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Labour Chart: Intranatal Case Record - 9
Labour Chart: Intranatal Case Record - 9
Labour chart
If No, admitted with complaints of Pain/Leaking PV/Show/Other complaints: Pain and leaking PV
Oedema: No
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
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