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  • Labour Chart: Intranatal Case Record - 9

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    Mrinmoy Maiti
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    Mrs. Jishila was admitted to the labour room on 09.04.2020 at 8am for pain

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    Mrs. Jishila was admitted to the labour room on 09.04.2020 at 8am for pain

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    63 views4 pages

    Labour Chart: Intranatal Case Record - 9

    Uploaded by

    Mrinmoy Maiti
    Mrs. Jishila was admitted to the labour room on 09.04.2020 at 8am for pain

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 4

    INTRANATAL CASE RECORD - 9

    Labour chart

    Date and Time of admission to the labour room: 09.04.2020 at 8am

    Admitted for safe confinement: Yes

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

    Condition on admission: True labour pain

    Vital Signs: T - 98.60F P - 76bpm R - 22bpm BP – 120/80 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 – 8am - Intact 2) Spotting 2) Present √ 2) NST √
    - 36cms 2) Sterile vaginal 2) Ruptured – Not present Date and Time- 3) Ultrasoun
    2) Presentation Examination 3) Leaking 3) Blood show - 09.04.2020 at d
    - Cephalic - Yes 09.04.2020 at √ 9.00am 4) Biophysic
    3) Position 3) Sterile speculum 7.30am 4) Frank 3) Regular √ al Profile
    - LOA examination- 4) Colour bleeding 4) Frequency - √
    4) Engagement 4) Dilatation –Clear - Not 3-4 DFMC
    - Engaged – 4 cms 5) Odour present contractions 5) Drugs
    5) FHR: 5) Effacement - Normal 5) Any other 5) Duration Given
    - 138bpm – 40-50% - 20-40 sec Inj.
    6) Consistency 6) Intensity Pitocin
    - soft - Moderate 5U
    7) Station IVF RL
    0 500ml
    8) Ballotment Inj.
    - Not ballotable Methergi
    9) Position of occiput n 1 amp
    LOA IV

    Modified WHO Partograph

    Name: Mrs. Jishila 8am: FHS- 138, BP-120/80, HR- 74, Amniotic Fluid-C, Moulding +, Cervix 7cm,
    Descent 0, IVF RL 500ml, protein & acetone-nil, urine-100cc, 2 mild and 1
    Gravida: 3
    moderate contraction
    Para: 2
    8.30am: FHS- 140, 3 moderate contractions
    Hospital No:
    9am: FHS- 136, BP-120/80, HR- 76, Temp-98.6 0F, 4 moderate contractions
    Date of admission: 09.04.2020 9.30am: FHS-144, 4 severe contractions
    Time of admission: 8am 10am: FHS-142, BP-120/80, HR-74, Inj. Oxytocin 5U at 16 drops/min, Inj.
    Methergin, 5 severe contractions
    Ruptured membrane: at 7.30am
    10.30am: FHS-148, cervix-10cm, descent +3, 5 severe contractions
    (Spontaneous)
    Baby delivered at 10.54am
    11am: BP- 110/70, HR-68, Temp- 98.6 0F, urine-300cc
    11.30am: BP-110/70, HR-70

    Intrapartum Observation
    Type Time Total Hours Date and Time Nature of Mode of
    of Delivery Delivery Delivery
    From To
    I Stage 12.30am 10.34 am 10hrs 4 min 09.04.2020 at Spontaneous Full term
    II Stage 10.34am 10.54am 20min 10.54am Normal normal
    III Stage 10.54am 12.05pm 11min Vaginal vaginal
    IV Stage 12.05pm 1.35pm 1.5hour Delivery with delivery
    Right Medio
    Lateral
    Episiotomy
    Total Duration: 12 hours 5 min

    Episiotomy Placenta
    Type: - Method of:
    a) Separation: Mathew Duncan
    b) Expectant Management:
    c) Active Management: Controlled cord traction
    Anaesthesia: - Mannual removal of Placenta: No
    Suture: - Abnormalities any: No
    Laceration: No Weight of the Placenta: 480gms
    Length of the cord: 46cms
    Membranes: Complete
    Repair: - Bleeding: WNL

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