INTRANATAL CASE RECORD - 8

Labour chart

Date and Time of admission to the labour room: 08.04.2020 at 12pm

Admitted for safe confinement: Yes

If No, admitted with complaints of Pain/Leaking PV/Show/Other complaints: Pain

Condition on admission: True labour pain

Vital Signs: T - 98.60F P - 72bpm R - 22bpm BP – 130/90 mm of Hg

Bowel: Enema given Bladder: Emptied

Urine: Alb - Nil Sugar - Nil

Oedema: No

Modified Bishop’s Pre-Induction Cervical Scoring

Parameters Score
Date: 0 1 2 3
Time:
1) Cervical Dilatation √
2) Cervical Length √
 3) Cervical Consistency √
4) Fetal Head Station √
√
Total Score 10
Interpretation: Favourable for vaginal delivery

Obstetrical Examination (During active phase of labour/ <3cm dilation)

Abdominal Vaginal Examination Status of Vaginal Bleeding Nature of Special

Examination Membranes Contraction Procedures
1) Fundal 1) Time 1) Intact 1) None 1) NA 1) None
Height – 12pm - Intact 2) Spotting 2) Present √ 2) NST √
- 34cms 2) Sterile vaginal 2) Ruptured – Not Date and 3) Ultrasoun
2) Presentation Examination ARM done at present Time- d
- Cephalic - Yes 1 pm 3) Blood show - 08.04.2020 at 4) Biophysica
3) Position 3) Dilatation 3) Leaking √ 12.30pm l Profile
- LOA – 5 cms 4) Colour 4) Frank 3) Regular √ √
4) Engagement 4) Effacement –Clear bleeding 4) Frequency - DFMC
- Engaged – 50-60% 5) Odour - Not 2-3 5) Drugs
5) FHR: 5) Consistency - Normal present contractions Given
- 142bpm - soft 5) Any other 5) Duration Inj. Pitocin
6) Station - <20 sec 5U
0 6) Intensity IVF RL
7) Ballotment - Moderate 500ml
- Not ballotable Inj.
8) Position of occiput Methergin
 LOA 1 amp IV

Modified WHO Partograph

Name: Mrs. Aleesha
Gravida: 1
Para: 0
Hospital No:
Date of admission: 08.04.2020
Time of admission: 12pm
Ruptured membrane:
12pm: Amniotic fluid – I, FHS- 134, BP-120/80, HR-76, Cervix-5cm. descent-
0, protein & acetone-nil, 4 mild contractions
12.30pm: FHS- 138, 3 mild contractions
1pm: Amniotic Fluid –C, Moulding +, FHS- 140, BP-110/70, HR-74, urine-
200cc, 4 mild contractions
1.30pm: FHS- 144, 4 moderate contractions
2pm: FHS- 146, BP-120/80, HR-76, Temp-98.6 0F, 5 moderate contractions
2.30pm: FHS- 142, 5 moderate contractions, 5moderate contractions
3pm: FHS – 136, BP-130/80, HR-80, Inj. Oxytocin 5U at 16 drops, 2 severe
and 3 moderate contractions
3.30pm: FHS- 140, 5 severe contractions
4pm: FHS-148, BP-120/80, HR-74, urine-250cc, Inj. Oxytocin 10U, Inj.
Methergin, 5 severe contractions
4.30pm: cervix-10cm, descent +3, Baby delivered at 4.30pm
5pm: BP-120/80, HR-74
 Intrapartum Observation

Type Time Total Hours Date and Time Nature of Mode of

of Delivery Delivery Delivery
From To
I Stage 10.10am 4.10pm 6 hrs 08.04.2020 at Spontaneous Full term
II Stage 4.10pm 4.30pm 20min 4.30 pm Normal normal
III Stage 4.30pm 4.40pm 10min Vaginal vaginal
IV Stage 4.40pm 6.10pm 1.5hour Delivery with delivery
Right Medio
Lateral
Episiotomy
Total Duration: 8 hours

Episiotomy Placenta
Type: Right medio lateral epsiotomy Method of:
a) Separation: Mathew Duncan
b) Expectant Management: Inj. Pitocin 10U IV
c) Active Management: Controlled cord traction
Anaesthesia: Inj. Lignocaine Mannual removal of Placenta: No
Suture: Vicryl 2-0 Abnormalities any: No
Laceration: No Weight of the Placenta: 490gms
Length of the cord: 48cms
 Membranes: Complete
Repair: Episitomy repair is done in 3 layers Bleeding: WNL