amc clinical exam
A lady G2 P1+0 came for antenatal care and she wants to know when she should go to hospital for labour.
Task- Talk to the patient and address her concerns.Me- Hello, how are you today?
RP- I am very well doc, I came here today to know when should I go to hospital for labour. I am now 32 week pregnant.
Me- It is very good you came to see me to seek advice. Before advising you, can I ask you few questions first ?
RP- Yes
Me- How is your pregnancy so far? Blood tests ? Urine test? BP check ? Sweet drink test? 18 week USG ? Baby, placenta and fluid around baby ?
RP- Everything result is good so far. USG says single baby, placenta at the top.
Me- Any bleeding, water leakage ? Any high blood pressure, pain in the tommy, vision disturbance, swelling of the legs ? Is the baby kicking well? Any contractions ?
RP- No to all.
Me- So, is it your planned pregnancy? Any contraception? How are your periods? Regular? Did you exactly remember your LMP? Is the date consistent with USG?
RP- All normal answers.
Me- Can you tell me about your first baby? Any special events during pregnancy, labour and after delivery?
RP- Everything was good during pregnancy. But, the labour was prolonged for18 hours.
Me- Can you tell me more about it?
RP- I don’t know much doc but the labour was prolonged and finally I had to do lower segment Caesarian Section.
Me- Can I clarify a bit more about that? Please just answer me as much as you know.
RP- Yes
Me- What did the doctors say that time? Is the long labour due to poor contractions ? Or due to something obstructing the passage baby is coming out ? What is the birth weight of the baby? How many weeks pregnant were you that time? Was the labour of spontaneous onset?
RP- I am not really sure. But they didn’t tell me there is something obstructing my baby. He is 3.5 kg. I was at 40 weeks and the labour pain came spontaneously and it just got prolonged.
Me- Ok. Have you ever been bothered with mass of the uterus or ovaries before?
RP- No
Me- Any fractures of pelvis before? What is your height? Any prolonged labour in family due to pelvic bone abnormalities?
RP- No fractures. No problems in family. Height 1.7 m.
Me- How far do you live away from hospital ?
RP- 40 kms ( far )
Me- Whom do you live with at home? Where is your family? Any friends or relatives looking after you?
RP-I live with my husband. He is very supportive. Family is in interstate. I have friends as well but my husband is good enough.
Me- Any other medical issues with you or your family ?
RP- No
Me- Do you take folic acid?
RP- I am on multivitamin.
Me- Do you know your blood group? Rubella immunization status?
RP- A positive. Rubella immune.
Me – When was your last Pap Smear? Any STDs , PIDs before?
RP- Pap smear 1 year ago. Normal. No STDs.
Me- Ok Mrs X, it is very good that your pregnancy is going very well. However, as your previous pregnancy was prolonged, this pregnancy becomes high risk pregnancy. Your pregnancy should be cared in high risk antenatal clinic. Second pregnancy is generally shorter and easier than first pregnancy.
It is very hard to say exactly which time you have to come to hospital. Normal labour can start any time between 38 to 42 weeks.
For low risk pregnancies , we advise to come to hospital if pain and contraction starts, if there is breakage of water bag or passage of mucous mixed with blood.
However with you, I want to suggest you to relocate to a place near the hospital around 38 weeks of pregnancy. Do you have any one living near the hospital?
RP- No. Why do you want me to move to a place near hospital ?
Me- Well Mrs X, the reason of prolonged labour could be due to 2 causes. It could be due to just poor contraction of uterus. Or it can be due to obstruction either by mass in uterus or pelvis or due to small pelvis or due to big baby.
We have to look into that so that we can decide how we are going to deliver in second pregnancy. If it is due to contracted pelvis, we have to do CS which is unlikely in your case but OG will confirm it by doing internal examination with or without X ray.
Masses in pelvis or uterus is unlikely again given your normal USG in 18 weeks.
Babies tend to be bigger in subsequent pregnancy. We can check the size of the baby by USG at 34 weeks again.
Even if everything went well , I still want you to come near hospital at 38 weeks which is the time labour can start. And once labour pain starts, I want you to come to hospital immediately. Being near to the hospital, you can come to hospital with ambulance even if there is no one at home to bring you to hospital. And specialists will very carefully monitor your uterine contraction and baby’s well being since from the start of labour pain.
If you need help with that, I am able to organize social worker to help you with your relocation and looking after your child at home.
Examiner interrupted me at this stage and asked
Exminer: What other conditions should patient come to hospital?
Me- If there is headache, visual disturbance, RHC or epigastric pain, bleeding and reduced fetal movement.
Feedback: I felt I am pushing the patient for relocation near hospital and I am talking continuously. Actually I am totally not sure whether I should advise that or not. It just sticked into my mind that I always need to take safe side for both the patient and doctor in AMC exam!
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