IBN SINA COLLEGE FOR HEALTH SIENCES

Midwifery ll
Intra Partum Assessment Guide (80%)
Student Name: -Razan shehada
Identification data: (2 points )

Mother’s name (Initials):M . S . K . A

Age:33 years
Date of Admission: 7/10/2021

- Reason for admission/ chief complaints: as she said:" that the reason for her coming to the
hospital was passage of watery vaginal discharge" . SROM at 9: 20 am .
- Address: Kafr Ein (Ramallah villages) .
- Occupation: House wife .
- Educational level : Bachelor of Financial Sciences.

Present Obstetric History : (2 points)

LMP. EDD GA G/P/A/ T/P/L
2/1/2021 9/10/2021 39 weeks+ 5 days G3/P2/A0/L2

Antenatal history: (1 point)

Trimester No. of visits Any complication

I Trimester 5 visits There are no serious complications just

normal things such as morning sickness.
II Trimester 3 visits There are no complications .

III Trimester 5 visits She was suffering from backache, no

serious complications .

Past Obstetric history: (3 points)

No. Date Duration of Mode of Place of Previous sex Birth Birth Duration for
&year of pregnancy delivery birth obstetric or weight outcome breast feeding
birth postnatal
complication

1 18/7/201 40 weeks NSVD Al- No any Fem 3200 gm Live One year and
2 hellal complication ale 5 months
hospital s

2 13/6/201 39 weeks NSVD Al- No any Mal 3500 gm Live One year and
5 hellal complication e 6 months
hospital s

Family history: - (1 point)

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 1- Medical illness ( Cardiovascular disease,D.M, etc) Yes No
Her
mother
HTN
since
20
years .

2- Multiple birth. No

3- Hematologic disorder . No

4- History of congenital deformities. No

5- Mental and psychiatric disorder . No

6- Inherited disease . No

Past Medical and surgical History:- (3 points)

1- Child hood disease (Rubella, Rheumatic Yes No

fever,Hepatitis B etc).

2- Hospitalization. Yes ( past

delivery )

3- Epilepsy on medication. No

4- Presence of bleeding disorder like thalassemia, No

5- thrombocytopenia .

6- History of blood transfusion . No

7- History of allergies to the food or drug. No

8- Asthma . No

9- Heart disease. No

10- History of any operation . No

11- Accidents/Injury. No

12- Others. No

Marital history: :- (1 points)

- Consanguity No consanguity
Relationship Client has good relationship depend on respect and trust.

Intra partum high risk assessment:- (5.5 points)

1- Age less than 16 and more than 40 years . Yes No

2- Recurrent abortion more than 2-3 times . No

3- Grand multiparity > 6 . No

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 4- Previous C.S more than 2. No

5- Peri natal death > 1 . No

6- Pre-eclampsia -Eclampsia . No

7- Gestational diabetes . No

8- Previous APH. No

9- Renal disease . No

10- Heart disease . No

11- Previous preterm labor . No

12- Deep vein thrombosis . No

13- Thyroid disease . No

14- Cholelethiasis. No

15-Anemia. No ,
Hgb :
13.8(1216
)

Hct : 43
(

Within
normal
finding

16-Essential Hypertension. No

17-Rh Is immunization. No ,
blood
group is
O Rh +

18-Twins Or More. No

19-Smoking. No

20-Abnormal fetal presentation. No

21- Hx of prolonged labor. No

22-Hx of prolapse umbilical cord. No

Psychosocial with family adaptation assessment : (6 points)

1- Acceptance :The client is very satisfied, happy and excited to meet her new girl . As the client
said " I can`t wait to touch her with my hands".
2- Happiness or unhappiness : very happy because she will have her fist male baby.
3- Relationship with her partner :Her partner is careful about her health and they love each other.
4- Anxiety: little anxious from labor and child birth .
5- Body image :well sense of her body image. Satisfied and accepted her new body shape.
6- Childbearing experience "as She said: My experiences in pregnancy and childbirth were easy, as I
did not have any complications or postpartum bleeding ".

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 7- Support System: As she said "my husband help me and sometimes my mother, but I do everything
of housework"

8- Stability of living condition: The family have psychological stability, acceptance of all family
members, safe environment, physical stability and a readiness to new baby facility.
As She :" I live in a stable house and not rent, the number of rooms in my house is six, the income is
average, and my husband works in construction ".

9- Economic Status : Good status , everything is available , My husband's work is enough to support
the family.
10- Family structure: She have a family her girl , one boy and her husband 11- Family stress &
functioning: as she said "I am worrying about my family".

12- Domestic violence : As she said "No, I didn’t exposed to any type of violence".

Nutritional Assessment:- (1.5 points )

- NPO : the client not npo, but she didn’t eat any thing from the moment of admission to hospital, she
just drunk a water ,and drink juice for medical necessity( fetal heart rate adjustment) .
- Type of diet in labor : no food is eaten during labor except water and juice .
- Special diet: No special diet

Complete assessment (15 points )

Assessment Finding Comments

* Cardiovascular system:- 1- Within normal range,on Rt hand,

BP 116/78mmhg lying position,by dinamap.
2- Pulse 87 bpm Within normal range
3- Dizziness Doesn't c/o dizziness.
4-Light-headed Doesn't c/o, as the client looks Normal
relaxed . 5- Doesn't c/o
5- Pallor 6-Doesn't c/o , the client look Normal
6- Syncope oriented.
7-Doesn't c/o , when the client get Normal
7- Supine hypotension supine didn’t experience any Normal
hypotension signs (, tachycardia,
sweating, nausea, hypotension and
dizziness).. Normal
No edema.
8- Dependent edema 9- the Client said " I have a purple Normal
9- Varicose veins lines on my thigh."

10- Orthostatic hypotension

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11- Short Systolic Murmur
12- Palpitation
10-Doesn't c/o , client didn’t have , 9- She c/o varicose veins due
tachycardia, sweating, nausea, to inadequate rest and
hypotension and dizziness when she prolonged standing.
stand from supine position.
11-No murmur normal lub- dub heart
sound.
12-No palpitation; rythematic pulse.

Normal

* Respiratory system:-
1- R /R 17 breathe/ minuet Within normal range
2- Dyspnea No signs of dyspnea (no rapid, shallow Normal
breathing).
3- Tachypnea No signs of tachypnea. Normal
* Renal:- 1-
Urine output The client urinate 2-3 times Normal
2- Glycosuria No glucose in urine" negative" Normal
3- Proteinuria No protien in urine "negative"
4- Urinary frequency 2-3 times Normal
5- UTI (S&S) As the client answer there is no signs
of burning, itching , and difficulty in
urination. Normal

Normal
*Gastrointestinal System:- 1-
Nausea and vomiting (morning 1-Doesn't c/o morning sickness 2- Normal as 39 weeks
sickness ) Doesn’t c/o heat burn.
2- Esophagus and stomach, Heart burn 3-"I don’t have any strange taste Normal
3- Acidic taste in the mouth
4- Burping 4 - Doesn't c/o Burping 5-c/o Normal
5- Flatulence and constipation constipation . Normal
6- Itching 6-Doesn't c/o itching. Normal
7- Anorexia or bulimia 7-Doesn't c/o anorexia or bulimia. Normal
8- Hemorrhoid 8-Doesn't c/o Hemorrhoid. Normal
9- Cystocele or rectocele 9- Doesn't c/o cystocele or rectocele Normal
* Integumentary system:
1- Erythema No signs of erythema. Normal
2- Melasma No melisma. Normal
3- Shed hair Doesn't c/o shed hair Normal
4- Sweating No excessive sweating , moist warm Normal
5- Temp skin. Normal
Warm skin. Normal
* Neuromuscular system:- 1- As client said" I c/o backache Normal; related to enlarged uterus
Pelvic and back discomfort specially in third trimester, and l feel
2- Fatigue or exhausted heaviness on groin area"
As the client said"I feel anxiety Normal; related to labor and birth
process or fear
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*Breast: Two breasts are soft,summetry Normal
1- Soft /Nodular No tingling as the client said
Normal
2- Tingling There is slight enlargment
3- Enlargement Thick, yellow liqiud"colostrum" Normal
4- Discharge Darken areola and nipples
5- Pigmentation No absence of superfacial vein Normal
6- Superficial vein Slight stria on both breasts is noticed Normal, related to hormone changes
7- Stria Nipples and areola are moist Everted
8- Montgomery's Tubercle nipples. Normal
9- Nipples: everted ,inverted or flat
Normal
Normal

Abdominal Exam
1- Inspection : abdomen size appropriate with age, no scars or lesions are noticed, there was stria
gravidum, no movement is inspected, slight hair distribution on abdomen, abnormal abdomen
shape .
2- Any deviation from normal : there was no deviation from normal except the abdomen shape .
3- Fetal movement: not inspected ,but felt when palpation.

Size F.H FHR Lie position presentation engagement

Size is 38 cm 150 bpm Longitudinal ROA Cephlic 1/5 palpable

appropriate
with fetal
size

Vaginal examination:
Inspection for genital area : normal finding when inspecting for external genital area (vulva) .
Time Dilation Effacement Consistency Position Station Presenting Membrane
of cx part status
9 am 2 cm 50% Soft Anterior -3 Cephlic Contact
9:30 3 cm 60% Soft Anterior -2 Cephlic
am SROM at
9:20 am
10:15 4 cm 80 % Soft Anterior -1 Cephlic
am SROM at
9:20 am
10:25 7 cm 90 % Soft Anterior -1 Vertex
am
SROM at
9:20 am

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 10:35 10 cm 100% Soft Anterior 0 Cephlic
am SROM at
9:20 am

Bishops score :
Partogram attached: (3 points)

Description of first stage: the onset of labour at 8:45 am ( the client have labour pain and she
comes to hospital ) . (6 points)
1- Latent phase(0-4cm ) : 8:45 -10:15am / Duration : One hour + 30 minutes.
2- Active phase( 5- 7cm ): 10:15 - 10-25 / Duration : 5 minutes.
3- 3- Transition phase : 10:25- 10:35 am / Duration : 10 minutes.
4- 4- Total first stage of labor : 8:45 – 10:35 am /. Duration : 1 hours and 45minutes.
5- CTG Evaluation: Interpretation -----(Dr CBRVADO) :
Dr : High risk ( induction of labor, present of minimal variability at monitor ) .
C : 3 contraction per 10 min.
BR : 150 beat's per minute .
V : Minimal variability ( abnormal : apply changes position at left side , O2 and IV fluid ) .
A : within normal range one acceleration in 10 minute.
D : not found .
O not reassuring trace that cause present of minimal variabilitya that need to observation and
supervision evaluation.

Oxytocin
Time Indication Dose Midwifery consideration Increase oxytocin rate
/minute
10 : 20 10 u in Continue CTG , Monitor V\ Increase 6 the rate
am Augmentation 500 cc S for mother , Bladder care every1/2 hours .
Of labor . N/S IV as needed , documentation . Start at rate 6 .

9-Breathing Exercise: I teach the client to take deep breath when contraction occur .

10- Non pharmacological methods to relieve pain: I encourage the pregnant to take deep breath,
support him by talking and touch, and change the position.

Second stage of labor: (6 points)

1- Duration : 10 : 35-10:45 am ( 10 minutes )
2- Mode of delivery, (NSVD, or Vacuum or forceps mechanism. of Labor) : induction of labor
vaginal delivery.

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 3- Delivery Outcome : (sex .WT) : female , weight : 3470 gm

4- Apgar Scoring
Apgar Sign 2 1 0
Appearance Normal color all Normal color (but Bluish-gray or pale
(skin color) over (hands and hands and feet are all over
feet are pink) bluish)
Pulse Normal (above 100 Below 100 beats Absent
(heart rate) beats per minute) per minute (no pulse)
Grimace Facial movement Absent (no
Pulls away,
("reflex irritability") only (grimace) response to
sneezes, coughs, or
with stimulation stimulation)
cries with
stimulation
Activity Arms and legs No movement,
(muscle tone) Active, spontaneous flexed with little "floppy" tone
movement movement
Respiration Normal rate and Slow or irregular Absent (no
(breathing rate and effort, good cry breathing, weak breathing)
effort) cry

Infant Score : first minute 9 / after 5 minutes 10

Interpretation: healthy baby with no disstress

Management: support the client by talking and touch, she given 30 unit of oxyt, as active
management . IV with 500 cc N /S, and I take v/s for him immediately after delivery (Bp:
108/58 , P: 80 ,T: 36.4 ,Po2: 99), ,For baby: cord is clamped and cut ( done by midwife at
RCH ) , dry the baby and put him skin to skin with her mother .

Initiation of Breast Feeding: After transferred to postnatal unit , help the client to
start breastfeeding within first half hour after labor and teach him about
correct way to hold a breast ,her position, baby mouth position during breast
feeding.

Bonding: good bonding ; the client hug ,kiss her baby,and told him honey
words.
5- Any abnormalities in first or second stage of labor :no abnormalities during the first and second
stage of labor.
6- Type of medication taken at second stage of labor Intrapartum
Name of medication Dose Route Side effect on fetus and
mother
Syntocinone 10 units IM Nausea and vomiting for
( As active management of mother, jaundice for
third stage of labor) fetus.

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Third Stage of labor: (3 points)
1- Duration :10 minutes ( 10:45- 10:50) am
2- management 3rd stage of labor : delivery placenta and membrane completely by CCT ,check
placenta , the client is under 30 U Oxytocin IV with 500 cc , uterus massage done, fundus is one
finger below umbilica,assess if there is bleeding, no episiotomy or tear, there is no bleeding, EBL
150-+ cc, v/s taken and recorded.
5- Placenta check, Insertion of Cord, any abnormalities, Length of cord ,wt of placenta Placenta is
complete with 15-20 cotyledons,with two membranes' chorion,amnion'
The cord inserted laterally ,and it is about 45-50 ( within normal) cm in long, has 2 artery and
1 vein.
No abnormalities are found.
Fourth stage of Labor: (6 points)
Time Uterine Lochia BP Pulse Check Voiding
contraction Episiotomy
10:45 am Contracted MRL 108/58 80 Not done No
( episiotomy)
11am Contracted MRL 122/57 94 Not done No
( episiotomy)
11:15 am Contracted MRL 106/69 82 Not done No
( episiotomy)
11:30 am Contracted MRL 107/65 76 Not done No
( episiotomy)
11:45 am Contracted MRL 106/62 89 Not done No
( episiotomy)

Client as voided at 12 pm

Assessing Attachment Behavior:

yes No
1- Do they reach out for the child and call the child by name? No
2- Do the parents speak about the child in terms of identification (e.g., The mother
whom speak and
the infant looks like; what appears special about their child loved her
compared with other infants)? girl ,she and
her aunt
was talking
that she look
like her
brother ,the
father didn't
come to see
his girl .

3-what kind of body contact when parents are holding the infant? The mother
hugged her
baby and
kissed him,
and told him
honey
words.
4-Do parents feel at ease in changing the infant’s position; are fingertips or Ease in
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 changing
the baby
whole hands used; are there parts of the body they avoid touching or Position,
parts of the body they investigate and scrutinize? whole hand
use
5-When the infant is awake, what kinds of stimulation do the parents The mother
provide? start to
speak with
her and
touch her
nose,
cheeks and
hands.
6-Do they talk to the infant, to each other, or to no one? The mother
and her
aunt
talking
about
infant and
they were
happy.
7-How do they look at the infant—direct visual contact, avoidance of eye The mother
contact, or looking at other people or objects? look to her
baby with
all the
love , the
father
didn't come
to see her
during my
shift
8-How comfortable do the parents appear in terms of caring for the infant? The mother
was care to
her baby
very much
in
comfortable
situation.
9-Do they express any concern regarding their ability or disgust No
for certain activities, such as changing diapers?

10-What type of affection do they demonstrate to the newborn, such as The mother
smiling, stroking, kissing, or rocking? was smiling
and kissing
her baby.
11-If the infant is fussy, what kinds of comforting techniques do Talking,
the parents use, such as rocking, swaddling, talking, or talking.
stroking?

Midwifery/ Nursing Diagnosis: (3points)

1- Risk for Deficient Fluid volume ( dehydration) .

2-Risk for infection related to spontaneous Rupture of amniotic membranes.

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 3 Anxiety related to pain and baby.
4-Risk for postpartum hemorrhage related to delivery process.
MIDWIFERY /NURSING CARE PLAN (Midwifery care plan). (10 points)

Midwifery Diagnostic Planning Short Midwifery Supporting Evaluation of

term and Long Interventions Rationale Goals &
Statements: with term Goal Midwifery
Validating Evidence Statements Actions
(Subjective and
objective data)

Risk for Deficient Fluid STG : Reduce 1-Provide 1- Fluids may be Goal
volume ( dehydration) fluid deficiency supplemental fluids given in this partially met
related to Significant and dehydration. as indicated. manner if client is the pain
blood loss due to unable to take oral reduced.
premature separation of fluids and To
placenta and Decreased replace lost fluids.
electrolyte level
2_To aid in
replacing fluid
2_Encourage oral losses.
intake.

3_Monitor intake 3_ To ensure

and output balance. accurate
picture of
fluid status .

4_Note client’s 4_To evaluate

level of ability to express
consciousness and needs or level of
mentation. dehydration if
moderate or severe
.
5_ Administer 5_To restore and
medications as rule out any
indicated. underlying
conditions.

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 LTG:The patient
does not suffer
Subjective data: As the from dehydration
woman said That she and electrolytes
was very thirsty and her imbalance
throat was dry
Patient will
demonstrate
behaviors or
lifestyle changes to
prevent
development of
fluid volume
shortage.

Objective data :As l

observed the woman was
pale and her lips is dry

MIDWIFERY /NURSING CARE PLAN (Midwifery care plan).

Midwifery Diagnostic Planning Short Midwifery Supporting Evaluation of
term and Long Interventions Rationale Goals &
Statements: with
term Goal Midwifery
Validating Evidence
Statements Actions
(Subjective and
objective data)

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Risk for infection related STG : During 1-Monitor vital 1-The incidence of Goals were
spontaneous Rupture of my shift prevent signs ( temperature chorioamnionitis partially met .
amniotic membranes. infection as and pulse ) and
(intra-amniotic
possible white blood cell
(WBC) count, as infection)
indicated. increases within 4
hours after
Sub: the client have a rupture of
history of vaginal LGT : after
membranes, as
inflammation. hospitalization the
client free of any evidenced by
infection . elevations of WBC
count and
abnormal vital
signs.
Obj :as I observed
High temperature
indicates to present
the infection .

2-Use aseptic 2-help prevent the

technique during a growth of bacteria;
vaginal limits
examination. . contaminants from
reaching the vagina
3-monitor and .
describe the
character of 3-The amniotic fluid
amniotic fluid. during an infection
becomes thicker and
Bladder care q2 to 4 yellowtinged and
hrs . has a foul-smelling
odor.

4- perineal care
after elimination

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 and prn as 4-Reduces risk of
indicated; change ascending tract
under pad/ linen infection.
when wet.

5-Obtain blood
cultures if 5-Detects and
identifies causative
symptoms of sepsis
organism(s).
are present .
6-Administer
prophylactic 6-Although
antibiotic IV, if antibiotic
indicated ) if administration
infection is present during the
). intrapartal period is
controversial
because of antibiotic
load for the fetus, it
may help protect
against development
of chorioamnionitis
in the client at risk.
7-Reduces risk of
acquiring/spreading
7- good hand infective agents.
washing techniques
.

MIDWIFERY /NURSING CARE PLAN (Midwifery care plan).

Midwifery Diagnostic Planning Short Midwifery Supporting Evaluation of
term and Long Interventions Rationale Goals &
Statements: with term Goal Midwifery
Validating Evidence Statements Actions

14
 (Subjective and
objective data)

Risk for postpartum STG : reduce the 1-Pitocin 1-Oxytocin helps Goal partially met
hemorrhage related to risk of postpartum ( Oxytocin) contract the uterine .
induction of labor. hemorrhage by injection to help muscles, thus
good management ensure that the preventing
of the second stage placenta comes bleeding.
of labor. quickly and
completely , give
during second stage
LTG: women of labor.
discharge from
Subjective: hospital without
any complications 2_breastfeeding as
or blood loss. soon as possible
after birth. This 2_ Breast feeding
prompts the release prompts the release
of oxytocin of oxytocin
(nature's Pitocin) to (nature's Pitocin) to
help contract the help contract the
Objective: uterus and expel the uterus and expel the
placenta. placenta.

3_Massaging the
uterus done to help
expel clots of blood 3_ Uterine
and check uterine massage after
tone to ensure that delivery of the
it is clamping down placenta can also
to prevent excessive promote
bleeding. contraction of the
uterus. This
4_Encourage the involves placing a
woman to empty hand on the
her bladder woman's lower
immediately after abdomen and
the birth. The stimulating the
uterus may stay soft uterus by repetitive
because the massaging or
mother's bladder is squeezing
fully. movements.

4_Help uterus to
contact ,The uterus
may stay soft
because the

15
 mother's bladder is
fully.

Reference:- (1 points)
Fraser, Diane.(2014).Myles Text Book For Midwives.16th ed.Elsevier,china.
Williams. L(2010), and wilkins, (2010), maternal and child health nursing care of the childbearing and
childbearing family 97th edition).
The client .
The client file.
CTG

English, Spelling and Tidiness:- (1 point)

__________________________________________________________________________________
__________________________________________________________________________________

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Ibn Sina for Health Sciences
Case dilevery 2
Student name: Razan
Shehade
17
Instructor name: Siham
shamasneh .

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