GOVERNMENT COLLEGE OF NURSING, JODHPUR

(RAJ.)

Subject-Obstetrics & Gynecology Specialty-I

NCP ON-INTRANATAL MOTHER

SUBMITTED TO - SUBMITTED BY-

Mrs. ANNMA SUMON HEMLATA BHANWARIA

NURSING LECTURER M.sc (N) Pre. Year
GCON, Jodhpur GCON, Jodhpur
PATIENT PROFILE:-

Name of patient : Prabha w/o Deepak ji

Age : 25 years

Marital status : Married

Religion : Hindu

Education : B.A

Occupation : House Wife

Address : Karni Nagar, Jodhpur.

Ward : Intra-natal Ward

Obstetrical Score : G2P1A0L1

L.M.P. : 03.10.2018

E.D.D. : 10.07.2019

Date of Admission : 05.07.2019

Medical diagnosis : Full term pregnancy with labour pain.

Chief complaints:-

- Amenorrhoea from 9 months

- Having labour pain since last night 1 pm
- Back ache.

Patient’s history:

i) History of present illness-

Patient was admitted on 7.07.2018 at 4.45 am with complain of pain in lower abdomen with
amenorrhea sinse 9 months. No leaking per vagina and “show” present.
ii) History of past illness:-
Medical history- No h/o DM,HTN, CAD and T.B. etc.
Surgical history- Not significant.
iii) Family history:-

No history of hereditary and genetic disorder.

iv) Personal history:-

Patient is vegetarian. No history of drug allergy or drug addiction. Absence of any type of
substance abuse like smoking, drug, alcohol etc.

v) Functional history:-

Sleep pattern, appetite, bladder and bowel function are normal.

 vi) Menstrual history:-

Menstrual cycle is regular of 4-5 days. No intermenstrual bleeding and no coital bleeding.

vii) Contraceptive history:-

Use of oral contraceptives.

viii) Past obstetrical history:-

G2P1A0L1

ASSESSMENT OF PATIENT ON ADMISSION

General:-

Body built : moderate

Weight : 65 kg

Vital signs:- ( at the time of admission)

Temperature : 37.40C

Pulse : 76/min

Respiration : 19/min

B.P. : 120/80 mm of Hg

Hydration : Adequate
Anaemia : no

Pallor : no

Heart : NAD

Lungs : NAD

Liver : NAD

EXMINATION:-

ABDOMINAL EXAMINATION:-

On inspection fundal height : below xyphisternum.

On Auscultation : F.H.S. 146/min

On palpitation through grip

Fundal grip : softer consistency.

Lateral grip : left side felt like hard, continuous, flat surface and irregular small knobs

opposite side.

Pelvic grip : hard round part felt it means presenting part is hed and station is 3/5.

Pawlik’s grip : head is fixed.

Uterine contraction : 4 contractions /10 min, duration>30 second.

Vaginal examination:

Vulva : normal

Vgina : normal

Cervix : dialatation is 4 cm and effacement is 60%

Membrane : intact

Presenting part : head

Pelvis : adequate

INVESTIGATIONS:-

s.no. INVESTIGATION IN PATIENT NORMAL VALUE

1. Sodium 139 mEq/lit 135-145 m Eq/lit
2. Potassium 3.9 mEq/lit 3.5-5.5 mEq/lit
3. CBC
RBC 5.12 mil/cumm 4.3-6.3 mil/cumm
Hb 8.9 gm/dl 12-14 gm/dl
Platelet count 4.43 lakh/ml 1.4-4.4 lakh/ml
Blood group A +ve
4. Blood glucose 90mg/dl 80-120 mg/dl
5. SGOT 219 U/L 0-40 U/L
SGPT 67U/L 5-36 U/L
Urine examination:
Albumin : nil
Sugar : nil
RBC : nil
WBC : nil

NEED ASSESSMENT:-

NEED PROBLEM

Physical need 1. Risk of fetal distress related to impaired gas exchange.

2. potential for injury related to induction of labour.

3. potential for infection related to labour process.

4. pain related to uterine contractions.

Psychological need 1. Anxiety related to labour process.

2. altered family coaping.

Nursing care plan:-

Main objective:-

To arrange clean and safe delivery.

Specific objectives:-

1. To identify early complications.

2. To establish respiration of newborn baby.
3. To minimize risk of injury during labour.
4. To maintain hygienic condition during and after labour.
5. To provide comfort to mother.
6. To introducethe family members about potential complication.
S.No NURSING NURSING NURSING INTERVENTION NURSING EXPECTED
. DIAGNOSIS OBJECTIVES IMPLEMENTATION OUTCOME

1. Impaired gas To prevent -Locate the fetal heart by -Fetal heart sound is recorded Fetal
exchange fetal hypoxia determining fetal position and every 30 minutes throughout hypoxia will
(fetal) related presentation. active phase. be relieved.
to altered -Ausculate fetal heart through -Left lateral position is given
oxygen fetal back. to patient.
supply -Count and record the fetal
heart rate half hourly in
active phase and every 15
min during second phase.
-Provide the left lateral
position to relieve pressure
on inferior vena cava and
improve uterine blood flow.

2. Altered To prevent -Record frequency and -Uterine contraction is Labour will

progress of complications duration of contraction in assessed every half hourly for progress
labour related and progress every half an hour during 10 min and durationof one normally.
to labour active phase of labour. contraction.
physiological normally. -assess and record cervical -the duration and frequency
process. dialation and effacement of contraction on recorded on
every four hourly and ecord partograph.
partograph. -Cervical dialatation and
-Assess pelvic size during PV effacement is recorded every
examination. 4 hourly.
3. Potential for To protect -Provide care related to
injury related from injury. admission protocol eg. Take
physical, nursing history, note vitals
chemical and and laboratory investigation.
external -record vitals every 2 hourly.
factors. -Encourage the patient to
void every 2 hourly, if
bladder is distended then
empty it by catheterization.
-Give enema if ordered by
doctor.
-Secure legs in stirrups.
-Discontinue oxytocin if
indicated and notify doctor.
e.g. fetal distress.

4. Potential for To prevent -Wash hands scrupulously. -Strict aseptic technique is Risk of
infection infection. --Wear cover gown, scrub maintained. infection is
related to clothes, hair, shoe covers etc - perineal area is washed with minimized.
invasive according to policy. 50% butadiene solution.
procedures, -Use sterile gloves for - At the time of P/V
rupture of vaginal examination. examination sterile gloves
amniotic -P/V examination should worn.
membrane. minimally, in every 4 hours. -P/V examination is done in
-Use antiseptic solution to every 4 hours.
prepare perineal area.
-Use sterilized articles.
5. Anxiety To reduce -orient client to ward. -patient is oriented about Anxiety is
related to anxiety level. -Explain all procedures. ward and hospital policy. relieved to
situational -Explain reason for protocol -Every procedure is some extent.
crisis. for e.g. restriction of food explained before performing.
and luid side lying position -Attendant or coach is
etc. allowed full time.
-Explain about progress of -Feeling of patient is
labour. assessed.
-Encourage expression of
feelings and convey
understanding and
acceptance.
-Do not leave woman alone.

6. Pain related To relieve -Assess pain via verbalization - pain level is assessed by Pain is
to physical pain. and body language. body language of patient. relieved.
and -Assess coping mechanism, -Touch therapy, effleurage
psychologica verbal and non-verbal and back massage is given.
l factors. expression of fear. - reinforced for breathing and
-Use touch therapy, stroking- relaxation techniques.
holding hand, effleurage, -Left lateral position is given.
massage of back.
-Teach of reinforce breathing
and relaxation techniques.
-Provide comfortable
position.
INSTRUCTIONS FOR INTRA-PARTUM PERIOD:-

1. Explain all procedures, seek permission for examination and carrying out procedures and discuss the finings
with woman.
2. Keep the woman informed about progress of labour.
3. Praise the woman, encourage her and reassure her that things are going well.
4. Ensure respect and privacy of woman during examination and discussion.
5. Encourage woman to bath or wash herself and her genitals at the onset of labour.
6. Ensure cleanliness of birth area.
7. Encourage woman to empty the bladder frequently. Remind her in every two hours.
8. The woman should be allowed to remain mobile during labour especially during first stage, as this helps in
having a shorter and less painful labour.
9. The woman should be free to choose any position she desires and feel comfortable during labour and
delivery.
10.Woman who are not at risk of requiring general anesthesia can have light, easily digested, low fat food
during labour, if they wish.