GOVERNMENT COLLEGE OF NURSING,

C.R.P LINE, INDORE

SUBJECT: OBSTETRIC & GYANAECOLOGICAL NURSING.

TOPIC: CARE PLAN ON INTRANATAL CARE

“INTRANATAL” (LABOUR ROOM)

SUBMITTED TO: SUBMITTED BY:

Mrs. A. ram Ms. Bhumika Chouhan

Mrs. M. Auchat MSc. Nursing 1st Year

Mrs. K. Vincent Govt. College of Nursing

Govt. College of Nursing C.R.P Line Indore (M.P)

C.R.P Line Indore (M.P)

IDENTIFICATION DATA:
 Name of the Mother : Mrs. Saniya
 Name of husband : Mr. Rajesh
 Age : 23 year
 Sex : Female
 Consultant : Dr. D. Joshi
 Address : Juni Indore
 Date of admission : 06/01/2021
 Reg. no. : 665308
 Marital status : Married
 Diagnosis : Labour pain.

HISTORY OF MOTHER:
 Chief concern: My mother Mrs. Saniya Sharma w/o Rajesh Sharma 23 Y old female
patient admitted in M.Y hospital, Indore on date 06/01/2021 under Dr. D. Joshi
with chief concern of backache and labor Pain since last night.
 Present concern: My mother Mrs. Saniya Sharma admitted with the chief concern of
labor & she is having uterine contraction with cervical dilation i.e., 5 cm is having
continuous contraction with labor Progress.

 HISTORY OF PRESENT PREGNANCY:

 NAME: Mrs. Saniya

 WEEKS OF GESTATION: 38 Weeks
 LMP: 30/04/2021
 EDD: 07/01/2022
 OBSTESTRICAL SCORE: G1P0A0L0.

EVENTS OF TRIMESTER:
 1ST Trimester: My mother LMP was 30/04/2021. In the first trimester her weight is 50kg
& her height is 155 cm & her B.P is 110/70 & Hb is 12.59 m at the gestation week 8.

 2nd Trimester: In the second trimester the wt. is 54kg & Hb is 12.5 gm & the doesn’t
have any kind of complaint related to health but she was having pitting edema on her
lower extremities.

 3nd Trimester: In the 3rd trimester & the weight is 60kg & Hb is 12.5gm and the height
of fundus is 34cm at the week of gestation 38 week and the position is ROA & doesn’t
have any kind of complaint regarding health.
 MEDICAL HISTORY
 Chronic illness: My patient doesn’t have any kind of chronic illness.
 Allergy: My patient dosen’t have any allergy.
 Communicable disease: My mother is not having any medical of communicable
diseases.
FAMILY HISTORY:
 Type of family: Joint family.
 No. of members: 4

S.N NAME OF AGE SE RELATIO MARRI EDUCATIO OCCUPATI HEALT

O FAMILY X N WITH TAL N ON H
MEMBERS MOTHER STATU STATUS
S
1. Mr. Kamlesh 50Yr Mal Father-in- Married Illiterate Farmer Healthy
Sharma e law
2. Mrs. Rekha 40Yr Fe Mother-in- Married Illiterate Housewife Healthy
Sharma mal i-law
e
3. Mr. Rajesh 30Yr Mal Husband Married 10th Pass Farmer Healthy
e
4. Mrs. Saniya 23 Yr Fe Mother Married 5th Pass Housewife Healthy
mal
e

FAMILY TREE:

Father in law Mother

in law

Husband Mother

HISTORY OF MULTIPLE BIRTH: Mrs. Saniya doesn’t have history of multiple birth.
SOCIOECONOMIC BACKGROUND:
 Religion: Hindu
 Income: 20,000/Month
 Education: 10th Pass
 Occupation: Farmer
MENSURATION HISTORY:
 Menarche: Mrs. Saniya, menarche is started at 17 yrs.
 Duration: 3 Day’s
 Interval: 28-30 Day’s
 Flow: Normal
PRESENT PREGNANCY:
 Admission Note: My mother Mrs. Saniya Sharma w/o Rajesh Sharma 23 Y old female
patient admitted in M.Y hospital, Indore on date 06/01/2021 under Dr. D. Joshi
with chief concern of backache and labor aim since last night.
 Admitted On: 06/01/2021
 Contraction Commenced on: Moderate
 Period of Gestation: 38 Weeks
 Membrane: Intact
 Height of Fundus: 34 Cm
 Presentation: Cephalic
 Position: ROA
 Engagement: Not Engaged
 FHR: 135 BPM
 Bladder: Empty
 Bowel: Passed
 B.P: 110/70 Bpm
 Temperature: 99.6F
 Pulse: 72B/min
 Respiration: 24B/ Min
MARRTIATL HISTORY:
 Age of marriage: 21 Yr.
 Year of marriage: 1 Year.
DIETARY PATTERN:
 Vegetarian/non-vegetarian: Vegetarian
 Habits: No any kind of habits.
 OBSTETRICAL HISTORY: Primi-gravida.
S.NO YEAR FULL PRETERM ABORTION NATURE WEIGHT REMARKS
TERM OF OF
DELIVERY BABY
-- -- -- -- -- -- -- --

PRENATAL VISITS:
DATE HT. WT. URI B. FH GESTA HT.OF PRESNTAT POSI TREAT
OF NE P R TION 1 FUNDUS ION TION MENT
BOOKI WKS
NG

25/06/20 135cm 52kg NIL 11 -- 8Wk -- -- -- Tab.

21 0/8 Iron.
0 Tab.
Calcium.
05/11/20 135 54kg NIL 11 135 28Wk 26cm Cephalic ROA Tab.
21 0/8 bau Iron.
0 Tab.
Calcium.

PHYSICAL EXAMINATION:

 GENERAL CONDITION:
 Body Built: Mother is healthy.
 Nourishment: Mother is Nourished.
 Height: 135cm.
 Weight: 54Kg.

 VITAL SIGN:
 Temperature: 99.6F
 Pulse: 72B/min
 Respiration: 24B/ Min
 Blood pressure: 110/70 Bpm.

 SKIN:
 Color and Temperature:: Mother skin color is fair and temperature is normal.
 Texture & turgor: Mother texture is Normal.
 Ulcer: Ulcer are not present.
 Edema: Not present during 3rd trimesters but during labor present.
 HEAD:
 Hair: Hair are dry and rough brittle hair.
 Symmetry: Mother is symmetrical & developed.

 EYES:
 Vision: Mother vision is clear.
 Pupils: Normal.
 Eye brows: Symmetry eyebrows.
 Eye lid: Eyelid are fully present.

 EARS:
 Hearing: Mother is able to hear properly.
 Size & shape: Normal in size and shape.

 NOSE:
 Symmetrical discharge or bleeding: Nose are symmetry & discharge are not
present.
 Sinuses: Not present.

 MOUTH:
 Dental carries or plague present: Mother don’t carry any dentures.
 Symmetry: Symmetrical.
 Tongue: Mother tongue is normal & coating are not present.
 Gums: Gums are not present.

 NECK:
 Carotid pulse feels: Yes present.
 Enlargement of thyroid or lymph nodes: Lymph node are not present.
 Range of motion: Mother is able to do R.O.M exercise.

 CHEST:
 S1 S2 Sound: S1 S2 Sound is clear.
 Chest expansion: Normal.
 Breathing: Breathing pattern normal.
 Cough: Absent.
 BREAST:

 ON INSPECTION:
 Shape: Symmetrical.
 Size: Symmetrical.
 Nipple: Flat nipple
 Breast engorgement: Absent.
 Development of Montgomery tubercles: Present.
 Presence of secondary areola: Present.

 ON PALPATION:
 Lump Palpation: Lump palpation done & lump are not seen.
 Breast enlargement: Breast enlargement present & cracked nipple are not
present.
 Auxiliary lymph nodes: Not present.

 ABDOMEN:
 ON INSPECTION:

Shape: Longitudinal

Skin condition: Dry

Straie gravidarum: Present

Fundal height: 40cm

Scar: Present
 ON AUSCULTATION: 110 bpm

 GENITALIA:
 Vulva: Swelling and redness are absent.
 Discharge: There is no any discharge present
 Rectum: Anal opening is present, inflammation are not present, hemorrhoids are
not present, rashes or ulcers not seen.
 Redness: Redness are not present
 Edema: Edema are not present.
 Eschymosis: Discoloration are present.

 EXTREMITIES:
 Symmetrical: Normal
 R.O.M: R.O.M are normal
 Varicosity or Homan’s sign present: Normal
 Sensory or motor power: Normal.
 DELIVERY RECORD:

 Onset of true labour: date: 07/01/2021, 8:00 am

 Time of full dilatation: date : 07/01/2021, 10:00 am
 Membranes ruptured: Ruptured
 Spontaneous/Artificial: Spontaneous
 P.R.O.M: Absent

 DELIVERY OF BABY:

 Baby born at: 10:15 am

 Male/Female: Female
 Mode of delivery: FTVD
 Condition of baby active/limp: Active.

 DELIVERY OF PLACENTA AND MEMBRANE:

 Delivered at: 10:30am
 Spontaneously\manually removed: Spontaneously
 Type of placenta: battledore insertion
 Placenta and membrane: completely removed
 Cord length: approx. 45cm
 Any abnormality: no

 BLOOD LOSS:(APPROXIMATE TOTAL AMOUNT)

 Before delivery of the placenta: Approx. 50 ml

 During Delivery of the placenta: Approx. 300 ml
 After delivery of the placenta: Approx. 100 ml
 Total: 450ml

 PERINEUM:

 Intact/Episiotomy: Rt mediolateral episiotomy present.

 Laceration: Absents
 Repair: Episiotomy repair with suturing.
 Medication given: Local anesthesia

 LENGTH OF LABOUR:

 Mode of delivery: FTVD

 Duration of Labor: 13 to 14min
  CONDITION OF THE MOTHER FOLLOWING DELIVERY:

 Pulse: 86 BPM.
 B.P: 110/70mm of Hg.
 Height of uterus: 18cm
 Vaginal bleeding: Lochia lubra is present
 Breast feeding initiated at: 10:20 a.m.

 MEDICATION:

S.NO DRUG NAME DOSE ROUTE ACTION

1. Oxytocin 10unit In Act directly on may of briefs thereby
producing uterine contraction, stimulates
milk objection by the breast vasoactive
antidivvretic effect.
2. Lignocaine 4.5mg Topical Lignocaine stabilizes all potentially
prevents the initiation & transmission of
nerve impulse. This produces a local
analstetic effect.
3. Ampicillin 250mg Oral (Antibiotic) interferes with cell wall
replication of susceptible organism the
cell wall rendered unstable swales burst
from asthmatic pressure, lysis mediated
by cell wall outolysis.

 DIAGNOSTIC PROCEDURE:

INVESTIGATION:
 BLOOD EXAMINATION:
Blood Examination Result Unit/ NR
HB 11.5 11-14.5g\dl
RBc 6.14 4.0-5.5MILLION/
Neutrophils 63% 34.9-76.2
Lymphocytes 30% 17.5-45
Monocytes 0.2% 3.9-10
Eosinophils 05% 0.3-7.4

 CHEMICAL EXAMINATION:

Chemical exam Result

Protein Negative
 Glucose Negative
Bile pigment Negative
Bile salt Negative
Occult blood Present Trace

 EXAMINATION OF URINE:
Physical Exam

Color Yellowish
Appearance Clear
S.P. Gravity NIL
Reaction Neutral.7

NURSING PROCESS IS BASED ON ROYS ADAPTATION

ASSESSMENT NURSING EXCEPTED PLANNING IMPLEMENTATION EVALUTION

DIAGNOSIS OUTCOME
Objective Pain related Use Monitor and Monitored every Pain was
Data: Patient to mechanical appropriate record uterine contraction with time. reduced some
said that I’m pressure of techniques to activity with extend and
having pain at presenting control pain. each patient was
time of part as contraction. comfortable
contraction. evidenced by Identify degree Asked to patient
verbalization. of discomfort through pain scale.
Objective data and its source.
: I observe that
patient having Observe for Checked fetal station.
pain. Pain score perineal and
6/10 rectal bulging

Provide Perineal massage and

comfort clean dry under pads
measure. given.

Encourage Explained client about

client to relax the relaxation
all muscle and technique.
rest between
contractions.
ASSESSMENT NURSING EXCEPTED PLANNING IMPLEMENTATI EVALUTI
DIAGNOSIS OUTCOME ON ON
Subjective Risk for Patient will Assess vital signs Checked, elevated Pain of
infection relief from of patient. temp. Pulse, BP patient was
data: Patient
related to pain and recorded. reduced and
said that ‘I have episiotomy as discomfort. risk of
evidenced by Check any Pus discharged was infection
itching and pain
observation. abnormal color not present. some
at episiotomy and odor of extent. Pain
vaginal discharge. score-1/10.
side’
Provide aseptic Maintained aseptic
care to client. procedure during p-
Objective data: care.

I observed that Sent blood and Blood culture and

redness and vaginal culture as vaginal swab culture
indicated. sent.
swelling present
at side. Given broad - Antibiotics
spectrum administered as
antibiotic as prescribed.
prescribed.