3 CONDUCTION NORMAL DELIVERY OBS p162-321

Conduction of Normal Delivery
Case No. – 1
Identification Data
Name of the hospital : Barasat District Hospital
Name of the client : Jesmina Bibi. Age : 23 yrs.
Address with husband’s name : w/o- Mahammad Rafik Abdul, Vill- Gosaipur,
P.O.- Kharua Chandpur, P.S-DegangaDist. – 24 pgs.(N)
Religion : Muslim Under Dr. : Dr. D.Roy
Date of admission : 10/02/2020 at 7.30am Registration no: 13468
GPLA : G1P0L0A0 Period of gestation : 39 weeks 5days
LMP : 07/05/2019 EDD :14/02/2020
Onset of labour pain : Complain on admission : Labour pain with 39 weeks amenorrhea.
On examination findings: Os- 3 cm, Cervix- 40% Effaced, FHR- 144 bts/min
BP of the mother- 120/70 mm Hg, Pulse - 76 bts/min, Resp - 20 brs/ min.
Brief History:
Social : Education: Husband : Class XII Wife: Class X
Occupation : Husband : Business Wife : Housewife
Family members : 4 members Support Person : Mother-in-law and husband
Personal : Any drug allergy : Nothing significant
Medical and surgical :
Past : Nothing significant Present : Nothing significant
Family : Nothing significant
Financial assistance : From husband
Marital history : Married for 3 years
Relationship : Maintains good relationship with family members and neighbours.
Diet : Last meal time and contents : Chapati, Sabji. At 7 pm.
Bowel and bladder: Passed urine and stool.
162
Past Obstetric History: LCB :
No. of Year Abortion Any Mode of Place of Sex Baby Any Remarks
pregnancy (with problems delivery delivery (alive/ problem
period) during stillbirth) during
antenatal puerperium
period
Primigravida
Present Obstetric History:

Booked/ unbooked : Booked No. of antenatal check up : 4
Immunization : Inj TT 2 doses taken. Total weight gain : 12kg
Any problem during pregnancy : No.
If yes, treatment given :
Nature of labour pain (with time) : Started at 09 pm on 11/2/20. She complain pain from
abdomen towards thigh.
Laboratory investigations :
Blood Group : B Hb % : 11.8 gm/dl
Rh : +ve PPBS /Fasting : 78 mg/dl(fasting)
HIV : Nonreactive HbsAg : Nonreactive VDRL : Nonreactive
Urine : Sugar : Nil Alb : Nil
USG report : Single live fetus with changing lie.Active etal movement and cardiac pulsation
are visualized and corroborated with M- mod study.measurement-B.P.D:64mm corresponds
to 26weeks 3days; F.L:44mm corresponds to 24weeks 2days; A.C: 216mm corresponds to
25weeks 6days; F.H.R:160BPM.
Average sonographic age is 25weeks 4days+/-2 weeks 0days.
Placenta is Fundo-anterior and right.Grade- 1. Lower mergin is well above cervix. No
retroplacentl collection seen.
Cervix tabular;internal os is closed; liquor is adequate; no obvious congenital anomaly seen.
163
Physical examination :
Vital signs : BP- 120/78 mm of Hg, Pulse- 84 bts/min, Resp - 18 brs/min, Temp : 980F
General condition : Good. Eye - Pallor/normal: Normal Lung : Normal.
Breast : Soft and secretory Heart : Normal. Tongue : Dehydrated/Moist: Moist
Bladder- Distended/ Evacuated : Evacuated Oedema : absent.
Any other specific findings : Nothing significant.
Any other associated condition : Nothing significant.
Abdominal examination :
Inspection : Uterine ovoid is longitudinal. Pink striaes are present . no scar mark, or sign of
infection. Uterine contraction is present. Fetal movements are visible.
SFH in cm.: 32 cm. In weeks : 39 weeks Abdominal girth : 98cm.
Palpation:
Fundal grip : A broad soft mass suggestive of buttocks is palpable.
Lateral grip: In the left lateral grip - A smooth curved and resistant mass is felt suggestive
of back.
In right lateral grip : Small, knob like, irregular parts are felt, suggestive of limbs.
First Pelvic Grip :
Second Pelvic Grip :
Auscultation : 140 beats/ min.
Per vaginal examination/ vulval inspection : no signs of infection is present. Show is present.
Remarks (specifying presentation, position, engagement, etc.)
A full term pregnant with true labour pain. Findings reveal vertex presentation, LOA
position, FHR- 140 beats/min and regular. Other findings are recorded in the partograph
Management during first stage of labour

Time of onset of labour pain
Time of full dilation of os
Rest/ walk, diet, bowel, bladder, relief of Woman is instructed to walk and to practice
pain (relaxation technique/ medication), deep breathing and relaxation technique
general care, vulval toileting, bath, clothing, during and after contraction. She has passed
assurance, advices regarding Dos and Don’ts stool and urine. She has taken tea. No
in first stage of labour, progress notes of analgesic is given. Garments are changed.
labour, fetal and maternal condition(to be Reassurance is given. Mother is instructed
recorded in the partograph). not to bear down. Her progress of labour is
satisfactory.
164
Management during second stage of labour
Preparation of woman for delivery, shifting Woman is shifted to the labour table. She is
to labour table, positioning of the woman, advised to lie on her back with knee flexed
catheterisation, instructions for bearing and legs/ thighs apart. She is encouraged to
down, progress notes of labour, fetal and bear down during contraction. FHR is
maternal condition ( to be recorded in checked in 15 mins interval and recorded in
partograph) partograph.
Conduction of delivery
Mode of delivery Normal delivery with episiotomy
Time of delivery
Delivery of head (specify if episiotomy Vulval toileting is done. Perineal guard is given.
required) Inj. Lignocaine 1% 5ml given in a fan shaped way.
Care following delivery of head , A left sided medio-lateral episiotomy is given. Head
delivery of shoulder, delivery of trunk. is delivered in between contraction. Eyes and mouth
are cleaned. There is no cord around the neck.
Restitution occurs. Then external rotation of head is
occurred and baby is born by laboured flexion
,whole body is delivered and kept on mother’s
abdomen. Cord is clamped and cut. A full term
normal living girl baby is delivered at 9.46 PM
on12/02/2020. Baby cried immediately after birth.
In syntocin 10 unit IM is given a gush of bleeding
with permanent lengthening of cord is seen
vaginally. Uterus is hard, globular. Placenta is
expelled by controlled cord traction. Placenta and
membrane are completely expelled out at 9.55 PM
0n 12/02/2020. A quick placenta examination is
done.
Sex of the newborn : Girl.

Disc no. of the newborn : 40
Birth weight of the newborn : 2.7 kg
165
Condition of the newborn :
Record if any resuscitation Baby cried immediately after birth. No resuscitation
measures taken and time of cry. measures required. General condition- good. Posture-
Respiration, heart arte, colour of well flexed. Baby cried at birth. Skin- pink, smooth,
the baby. soft. Vernix present on back, shoulder. FHR- 136 beats/
Further resuscitation measures min. respiration- 36 breaths/min, length -48 cm, HC- 33.
taken. CC- 31cm. anterior fontanelle diamond shaped and
measures 3cmx 2.5 cm. No overriding of sutures. Eyes
clean , no discharge present. Sclera is white. Top of the
pinna of ear is in horizontal plane to the outer canthus .
nasal passage is patent. Breast tissue more than 10mm.
Abdomen – soft. Labia majora completely covers the
minora. Anus- patent.
Total hour of labour : 12 hrs 55min

1st stage : 11hrs.
2nd stage : 1hrs 46min
3rd stage : 9 min
Medical treatment advised (if any ): Nothing Significant
Management of fourth stage of labour :

Condition of mother :
BP : 110/70 mmHg Temp : Afebrile Pulse : 84 bts/min Resp: 20 brs/min
Vaginal bleeding : Lochia rubra is present in average amount.
Uterus : Hard, globular and mobile, SFH- 14 cm.
Level of hydration : Normal. Bladder : Emptied.
General care : Water is given to the mother.
Condition of the baby : No cord bleeding. Baby is put on mother’s breast. Baby is active and
sucking the breast.
166
Nursing Care process
( For mother before delivery)
Nursing Expected Nursing Intervention Evaluation
Diagnosis Outcome
Acute pain related To modify  Intensity, duration and Woman
to uterine behaviour to interval of contractions are practiced deep
contractions as decrease assessed. breathing and
evidenced by intensifying of  Woman is advised to relaxation
verbalisation and labour pain practice deep breathing and technique.
facial expression, relaxation technique.
restlessness.  Is instructed to relax after
each contraction.
 Is advised not to bear down
in first stage .
 Is taught when and how to
bear down in 2nd stage of
labour.
Impaired fluid & To maintain  Hydration level is assessed. Hydration level
electrolyte balance adequate  Provide liquid diet is normal.
related to nutrition.  A glass of water given
restriction and during latent phase.
perspiration in  Only sips of water is given
labour pain in 2nd stage of labour.
 Intake and output is
maintained
Impaired personal To maintain  Woman is encouraged to Woman
hygiene related proper personal take bath in 1st stage of expresses
labour pain hygiene. labour. refreshed.
 Is advised to take mouth
wash.
 Sponging of face is done.
 Hair is made tidy.
167
Nursing care process
( For mother after delivery)
Diagnosis Outcome
Disturbed body To maintain  Vital signs checked and BP -110/70 mm of
system related to normal body recorded. Hg, Temp:afebrile,
labour process system- vital  Hydration level is Pulse : 84 bts/min,
signs, size and assessed. Resp:20 brs/min
position of uterus,  Fundal height and Uterus is hard,
lochia. consistency is checked. globular, lochia is
 Lochia(amount, colour) normal in amount.
is checked.
 Sips of water is given to
the mother.
Impaired comfort To maintain  Comfortable position is Woman expresses

related to after adequate comfort. given. comfort.
pain, pain in  Is advised early
episiotomy area, ambulation.
uterine cramps,  Assessed breast for
bleeding as engorgement.
evidenced by  Wet clothes are
verbalisation removed.
 Mother is instructed to
breast feed the baby.
 Is encouraged proper
breast emptying by
giving colostrum and
hind milk and continue
exclusive breastfeeding.
168
( For Baby)
Diagnosis Outcome
Ineffective To maintain  Baby is received in a pre warmed, Baby’s body
thermoregulation adequate sterile towel. temperature is
related to thermoregulation.  Baby is dried immediately and normal.
transition of changed the wet towel.
newborn to extra  Wrapped the baby with another pre
uterine warmed towel.
environment.  Baby is put to the mother’s chest
for to promote skin to skin contact.
 Fan is put off in the baby corner.
 Skin colour is assessed to detect
any signs of hypothermia.
Potential risk for To establish  Baby is kept at the room Baby cried
ineffective airway effective temperature of 28˚-32˚C. after birth.
related to presence breathing.  Mouth is cleaned with sterile gauze
of mucous in piece after delivery of head.
mouth and nose.  Suction of mouth and oropharynx
and nose is done.
 Tactile stimulation is given.
Signature of Studen
Signature of supervisor
169
Case No. – 2
Identification Data
Name of the client : Tuhina Mandal Age : 20 yrs.
Address with husband’s name : w/o- Sahidul Mandal, Vill-Pratick Pally, Duttapukur,
P.S.- Duttapukur, Dist: North 24 pgs
Religion : Muslim Under Dr. : Dr. S.S.Roy
Date of admission : 10/02/2020 at 6.08 AM Registration no. : 13345
GPLA : G1P0L0A0 Period of gestation :39 weeks
LMP : 10/05/2019 EDD :17/02/2020
Onset of labour pain : Complain on admission : labour pain with 39 weeks amenorrhea.
On examination findings: Os- 8 cm., Cervix- 90% effaced, FHR- 142 bts/min
BP of the mother- 130/70 mm of Hg, Pulse- 76 bts/min, Resp- 20 brs/ min.
Brief History :
Social : Education: Husband : Class X Wife: Class VII
Occupation : Husband : Private Farm Wife : Housewife.
Family members : 4 members. Support Person : Mother-in-law and husband
Personal : Any drug allergy : Nothing significant.
Medical and surgical : Past : Nothing significant.
Present : Nothing significant.
Family : Nothing Significant
Financial assistance : From husband.
Marital history : Married for 1 years.
Diet : Last meal time and contents : Chapati, Sabji. at 8 PM.
170
period
Primigravida
Present Obstetric History :

Any problem during pregnancy : No
Nature of labour pain (with time) : Started at 9 am on 10/02/20. She complain pain from
Blood Group : A Hb % : 12 gm/dl
Rh :+ve PPBS /Fasting : 78 mg/dl(fasting)
to 26weeks 3days; F.L:44mm corresponds to 23 weeks 2days; A.C: 216mm corresponds to
Vital signs : BP- 120/78 mm of Hg, Pulse- 80 bts/min Resp - 20 brs/min, Temp -98.40F
General condition : Good
Eye - Pallor/normal: Normal
Tongue - Dehydrated/Moist: Moist Breast : Soft and secretory
Heart : Normal Bladder - Distended/ Evacuated : Evacuated
Lung : Normal Oedema : Absent
171
SFH in cm.: 38 cm. In weeks : 39 weeks
Abdominal girth : 96 cm.
Palpation:
Lateral grip : In the left lateral grip – A smooth curved and resistant mass is felt
suggestive of back.
In right lateral grip : Small, knob like, irregular parts are felt , suggestive of limbs.
First Pelvic Grip :
Second pelvic grip :


Rest/ walk, diet, bowel, bladder, relief of pain Woman is instructed to walk and to practice
(relaxation technique/ medication,), general deep breathing and relaxation technique
care, vulval toileting, bath, clothing, during and after contraction. She has passed
labour, fetal and maternal condition( to be Reassurance is given. Mother is instructed
recorded in the partograph.) not to bear down. Her progress of labour is
satisfactory.
172
Time of delivery
Delivery of head9specify if Vulval toileting is done. Perineal guard is given. Inj.
episiotomy required) Lignocaine 1% 5ml given in a fan shaped way. A left
Care following delivery of head sided medio-lateral episiotomy is given. Head is delivered
, delivery of shoulder, delivery in between contraction. Eyes and mouth are cleaned. There
of trunk. is no cord around the neck. Restitution occurs. Then
external rotation of head is occurred and baby is born by
laboured flexion ,whole body is delivered and kept on
mother’s abdomen. Cord is clamped and cut. A full term
normal living boy baby is delivered at 9.04 am
on11/02/20. Baby cried immediately after birth. In
syntocin 10 unit IM is given a gush of bleeding with
permanent lengthening of cord is seen vaginally. Uterus is
hard, globular. Placenta is expelled by controlled cord
traction. Placenta and membrane are completely expelled
out at 9.15 am on11/02/20. A quick placenta examination
is done.
Sex of the newborn : Boy

173
Abdomen – soft. Anus- patent.
Total hour of labour : 12 hrs. 15 mins

1st stage : 10hrs.04 Min
2nd stage : 2 hrs.
3rd stage : 11min
Medical treatment advised (if any ):
BP : 110/70 mmHg Temp : afebrile Pulse : 80 bts/min Resp: 20 brs/min
Uterus : hard, globular and mobile, SFH- 13.5 cm.
Level of hydration : Normal.
Bladder : Emptied.
sucking the breast.
174
Diagnosis Outcome
Acute pain related To modify  Intensity, duration and Woman
to uterine behaviour to interval of contractions are practiced deep
contractions as decrease assessed. breathing and
evidenced by intensifying of  Woman is advised to relaxation
verbalisation and labour pain practice deep breathing and technique.
facial expression, relaxation technique.
restlessness.  Is instructed to relax after
each contraction.
 Is advised not to bear down
in first stage .
 Is taught when and how to
bear down in 2nd stage of
labour.
related to nutrition.  A glass of water given
restriction and during latent phase.
perspiration in  Only sips of water is given
labour pain in 2nd stage of labour.
 Intake and output is
maintained
Impaired personal To maintain  Woman is encouraged to Woman
hygiene related proper personal take bath in 1st stage of expresses
labour pain hygiene. labour. refreshed.
 Is advised to take mouth
wash.
175
Diagnosis Outcome
Disturbed body To maintain  Vital signs checked and BP -110/70 mm
system related to normal body recorded. of Hg, Temp.-
labour process system- vital  Hydration level is assessed. afebrile, Pulse :
signs, size and  Fundal height and 84 bts/min,
position of uterus, consistency is checked. Resp.- 20
lochia.  Lochia(amount, colour) is brs/min
checked. Uterus is hard,
 Sips of water is given to the globular, lochia
mother. is normal in
amount.
Impaired comfort To maintain  Comfortable position is Woman

related to after adequate comfort. given. expresses
pain, pain in  Is advised early ambulation. comfort.
episiotomy area,  Assessed breast for
uterine cramps, engorgement.
bleeding as  Wet clothes are removed.
evidenced by  Mother is instructed to
verbalisation breast feed the baby.
 Is encouraged proper breast
emptying by giving
colostrum and hind milk and
continue exclusive
breastfeeding.
176
( For Baby)
Diagnosis Outcome
Ineffective To maintain  Baby is received in a pre Baby’s body
thermoregulation adequate warmed, sterile towel. temperature is
newborn to extra  Wrapped the baby with
uterine another pre warmed towel.
environment.  Baby is put to the mother’s
chest for to promote skin to
skin contact.
 Fan is put off in the baby
corner.
 Skin colour is assessed to
detect any signs of
hypothermia.
ineffective effective temperature of 28˚-32˚C. after birth.
airway related to breathing.  Mouth is cleaned with sterile
presence of gauze piece after delivery of
mucous in mouth head.
and nose.  Suction of mouth and
oropharynx and nose is done.
Signature of Studen
177
Case No. – 3
Identification data
Name of the client: Asma Khatun. Age : 19 yrs.
Address with husband’s name : w/o- Jamati Ali
Vill- Dadpur, P.S- Duttapukur, Dist. –North 24 pgs.
Date of admission : 09.02.20 at 8pm Registration no. : 13081
LMP : 05/05/2019 EDD :12/02/20
On examination findings: Os- 4 cm., Cervix- 70% Effaced, FHR- 140 bts/min
Brief History :
Social : Education: Husband : Class VII. Wife: Class V.
Occupation : Husband : Business. Wife : Housewife.
Family members : 6 members. Support Person : Mother and husband
178
period
Primigravida

Nature of labour pain (with time) : Started at 7.15 AM on 10/02/2020. She complain pain
from abdomen towards thigh.
Blood Group : AB Hb % : 12 gm/dl
Vital signs : BP- 130/80 mm of Hg Pulse : 80 bts/min Resp: 18 brs/min
Temp : 98.20F
Eye - Pallor/normal: Normal Tongue - Dehydrated/Moist : Moist
Breast - Soft and secretory Heart - Normal
Bladder- Distended/ Evacuated : Evacuated
179
Lung - Normal Oedema - Absent
Palpation:
suggestive of back.
First Pelvic Grip :.
position, FHR- 140 beats/min and regular. Other findings are recorded in the partograph.

satisfactory.
180
Time of delivery
Delivery of head specify if episiotomy Vulval toileting is done. Perineal guard is given.
normal living boy baby is delivered at 7.51am
syntocin 10 unit IM is given a gush of bleeding
membrane are completely expelled out at 07.59 am
0n 11/02/20. A quick placenta examination is done.
Sex of the newborn : Boy.

181


1st stage : 10hrs 36min
2nd stage : 2hrs
3rd stage : 8min
BP : 110/80 mmHg Temp : 98.4 0F, Pulse : 80 bts/min, Resp : 20 brs/min
Uterus : hard, globular and mobile, SFH- 13 cm.
Bladder : Emptied.
General care : water is given to the mother.
sucking the breast.
182
Diagnosis Outcome
Acute pain related To modify  Intensity, duration and interval Woman
to uterine behaviour to of contractions are assessed. practiced deep
contractions as decrease  Woman is advised to practice breathing and
evidenced by intensifying of deep breathing and relaxation relaxation
verbalisation and labour pain technique. technique.
facial expression,  Is instructed to relax after each
restlessness. contraction.
 Is advised not to bear down in
first stage .
 Is taught when and how to bear
down in 2nd stage of labour.
related to nutrition.  A glass of water given during
restriction and latent phase.
perspiration in  Only sips of water is given in
labour pain 2nd stage of labour.
 Intake and output is maintained
Impaired personal To maintain  Woman is encouraged to take Woman

hygiene related proper personal bath in 1st stage of labour. expresses
labour pain hygiene.  Is advised to take mouth wash. refreshed.
183
Diagnosis Outcome
Disturbed body To maintain  Vital signs checked and recorded. BP -110/70 mm
system related to normal body  Hydration level is assessed. of Hg, Temp -
labour process system- vital  Fundal height and consistency is afebrile, Pulse -
signs, size and checked. 84 bts/min,
position of uterus,  Lochia(amount, colour) is checked. Resp- 20
lochia.  Sips of water is given to the brs/min
mother. Uterus is hard,

globular, lochia
is normal in
amount.
Impaired comfort To maintain  Comfortable position is given. Woman

related to after adequate comfort.  Is advised early ambulation. expresses
pain, pain in  Assessed breast for engorgement. comfort.
episiotomy area,  Wet clothes are removed.
uterine cramps,  Mother is instructed to breast feed
bleeding as the baby.
evidenced by  Is encouraged proper breast
verbalisation emptying by giving colostrum and
hind milk and continue exclusive
breastfeeding.
184
( For Baby)
Diagnosis Outcome
and nose is done.
Signature of Student
185
Case No. – 4
Identification data
Name of the client : Parveen Khatun. Age : 25 yrs.
Address with husband’s name : w/o- Md. Halibar Rahaman.
Vill- Odanpur, P.S.- Deganga, Dist. – North 24 pgs.
Religion : Muslim Under Dr. : Dr. S.Samanta
Date of admission: 14/02/20 at 01.35 AM Registration no. : 13408
GPLA : G1P0L0A0 Period of gestation : 40weeks
LMP : 08/05/2019 EDD :15/02/2020
BP of the mother- 120/80 mmhg., Pulse- 86 bts/min, Resp- 20 brs/ min.
Brief History :
Social : Education: Husband : Class XI. Wife: Class IX.
Family members : 6 members. Support Person : Mother-in-law
Past : Nothing significant
Present : Nothing significant
Diet : Last meal time and contents : Chapati, sabji. At 9 pm.
186
period
Primigravida
Nature of labour pain (with time) : Started at 11 pm on 14/02/20. She complain pain from
HIV : NonRreactive HbsAg : Non Reactive VDRL : Non Reactive
Vital signs : BP- 120/70 mm of Hg, Pulse : 80bts/min, Resp: 19 brs/min, Temp : 98.40F
General condition : Good. Eye - Pallor/normal: Normal
Tongue - Dehydrated/Moist : Moist Breast : Soft and secretory
Heart : Normal Lung : Normal
Bladder - Distended/ Evacuated : Evacuated Oedema : Absent
187
Abdominal girth : 98cm.
Palpation:
Lateral grip : In the left lateral grip – Small, knob like, irregular parts are felt , suggestive
of limbs.
In right lateral grip :A smooth curved and resistant mass is felt suggestive of back.
First Pelvic Grip :Head engaged,not balottable
Second pelvic grip :Divergence found
A full term pregnant with true labour pain. Findings reveal vertex presentation, ROA

satisfactory.
188
Time of delivery
Delivery of headspecify if episiotomy Vulval toileting is done. Perineal guard is given.
Care following delivery of head , A left sided medio-lateral episiotomy is given.
delivery of shoulder, delivery of trunk. Head is delivered in between contraction. Eyes and
mouth are cleaned. There is no cord around the
neck. Restitution occurs. Then external rotation of
head is occurred and baby is born by laboured
flexion ,whole body is delivered and kept on
mother’s abdomen. Cord is clamped and cut. A full
term normal living girl baby is delivered at 11.51
am on15/02/20. Baby cried immediately after birth.
membrane are completely expelled out at 12.05 pm

189

1st stage : 11hrs
3rd stage :14min

BP : 110/70 mmHg Temp : 98.40F Pulse : 84 bts/min Resp : 20 brs/min
Bladder : Emptied.
Condition of the baby : no cord bleeding. Baby is put on mother’s breast. Baby is active and
sucking the breast.
190
Diagnosis Outcome
Acute pain related To modify  Intensity, duration and interval of Woman
to uterine behaviour to contractions are assessed. practiced deep
contractions as decrease  Woman is advised to practice deep breathing and
evidenced by intensifying of breathing and relaxation technique. relaxation
verbalisation and labour pain  Is instructed to relax after each technique.
facial expression, contraction.
restlessness.  Is advised not to bear down in first
stage .

related to nutrition.  A glass of water given during latent
restriction and phase.
perspiration in  Only sips of water is given in 2nd
labour pain stage of labour.
Impaired personal To maintain  Woman is encouraged to take bath Woman

hygiene related proper personal in 1st stage of labour. expresses
191
Diagnosis Outcome
position of uterus,  Lochia(amount, colour) is checked. Resp - 20

globular, lochia
is normal in
amount.

breastfeeding.
192
( For Baby)
Diagnosis Outcome
and nose is done.
193
Case No. – 5
Identification data
Name of the client :Jaba Nath Age : 20 yrs.
Address with husband’s name : w/o-Asim Nath
Vill-Narayanpur, P.O-Laxmipur P.S.-Habra, Dist. – North 24 pgs.
Religion : Hinduism Under Dr. : Dr. S.S.Roy
Date of admission:15.02.20 at 6am Registration no. : 13054
GPLA : G1P0L0A0 Period of gestation : 40Weeks
LMP : 12/05/2019 EDD :17/02/2020
On examination findings : Os- 2 cm., Cervix- 40% Effaced, FHR- 138 bts/min
BP of the mother - 120/70 mm of Hg, Pulse- 76 bts/min, Resp- 20 brs/ min.
Brief History :
Social : Education: Husband : Graduate Wife: Class X.
Family members : 4 member Support Person : Mother-in-law and husband
Past : Nothing significant.
Relationship : maintains good relationship with family members and neighbours.
Diet : Last meal time and contents : Chapati, sabji. at 8 pm.
194
period
Primigravida

Nature of labour pain (with time) : Started at 9 am on 15/02/20. She complain pain from
Blood Group : B Hb %: 12.8 gm/dl
Vital signs : BP- 120/80 mmHg, Pulse- 80 bts/min Resp.- 18 brs/min Temp.-98˚F
Eye - Pallor/normal: Normal Tongue - Dehydrated/Moist : Moist
Breast : Soft and secretory Heart : Normal Lung : Normal
Bladder- Distended/ Evacuated : Evacuated Oedema : Absent
Any other specific findings : Nothing significant
Any other associated condition : Nothing significant
195
Palpation:
suggestive of back.

satisfactory.
196
Time of delivery
normal living girl baby is delivered at 8.55 am

197
the baby. soft. Vernix present on back, shoulder. FHR- 1368beats/

1st stage : 10 hrs
2nd stage : 1hrs 55 min
3rd stage : 15 min
BP : 110/70 mmHg Temp : 98.4 0F Pulse : 84 bts/min Resp : 20 brs/min
Bladder : Emptied.
sucking the breast.
198
Diagnosis Outcome
stage .


199
Diagnosis Outcome

globular, lochia
is normal in
amount.

breastfeeding.
200
( For Baby)
Diagnosis Outcome
and nose is done.
201
Case No. – 6
Identification data
Name of the client : Resma Khatun Age : 23 yrs.
Address with husband’s name : w/o- Sofikul Islam
Vill-Teghoria, P.O-Golabari bazar, P.S.-Sashan , Dist- North-24 Parganas.
Religion : Muslim Under Dr. : Dr. R.K.Mondal
Date of admission:12/02/2020 at 1.30 PM Registration no: 13444
GPLA : G1P0L0A0 Period of gestation : 40 Weeks
LMP : 07/05/2019 EDD : 14/02/2020
Brief History :
Social : Education: Husband : Class VI Wife: Class V
Occupation : Husband : Labour Wife : housewife.
Bowel and bladder : Passed urine and stool.
202
period
Primigravida
Nature of labour pain (with time) : Started at 2.30 pm on 12/02/20. She complain pain from
Blood Group : B Hb % : 11 gm/dl
HIV : Nonreactive HbsAg : Nonreactive VDRL : Non-reactive
Vital signs : BP- 120/78 mm Hg, Pulse : 84 bts/min Resp : 18 brs/min Temp : 980F
Eye - Pallor/normal: Normal Tongue - Dehydrated/Moist: Moist
Bladder: Distended/ Evacuated : Evacuated Oedema : Absent
203
Palpation:
suggestive of back.

satisfactory.
204
Time of delivery
Delivery of head9specify if episiotomy Vulval toileting is done. Perineal guard is given.
term normal living girl baby is delivered at 3.30PM
membrane are completely expelled out at 3.40PM

Birth weight of the newborn : 2.6kg
205
Total hour of labour : 13 hrs 40 mins

1st stage : 12 hrs.
3rd stage : 10 min
Medical treatment advised (if any ):Nothing Significant

BP :110/70 mmHg Temp : Afebrile Pulse : 84 bts/min Resp : 20 brs/min
Bladder : Emptied.
sucking the breast.
206
Diagnosis Outcome
stage .


207
Diagnosis Outcome

globular, lochia
is normal in
amount.

breastfeeding.
208
( For Baby)
Diagnosis Outcome
and nose is done.
209
Case No. – 7
Identification data
Name of the client : Kakali Ghosh Age : 24yrs.
Address with husband’s name : w/o- Dipankar Ghosh
Vill- Sonadanga, P.O-kamdevpur, P.S-Amdanga , Dist- North-24 Parganas.
Religion : Muslim Under Dr. : Dr.Dalia Roy
Date of admission:15.02.20 at 7.30am Registration no. : 13141
GPLA : G1P0L0A0 Period of gestation : 40 weeks
LMP : 08/05/2019 EDD : 15/02/2020
Onset of labour pain : Complain on admission labour pain with 40 weeks amenorrhea.
Brief History :
Social : Education: Husband : Class X. Wife: Class VII.
Occupation : Husband : Business. Wife : housewife.
Diet : Last meal time and contents : Chapati, sabji. at 8 PM.
210
period
Primigravida

Nature of labour pain (with time) : Started at 7.40 AM on 15/02/20. She complain pain from
Vital signs : BP- 120/78 mm of Hg, Pulse : 80 bts/min, Resp : 20 brs/min, Temp:98.40F
Eye - Pallor/normal: Normal Tongue - Dehydrated/Moist: Moist
Bladder- Distended/ Evacuated : Evacuated Oedema : Absent
211
Palpation:
suggestive of back.

satisfactory.
212
Time of delivery
term normal living boy baby is delivered at 9.30 am
on16/02/20. A quick placenta examination is done.

213
Total hour of labour : 14 hrs 10 mins

1st stage : 11hrs 50 mins
2nd stage : 2 hrs
3rd stage : 15 min
BP : 110/70 mmHg Temp: 98.60F Pulse : 80 bts/min Resp : 20 brs/min
Level of hydration : Normal
Bladder : Emptied
General care : Water is given to the mother
sucking the breast.
214
Diagnosis Outcome
stage .


215
Diagnosis Outcome

globular, lochia
is normal in
amount.

breastfeeding.
216
( For Baby)
Diagnosis Outcome
and nose is done.
217
Case No. – 8
Identification data
Name of the client: Sabana Yeasmin Age : 24yrs.
Address with husband’s name : W/o- Abu Sadak
Vill-Petokhal, P.O- Barasat, P.S.- Barasat, Dist- North-24 Parganas.
Religion : Muslim Under : Dr.S.Samanta
Date of admission:10/02/2020 at 7.40 AM Registration no. : 13532
LMP : 07/05/2019 EDD : 14/02/2020
Brief History :
Social : Education: Husband : Class IX. Wife: Class VI.
Occupation : Husband : Shoe maker Wife : Housewife.
Family members : 6 members. Support Person : Father-in-law
Relationship : maintains good relationship with family members and neighbours.
Diet : Last meal time and contents : Chapati, sabji. at 7 pm.
218
period
Primigravida
Nature of labour pain (with time) : Started at 9.45am on 10/02/20. She complain pain from
Vital signs : BP- 130/80 mm of Hg, Pulse : 80 bts/min Resp : 18 brs/min
0
Temp : 98.2 F
General condition : Good Eye : Pallor/normal: Normal
Tongue :Dehydrated/Moist : Moist Breast : Soft and secretory
Heart : Normal Bladder: Distended/ Evacuated : Evacuated Lung : Normal
Oedema : Absent.
219
Palpation:
suggestive of back.

satisfactory.
220
Time of delivery
term normal living boy baby is delivered at 11.40

221


1st stage : 10 hrs
2nd stage : 1 hrs 55 mins
3rd stage : 15 min
BP : 110/70 mmHg Temp: Afebrile Pulse : 80 bts/min Resp : 20 brs/min
Uterus : Hard, globular and mobile, SFH- 13.5 cm.
Bladder : Emptied
sucking the breast.
222
Diagnosis Outcome
stage .


223
Diagnosis Outcome
Disturbed body To maintain  Vital signs checked and recorded. BP -110/70
system related to normal body  Hydration level is assessed. mmHg, Temp.-
labour process system- vital  Fundal height and consistency is afebrile, Pulse :
position of uterus,  Lochia(amount, colour) is checked. Resp.- 20

globular, lochia
is normal in
amount.

breastfeeding.
224
( For Baby)
Diagnosis Outcome
and nose is done.
225
Case No. – 9
Identification data
Name of the client : Tuhina Bibi . Age : 24yrs.
Address with husband’s name : w/o- Saber Ali Gazi
Vill-Petokhal, P.O- Barasat, P.S.- Barasat, Dist- North-24 Parganas.

Date of admission: 15/02/20 at 5am Registration no. : 13062
GPLA : G1P0L0A0 Period of gestation :39 weeks 5days
LMP : 09/05/2019 EDD : 16/02/2020
Brief History :
Social : Education: Husband : Class IX Wife: Class IV.
Occupation : Husband : Hawker Wife : Housewife.
226
Past Obstetric History : LCB :
No. Year Abortion( Any Mode Place Sex Baby(aliv Any Remarks
of with problem of of e/stillbirt problem
pregn period) s during deliver delive h) during
ancy antenata y ry puerperium
l period
Primigravida

Nature of labour pain (with time) : Started at 7am on 15/02/20. She complain pain from
Blood Group : A Hb % : 12gm/dl
Vital signs : BP- 120/70 mm of Hg Pulse: 84 bts/min Resp :18 brs/min Temp:98.40F
Tongue :Dehydrated/Moist : Moist Breast : Soft and secretory
Heart : Normal Bladder: Distended/ Evacuated : Evacuated
227
Palpation:
of limbs.
First Pelvic Grip :

satisfactory.
228
Time of delivery
term normal living girl baby is delivered at 9am

229

1st stage : 12 hrs
2nd stage : 2 hrs
3rd stage :6 min

BP :110/70 mmHg Temp : Afebrile Pulse : 84 bts/min Resp : 20 brs/min
Bladder : Emptied.
Condition of the baby : no cord bleeding. Baby is put on mother’s breast. Baby is active and
sucking the breast.
230
Diagnosis Outcome
stage .


231
Diagnosis Outcome

globular, lochia
is normal in
amount.

breastfeeding.
232
( For Baby)
Diagnosis Outcome
and nose is done.
233
Case No. – 10
Identification data
Name of the client : Aleya Bibi Age : 24 yrs.
Address with husband’s name : w/o- Piyarul Sekh
Vill-Subarnapur, P.O- Chakla, P.S.- Deganga, Dist- North-24 Parganas.
Religion : Muslim Under Dr. : D. Roy

Date of admission: 14/2/20 at 12.10am Registration no. : 13071
LMP : 08/05/2019 EDD : 15/02/20
Brief History :
Occupation : Husband : Business. Wife : housewife.
Diet : Last meal time and contents : Chapati, sabji. At 7 pm.
234
period
Primigravida

Immunization : Inj TT 2 doses taken Total weight gain : 12kg
Vital signs : BP- 120/78 mmHg Pulse : 84 bts/min Resp : 18 brs/min Temp : 980F
Tongue : Dehydrated/Moist : Moist Breast : Soft and secretory
235
SFH in cm.: 32 cm. In weeks : 40weeks
Palpation:
suggestive of back.
First Pelvic Grip :

satisfactory.
236
Time of delivery
normal living girl baby is delivered at 1.45 PM

237

1st stage : 11hrs 25mins
2nd stage : 2 hrs
3rd stage : 10 min
BP : 110/70 mmHg Temp : Afebrile Pulse : 84 bts/min Resp : 20 brs/min
Bladder : Emptied
sucking the breast.
238
Diagnosis Outcome
stage .


239
Diagnosis Outcome

globular, lochia
is normal in
amount.

breastfeeding.
240
( For Baby)
Diagnosis Outcome
and nose is done.
241
Case No. – 11
Identification data
Name of the client :Khadija Khatun Age : 18 yrs.
Address with husband’s name : w/o- Habibulla Dhali
Vill-Mirjanagar, P.O-Barachala, P.S.-Deganga , Dist- North-24 Parganas.
Religion : Muslim Under Dr. : Dr. R.Mondal

Date of admission:15/02/2020 at 3.30am Registration no: 15043
LMP : 10/05/2019 EDD : 17/02/2020
On examination findings: Os- 3 cm.,Ccervix- 40% Effaced, FHR- 142 bts/min
Brief History :
Social : Education: Husband : Class VIII. Wife: Class VII
Occupation : Husband : Hawker. Wife : Housewife.
Diet : Last meal time and contents : Chapati, Sabji, at 7 PM
242
l period
Primigravida

Immunization : Inj TT 2 doses taken. Total weight gain : 11 kg
Nature of labour pain (with time) : Started at 3.40 AM on 15/02/20. She complain pain from
Vital signs : BP- 120/78 mmHg, Pulse : 86 bts/min Resp : 18 brs/min Temp: 98.40F
General condition : Good Eye - Pallor/normal: Normal
Tongue :Dehydrated/Moist : Moist
Breast : Soft and secretory Heart : Normal
Bladder: Distended/ Evacuated : Evacuated Lung : Normal
Oedema : Absent
.
243
Palpation:
suggestive of back.
Per vaginal examination/ vulval inspection : No signs of infection is present. Show is
present.

satisfactory.
244
Time of delivery
AM on15/02/20. Baby cried immediately after
birth. In syntocin 10 unit IM is given a gush of
bleeding with permanent lengthening of cord is
seen vaginally. Uterus is hard, globular. Placenta is
on 15/02/20. A quick placenta examination is done.

245
Total hour of labour : 12 hrs.15 mins

1st stage : 10hrs.
3rd stage : 5min
BP : 110/70 mmHg Temp : 980 F Pulse : 84 bts/min Resp: 20 brs/min
Bladder : Emptied
sucking the breast.
246
Diagnosis Outcome
stage .
 Hydration level is assessed.

Impaired fluid & To maintain  Provide liquid diet
electrolyte balance adequate Hydration level
 A glass of water given during latent
related to nutrition. is normal.
phase.
restriction and
 Only sips of water is given in 2nd
perspiration in
stage of labour.
labour pain
 Intake and output is maintained.
 Woman is encouraged to take bath

in 1st stage of labour.
Impaired personal To maintain Woman
 Is advised to take mouth wash.
hygiene related proper personal expresses
labour pain hygiene. refreshed.
247
Diagnosis Outcome
system related to normal body  Hydration level is assessed. of Hg, Temp.-

globular, lochia
is normal in
amount.
Impaired comfort To maintain  Comfortable position is given.
related to after adequate comfort.  Is advised early ambulation.
pain, pain in Woman
 Assessed breast for engorgement.
episiotomy area, expresses
 Wet clothes are removed.
uterine cramps, comfort.
 Mother is instructed to breast feed
bleeding as
the baby.
evidenced by
verbalisation
emptying by giving colostrum and
breastfeeding.
248
( For Baby)
Diagnosis Outcome
 Baby is kept at the room

Potential risk for To establish Baby cried

and nose is done.
 Tactile stimulation is given
249
Case No. – 12
Identification data
Name of the client :Nasima Bibi Age : 22 yrs.
Address with husband’s name : w/o- Rintu Gazi
Vill-Maligram(N), P.O-Prithiba, P.S.-Habra , Dist- North-24 Parganas.
.
Religion : Muslim Under Dr : Dr. R. Mondal
Date of admission:15/02/2020 at 7.08am Registration no. : 13290
GPLA :G1P0L0A0 Period of gestation : 40 weeks
LMP : 08/05/2019 EDD : 15/02/2020
Brief History :
Social : Education: Husband : Class VIII Wife: Class VI
Occupation : Husband : Farmar Wife : Housewife.
Family members : 3 members. Support Person Father-in-law
Diet : Last meal time and contents : Chapati, Sabji, at 8 pm.
Bowel and bladder : Passed urine and stool
250
l period
Primigravida

USG report :Not done
Vital signs : BP- 120/78 mm of Hg Pulse - 80 bts/min Resp - 20 brs/min Temp -980F
Eye - Pallor/normal: Normal Tongue -Dehydrated/Moist : Moist
Breast : Soft and secretory Heart : Normal
Bladder-Distended/ Evacuated : Evacuated Lung : Normal
Oedema : Absent.
251
SFH in cm.: 32 cm. In weeks : 40weeks
Palpation:
suggestive of back.
present.

satisfactory.
252
Time of delivery
normal living boy baby is delivered at 11.35 am

253

Abdomen – soft.. Anus- patent.

1st stage : 12 hrs
2nd stage : 2 hrs
3rd stage : 15 min
BP :110/70 mmHg Temp : 98.40F Pulse : 80 bts/min Resp : 20 brs/min
Bladder : Emptied
sucking the breast.
254
Diagnosis Outcome
stage .

related to nutrition.
restriction and
phase.
perspiration in
labour pain
stage of labour.

255
Diagnosis Outcome

globular, lochia
is normal in
amount.
pain, pain in Woman
bleeding as
the baby.
evidenced by
verbalisation
breastfeeding.
256
( For Baby)
Diagnosis Outcome
Potential risk for To establish  Baby is kept at the room

ineffective airway effective temperature of 28˚-32˚C. Baby cried
related to presence breathing. after birth.
 Mouth is cleaned with sterile gauze
of mucous in
piece after delivery of head.
mouth and nose.
 Suction of mouth and oropharynx
and nose is done.
257
Case No. – 13
Identification data
Name of the client : Rijiya Khatoon Age : 23 yrs.
Address with husband’s name : w/o- Minarul Hossain.
Vill-Bagpul, Paschim para , P.O-Joypul, P.S.-Duttapukur , Dist- North-24 Parganas.
Date of admission:13/02/2020 at 6.50 AM Registration no. : 13356
GPLA : G1P0L0A0 Period of gestation :39 weeks 3days
LMP : 10/05/2019 EDD : 17/02/2020
BP of the mother- 110/80 mm of Hg, Pulse - 78 bts/min, Resp- 20 brs/ min.
Brief History :
Social : Education: Husband : Class VII. Wife: Class V.
Occupation : Husband : Carpenter Wife : Housewife.
Family members : 4 Members. Support Person : Mother-in-law
Diet : Last meal time and contents : Chapati, Sabji. at 7 pm.
258
l period
Primigravida

Nature of labour pain (with time) : Started at 9.15am on 13/02/20. She complain pain from
25weeks 6days; F.H.R:160BPM
Vital signs : BP- 120/80 mmHg, Pulse- 80 bts/min Resp.- 18 brs/min Temp.-98˚F
Tongue -Dehydrated/Moist: Moist Breast : Soft and secretory
Heart : Normal Lung : Normal Bladder- Distended/ Evacuated : Evacuated
Oedema : Absent
259
Palpation:
suggestive of back.
present.

satisfactory.
260
Time of delivery
term normal living boy baby is delivered at 9.25 am
membrane are completely expelled out at 9.35am

261

1st stage : 10 hrs
2nd stage : 2 hrs
3rd stage : 10 min

BP : 110/80 mmHg Temp : 98.40F Pulse : 80 bts/min Resp : 20 brs/min
Bladder : Emptied
sucking the breast.
262
Diagnosis Outcome
stage .

phase.
restriction and
perspiration in
stage of labour.
labour pain

263
Diagnosis Outcome
Disturbed body To maintain  Vital signs checked and recorded. BP -110/70
system related to normal body  Hydration level is assessed. mmHg, Temp.-
labour process system- vital  Fundal height and consistency is afebrile, Pulse :
position of uterus,  Lochia(amount, colour) is checked. Resp.- 20

globular, lochia
is normal in
amount.

Woman
expresses
pain, pain in
comfort.
episiotomy area,
uterine cramps,
bleeding as
the baby.
evidenced by
verbalisation
breastfeeding.
264
( For Baby)
Diagnosis Outcome
related to presence breathing.
of mucous in
mouth and nose.
and nose is done.
265
Case No. –14
Identification data
Name of the client : Durga Patra Age : 20 yrs.
Address with husband’s name : w/o- Sadhar Patra
Vill-Donaria, P.O-Ganganagar, P.S.-Madhyamgram , Dist- North-24 Parganas.
Religion : Hindu Under Dr. : Dr. D. Roy
Date of admission: 17/02/2020 at 1.45 AM Registration no. : 13428
LMP : 11/05/2019 EDD : 18/02/2020
Brief History :
Social : Education: Husband : Class X. Wife: Class VI.
Occupation : Husband : Business Wife : Housewife
Family members : 4 members Support Person : Mother-in-law
266
l period
Primigravida

Nature of labour pain (with time) : Started at 10.40 pm on 17/02/2020. She complain pain
Blood Group : A Hb % : 11.8 gm/dl
HIV : Non-reactive HbsAg : Nonreactive VDRL : Nonreactive
25weeks 6days; F.H.R:160BPM
Vital signs : BP- 120/70 mm of Hg, Pulse- 84 bts/min, Resp - 18 brs/min,Temp- 98.60F
267
Tongue -Dehydrated/Moist: Moist Breast :Soft and secretory Heart : Normal
Bladder: Distended/ Evacuated : Evacuated Lung : Normal Oedema : Absent
Palpation:
of limbs.
First Pelvic Grip : Head engaged,not balottable
Second pelvic grip : Divergence found
present.

268
satisfactory.

Time of delivery
normal living girl baby is delivered at 12.31 pm
done.
269

1st stage : 12 hrs
3rd stage :15 min

Bladder : Emptied.
270
sucking the breast.

Diagnosis Outcome
stage .
 Hydration level is assessed. Hydration level

Impaired fluid & To maintain  Provide liquid diet is normal.
electrolyte balance adequate
phase.
restriction and
perspiration in
stage of labour.
labour pain
Woman
expresses
Impaired personal To maintain refreshed.
hygiene related proper personal
labour pain hygiene.
271
Diagnosis Outcome

globular, lochia
is normal in
amount.
pain, pain in Woman
bleeding as
the baby.
evidenced by
verbalisation
breastfeeding.
272
( For Baby)
Diagnosis Outcome

effective temperature of 28˚-32˚C. Baby cried
ineffective airway
breathing. after birth.
related to presence  Mouth is cleaned with sterile gauze
and nose is done.
273
Case No. – 15
Identification data
Name of the client : Marufa Bibi Age : 21 yrs.
Address with husband’s name : w/o- Sahidul Haque
Vill-Panigobra, P.O-Rajnagar, P.S.-Basirhat, Dist- North-24 Parganas
Religion : Muslim Under Dr : Dr. R. Mandal

Date of admission: 13/02/2020 at 12.10am Registration no. : 13224
LMP : 08/05/2019 EDD : 15/02/2020
Brief History :
Family members : 4 Members. Support Person : Mother-in-law
Family : Nothing Significant.
274
pregna (with problems delivery delivery (alive/ problem
ncy period) during stillbirth) during
period
Primigravida

Nature of labour pain (with time) : Started at 09.10 PM on 13/02/2020. She complain pain
Vital signs : BP- 120/78 mm of Hg Pulse- 84 bts/min Resp.- 18 brs/min Temp.-98.40F
General condition : Good Eye -Pallor/normal: Normal
Tongue -Dehydrated/Moist : Moist Breast : Soft and secretory
Heart : Normal. Bladder-Distended/Evacuated: Evacuated
Lung : Normal. Oedema : absent.
275
Palpation:
suggestive of back.
Per vaginal examination/ vulval inspection : no signs of infection is present. Show is
present.

satisfactory.
276
Time of delivery
0n on14/02/20 . A quick placenta examination is
done.

277
Total hour of labour : 13hrs. 10 mins

1st stage : 11 hrs10 min
2nd stage : 1 hrs 45 min
3rd stage : 15 min
Bladder : Emptied
sucking the breast.
278
Diagnosis Outcome
stage .

phase.
restriction and
perspiration in
stage of labour.
labour pain
 Woman is encouraged to take bath Woman

Impaired personal To maintain
in 1st stage of labour. expresses
hygiene related proper personal
 Is advised to take mouth wash. refreshed.
279
Diagnosis Outcome
system related to normal body  Hydration level is assessed. of Hg, Temp-

globular, lochia
is normal in
amount.
pain, pain in Woman
bleeding as
the baby.
evidenced by
verbalisation
breastfeeding.
280
( For Baby)
Diagnosis Outcome

and nose is done.
281
Case No. – 16
Identification data
Name of the client : Chhaya Paik Age : 21 yrs.
Address with husband’s name : w/o- Tarun Paik
Vill-Bira NabajinaPally, P.O-Joypur, P.S.-Duttapukur , Dist- North-24 Parganas.
Religion : Hindu Under Dr. : Dr. M.L. Maity
Date of admission: 12/02/2020 at 3.05am Registration no: 15832
LMP : 07/05/2019 EDD : 14/02/2020
BP of the mother- 120/70 mmhg, Pulse- 76 bts/min, Resp- 20 brs/ min.
Brief History :
Social : Education: Husband : Class XII. Wife: Class X.
Family members : 4 members. Support Person : Husband
Any drug allergy : Nothing significant.
Medical and surgical : Past : Nothing significant. Present : Nothing significant.
282
period
Primigravida

Blood Group :B Hb % : 11.8 gm/dl
Vital signs : BP- 120/78 mm of Hg pulse- 84 bts/min Resp - 18 brs/min Temp-98.20F
Heart : Normal Bladder- Distended/ Evacuated : Evacuated
283
Palpation:
suggestive of back.
present.

satisfactory.
284
Time of delivery
term normal living girl baby is delivered at 11 am
membrane are completely expelled out at 11.15am

Birth weight of the newborn : 2.6kg
285
Total hour of labour : 13 hrs.

1st stage : 11hrs.
3rd stage : 15 min
BP : 110/70 mm of Hg Temp - 980F Pulse - 84 bts/min Resp - 20 brs/min
Bladder : Emptied
sucking the breast.
286
Diagnosis Outcome
contractions as decrease  Woman is advised to practice breathing and
evidenced by intensifying of deep breathing and relaxation relaxation
verbalisation and labour pain technique. technique.
facial expression,  Is instructed to relax after each
restlessness. contraction.
 Is advised not to bear down in
first stage .
Impaired fluid & To maintain  Hydration level is assessed.

electrolyte balance adequate  Provide liquid diet Hydration level
 A glass of water given during
restriction and
latent phase.
perspiration in
labour pain
stage of labour.
 Woman is encouraged to take

bath in 1st stage of labour.
287
Diagnosis Outcome

globular, lochia
is normal in
amount.
pain, pain in Woman
bleeding as
the baby.
evidenced by
verbalisation
breastfeeding.
288
( For Baby)
Diagnosis Outcome
Potential risk for  Baby is kept at the room Baby cried

To establish
ineffective airway temperature of 28˚-32˚C. after birth.
effective
related to presence
breathing.  Mouth is cleaned with sterile gauze
of mucous in
mouth and nose.
and nose is done.
289
Case No. – 17
Identification data
Name of the client : Laxmi Paul Age : 24 yrs.
Address with husband’s name : W/o- Nani Gopal Paul
Vill-Balui Gachi, P.O- Paul para, P.S.-Hasnabad , Dist- North-24 Parganas.
Religion : Hindu Under Dr. : Dr. S. S.Roy
Date of admission : 14/02/20 at 7.08am Registration no. : 13081
LMP : 07/05/2019 EDD : 14/02/2020
On examination findings : Os- 8 cm., Cervix- 90% Effaced, FHR- 144 bts/min
BP of the mother- 130/70 mm of Hg, Pulse- 76 bts/min, Rresp- 20 brs/ min.
Brief History :
Social : Education: Husband : Class X. Wife: Class IX.
290
period
Primigravida

Vital signs : BP- 120/78 mm of Hg Pulse- 80 bts/min Resp - 20 brs/min Temp-980F
General condition : Good Eye -Pallor/normal:Normal
Heart : Normal Bladder- Distended/ Evacuated : Evacuated
291
Palpation:
suggestive of back.
present.

satisfactory.
292
Time of delivery
term normal living boy baby is delivered at 11.20

293

Abdomen – soft . Anus- patent.

1st stage : 12 hrs
2nd stage : 2 hrs
3rd stage : 15 min
BP : 110/70 mm of Hg Temp - afebrile Pulse - 80 bts/min Resp - 20 brs/min
Bladder : Emptied.
sucking the breast.
294
Diagnosis Outcome
stage .

phase.
restriction and
perspiration in
stage of labour.
labour pain

295
Diagnosis Outcome

globular, lochia
is normal in
amount.
related to after adequate comfort.  Is advised early ambulation. Woman
pain, pain in expresses
episiotomy area, comfort.
uterine cramps,
bleeding as
the baby.
evidenced by
verbalisation
breastfeeding.
296
( For Baby)
Diagnosis Outcome

ineffective airway effective temperature of 28˚-32˚C. Baby cried
related to presence breathing. after birth.
of mucous in
mouth and nose.
and nose is done.
297
Case No. – 18
Identification data
Name of the client : Arbina Bibi. Age : 24yrs.
Address with husband’s name : W/o- Saifuddin Sardar
Vill-Debraj pur , P.O- Sreenagar, P.S.- Basirhat , Dist- North-24 Parganas
Religion : Muslim Under Dr : Dr. D.Roy
LMP : 07/05/19 EDD : 14/02/2020
Brief History :
Social : Education: Husband : Class X. Wife: Class V.
Occupation : Husband : Mason. Wife : Housewife.
Diet : Last meal time and contents : Chapati, Sabji, at 7 PM.
298
period
Primigravida

Nature of labour pain (with time) : Started at 10pm on 10/02/2020. She complain pain from
HIV : Non-reactive HbsAg : Nonreactive VDRL : Non-reactive
Vital signs : BP- 120/80 mm of Hg Pulse- 80 bts/min Resp- 18 brs/min
Temp -98.60F
Tongue -Dehydrated/Moist: Moist Breast :Soft and secretory
Heart : Normal Bladder-Distended/ Evacuated : Evacuated
299
Inspection : Uterine ovoid is longitudinal. Pink striaes are present . No scar mark, or sign of
Palpation:
suggestive of back.
Per vaginal examination/ vulval inspection : No signs of infection is present. Show is present.

satisfactory.
300
Time of delivery
term normal living boy baby is delivered at
12.10pm on11/02/2020. Baby cried immediately
after birth. In syntocin 10 unit IM is given a gush of
bleeding with permanent lengthening of cord is
seen vaginally. Uterus is hard, globular. Placenta is
done.

301

1st stage : 12hrs
2nd stage : 2hrs
3rd stage : 15min
BP : 110/80 mmHg Temp- Afebrile Pulse - 80 bts/min Resp- 20 brs/min
Bladder : Emptied.
sucking the breast.
302
Diagnosis Outcome
stage .

phase.
restriction and
perspiration in
stage of labour.
labour pain

303
Diagnosis Outcome

globular, lochia
is normal in
amount.
uterine cramps,
bleeding as
the baby.
evidenced by
verbalisation
breastfeeding.
304
( For Baby)
Diagnosis Outcome
of mucous in
mouth and nose.
and nose is done.
305
Case No. – 19
Identification data
Name of the client : Gouri Das Age : 21 yrs.
Address with husband’s name : w/o- Bijoy Das
Vill-Suryasen Pally, P.O-Naba Pally, P.S.-Barasat , Dist- North-24 Parganas
Religion : Hindu Under Dr : Dr. S.Samanta
LMP : 07/05/2019 EDD : 14/02/2020
Brief History :
Social : Education: Husband : Class XII. Wife: Class X.
Family members : 4 members. Support Person : Father-in-law
Bowel and bladder : Passed urine and stool.
306
period
Primigravida

Vital signs : BP- 120/70 mm of Hg Pulse - 84 bts/min Resp- 18 brs/min Tem.-980F
Lung : Nnormal Oedema : Absent
307
Palpation:
of limbs.
First Pelvic Grip :Head engaged,not balottable
Second pelvic grip :divergence found
present.

satisfactory.
308
Time of delivery
normal living girl baby is delivered at 1.01 pm
done.

309

1st stage : 12 hrs
3rd stage :15 min
BP : 110/70 mm of Hg Temp - 98.40F Pulse - 84 bts/min Resp- 20 brs/min
Bladder : Emptied.
sucking the breast.
310
Diagnosis Outcome
stage .

Impaired fluid & To maintain  Provide liquid diet Hydration level
electrolyte balance adequate is normal.
phase.
restriction and
perspiration in
stage of labour.
labour pain

Woman
Impaired personal To maintain expresses
hygiene related proper personal refreshed.
311
Diagnosis Outcome

globular, lochia
is normal in
amount.
uterine cramps,
bleeding as
the baby.
evidenced by
verbalisation
breastfeeding.
312
( For Baby)
Diagnosis Outcome
of mucous in
mouth and nose.
and nose is done.
Signature of Conduction
313
Case No. – 20
Identification data
Name of the client : Rashma Bibi Age : 19 yrs.
Address with husband’s name : W/o- Monirul Biswas .
Vill-Majanpur, P.O-Khalisadi, P.S.-Haroa , Dist- North-24 Parganas.
Religion : Muslim Under Dr. : Dr. R. Mondal
Date of admission: 24/02/2020 at12.05am Registration no. : 12879
LMP : 12/05/2019 EDD : 24/02/2020
Brief History :
Social : Education: Husband : IX Wife: Class VI
Occupation : Husband : Hawker Wife : Housewife.
Present : Nothing Significant.
Diet : Last meal time and contents : Chapati, sabji, at 7 PM.
314
period
Primigravida

Any problem during pregnancy : No. If yes, treatment given :
Blood Group : B Hb %: 11 gm/dl
Vital signs : BP- 120/78 mm of Hg Pulse- 84 bts/min Resp - 18 brs/min Temp-980F
General condition : Good Eye -Pallor/normal: Normal Breast : Soft and secretory
Tongue -Dehydrated/Moist : Moist Heart : Normal
Bladder- Distended/ Evacuated : Distended Lung : Normal Oedema : Absent
315
Palpation:
suggestive of back.
present.

satisfactory.
316
Time of delivery
term normal living girl baby is delivered at 10 am
done.

317

1st stage : 11hrs
2nd stage : 2 hrs 5min
3rd stage : 5 min
BP : 110/70 mm of Hg Temp - 98.40F Pulse - 84 bts/min Resp- 20 brs/min
Bladder : Emptied.
sucking the breast.
318
Diagnosis Outcome
stage .

Impaired fluid & To maintain  Provide liquid diet Hydration level
electrolyte balance adequate is normal.
phase.
restriction and
perspiration in
stage of labour.
labour pain

319
Diagnosis Outcome
system related to normal body  Hydration level is assessed. of Hg, Temp.-

globular, lochia
is normal in
amount.
uterine cramps,
bleeding as
the baby.
evidenced by
verbalisation
breastfeeding.
320
( For Baby)
Diagnosis Outcome
and nose is done.
321

3 CONDUCTION NORMAL DELIVERY OBS p162-321

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3 CONDUCTION NORMAL DELIVERY OBS p162-321

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Conduction of Normal Delivery

Social : Education: Husband : Class XII Wife: Class X

Occupation : Husband : Business Wife : Housewife

Family members : 4 members Support Person : Mother-in-law and husband

Personal : Any drug allergy : Nothing significant

Medical and surgical :

Past : Nothing significant Present : Nothing significant

Family : Nothing significant

Financial assistance : From husband

Marital history : Married for 3 years

Relationship : Maintains good relationship with family members and neighbours.

Diet : Last meal time and contents : Chapati, Sabji. At 7 pm.

Bowel and bladder: Passed urine and stool.

Present Obstetric History:

Management during first stage of labour

Sex of the newborn : Girl.

Total hour of labour : 12 hrs 55min

Management of fourth stage of labour :

 Lochia(amount, colour) normal in amount.

Impaired comfort To maintain  Comfortable position is Woman expresses

Social : Education: Husband : Class X Wife: Class VII

Occupation : Husband : Private Farm Wife : Housewife.

Family members : 4 members. Support Person : Mother-in-law and husband

Personal : Any drug allergy : Nothing significant.

Medical and surgical : Past : Nothing significant.

Present : Nothing significant.

Family : Nothing Significant

Financial assistance : From husband.

Marital history : Married for 1 years.

Relationship : Maintains good relationship with family members and neighbours.

Diet : Last meal time and contents : Chapati, Sabji. at 8 PM.

Bowel and bladder: Passed urine and stool.

Present Obstetric History :

Remarks (specifying presentation, position, engagement, etc.)

Management during first stage of labour

Sex of the newborn : Boy

Total hour of labour : 12 hrs. 15 mins

checked. Uterus is hard,

 Sips of water is given to the globular, lochia

Impaired comfort To maintain  Comfortable position is Woman

Social : Education: Husband : Class VII. Wife: Class V.

Occupation : Husband : Business. Wife : Housewife.

Family members : 6 members. Support Person : Mother and husband

Personal : Any drug allergy : Nothing significant.

Medical and surgical : Past : Nothing significant.

Present : Nothing significant.

Family : Nothing significant

Financial assistance : From husband.

Marital history : Married for 2 years.

Relationship : Maintains good relationship with family members and neighbours.

Diet : Last meal time and contents : Chapati, Sabji. at 7 PM.

Bowel and bladder: Passed urine and stool.

Present Obstetric History :

Management during first stage of labour

Sex of the newborn : Boy.

Condition of the newborn :

Total hour of labour : 12 hrs. 44 mins

Impaired personal To maintain  Woman is encouraged to take Woman

mother. Uterus is hard,

Impaired comfort To maintain  Comfortable position is given. Woman

Social : Education: Husband : Class XI. Wife: Class IX.

Occupation : Husband : Business. Wife : Housewife.

Family members : 6 members. Support Person : Mother-in-law

Personal : Any drug allergy : Nothing significant.