Initial management done after
admission were:

 Monitoring:
o Vital signs
o Cardiotocography
o Blood glucose
o Fetal kick chart
o Partogram
 Plan for induction of labour:
o Indications for induction of labour: Oligohydramnios
o Bishop score
o Prostin 3mg, maximum twice a day (Patient has no contraction pain, Prostin is
preferable)
o Monitor cervical dilatation
o Monitor CTG
o Watch out for complications of induction of labour
 Uterine hyperstimulation
 Uterine rupture
 Failed induction and the need for caesarean section
 Fetal distress
 Send blood for investigation (FBC, cross match of blood)
Intrapartum:

 She has been sent to the labour ward when her cervix os dilated to 4cm after one prostin
being inserted. She was given one pint of Hartmann solution.
 Her vital signs were normal.
 During CTG monitoring at the labour room, it was noted that the fetal heart rate
deteriorate to 70 beats per minute for 5 minutes.
 Therefore, she was rushed for a Emergency Lower Segment Caesarean Section (ELSCS)

Intra-operatively:

 Madame A was put in supine position under spinal anaesthesia

 Abdomen was cleaned and draped
 Pfannensteil incision was made and abdomen opened in layers
 Bladder pushed away caudally and retracted inferiorly with Doyan’s Retractor.
 Transverse incision made at the lower segment of the uterus
 Amniotomy was done and baby delivered.
 Placenta and membranes were delivered via controlled- cord traction. IV 40 units of
Pitocin and normal saline were given.
 Uterus is closed in 2 layers with Vicryl 1.0
 Rectus sheath was closed with Vicryl 1.0
 Skin was closed with Vicryl 3.0
 Vaginal toilet was done and blood clots evacuated.
 Intra-op findings:
o Peritoneal cavity was normal
o Lower segment was well formed.
o Fetus was engaged in left occiput transverse position
o Placenta was normal, weighed 480g. Cord normal with a length of 40cm. Cord
blood was taken for thyroid function test and G6PD assessment.
o Clear liquor
o Blood loss 200mls
o Fallopian tubes and ovaries were normal.
o Baby:
 Gender: boy, birth weight: 2.5kg
 Baby cried vigorously, good muscle tone. Apgar score 9/10 at 1 minute
and 5 minutes.
 No resuscitation needed. Pink, not in respiratory distress.
 Heart rate more than 100 beats per minute
 Newborn examination: No significant abnormality detected.
 Skin to skin and breastfeeding was done.
Post-operatively:

 Arterial blood gas was taken and it was normal.

 Monitor vital signs
 Madame A was told to lie in bed for 6 hours.
 Insert continuous bladder drainage for 6 hours.
 Pad chart monitoring
 Infuse 3 pints of normal saline and 2 pints of dextrose 5% over 24 hour
 IV Cefobid (Cephalosporin) 1g BD, IV Flagyl (Metronidazole) 500mg TDS for one day
 IV pitocin 40 unit over 6 hours.
 Voltaren 75mg BD. First dose is stared after 6 hours post-operatively
 Subcutaneous Clexane 40mg OD for 10 days.

Follow-up in the hospital:

 There was a dressing covering site of incision over the suprapubic region. It was not
soaked with blood. Madame A was not in respiratory distress, no fever but mild pain over
the site of incision. No calf tenderness.
 Abdomen was soft and there was pain over the site of incision. Uterus was well
contracted to 20 weeks size. No calf tenderness
 Lochia was normal.
 Vital signs were normal.

On Discharge:

 Wound inspection was done. No discharge or slough seen or erythematous around

wound.
 She was being discharged with:
o Hematinics
o Ponstan
o Gelusil
o Subcutaneous Clexane 40mg OD for 10 days.
o Follow-up in Klinik Kesihatan after 6 weeks for post-natal review, PAP smear
and also advise for contraception.
o Encourage breastfeeding
o Wound care
Final Diagnosis:

 Idiopathic Oligohydramnios with underlying Gestational Diabetes Mellitus on diet

control.

A MOCK discharge summary to GP and a MOCK prescription for patient at discharge, if

relevant.

Discharge Summary (MOCK)

Patient’s name: Madame A Ethnic group: Malay

Gender: Female
Age: 32-year-old

Date of admission: 24/10/2017

Date of discharge: 27/10/2017

Final diagnosis: Idiopathic Oligohydramnios with underlying Gestation Diabetes Mellitus on diet
control

Summary:

Status: Day 2 Post ELSCS

Madame A, Para 2+1, currently at 38 weeks of period of gestation, with a background history of
gestational diabetes mellitus on diet control electively admitted for induction of labour due to
oligohydraminios presented with one day history of show. There was a history of vagina
discharge but there was no history of regular contraction pain, leaking of liquor, fever or signs
and symptoms of urinary tract infection. Her diabetes mellitus was well controlled. No other
medical disorder or fetal anomalies noted in antenatal follow up. Physical examination shows
gravid uterus smaller than date, singleton with a cephalic presentation, fetal head was 3/5
palpable, cervical os opened at 1cm with a Bishop Score of 6/13.

She was being induced labour with Prostin. However, fetal distress noted at cervical dilatation of
4cm. Therfore, Emergency Lower Segment Caesarean Section was done. Post-operatively,
Madame A was well. Baby was normal, no resuscitation needed.

 She was being discharged with:

o Hematinics
o Ponstan
o Gelusil
o Subcutaneous Clexane 40mg OD for 10 days.
 o Follow-up in Klinik Kesihatan after 6 weeks for post-natal review, repeat MGTT,
PAP smear and also advise for contraception.
o Encourage breastfeeding
o Wound care

Report written by,

Ng Chiew Min

UTAR MBBS Year 5

Discussion:
Oligohydramnios is defined as amniotic fluid index less than 5th centile for gestation.
The amniotic fluid index (AFI) for an ultrasound estimation of amniotic fluid derived by adding
together the deepest vertical pool in four quadrants of the abdomen. The AFI, measured in cm, is
therefore associated with some degree of error. In general, however, it is possible to differentiate
subjectively on ultrasound among normal, excessive or reduced.

It may be the result of decreased fetal urine production or excretion, or excessive loss of
amniotic fluid. Causes of oligohydramnios include premature preterm rupture of amniotic
membranes, congenital abnormalities of the fetus’s urinary tract, placental insufficiency, twin-to-
twin transfusion syndrome, post-maturity, maternal hypertension or the mother taking certain
medications such as NSAIDs or ACE inhibitor. Oligohydramnios in early pregnancy can lead to
underdevelopment of pulmonary hypoplasia, limb defect such as congenital talipes equinovarus
(CTEV) or intrauterine growth restriction. There is also increased risk of miscarriage, preterm
labour and also intrauterine death.

For Madame A, who was at 38 weeks of gestation, all her antenatal follow-ups are
uneventful except the gestational diabetes mellitus. Her liquor has been normal.
Oligohydramnios is only detected accidentally on the ultrasound scan based on the Amniotic
Fluid Index (AFI). There was no fetal anomaly detected and she has no hypertension or taking
medications which will lead to oligohydramnios. She presented with blood stained mucus which
is “show”, but there is no history of leaking liquor or contraction pain. Therefore, she was not in
labour when she presented to the hospital, but there was reduced in liquor volume. This might be
an idiopathic cause of oligohydramnios.

She was being admitted to the ward for induction of labour. The indication for the
induction was due to the oligohydramnios and the risk on the fetus. She was not being induced
because of her underlying gestational diabetes mellitus as her blood glucose was well controlled,
no insulin or oral hypoglycaemic agents needed. Besides, no complications develop because of
the diabetes mellitus, therefore, she can be delivered based on her estimated due date instead of
being induced labour at 38 weeks of gestation. To assess cervical status, Bishop score is used.
The cervix was favourable for induction of labour. Since she has not have uterine contraction,
Prostin, a Prostaglandin E2 is used instead of oxytocin. Risk and complications of the induction
of labour has been explained. However, fetal distress was noted during the first stage of labour.
Therefore, Emergency Lower Segment Caesarean Section (ELSCS) was done. No corticosteroids
is needed in this case as Madame A has reached term pregnancy. She has no risk factor or
contraindication for vaginal delivery, therefore, a vagina delivery would be appropriate for her.

My differential diagnosis for Madame A would be Prelabour Rupture of Membrane as I

detected that the uterus was smaller than date. However, on speculum examination, there was no
pooling of liquor seen. This indicates that is no leaking liquor and the membrane is still intact.
Yet, there is a possibility of “hind water” leak where the upper part of the membrane was
punctured. So, membrane can be still intact based on speculum examination. Therefore,
Amnisure test, fern test or Nizapine test can be done to differentiate whether there is leaking of
liquor. If the membrane is ruptured, the management would be different as antibiotic should be
prescribed prior to delivery.

Discuss patient safety, ethics and professionalism:

Madame A was friendly and cooperative and she was willing to share and tell me about the
illness. Rapport was established by respecting and giving the priority to patient's emotion and
feeling. Before asking the history from the patient and performing any physical examination,
self-introduction was done and consent was taken. Chaperone was provided and the curtains
were pulled throughout the physical examination to ensure patient's privacy. Hand washed was
performed for patient and also self-safety. One of the lifelong learning issues that I have learned
from this case are the theory is very important for us to perform a specific and relative clerking.
Technique to perform physical examination is also very important to elicit positive signs. More
practice is needed so that my technique is better.

Discuss communication issues:

Madame A is a Malay. Therefore, we communicated in Malay which we were both fluent in. So,
there is no communication issue in this case.
References:

1. Magowan, B. A., 2014. Clinical Obstetrics and Gynaecology. Third Edition ed. London :
Elsevier

2. Morgan A. Dobbs S. (2011). In: Morgan A. Dobbs S. Gynaecology by Ten teachers. 19th
ed. London: CRC Press

3. Sivalingam Nalliah, Sachchithanantham, 2015. Clinical Protocols in Obstetrics and

Gynaecology for Malaysian Hospitals, 1st Edition. Colour Box Publishing House.