Introduction

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MINISTRY OF EDUCATION AND SCIENCE OF RUSSIAN FEDERATION

Federal State Autonomous Educational Institution of Higher Education

«V. I. VERNADSKY CRIMEAN FEDERAL UNIVERSITY»

Medical Academy named after S. I. Georgievsky (structural subdivision)

ABSTRACT

SUBJECT: FILLING IN CASE HISTORIES OF LABOUR

STUDENT: Mohammed Jaffer Shariff

faculty IMF

course 4^th

group La-1-172(2)

NAME OF PRACTICE: Gynecology and obs. Department

SPECIALIZED ORGANIZATION__

CITY (urban village): Simferopol

DURATION OF PRACTICE: from 21 /6/2021_______till 2/7/2021

Simferopol, 2021

Introduction

When you have completed this skills chapter you should be able to:

Record and assess the condition of the mother.

Record and assess the condition of the fetus.

Record and assess the progress of labour.

The partogram

The condition of the mother, the condition of the fetus, and the progress of labour are recorded on the partogram.

Main

PATIENT PROFILE

Name of patient: Uzumaki Sakura

Husband name: Sasuke

Age 28

Religion: Cristian

Occupation House wife Education 10th pass

Date of admission 05. 12. 10 8 A. M

Registration No. 4290

Obstetrical score G1P0 A0 L L. M. P. 02. 03. 2010 E. D. D. 09. 12. 2010 A.

CHIEF COMPLAINTS: -

(i) Amenorrhoea from 9months

(ii)Having Labor pain since 4A. M

(iii) Back ache B.

HISTORY COLLECTION

(i) HISTORY OF PRESENT ILLNESS: - Patient was admitted on 05-12-2010 at 8. A. M. with complain of amenorrhoea from 9 months, pain in lower abdomen since 4. A. M

. (ii) HISTORY OF PAST ILLNESS: - Medical History: - No H/o D/M, HTN, CAD and T. B. Surgical History – Not significant.

(III) FAMILY HISTORY: - No history of heretical and genetically disorder. PERSONAL HISTORY: - Patient is vegetarian. No history of drug allergy or drug addiction. No use of any type of substances use like smoking, drug abused and alcohol etc.

FUNCTIONAL HISTORY: - Sleep pattern and appetite is normal.

MENSTRUL HISTORY: - Menstrul cycle is regular of 4-5 days. No intermenstrul bleeding and no coital bleeding.

2. PAST OBSTETRIC HISTORY: - G1P0A0L0 ASSESSMENT OF PATIENT ADDMISSION General

Body built –moderate

Weight- 56 kg

Vital signs (at the time of admission)

Temperature -37. 4 degree C

Pulse -94/min

Respiration -24/min

B. P. - 124/80 mm of Hg Hydration-Adequate Anaemia –no Pallor –no Heart –NAD Lungs

- NAD Liver-

NAD EXAMINATION:

ABDOMINAL: On inspection fundal height: below the xyphisternum. On auscultation: F. H. S. 148/min On palpitation through GRIP: Fundal Grip: Sofiter consistency Lateral Grip: in left lateral Grip felt like a continuous hard, flat surface Pelvic Grip: heard round part felt it means presenting part is Head. Paulic Grip: head is fixed

Uterine contraction: 2contraction/10min, duratrion> 20 second VAGINAL EXAMINATION: Vulva: normal Vagina: normal Cervix: dilatation 2cm: effacement 30% Membrane: intact Presenting part: Head Pelvis: seems adequate INVESTIGATION: S. N. INVESTIGATION IN PATIENT NORMAL VALUE 1. Sodium 139 mEq/lit 135-145 mEq/lit

3. 2. Potassium 3. 9 mEq/lit

3. 5 -5. 5 mEq/lit

3. Complete blood count-

RBC Hb PCV PLATELET COUNT Blood group ------------------ 5. 12 mil/cumm 8. 9 gm/dl 36. 4% 4. 43 lakh /ml B +ve ------------------------- 4. 3-6. 3mil/cumm 12-14gm/dl 40-50 % 1. 4-4. 4lakh/ml 4. Blood glucose 90mg/dl 80-120mg/dl 5. Serum cholesterol LDL HDL 242mg/dl 167mg/dl 33mg/dl 120-250mg /dl < 155 < 35 6, SGOT SGPT 219U/L 67U/L 0-40U/L 5-36U/L

Urine examination:

Albumin: Nil Sugar: Nil RBC: Nil WBC: Nil Litrature view of Normal Labour

. NORMAL LABOUR Definition Series of events that take place in the genital organ in an effort to expel the viable products of conception out of the womb through the vagina into the outer world is called labour. Duration of the second stage Duration of the second stage is difficult to predict with any degree of certainty. In multi gravidae it may last as little as 5 minitues, in primi gravidae the process may take 2 hours. Observations during the second stage of labour Uterine contraction  Descent of the presenting part  Fetal condition  Maternal condition

4. The transition from the first stage to the second stage is evidenced by the following features: • Increasing intensity of uterine contraction. • Appearance of bearing down efforts. •

Urge to defecate with descent of the presenting part. •

Complete dilatation of the cervix as evidenced on vaginal examination. Principles

1) To assist in the natural expulsion of the fetus slowly and steadily.

2) To prevent perineal injuries.

GENERAL MEASURES:

 The patient should be in bed. 

Constant supervision is mandatory and the FHR is recorded at every 5 minutes.  To administer inhalation analgesic, if available, in the form of gas N2O and O2 to relieve pain during contractions.

 Vaginal examination is done at the beginning of the second stage not only to confirm its onset but to detect any accidental cord prolapse. The position and the station of the head are once more to be reviewed and the progressive descent of the head is ensured.

PREPARATION FOR DELIVERY: 

Position -Positions of the woman during delivery may be lateral or partial sitting. Dorsal position with 150 left lateral tilt is commonly favoured as it avoids aortocaval compression and facilitate pushing effort.  The accoucherur scrubs up and puts on sterile gown, mask and gloves and stands on the right side of the table. 

Toileting the external genitalia and inner side of the thighs is done with cotton swabs soaked in Savlon or Dettol solution. One sterile sheet is placed beneath the buttocks of the patient and one over the abdomen. Sterilized legging are to be used. Essential aseptic procedures are remembered as 3'C's: 

clean hands

(b) clean surface and

5.  To catheterize the bladder, if it is full.

CUNDUCTION OF DELIVERY:

The assistance required in spontaneous delivery is divided into three phases:

1)Delivery of the Head

2)Delivery of the shoulder

3)Delivery of the trunk.

DELIVERY OF THE HEAD:

The principles to be followed are 'to maintain flexion of the head, to prevent its early extension and to regulate its slow escape out of the vulval outlet. • The patient is encouraged for a bearing down efforts during uterine contraction. This facilitate descent of the head. • When the scalp is visible for about 5cm in diameter, flexion of the head is maintained during contraction. This is achieved by pushing the occiput downward and backward by using thumb and index finger of the left hand while pressing and premium by the right palm with a sterile vulval pad. If the patient passes stool, it should be cleaned and the region is washed with antiseptic lotion. • The process is repeated during subsequent contractions until the sub-occiput is placed under the symphysis pubis. At this stage the maximum diameter of the head (biparietal diameter) sretches the vulval outlet without any recession of the head even after the contraction is over and it is called " crowning of the head". The purpose of increasing the flexion of the head is to ensure that the small suboccipito- frontal diameter 10 cm (4" ) distends the vulval outlet instead of larger occiputo-frontal diameter 11. 5cm (4. 5" ). • When the perineum is fully stretched and threatens to tear specially in primi -gravidae, episiotomy is done at this stage after prior infiltration with 10 ml of 1% lingociane. Bulging thinned out perineum is a better criterion than the visibility of 4-5cm of scalp to decide the time of performing episiotomy. Episiotomy is done selectively and not as a routine. • Slow delivery of the head in between the contraction is to be regulated. This is accomplished by pushing the chin with a sterile towel covered fingers of the right hand placed over the anococcygeal region while the left hand exerts pressure on the occiput (Ritzen maneuver).

6. The fore head, nose, mouth & chin are thus born successively over the stretched perineum by extension. CARE FOLLOWING DELIVERY OF THE HEAD • Immediately following delivery of the head, the mucus and blood in the mouth and pharynx are to be wiped with sterile gauze on a little finger. Alternatively mechanical or electrical sucker may be used. This simple procedure prevents the serious consequence of mucus blocking the air passage during vigorous inspiratory efforts. • The eyelids are then wiped with sterile dry cotton swabs using one for each eye starting from the medial to the lateral canthus to minimize contamination of the conjunctival sac • The neck is then palpated to exclude the presence of any loop of cord (20-25%). If it is found and is loose enough, it should be slipped over the head or over the shoulders as the baby is being born. But if it is sufficiently tight enough, it is cut in between two pairs of Kocher's forceps placed 1" apart. PREVENTION OF PERINEAL LACERATION More attention should be paid not to the perineum but to the controlled delivery of head.  Delivery by early extension is to be avoided. Flexion of the sub-occiput comes under the symphysis pubis so that lesser sub occiputo -frontal 10 cm diameter emerges out of the introitus.  Spontaneous forcible delivery of the head is to be avoided by assuring the patient not to bear down during contractions.  To deliver the head in between contractions.  To perform timely episiotomy (when indicated).  To take care during delivery of the shoulders as the wider bisacromial diameter (12cm) emerges of the introitus. DELIVERY OF THE SHOULDER Do not be hasty in delivery of the shoulder. Wait for the uterine contraction to come and for the movements of restitution and external rotation of the head to occur. The indirectly

7. signifies that the bisacromial diameter is placed in the antero-posterior diameter of the pelvis. During the next contraction, the anterior shoulder is born behind the symphysis. If there is delay, the head is grasp by both hands is gently drawn posteriorly until the anterior shoulder is released from under the pubis. By drawing the head in upward direction, the posterior shoulder is delivered out of the perineum. Traction of the head should be gentle to avoid excessive sretching of the neck causing injury to the brachial plexus, haematoma of the neck or fracture of the clavicle. DELIVERY OF THE TRUNK After the delivery of the shoulders, the fore finger of each hand are inserted undue the axillae and the trunk is delivered gently by lateral flexion.

Labour complication 

Mal presentation 

Failure of descent of the fetal head through the pelvic brim 

Poor uterine contraction strength 

Cephalo pelvic disproportion (CPD) 

Shoulder dystocia Maternal complication 

Vaginal birth injury

 Pelvic girdle pain 

InfectHaemorrhage

Fetal complication 

Fetal injury 

Neonatal infection 

Rupture of membrane 

Neonatal death Progress Notes During First And Second Stage Of Labour Date and Time. Interval & duration Of pain Membrane F. H. R Dilatation & effacement Of cervix Station Of present- ting part pelvis Any drugs/ treatment 05. 12. 10 06Am. 2-3/10 min. > 20 sec Intact 150/min 1-2cm. 25% -3 - -

8. 09 AM 1 PM 3PM 4-5/10 min > 20sec 6-8/10 min > 30 sec 6-8/10min < 40sec Intact Ruptured - 140/min 150/min 140/min 6cm. 50% 8 cm 75% 10cm 100% -2 -1 0 - Adequate - - Inj. R. L 500ml + Inj Oxytocin 2. 5 U - Date and time of onset of labour pain— ----05. 12. 2011---8AM- Date and time of full dilatation of os---3 PM Date and time of birth of the child—4 pm. Date and time placental expulsion- 4. 15 PM Total hours 1st stage----7 hr. ------2nd stage—1 hr. min----- 3rd stage ---15 min-------Total hours-8. 30 min. ------ Delivery Notes- Mother delivered a normal healthy male child. After 15min placenta and membrane expeld. Both plecenta and membrane inspected. Episiotomy sutured with aseptic technique. Post delivery assessment of mother- - cheked vital sign every 15 min. - assessed bleeding - clothes changing - exertion of labour. Condition of mother on transfer- Condition of baby on transfer

9. NURSING CARE PLAN SN NURSING DIAGNOSIS NURSING OBJECTIVE NURSING INTERVENTION NURSING IMPLIMENTION EXPECTED/DE RED EVALUATION/ UTCOME CRITERIA- PATIENT WILL

1. Impaired gas exchange (fetal) r/t altered oxygen supply Fetal hypoxia will be prevented -locate the fetal heart by determine fetal position and presentation -Ausculate fetal heart through fetal back. -count and record the fetal heart rate half an hourly in active phase and every 15 minute during second phase. -provide the left lateral position to relieve pressure on inferior vena cava and improve uterine blood flow. - Fetal heart sound is recorded every 30 minutes through out active stage of labor. - left lateral position is given to patient. Fetal hypoxia will be relieved

. 2. Altered progress of labor r/t physiological process Labor will progress - Record the frequency and duration of contraction every half an hourly during active phase of labor. - Assess and record the cervical -uterine contraction is assessed every half hourly for 10 minute and duration of one contraction. Labor will progre with in time.

10. dilatation and effacement every four hourly. - Assess the station or descend of fetus every four hrly and record on partograph. - Assess the pelvic size during PV examination. - uterine contraction’s frequency and duration is recorded on partograph. -recording of cervical dilatation and effacement every four hourly.

3. Potential for injury r/t physical, chemical and external factors Will be protected from injury. - Provide care related to admission protocol e. g. take nursing history, note vital sign and laboratory investigation. - Record temp, pulse, B. p. every two hourly. - Encourage to voiding every two hourly if bladder is distended then empty bladder by catheteriazation. - Give enema if ordered by doctor. - Secure leg in stirrups simultaneously on delivery table - Discontinue oxytocin if indicated and notitfy by doctor. e. g. fetal distress. -history is taken -vital signs are recorded two hourly in active stage of labor. - bladder is emptied by K-90 cather. -enema is given. Risk of injury wil be minimized.

4. Potential for To prevent the -wash hands scrupulously - Maintain the strict aseptic - Risk of infection

11. infection invasive procedures, rupture of amniotic membrane. infection -wear cover gown, scrub clothes, hair, and shoe covers etc.

according to policy. -use sterile gloves for vaginal examination -P/V examination done minimally in normal labor 4 hrly. -use antiseptic solution to prepare perineal area for delivery. -use sterilized articles.

technique. - Perineal area is washed with 50 % butadiene solution. - At the time of p/v examination sterile gloves are wearied. - p/v examination is done 4 hrly. minimized. 5. Anxiety r/t situational crisis. To reduce the anxiety level. -orient to ward the client. -explain all the procedure. -explain reason for protocol e. g. restriction of food and fluid, side lying position ect. -explain about labor progressing. -encourage expression of feelings and convey understanding and acceptance. -do not woman leave alone. - pt. is oriented about ward and hospital policy. -every procedure is explained before perform. -attendant or coach is allowed for full time. -felling of patient is assessed. 6. Pain r/t physical and To relieved pain -assess pain via verbalization and body language. -assessed the pain level by body language of pt. Pain is relieved

12. psychological factors. -ass breathing and relaxation techniques. - Allow couple to spend time alone together. - Support couple’s effort by -offering praise freely. - Be nonjudgmental if woman become -child birth preparation discuss with spouse and their relatives. - spouse given touch therapy, provide the fluid and food to patient. -reassured the family member about birth process. -praised of woman for their efforts. -spouse is spent his time with woman during first stage of labor. Family member participated in labor process.

13. irritable, noncompliant, or loses control.

HEALTH EDUCATION: -

1. Explain all procedure, seek permission for examination and carrying out procedures and discuss the findings with the woman.

2. Keep the woman informed about the progress of labor.

3. Praise the woman, encourage her and reassure her that things are going well.

4. Ensure the respect and privacy of the woman during examination and discussion.

5. Encourage the woman to bath or wash herself and her genitals at the onset of labor.

6. Ensure cleanliness of birthing area

. 7. Encourage the woman to empty her bladder frequently. Remind her every 2hours or so

. 8. The woman should be allowed to remain mobile during labor especially the first stage, as this help in having a shorter and less painful labor.

9. The woman should be free to choose any position she desires and feels comfortable in during labor and delivery. 10. Woman who are not at risk of requiring general anaesthesia can have light, easily digested, low fat food during labor, if they wish

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