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Case Presentation Normal Veginal Delivery
Case Presentation Normal Veginal Delivery
YEAR OF STUDY—2018
IDENTIFICATION DATA
AGE— 25years
SEX— Female
RELIGION— Hindu
EDUCATION— Graduation
DISCHARGE DATE—
DIAGNOSIS – Primigravida at 37wk 1day with latent labourP1L1 (VD WITH ii0 perineal tear)
OCCUPATION— Housewife
WEIGHT—59 kg
HIGHT—152cm
CHIEF COMPLAINS—
FAMILY HISTORY—
She belongs to a joint family having 6 numbers. Her husband &1 Brother-in-law are the supporting person in her family. The monthly income
of her family is nearly about Rs 40,000. There is no history of any disease like TB, HTN, DM & hereditary disease , twin pregnancy in her family.
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 bore well 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 & 3-5 days duration with average amount of bleeding. Her LMP is
18/5/18 and EDD- 25/02/19.
She is married since 1 years & she has satisfactory relationship with her spouse. General health of her spouse is good.
OBSTETRICAL HISTORY—
INVESTIGATIONS—
Hb=10.6gm%
FBS=88mg/dl
Urine for HCG=positive
Blood group— ‘A’ 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 20/1/19 showing single live intra-uterine foetus in cephalic presentation.
PHYSICAL XAMINATION—
VITAL SIGN—
Temp –98.4 F
BP—130/80mmhg
Pulse –88beat/min.
Resp –22 braeth/min.
INSPECTION—
PALPATION—
P/V EXAMINATION—
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 st
The duration of 1 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 2/8 th 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.
ACTUAL MANAGEMENT:
General
Fluids in the form of plain water, ice chips or fruit juice may given
be given in early labour. Intravenous fluid with ringer solution
is started where any intervention is anticipated or the patient
is under regional anaesthesia.
GENERAL MEASURES
Expectant management
Active management
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.
Timing: Episiotomy is specially done during contraction just prior to crowning when the head is visible 3-4 cm. in diameter.
INDICATION:
TYPES:
There are 4 main types of episiotomy these are as follows
Degree of episiotomy
REPAIR OF EPISIOTOMY
The repair is done soon after the expulsion of placenta and membrane
Timing of repair: the repair is done soon after expulsion of placenta. If repair is done prior to that, disruption of the wound is inevitable, if
subsequent manual removal or exploration of the genital tract is needed. Oozing during this period should be controlled by pressure with a
sterile gauze swab and bleeding by the artery forceps. Early repair prevents sepsis and eliminates the patient’s prolonged apprehension of
“stitches”.
Preliminaries: The patient is placed in lithotomy position. A good light source from behind is needed. The perineum including the wound area
is cleansed with antiseptic solution. Blood clots are removed from the vagina and the wound area. The patient is draped properly and repair
should be done under strict aseptic precautions. If the repair field is obscured by oozing of blood from above, a vaginal pack may be inserted
and is placed high up. Do not forget to remove the pack after the repair is completed. The repair is done in three layers.
The vaginal mucosa is sutured first. The first suture is placed at or just above the apex of the tear. Thereafter, the vaginal walls are apposed by
interrupted sutures with polyglycolic acid suture (Dexon) or No. “0” chromic catgut, from above downwards till the fourchette is reached. The
suture should include the deep tissues to obliterate the dead space. A continuous suture may cause puckering and shortening of the posterior
vaginal wall. Care should be taken not to injure the rectum.
DAY – 1 (27/11/2017)
DAY 2 (28/11/17)
SUBJECTIVE DATA: Risk of infection related To reduce the risk of The risk of getting
She said I am not to the surgical incision getting infection Assess the incision site. infection was reduced a
able to take care as evidenced by Advice her to take daily care little.
of the incision site. observation of the site of the incision site.
Objective data Antibiotic medication is given
Swelling of the site to reduce the risk of infection.
Local tenderness
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 :
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 3 rd edition (2012)
pg no- 572.
College of nursing ,
Berhampur
Antenatalcasestudy
on
chronicHTN
SUBMITTED BY : Miss Madhusmita Nayak
SUBMITTED ON :04/04/2014