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HISTORY COLLECTION
Name of the mother: Mrs Gita Debbarma
Age of the mother : 20 years
Antenatal diagnosis :Cephalopelvic Disproportion
Last menstrual period :23/12/22
Expected date of delivery :30/09/23
Gestational age (on admission)
Date of admission :30/09/23
Date of delivery : 30/09/23
Mode of delivery: SVD
Post natal day : 1 day
Name of the husband : Fharuk begam
Age of the husband :33 years
Language spoken : bengali
Religion : hindu
IP number :3456681

SOCIO ECONOMIC HISTORY—

Types of family: Joint family
Family member:5
No of adults :4
Total monthly income of family: 20000
Earning member of family:1
No .of children:1
Socio economic class: lower class
Education:10th pass
Occupation:house wife

FAMILY HISTORY— mothers father having diabetes mellitus since 2 years.

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FAMILY TREE—

PERSONAL HISTORY—
Nutrition- adequate
Education- 10th pass
Rest and sleep-adequate and proper. She slept for 8 hours per day
Activity – dull
Habits and hobbies- cooking
Hygiene- maintained

Menstrual history-
Menarche: 12 years
Amount :normal
Interval:28 days
Marital history- married
Contraception history- nothing significant
Drug history- nothing significant
Elimination history- she passed 6 times bladder and 2 time bowel

PAST MEDICAL HISTORY— she had no past medical history except common cold and
cough.
PAST SURGICAL HISTORY—she had no past surgical history.
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PRESENT MEDICAL HISTORY— mother was having pain and baby delivered on 30/09/23
at 6 pm, after delivery there was absence of cotyledons and some part of placenta retained in
uterous ,so she was diagnosed retained placenta .

PRESENT SURGICAL HISTORY—she has not undergone any surgical history

SI MOTHER CHILD
NO
YEAR GRAVIDA PERINA FULL ABORTI MODE REMAR SEX ALIVESTILL WEIGH REMARK
TAL TERM ON OF KS OF BORN T S
PERIOD DELIVE BABY
RY
2o23 1 39 weeks term no SVD unhealth boy alive yes 2.6kg healthy
5 days y

OBSTETRICAL HISTORY—

LMP- 23/12/22
EDD- 30/09/23
Model of delivery: SVD
Gestational age at birth (with date) – 39 weeks 7 days
Sex of the baby: boy
1st trimester- nausea, vomiting
2nd trimester- nothing significant
3rd trimester- pelvic pain
Delivery note: baby delivered at 6.pm and placenta expulsion at 6.15 pm, weight
is 2.6 kg
PHYSICAL EXAMINATION—
VITAL SIGNS-
Temperature- 96.6 f
Pulse- 65bpm
Respiration- 24 bpm
B.P.- 100/70 mmhg
ANTHROPOMETRIC MEASUREMENTS—
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Weight- 51 kg
Height- 149 cm
HEAD TO FOOT EXAMINATION—
General appearance-
Head- no infection ,no dandruff, no pedicuolosis is present
Eyes- no edema, no redness, no anemia is present
Nose- no discharge , clean nostrils.
Ears-symmetrical, no discharge is present
Mouth- no gingivitis, no somatitis is present
Neck- no enlargement is present
Chest- no abnormal sound is present
Abdomen- no gas is present
Back- normal
Extremities- nothing significant
Genitalia- discharge is present

OBSTETRIC EXAMINATION—
ABDOMEN-
Inspection- linea nigra,stria albicans is present
Palpation- fundal hight is 13 cm , uterous is bulky

BREAST EXAMINATION-
Inspection- primary and secondary areola is present, discharge is present
Palpation- nothing significant
VAGINAL EXAMINATION-
External- discharge is present.
ANATOMY AND PHYSIOLOGY OF PELVIST HOONT
pelvis is composed of four bones –
-Two innominate bones,
-Sacrum
-Coccyx.
These are united together by four Joints .These are,
-two sacroiliac Joints
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-Sacro-coccygeal joint.
- symphysis pubis.
The pelvis is anatomically divided int a false pelvis and true pelvis. The true pelvis are divided
into inlet, cavity and outlet.
The inlet in the brim of the pelvis, the circumference of the inlet is formed by the bony
landmarks. It is almost round. The Antero posterior diameter is 11cm, tranverse diameter 13 cm
and oblique diameters 12 cm
FIG:-NORMAL FEMALE PELVIS

FIG:-DIAMETER OF FEMALE PELVIS

cavity is the segment of the pelvis bounded above by the inlet. Diameters are antero posterior
12cm and transverse is 12 cm.
outlet anterior wall is deficient at the pubic arch ,its lateral walls are formed co by ischial bones
and the posterior wall includes whole of the coccyx
Diameters are Transverse (10.5cm), Antero-poster -on (11cm). Posterior 11cm
FUNCTION
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 The function of the pelvis is to protect the reproductive organ

 It is also important for bearing some load
 Giving humans the ability to walk, bun, sit.
 It also surround the reproductive organ bladder and rectum forming cavity in which these
organ can be supported and protected.
 Allowing the baby’s head to pass safely through the birth canal.
DISEASE CONDITION
Introduction
Cephalo pelvic disproportion is the most common cause of obstructed labor. The fetus may The
large in relation of the pelvis. This is said to exit when the fetus is longer than the maternal
pelvic inlet. outlet on when the fetal position places the head at an angle that is larger than the
size.
Definition
Cephalopelvic disproportion is the disparity in the relation between the fetal head and The
maternal pelvis.
Disproportion may be either due to an average size baby a small pelvis or due to a big size aby
with normal size pelvis on due -o combination of both.
Pathophysiology
Cephalopelvic disproportion (CPD) occurs when there is an inadequate size or shape of the
pelvis in relation to the fetal head, preventing the baby from passing through the birth canal
during labor. The pathophysiology involves a combination of factors such as:
Maternal Pelvic Anatomy:
Variations in the shape and size of the maternal pelvis can impede the passage of the fetus. This
can include a contracted pelvis, android pelvis, or other anatomical abnormalities.
Fetal Size:
A large fetal head or body size relative to the maternal pelvis can contribute to CPD. This can be
due to factors such as macrosomia (excessive fetal growth), hydrocephalus (accumulation of
cerebrospinal fluid in the brain), or congenital anomalies.
Mechanical Obstructions: Any physical obstruction in the birth canal, such as tumors, fibroids, or
pelvic masses, can further hinder the passage of the fetus.
Uterine Dysfunction:
Abnormalities in uterine contractions or ineffective maternal pushing efforts can also exacerbate
CPD by preventing the fetus from descending properly through the birth canal.
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Overall, the pathophysiology of CPD involves a mismatch between fetal

size and maternal pelvic dimensions, along with potential mechanical obstructions and uterine
dysfunction, leading to difficulty or impossibility of vaginal delivery.
ETIOLOGY
Book picture Patient picture
 Large baby
 Hereditary factors
 Diabetes
 Post maturity
 Multiparity
 Small pelvis
 Abnormal shaped pelvis Patients pelivis shape is not normal
 Child hood poliomyelitis

CLINICAL MENIFESTATION

Book picture Patient picture

1. Fetal distress 1. Present

2. Pronged labour 2. Present
3. Cervical dilation is slowed 3. Present
4. Dehydration 4. Present
5. Sepsis
6. Shock
7. Early rupture of membrane
8. Cord prolapse
9. Obstructed labour
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DIAGNOSTIC TEST

Name of the Patient value Normal value Remarks

investigation
1. Haemoglobin 11.08gm% 12-16 gm% Decrease
2. Sodium 140meq/L 135-145meq/L Normal
3. Creatinine 0.55mg/dl 0.5-1.5mg/dl Normal
4. HIV Negative - Normal
5. VDRL Negative - Normal
6. Hbsag Negative - Normal
7. Blood suger(f) 80mg/dl 70 -120mg/dl Normal
8. Blood suger(pp) 100 mg/dl 80-140mg/dl Normal

COMPLICATIONS:

Book picture Patient picture

1. Trauma
2. Birth asphyxia Birth asphyxia
3. Post partum hemorrhage
4. Puperial sepsis

MANAGEMENT

BOOK PICTURE PATIENT PICTURE

 Pre term induction of labor
 Caesarean section Caesarean section
 Trial labour
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PHARMACOLOGICAL MANAGEMENT

PHARMACO TRAD DOS RO FREQU MODE OF SIDE NURSING

L E E U E ACTION EFFECT RESPONS
OGICAL NAME TE NCY I
NAME BILITY
1)Inj Inj 50 mg IV 12hourly Proton pump Head -Check the
Pantoprazole Pantop inhibitors ache, doctors
which dizziness order
suppresses , -Check the
gastric chest vital sign
secretion pain -Follow the
16 rights
2)Inj Inj 1 gm IV 12 Antibiotic Nausea, Check the
cefotaxime Taxim hourly It inhibits Vomiting doctors
bacterial cell diarrhoea order
wall -Check the
synthesis vital sign
osmotically -Follow the
unstable 16 rights
leads to cell
death

3)Inj Iron Inj Iron 25 mg IV 24 Elevate the Nausea, Check the

dextran dextran hourly serum iron Vomiting doctors
concentratio order
n and is then -Check the
converted to vital sign
haemoglobin -Follow the
16 rights
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Theory application
Mrs. Nargis begam admitted in the hospital . she was having labour pain, so she can’t do care
herself due to his condition. He needs support from others to perform daily living activities.
So, I applied Dorothea Orem’s Self-Care Deficit Theory for my patient while caring him to
improve his health status by setting the goals with both the nurse and the patient’s mutual
understanding.
According to Dorothea Orem the conceptual framework is

SELF CARE

SELF CARE SELF CARE

AGENCY DEMANDS

NURSING
AGENCY
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In my patient’s condition the framework are as following

SELF CARE

SELF CARE CAPABILITIES Therapeutic Self

1.Poor Activity level Care demand
2.Poor Nutrition 1.Activity
3.Anorexia 2.Communication
4.Nausea,weekness 3.Self Care
5.Self care deficit 4.Nutrition
6.Risk for infection 5.Skin care

NURSING CAPABILITIES
1.Improve Activity level
2.Improve Appetite,reduce nausea and
vomitting
3.Reduce Risk for infection
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NURSING MANAGEMENT

NURSING ASSESSMENT

I)Assess the general condition of the Patient

II) Assess the pain level of the patient
III) Assess the fluid level of the patient
IV)Assess the nutritional level of the patient.
v) Assess the knowledge level of the patient

NURSING DIAGNOSIS

1) pain related to surgical incision caesarean section as evidence by anxious on facial

expression.

2)Risk for infection related to unsterile dressing as evidence by high body temperature

3) Fluid volume deficit related to vomiting On inadequate intake of water as evidence by dry lips
and dry skin.

4) Imbalanced nutrition less than body requirement related to loss of appetite as evidence by
weakness.

5) knowledge deficit regarding disease process and treatment modalities.

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CARE PLAN:

Assessment Nursing goal Planning Implementation Evaluation

diagnosis

SUBJECTIVE Pain related To -Assess the pain -Assessed the pain Patients pain
DATA: reduce level level slightly reduce
to surgical
mother said i pain of the patient of the patient
am having incision or
suffering pain -Provide comfortable -Provided
caesarean
incision site position(supine) comfortable
sections position(supine)
OBJECTIVE -Give comfort
evidence by
DATA: device -Given comfort
Patient looks anxious or or divertional device
restlessness therapy or divertional therapy
facial
and anxious to the patient to the patient
expression
-Provide analgesics -Provided analgesics
as per as doctors as per as doctors
order order
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Assessment Nursing goal Planning Implementation Evaluation

diagnosis

Subjective Risk for To Assess the -Assessed the Patients

data: infection reduce mothers mothers infection will
Mother related to risk of condition condition be reduce
complain that unsterile infectio
she is feel dressing as n Assess the -Assessed the
itching in her evidence by incisional site incisional site
itching in her high body
incisional site temperature Do sterile dressing -Done sterile dressing

Provide antibiotic as -Provided antibiotic

objective per as doctors advice as per as doctors
data: advice
Red is present
in incision site
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assessment Nsg goal Planning Implementation Evaluation

diagnosis

Subjective Imbalanced To Assess nutritional Nutritional pattern Nutrition is

data: balance pattern was assessed balanced
nutrition Less
Mother says I nutritio
am having than body n assess mothers Mothers choice of
Nausea. choice of food food was assessed
requirement
Objective data: related to provide high caloric High caloric diet was
Tiredness, diet provoded
nausea an
weekness
evidenced by provide small and Small and frequent
frequent diet diet was provided
weakness,
tiredness encourage fluid Fluid intake was
intake encouraged
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Health education:
Diet:
 Take green leafy vegetables
 Take high caloric diet
 Take iron rich food

Medication:
 Take medicine by doctors provided
 Check the expirery date of medicine
 Don’t skip the medicine

Exercise:
 Do free hand exercise
 Take proper rest between exercises

Follow up:
 Go for follow up regularly
 If any complication will arise than immediately go for checkup
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CONCLUSION
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Bibliography:-

1).John T. Queenan, John C. Hobbins, Catherine Y.2005. Protocols for high-risk pregnancies
Spong.4th edition

2) Dutta D.C, Text book of Obstretics, 2007, new central books agency; page 246-250

3) Daftery Shirish N., Chakrevarty Sudip, assisted by Daftery.S.:2007, Manual of Obstretics, 2nd
edition,page no 230-235

4)Boback M Irene & Jenson Margaret" Maternity & Gynaecologic Care, mosby company (5th
edition) page no;964-971

5)Myles (2003) text book for midwifes" 15th edition, Philadelphia: Churchill livingstone
publishers, page no:625-653

6)Raman A V text book of maternity nursing ,19 th edition ,Wolters Kluwer, page no :689-691

7)Richi Susan Scoti Essentials Maternity ,New born ,and Womens Health Nursing,4 th edition
Wolters Kluwer : page no 499-521