Intra partum care

Internal examination 10cm

FHT-14 BP 110/70
PR:81
Temperature:36.8
Transferred to delivery table
Hook to pt monitor
Positioned lithotomy
Perneal repped done
Coach 10 proper bearing down
Delivered to an alive babyboy via normal spontaneous delivery
Cephalic presentation
Placenta oct completely
10 units oxytoxin incorporated to present NF 42gtts/min
Uterus well contracted
After care done
Transferred to recovery room
Post-partum care
D.BP110/ PR:80 Temperature:3 O2 Sat:99
A.Hooked 1/1 PT.Monitor
Encourage BF
Dra as instructed
Oral medication to start
R.Minimal vaginal bleeding
Uterus well constructed
BP 100/70 PR:81 Temperature:36.8

Course in the ward: Oct 17,2022- admission A 35 years old pregnant woman
presented to a physicians complaining of plank pain with epigastric pain, No dysuria ,
No fever consultation was done at the OPD AD her physician diagnosed CHRONIC
NON ACUTE PYELONEPHRITIS. She decided to order CBC urinalysis amylase, lipose,
HBsag, creatinine ,FBS 47, lipid profile SGOT 128 AND SGPT 95 and the laboratory
result is ACCALCULOUS CHOLECYSTITIS URINARY TRACT INFECTION The patient was
treated with Nitrofurantion 100mg, BID and was advised for admission if pain
becomes untolerable due to persistent flank pain consult was done at ER and was
admitted Day 1 10-18-22 Patient admitted to OB ward IVF = PL RS X 16 Doctors
order: CBC TX Cefuroxime 750mg. N 98 Monitor V/S 94 Fetal heart tone 92 Additional
meds. Methyldopa 250mg tab.P.O every other day Continue medication Paracetamol
lgm intravenous drip 96 For SGOT/SGPT Isoxuprine Hcl 10mg. 1 tab. 98
Doxomethasone 6mg. IM q 12 x 4 doses *high SGOT (X) epigastric pain radiating to
the back (X) nausea Patient scan examined Suggest the ff NPO for NOU Shift NF to
D5 Diagnostic Amylase, lipose, HBsag, creatinine, FBS, Lipid profile whole abdomen
ultrasound Repeat SGOT,SGPT tomorrow morning.

Day 5 Low back pain (+) clearance -May go home today -Home Meds Altered
comfort related to labor Concious and adherent -10:30 am Initial vital signs taken and
recorded -need attended Ensured safety Consent ward for admission Ampicillin skin
tested NST hooked and referred All laboratories requested Endorsed to LR ROO Ibbot
• Labor pains BP- 110/60, RR-19  T- 36.2, PR- 79 FNT: 145 LLQ IE: 3cm done be mon
olivette IVF receive of P Oxytocin x 15 g homis Monitor patient closely Seen and
examined by maam olivette DUC meds give Regulated present IVF to 5 wqll • O²
inhalation via nasal cannula at 2.6 cm Hooked PNSS 300 as fast drip doc Discontiue
oxytocin drip Hooked O⁵ LRS 12×8 hours Left side lying position Intra Partum Care
Intonam examination 10 cm FNT- 145 BP-110/70 PR-80   T- 36.8 Transferred to
delivery table Hooked to patient monitor Positioned Lithotomy Perineal prepped doc
Coach 10 proper bearing down Delivered to an alive baby boy via normal
spontaneous delivery Cephalic presentation Placenta Oct completely 10 units
oxytocin IM as per Doctors Order Another 10 unit of Oxytocin incorporated PO 42
gtts/min - Uterus  well contracted After care done Transferred to recovery room Post-
partum Care D- BP- 110/70 PR-80 T- 36.8 O² Sat- 99% A- hooked and patient
monitor Encourage BF Dra. Olivette Post Partum Order Dict as hooked instructed Oral
medications to start R- Minimal Viginal Bleeding Uterus well Contracted BP- 100/70
PR- 81 T- 36.8

Day 2- FHT-142 •Pain •Ranitidine not available •110/80 •Paracetamol to 1gm

(x30mins) N q8 •Maintain NPO •Whole Abdomen ultrasound as ordered •Vital signs
FNT q4 Day 3 •Refer to surgery •Pt. Seen and Examined •Approved with antibiotic
•No, surgical interventions •Repeat ultrasound after delivery Day 4 •On and off pain
•Complete 3 days of N ceforoxime then shift ceforoxime 500mg •Paracetamol 500mg
1 tab q4 for pain •Ferrous sulfate 1cap •FHT v/s q •Low back pain •Continue antibiotic
•Give ketorolac 30mg N PRN for low back pain •Still low back pain •DAT •Continue
meds •Shift NF to Heplock •V/s q4 •No Objection to discharge from confinement