OBSTETRICAL HISTORY

PRESENT OBSTETRICAL HISTORY

Mrs Jenny Mary Joy 28years/F multigravida mother got admitted in TMM hospital
Thiruvalla for safe confinement. On examination no pallor , per abdomen uterus is firm and
relaxed, visible fetal movements are perceived. Fetal heart rate is normal 148 beats per
minutes.

1st TRIMESTER

The pregnancy was planned and confirmed by the urine pregnancy test. Her first scan was
done on 5th week which should confirm the pregnancy. She started to take Tab. flovite 5mg
OD from the fifth week onwards. During the first trimester she had increased frequency of
micturition, weakness and morning sickness such as nausea and vomiting. She completed
first dose of T.T on 12th week.

II nd TRIMESTER

Morning sickness was increased and frequency of micturition was decreased. The mother
was more active. She started Tab.shelcal 500 mg in the morning. She gained all the antenatal
checkups. Anomaly scan was performed at 20 th week of pregnancy, it was normal. She
completed her second dose of T.T at 18th week.

3rd TRIMESTER

She gained 5 kg weight. She had increased urinary frequency, mild itching, over the abdomen
and backache due to the overstretching of the abdomen. She underwent all the regular
antenatal checkups.

INTRANATAL HISTORY
Mrs Jenny Mary Joy was delivered a female baby weighing 2.740kg through vacuum assisted
vaginal delivery. The indication was fetal distress in 2 nd stage of labor and it is identified by
assessing fetal heart rate. The baby cried immediately after the birth. The placenta and
membrane taken out intact. Uterus retracted well. RMLE sutured in layers. The baby and
mother having no complications during the intranatal period.
POST NATAL HISTORY
During the immediate postnatal time she was conscious and oriented and has minimal
bleeding. Vitals are checked and recorded .
Temperature-98.6, pulse-98 beats per minute, respiration 24 breaths per minute, bp-130/80
mm of Hg
Expansion : symmetrical

Heart sound : s1s2 heard

Heart rate : 140 beats per minute

Respiratory rate : 30 breaths per minute

Respiratory distress : absent

GENITAL

Pseudomenustration : present

EXTRIMITIES

Edema ; Absent

Cyanosis : absent

ROM : Possible
 Respiratory rate : 30 breaths per minute
Respiratory distress : absent
 GENITAL
Rougae : present
 EXTRIMITIES
Edema : Absent
Cyanosis : absent
ROM : Possible

REFLEXES

REFLEX BOOK PICTURE PATIENT PICTURE

Rooting Touch or strocking the Head turns towards the

cheek near the corner of the stimulations

mouth

Sucking Touching the nipple with the Suckling movements

nipples

Swallowing Accompanying the sucking Food reaching the posterior

reflex of the mouth

Blinking Exposure of eyes to bright Blinking the eyes by rapid

light eyelid response

Dolls eye When turning head in to the Normally the eyes are turns

left of the eye deviate in the to left

opposite direction

Paimar grasp Place finger in the palm of Baby finger curl around the

the hand examiners finger

Glabellar reflex Tap over fore head, bridge Newborn blinks the eyes
 of the nose or maxilla of the first four or five taps

newborn whose eyes are

open

Babinski reflex On sole of the foot All toes hyper extended with
beginning at heel stroke dorsiflexion of the big toe
upward and a long lateral
aspect of the sole
PRESENT HISTORY

Mrs Sangeetha prasad 29 years/F primigravida mother got admitted in TMM hospital
Thiruvalla with chief complaints dizziness and fatigue since 3 days .On examination no
pallor , per abdomen uterus is firm and relaxed, visible fetal movements are perceived. Fetal
heart rate is normal 148 beats per minutes.

OBSTETRICAL HISTORY

PRESENT OBSTETRICAL HISTORY

1st TRIMESTER

The pregnancy was planned and confirmed by the urine pregnancy test. Her first scan was
done on 5th week which should confirm the pregnancy. She started to take Tab. flovite 5mg
OD from the fifth week onwards. During the first trimester she had increased frequency of
micturition ,weakness and morning sickness such as nausea and vomiting. She completed
first dose of T.T on 12th week.

2nd TRIMESTER

Morning sickness was increased and frequency of micturition was decreased. The mother was
more active. She started Tab. shelcal 500 mg in the morning. She gained all the antenatal
checkups. Anomaly scan was performed at 20 th week of pregnancy, it was normal. She
completed her second dose of T.T at 18th week.

3rd TRIMESTER

She gained 5 kg weight. She had increased urinary frequency, mild itching, over the abdomen
and backache due to the overstretching of the abdomen. She underwent all the regular
antenatal checkups.

PAST OBSTETRICAL HISTORY

Mrs Sangeetha prasad has no significant past obstetrical history

PAST MEDICAL HISTORY

Mrs Sangeetha prasad has no significant past medical history.

PRESENT HISTORY

Mrs Meera Prasad 30 years/F primigravida mother got admitted in TMM hospital Thiruvalla
with chief complaints of uncontrolled blood sugar .On examination no pallor , per abdomen
uterus is firm and relaxed,visible fetal movements are perceived.Fetal heart rate is
normal148 beats per minutes.

OBSTETRICAL HISTORY

 PRESENT OBSTETRICAL HISTORY

1st TRIMESTER

The pregnancy was planned and confirmed by the urine pregnancy test. Her first scan was
done on 5th week which should confirm the pregnancy.She started to take tab.flovite 5mg OD
from the fidth week onwards.During the first trimester she had increased frequency of
micturition ,weakness and morning sickness such as nausea and vomiting. She completed
first dose of T.T on 12th week.

II nd TRIMESTER

Morning sickness was increased and frequency of micturition was decreased. The mother
was more active.She started Tab.shwelcal 500 mg in the morning.She gained all the antenatal
checkups.Anomaly scan was performed at 20 th week of pregnancy, it was normal.She
completed her second dose of T.T at 18th week.Gestational diabetes was diagnosed at 27 th
weel of gestation and started tab metformim 500mg OD.

3rd TRIMESTER

She gained 5 kg weight. She had increased urinary frequency, mild itching,over the abdomen
and backache due to the overstretching of the abdomen.She underwent all the regular
antenatal checkups.

PAST OBSTETRICAL HISTORY

Mrs Meera Prasad has no significant past obstetrical history,

 Date Name of the Patient value Normal value remarks
investigations
Hemoglobin 12.9 11.5-16.5
PCV 37.9 35-45
WBC count 8900 5000-10000
RBC count 4.44 4.35-5.65
million cells
Poly 67 40-75%
Lymph 27 20-40%
Esino 3 0-6%
Mono 3 1-3%
Mcv 85 80-100
31/05/23 Mch 39 27-32
Mchc 34 32-36
RDW 16 11.5-14.5
Platelet count 224 100-400 Normal
URINE
EXAMINATION
Colour Light yellow
Apperence Clear
PH 5.5
specific gravity 1.030
glucose Neg
protein Neg
ketones +
bilirubin Negative

1/05/23 Fbs 134 100-120mg/dl Increased

Ppbs 162 <140mg/dl
PRESENT HISTORY
Mrs Renu Roshan 33 years/F multigravida mother got admitted in TMM hospital Thiruvalla
for safe confinement .On examination no pallor , per abdomen uterus is firm and relaxed,
visible fetal movements are perceived. Fetal heart rate is normal 148 beats per minutes.
OBSTETRICAL HISTORY

PRESENT OBSTETRICAL HISTORY

1st TRIMESTER
The pregnancy was planned and confirmed by the urine pregnancy test. Her first scan was
done on 5th week which should confirm the pregnancy. She started to take tab. flovite 5mg
OD from the fifth week onwards. During the first trimester she had increased frequency of
micturition ,weakness and morning sickness such as nausea and vomiting. She completed
first dose of T.T on 12th week.
II nd TRIMESTER
Morning sickness was increased and frequency of micturition was decreased. The mother
was more active. She started Tab.shelcal 500 mg in the morning. She gained all the antenatal
checkups.Anomaly scan was performed at 20 th week of pregnancy, it was normal. She
completed her second dose of T.T at 18th week.
3rd TRIMESTER
She gained 5 kg weight. She had increased urinary frequency, mild itching, over the abdomen
and backache due to the overstretching of the abdomen. She underwent all the regular
antenatal checkups.
INTRANATAL HISTORY
Mrs Renu was delivered a male baby weighing 2.800kg through LSCS. The baby cried
immediately after the birth.the baby and mother having no complications during the
intranatal period.
POST NATAL HISTORY
During the immediate postnatal time she was conscious and oriented and has minimal
bleeding.vitals are checked and recorded .
Temperature-98.6, pulse-98 beats per minute, respiration 24 breaths per minute, bp-130/80
mm of Hg
CONCLUSION
Mrs Renu Roshan 33 years multigravida mother 38 weeks was admitted in TMM hospital
Thiruvalla on 08/08/2023 for elective cesarean section the indication was previous caesarean
section. She delivered a male baby on 10/08/2023at 9.30 am. Health education given to the
mother and family regarding the care of the baby and mother.
BIBLIOGRAPHY
 .Sabaratnam Arulkumaran, V Sivanesaratnam. Essentials of Obstetrics. Second
edition, Jaypee brothers’ medical publishers (p) ltd. New Delhi
 .Jayne Marshall, Naveen Raynox, Wylex. Text book of Midwives.16th edition.
Elsevier publications
 .Hiralal Konor. D C Duttas book of Obstetrics. 9th edition. Jaypee publications
 .Annamma Jacob. A Comprehensive text book of midwifery. 2nd edition. Jaypee
publications
 .Lynna V Littleton, Jonac Engebretson Obstetric and gynaecological nursing care.
Thomson Delmer learning publications.
 . P R Ashalatha, G Deepa. Text book of anatomy and physiology. 3rd edition. Jaypee
publications
 Hiralal Konar “Dc Dutta’s textbook of Obstetrics”9th edition, Jaypee publishers, New
Delhi.
 Annamma Jacob “maternal and neonatal nursing careplan”3 RD edition, Jaypee
brothers and medical publishers, New Delhi.
 Shwetha Naik and Hannah Roseline “Procedure manual for obstetrics and gynecology
nursing” first edition (2019) CBS publishers and distributers, New Delhi