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    Labour Chart: Intranatal Case Record - 7

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    Mrinmoy Maiti
    Dr. Suresh Anaesthesia: Inj. Lignocaine Suture: Vicryl 2-0 Postpartum Examination Perineum: Episiotomy repair done Cervix: Firm Vagina: Healthy Uterus: Firm, well contracted Lochia: Normal Per Abdomen: Soft FHR: 148/min BP: 120/80 mmHg Temp: 98.4°F Baby: Female, cried immediately, weight 3.2kg, Apgar score 8/10 at 1 min and 9/10 at 5 min Baby shifted to nur

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    Labour Chart: Intranatal Case Record - 7

    Uploaded by

    Mrinmoy Maiti
    84 views5 pages
    Dr. Suresh Anaesthesia: Inj. Lignocaine Suture: Vicryl 2-0 Postpartum Examination Perineum: Episiotomy repair done Cervix: Firm Vagina: Healthy Uterus: Firm, well contracted Lochia: Normal Per Abdomen: Soft FHR: 148/min BP: 120/80 mmHg Temp: 98.4°F Baby: Female, cried immediately, weight 3.2kg, Apgar score 8/10 at 1 min and 9/10 at 5 min Baby shifted to nur

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    Dr. Suresh Anaesthesia: Inj. Lignocaine Suture: Vicryl 2-0 Postpartum Examination Perineum: Episiotomy repair done Cervix: Firm Vagina: Healthy Uterus: Firm, well contracted Lochia: Normal Per Abdomen: Soft FHR: 148/min BP: 120/80 mmHg Temp: 98.4°F Baby: Female, cried immediately, weight 3.2kg, Apgar score 8/10 at 1 min and 9/10 at 5 min Baby shifted to nur

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    84 views5 pages

    Labour Chart: Intranatal Case Record - 7

    Uploaded by

    Mrinmoy Maiti
    Dr. Suresh Anaesthesia: Inj. Lignocaine Suture: Vicryl 2-0 Postpartum Examination Perineum: Episiotomy repair done Cervix: Firm Vagina: Healthy Uterus: Firm, well contracted Lochia: Normal Per Abdomen: Soft FHR: 148/min BP: 120/80 mmHg Temp: 98.4°F Baby: Female, cried immediately, weight 3.2kg, Apgar score 8/10 at 1 min and 9/10 at 5 min Baby shifted to nur

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 5

    INTRANATAL CASE RECORD - 7

    Labour chart

    Date and Time of admission to the labour room: 07.04.2020 at 11.30pm

    Admitted for safe confinement: Yes

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

    Condition on admission: True labour pain

    Vital Signs: T - 98.40F P - 80bpm 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 – 12.00pm - Intact 2) Spotting 2) Present √ 2) NST √
    - 38cms 2) Sterile vaginal 2) Ruptured – Not Date and 3) Ultrasoun
    2) Presentation Examination ARM done at present Time- d
    - Cephalic - Yes 12 pm 3) Blood show - 07.04.2020 at 4) Biophysica
    3) Position 3) Dilatation 3) Leaking √ 1.30pm l Profile
    - ROA – 6 cms 4) Colour 4) Frank 3) Regular √ √
    4) Engagement 4) Effacement –Clear bleeding 4) Frequency - DFMC
    - Engaged – 50-60% 5) Odour - Not 3-4 5) Drugs
    5) FHR: 5) Consistency - Normal present contractions Given
    - 144bpm - firm 5) Any other 5) Duration Inj. Pitocin
    6) Station - 20-40 sec 2.5U
    +1 6) Intensity IVF RL
    7) Ballotment - Moderate 500ml
    - Not ballotable Inj.
    8) Position of occiput Methergin
    ROA 1 amp
    Modified WHO Partograph

    Name: Mrs. Jaseela 12pm: Amniotic Fluid-C, Moulding ++, FHS-136, cervix-6cm, descent-0, 3
    moderate contractions, Inj. Oxytocin 5U in IVF RL 500 ml at 8 drops/min, BP-
    Gravida: 2
    120/80, HR-82, protein & acetone –nil, urine -200cc
    Para: 1
    12.30pm: FHS-142, Inj. Oxytocin at 16 drops/min, 3 moderate contractions
    Hospital No:
    1pm: FHS-144, 4 moderate contractions, BP-120/80, HR-76
    Date of admission: 06.04.2020 1.30pm: FHS-138, 4 severe contractions
    Time of admission: 11.30pm 2pm: FHS-146, 4 severe contractions, BP-130/80, Temp-98.6 0F, HR-74
    Ruptured membrane: 2.30pm: FHS-136, 5 severe contractions, Inj. Oxytocin
    3pm: FHS-148, cervix-10cm, descent +3, Inj. Methergin 1 amp, BP-130/80,
    urine-300cc, HR-72
    Baby delivered at 3.17pm
    3.30pm: BP-110/70, HR-78
    Intrapartum Observation

    Type Time Total Hours Date and Time Nature of Mode of


    of Delivery Delivery Delivery
    From To
    I Stage 5.57am 2.57pm 8 hrs 07.04.2020 at Spontaneous Full term
    II Stage 2.57pm 3.17pm 20min 3.17 pm Normal normal
    III Stage 3.17pm 3.27pm 10min Vaginal vaginal
    IV Stage 3.27pm 4.57pm 1.5hour Delivery with delivery
    Right Medio
    Lateral
    Episiotomy
    Total Duration: 10 hours

    Episiotomy Placenta
    Type: Right medio lateral epsiotomy Method of:
    a) Separation: Mathew Duncan
    b) Expectant Management: -
    c) Active Management: Controlled cord traction
    Anaesthesia: Inj. Lignocaine Mannual removal of Placenta: No
    Suture: Vicryl 2-0 Abnormalities any: No
    Laceration: No Weight of the Placenta: 460gms
    Length of the cord: 46cms
    Membranes: Complete
    Repair: Episitomy repair is done in 3 layers Bleeding: WNL

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