A CASE STUDY ON NORMAL VAGINAL DELIVERY WITH

EPISIOTOMY
STUDENT NAME—Miss Sushruta Mohapatra

HOSPITAL—IMS & SUM HOSPITAL , BBSR.

YEAR OF STUDY—2018

IDENTIFICATION DATA

NAME OF THE PATIENT—Mrs.Pinky Samantray

NAME OF THE HUSBAND—Mr. Dushasan Das

AGE— 25years

SEX— Female

MARITAL STATUS— married

HOPITAL REGISTRATION NO— 190115035

WARD/BED NO— 2(maternity Ward) / Bed No- 9

ADRESS— At- Aranga, Dist - Khordha

RELIGION— Hindu
EDUCATION— Graduation

ADMISSION DATE— 15/01/19

DISCHARGE DATE—

DIAGNOSIS – Primigravida at 38wk 6days with latent labour

NAME OF THE DOCTOR— Dr. Shakti

OCCUPATION— Housewife

MONTHLY FAMILY INCOME— Rs- 45,000

WEIGHT— 70 kg

HIGHT—152cm

CHIEF COMPLAINS—

 Pain in lower abdomen since 2 days

 Mucoid discharge per vagina since 2 day

HISTORY OF PAST ILLNESS —

There is no past medical history of TB, HTN, DM

she has not undergone any surgical procedure.

FAMILY HISTORY—
She belongs to a joint family having 8 numbers . Her husband &2 Brother-in-law are the supporting person in her family. The monthly income
of her family is nearly about Rs 45,000. There is no history of any disease like TB,HTN, DM & hereditary disease , twin pregnancy in her family.

HEALTH FACILITY NEAR HOME—

There is a CHC in her village at a distance of about 6 km. Transportation facility available like bicycle & motorcycle

HOUSING —

She lives in a pucca house having 8 numbers of rooms with adequate ventilation. They use sanitary latrine for toileting. Electricity supply is
available. They use municipality water supply taps as well as own borewell for drinking.

PERSONAL HISTORY—

PERSONAL HYGIENE—She is maintaining her oral hygiene by brushing daily and taking bath once daily with soap & normal water.

 DIET—She takes both vegetarian & non-vegetarian diet & She takes meals 4-5 times a day. She don’t have any addiction of alcohol &
tobacco. She drinks about 3-4 lts of water per day. She takes rest of about 2 hrs at day time & 8 hrs during night time. She takes no
drugs for sleep.
 ELIMINATION—She has a regular bowel & bladder habits
 MOBILITY & EXERCISE—No regular walking habits. Only moderate activity with normal house hold work.

MENSTRUAL HISTORY—

She got menarche at 14 year of age with regular cycles of 28-30 days interval & 3-4 days duration with average amount of bleeding. Her LMP is
16/4/18 and EDD- 23/01/19.

SEXUAL & MARITAL HISTORY—

She is married since 1and 1/2 years & She has satisfactory relationship with her spouse. General health of her spouse is good.
OBSTETRICAL HISTORY—

 PAST OBSTETRIC HISTORY—

Nothing significant as she is Primigravida.
 PRESENT OBSTETRIC HISTORY-
She is a registered case . She had attended antenatal clinic 4 times,
Her LMP was 16/4/18 & EDD - 23/01/19. Thus the Gestational age (GA) is 37 weeks 6days.
 FIRST VISIT—
She missed her menstrual period & went to nearby clinic & tested her urine for pregnancy & become confirm of her pregnancy. On her
examination her weight was 60kg, BP=120/70mmhg , pulse =84bpm.At that time she suffered from minor ailments like nausea &
vomiting.
 SECOND VISIT-
She went to nearby clinic for 2nd antenatal checkup after 2months at that time her weight was 62kg, BP=130/80mmhg,
pulse=90bpm.

INVESTIGATIONS—

 Hb=7.9gm%
 FBS=85mg/dl
 Urine for HCG=positive
 Blood group— ‘B’ positive
 Sickling -- Negative
 Urine test=Albumin-- Not Present
=Sugar--Not Present
 VDRL=Negative
 HIV=Non reactive
 HbsAg =Non reactive
  HCV =Non reactive

 USG= done on 11/12/18 showing single live intra-uterine fetus in cephalic presentation.

OBSERVATION & ASSESSMENT—

 Her general appearance is good

 Patient is conscious & anxious
 She has no foul body odour & foul breath

PHYSICAL XAMINATION—

VITAL SIGN—

 Temp –98.4 F
 BP—130/80mmhg
 Pulse –88beat/min.
 Resp –22 braeth/min.

HEAD TO TOE EXAMINATION—

 Her skin colour is normal

 Hair & scalp are clean & healthy. No dandruff & pediculosis is present
 In eye ,no Jaundice & Pallor is seen
 Mouth is clean
 Tongue is hydrated
 Gum is healthy
 Total no of teeth is 32
 Nose, ear, throat are clear
  In neck no abnormal enlargement of lymph node & glands.
 In breast secondary areola has formed & nipple are normal,.
 Liver & spleen are not palpable
 Leg ,spine & back are normal
 pedal oedema is present

OBSTETRICAL EXAMINATION—

INSPECTION—

 No undue enlargement of the Uterus .

 Skin condition—healthy & no discolouration.
 Linea nigra is prominent
 Striae gravidarum visible all over the abdomen but mainly on lower part.
 Episiotomy wound present.

PALPATION—

 Uterus is hard, mobile & globular.

 Fundal height is 14 c.m i.e. at the level of umbilicus.

P/V EXAMINATION—

Vulva – Normal, No oedema

Perineal area & Anus – Clean

Lochia rubra present in normal amount

Episiotomy wound - Healthy

DEPENDENCY LEVEL OF PATIENT –

Patient is partially dependent.

CLINICAL EXAMINTION & NOTES

DIAGNOSIS— Vaginal delivery with right mediolateral episiotomy

INTRODUCTION— vaginal delivery is a normal procedure of child birth which due to the changes occurs in the female genital organs that can
able to push the viable products of a conception out of the maternal uterus.

DEFINITION— Delivery is the expulsion or extraction of a viable fetus out of the womb.

Labour: Series of events that takes place in the female genital organs in an effort to expel the viable products of a conception out of the womb
through the vagina in to the outer world is called labour.

STAGES OF LABOUR

IN BOOK IN PATIENT
 First stage: It starts from the onset of true labour pain & ends  The duration of 1st stage is 9hr 30min.
with full dilatation of cervix. Its duration is 12 hour in
primigravida & 6 hour in multipara.
 Second stage: It starts from full dilatation of cervix & ends  The duration of 2nd stage is 1hr.
with expulsion of fetus from the birth canal. Its duration is 2
hour in primigravida & 30 min in multipara.
 Third stage: It starts after expulsion of fetus & ends with  The duration of 3rd stage is 10min.
expulsion of placenta & membrane. Its duration is 15 min in
both primigravida & multipara.
 Fourth stage: It is the stage of observation for at least 1hour  The duration of 4th stage is 1hr.
after expulsion of after birth products.
MECHANISM OF LABOUR

To accommodate itself to the maternal pelvic dimensions, the fetus must undergo a series of changes in the attitude of its presenting part. This
is required for fetal descent through the birth canal.

Nine discrete cardinal movements of the fetus occur over the course of labor and delivery: engagement, descent, flexion, internal rotation,
crowning, extension, external rotation, restitution, expulsion of trunk & shoulder.

Engagement: Engagement is the descent of the widest part of the fetus through the pelvic inlet. This normally occurs 2-3 weeks before labour
in nulliparous women and may occur any time before or after onset of labour in multiparous women. In this the antero-posterior diameter or
biparietal diameter (9.5cm) of head coinsides with the transverse diameter of maternal pelvis.

Descent: Descent refers to the downward passage of the presenting part through the pelvis. Descent of the fetus is not a steady, continuous
process. The greatest rate of descent occurs during the deceleration phase of the first stage and during the second stage of labor.

Flexion: While descending through the pelvis, the fetal head flexes so that the fetal chin is touching the fetal chest. This functionally creates a
smaller structure to pass through the maternal pelvis. When flexion occurs, the occipital (posterior) fontanel slides into the center of the birth
canal and the anterior fontanel becomes more remote and difficult to feel. The fetal position remains occiput transverse.

Internal Rotation: Internal rotation is the 2/8th rotation of the presenting part from its original position (usually transverse with regard to the
birth canal) or 1/8th if the presenting part is in oblique diameter to the anteroposterior position as it passes through the pelvis. As with flexion,
internal rotation is a passive movement resulting from the shape of the pelvis and the resistance of the pelvic floor musculature.

Crowning: In this the biparietal diameter of head stretches the vulval outlet without any recession of head even after the contraction is over.

Extension: Extension occurs once the fetus has descended to the level of the introitus. This descent brings the base of the occiput into contact
with the inferior margin of the symphysis pubis. At this point, the birth canal curves upwards. The fetal head is delivered by extension and
rotates around the symphysis pubis. The forces responsible for this motion are the downward force exerted on the fetus by uterine
contractions and maternal expulsive efforts along with the upward forces exerted by the muscles of the pelvic floor.
External Rotation: After the fetal head deflexes (extends), it rotates to the correct anatomic position in relation to the fetal torso; left or right
rotation depends on the orientation of the fetus. This is again a passive movement resulting from a release of the forces exerted on the fetal
head by the maternal bony pelvis and its musculature and mediated by the basal tone of the fetal musculature.

Expulsion of shoulder & trunk: Expulsion refers to delivery of the body of the fetus. After delivery of the head and external rotation, further
descent brings the anterior shoulder to the level of the symphysis pubis. The anterior shoulder rotates under the symphysis pubis, after which
the rest of the body usually delivers without difficulty.

EPISIOTOMY:

Definition:

Episiotomy, also known as perineotomy, is a surgical incision of the perineum and the posterior vaginal wall generally done by a midwife or
obstetrician. Episiotomy is usually performed during second stage of labor to quickly enlarge the opening for the baby to pass through. The
incision, which can be done at a 90 degree angle from the vulva towards the anus or at an angle from the posterior end of the vulva (medio-
lateral episiotomy), is performed under local anesthetic (pudendal anesthesia), and is sutured after delivery.

Types: There are 4 main types of episiotomy these are as follows

1. Medio-lateral: The incision is made downward and outward from the midpoint of the fourchette either to the right or left. It is directed
diagonally in a straight line which runs about 2.5 cm (1 in) away from the anus (midpoint between the anus and the ischial tuberosity).
2. Median: The incision commences from the centre of the fourchette and extends on the posterior side along the midline for 2.5 cm (1
in).
3. Lateral: The incision starts from about 1 cm (0.4 in) away from the centre of the fourchette and extends laterally. Drawbacks include
the chance of injury to the Bartholin's duct, therefore some practitioners have strongly discouraged lateral incisions.
4. J-shaped: The incision begins in the centre of the fourchette and is directed posteriorly along the midline for about 1.5 centimetres
(0.59 in) and then directed downwards and outwards along the 5 or 7 o’ clock position to avoid injury to the external & internal anal
sphincter.
INCIDENCE –

PROM occur in approximately 10% of all pregnancies.

ETIOLOGY —

IN BOOK IN CLIENT
In majority causes are not known. Idiopathic
Possible causes are - ( Causes are not known)
 Increased friability of the membranes
 Decreased tensile strength of the membranes
 Polyhydramnios
 Cervical incompetence
 Multiple Pregnancy
 Infection – Chorio – amnionitis, Urinary tract infections
and lower genital tract infection
 Cervical length < 2.5 c.m
 Prior preterm labour
 Low BMI ( < 19 kg/m2)

SIGNS & SYMPTOMS--

IN BOOK IN CLIENT
Head reeling Present
Weakness Present
Edema Present
Mild :- rise of blood pressure of more than 140/90mmhg but less than 160 mmhg systolic or 110 mmg diastolic without significant protienuria.

Severe :- 1) a persist systolic blood pressure above or equal to 160mmhg or diastolic pressure above 110mmhg. 2) protien more than
5g/24hrs. 3) oliguria 4) HELLP syndrome. 5) cerebral or visual disturbance.

DIAGNOSIS –

Immediate :-

During pregnancy :- accidental hemorrhage ,oliguria and anuria , dimness of vision and even blindness, preterm labour, cerebral haemorrhage.

During labour :- PPH –may be related to coagulation failure.

Puerperium :- eclampsia usually occurs within 48hrs. Shock, sepsis.

IN BOOK IN CLIENT
Consistent BP recording of 140/90 mmhg or more . Done
Physical examination may reveal the long term effect of HTN such as – Done
retinopathy, ischemic heart disease & renal damage

COMPLICATION

FETAL :

Fetal risk is related to the severity of preeclampsia ,duration of the disease and degree of protienuria a) IUD b) intrauterine growth
retardation c) asphyxia d) prematurity.

MANAGEMENT—

IN MILD CASE WITH BP < 160/100 mm/Hg

IN BOOK IN CLIENT
Adequate rest Not done as it
Low salt diet was severe
Sedative (phenobarbiton 60mg 1-3 times /day)
Weekly check up upto 28 weeks

IN SEVERE CASES :-

IN BOOK IN CLIENT
Hospitalization Done
Antihypertensive drug (when BP > 160/100 mm/hg) Done
Spontaneous labor at term in mild cases Not Done
Termination done after 38 weeks in severe cases Not Done

Other possible managements :-

 Treatment of mild to moderate chronic HTN neither benefits the fetus nor prevents pre eclampsia .Excessively lowering BP may result
in decreased placental perfusion & adverse perinatal outcomes.
 When a patient’s BP is persistently > 150-180 (systolic) & 100-110 mm/hg(diastolic), pharmacologic treatment is needed to prevent
maternal end organ damage
 Methyldopa, Labetalol & Nifedipine (Procardia) are oral agents commonly used to treat pregnancy induced hypertension.
 Angiotensin converting enzyme inhibitors angiotensin-II receptor antagonists are not used because of teratogenicity ,IUGR, neonatal
renal failure .
 The beta blocker , atenolol (Tenarmin) has been associated with IUGR
 Women in active labour with uncontrolled severe chronic HTN require treatment with IV labetalol or Hydralazine.
Advice

Foetal growth may be assessed by serial fundal height measurements supplemented by USG at every 4 weeks starting at 28 weeks of gestation

DAY – 1 (27/11/2017)

GENERAL CONDITION OF ADVICE NURSING

MOTHER-- INTERVANTION

Patient conscious Tab.asomex 1tab BD Bed making

Febrile done
Pallor (-- ve) USG to be done Low salt diet
Pulse= 82bpm Mouth care
BP= 150/100mmhg given
Chest/CVS== NAD Vital sign
P/A= contraction checked
present I/O chart
BP/V= nil maintain
U/O= Adequate Bleeding P/V
checked
Medication
given in due
time

DAY 2 (28/11/17)
GENERAL CONDITION OF ADVICE NURSING INTERVANTION
MOTHER--

Patient conscious Tab. Calcigard 20 1 Bed making done

Afibrile tab BD Low salt diet
Pallor (-- ve) Tab. Labebet 100 1 Mouth care given
Pulse= 80bpm tab 6hrly Vital sign checked
BP= 148/90mmhg Tab. Paxum 1 tab I/O chart maintain
Chest/CVS== NAD HS Bleeding P/V checked
P/A= contraction Medication given in
present time
BP/V= nil

DAY 3 — (29/11/17)

GENERAL CONDITION OF ADVICE NURSING INTERVANTION

MOTHER--

Patient conscious Bed making done

Afebrile Tab. Labebet 100 1 Low salt diet
Pallor (-- ve) tab 6hrly Mouth care given
Pulse= 80bpm Tab. Paxum 1 tab Vital sign checked
BP= 130/82mmhg I/O chart maintain
Chest/CVS== NAD Bleeding P/V checked
P/A= contraction Medication given in
present time
BP/V= nil
She has undergone LSCS and delivered healthy baby.

30/11/17 1st POD

GENERAL CONDITION OF ADVICE NURSING INTERVENTION

THE MOTHER
BP- 160/100mmhg NPO Advice to importance
Pulse-80 /mts Inj dynapar 50mg BD of breast feeding.
Chest- NAD Inj ranitidine 150 mg Bed making is done
bd Checked vital signs
Medication given IV.

1/12/17 2nd POD

GENERAL ADVICE NURSING INTERVENTION

CONDITION OF
MOTHER
BP- 130/90 mmhg Inj ranitidine 50 mg iv OD Bed making done.
Pulse- 78/mts Vital sign checked.
Respiration- Assist in breast feeding.
23/mts. Sips of water given.
All medication given in due time.
CARE PLAN OF ANTENATAL MOTHER pregnancy induced hypertension.

assessment Nursing diagnosis Expected outcome intervention evaluation

Subjective data Pain related to surgical The patient will Assess the patient pain, Patient will have reduce
Mrs.rasmita says procedure as evidenced experience less pain. severity, duration of pain. pain after 1 days
that i am having by facial expression. Give comfortable position.
pain on surgical Check vital sign.
area. Provide calm and quiet
Objective data environment.
Facial expression Restrict the visitors.
Administer analgesic as per
doctors order
Subjective data Imbalance nutrition less Patient will have good Assess the level of Patient will regain weight
She said i don’t feel like to than body requirement appetite. nutrition. and have adequate
eating. related to loss of appetite Formulate diet nutrition.
Objective data as evidenced by weight plan in
Weight loss. loss. consultation with
Loss of appetite. Dietitian.
Measure total
intake output
chart.
Health teaching
regarding
contuining
balanced diet.
Teach food
preparation to
lessen fatty food
in menu.

ADVICE ON DISCHARGE :

Low salt diet

Adequate fluid to drink
Regular health visit
Antenatal foetal monitoring
 Be alert for complication like oedema, B p/v, excess weight gain, severe abdominal pain , vomiting , head railing
To seek immediately the medical attention in case any complication arises.
To avoid heavy lifting& climbing upstairs
To maintain personal hygiene
To take highly nutritious diet .
Iron & calcium to be continued

SUMMARY—

Mrs rasmita is a multigravida having GA 36 weeks & with pregnancy induced hypertension, is taken to improve nursing care. The care giver
established a good IPR with the client & her trust & confidence was gained. The client revealed all her problems, thus the care giver was able
provide care to meet the need up to an optimum. During this period she gains knowledge on different aspects like care of herself, regarding
possible complications, regular follow up, which makes her more confident & her anxiety was reduced & due to this she is now able to cope to
any stressful situation . She was also educated on nutrition, personal hygiene, antenatal exercise & regular follow up.

CONCLUSION—

Effect of my care—

After providing nursing care, the client has improved her self confidence .She feels relaxed & no anxiety is there. The client & family members
are very co-operative & they have trust on me.

BIBLIOGRAPHY—

1. DUTTA.DC “ Text book of obstretics “jaypee brothers medical publisher ,new delhi ,(2016).pgno-255-270.
2. Jacob annamma, A text book of midwifery ang gynaecological nursing, jaypee brothers medical publishers, new delhi 3rd edition (2012)
pg no- 572.
SUBMITTED BY : Miss Madhusmita Nayak

M .Sc nursing 1st year

SUBMITTED ON :04/04/2014