HISTORY TAKING

I. INFORMATION DATA
Name : Mrs. SHABENAM
Husband Name : Mohmd.Aslam
Age : 20Years
Sex : Female
Address : bhogilal chali ; ahemdabad
Religion : Muslim
Marital status : Married
Ward : PN - I
Date of Admission : 11/2/2024 in Post-natal ward
L.M. P : 9/5/2023
E.D. D : 16/2/2024
Gestational age : 39weeks,5days
Obstetrical score : G1 P 0L 1D 0A0

DIAGNOSIS : Postnatal mother with elective LSCS

II. CHIEF COMPLAINT / CLIENTS REQUEST FOR CARE:

Patient shifted fromLabour room after delivery. She has the complaints of pain and discomfort atsite of perineum. She isfeeding the baby very nicely.
And she is getting milk to feed the baby. There is pain at the site of episiotomy. There is no PPH or vaginal bleeding.

III. PRESENT ILLNESS / PRESENT HEALTH STATUS:

a) Symptoms or complaints - she is having acute pain on back and abdominal area
b) Onset - Acute
c) Location - abdominal region
d) Quality - pinching in nature
e) Quantity - Continues pain
f) Associated phenomenon - physiological response to the pregnancy
g) Alleviating factors - walking
IV. PAST HISTORY:
a) No allergy to any medication and food.
b) No history found of TB, Diabetes mellitus, Hypertension, Thyroid.
c) Immunization – BCG scar
d) No evidence of Past medical history.
e) No evidence of Past surgical history.

V. FAMILY HISTORY:
She belongs to middle class family, got married 1 year back and has conceived for first time.
She has the no significant family history; all the family members are healthy.

S.No. Name of the Age Sex Occupation Education Relation Health status
family member
1. Mohd.Aslam 25yrs Male House building 10th std Husband Healthy
2. Mr. Zubeeda 20yrs Female Housewife 5th std Client Postnatalmother
3. B/o Saruben 5day male ------------ ----------- Son Healthy and living

VI. PSYCHO SOCIAL HISTORY:

Economic history -She belongs to Middle class family. Her husband is the bread winner of the family. She herself also supports the family.
Mother tongue -Gujrati
Language known -Gujrati

VII. NUTRITIONAL HISTORY:

She is vegetarian. She has no history of allergy to any type of foodstuff. She used to take 3 meals per day. Her staple food is wheat, prefer to take
chapatti or roti.

VIII. ENVIRONMENTAL HISTORY:

She lives with her family in concrete, rented house, which has three room and a kitchen is combined. They use toilet for defecation and has proper
supply of water in their house. They have a proper electricity supply and closed drainage systems in their house.
XI. Menstrual history:
She attained the menarche at the age of 13 years, she had regular menstrual cycles of 28-32 days with moderate flow for 4-5 days. There is no history of
premenstrual symptoms or dysmenorrhea.

XII. Present Obstetrical History:

First trimester: she had the complaints of nausea and vomiting. She is immunized against the tetanus with TT 0.5ml IM. And supplemented with iron and folic
acid tablets.

Second trimester: she had the complaints of leg cramps and backache, immunized with a 2nd dose of TT. Supplemented with iron and calcium. No discharges
from the vagina. Regular fetal movements felt.

Third trimester: she had the complaints of the frequency of micturition. Fetal movements are felt, no APH and PROM, she admitted with labor pains.

Clinical attendance:
Date Weight Urin Blood FHR Weeks of Fundal Position treatment
e pressure gestation height

14-9-10 52kg nill 120/80 ---- 17weeks 16weeks Inj.TT. 0.5ml IM

4days T.folic acid
T. ferrous sulphate

12-3-11 60Kg Nill 120/80 140 37weeks 34-36 ROA Admitted in hospital
3days weeks Cephalic with labor pains and
PROM

Labor notes:
First stage: Mother came to hospital with a complaint of pain in abdomen. On admission PV findings are 4 fingers tight, membranes are intact, no PROM or
leaking PV, effacement 4o%, show is present, vertex presentation, head is not engaged and ballotable, FHR monitored. Oxytocin 0.5 IU drip with RLslowly.
But labor progress very slow and ARM is done meconium stained liquor, mild CPD ruled out. Mother was posted for emergency LSCS.
Second stageby LSCS baby was delivered, extraction of head and then body. Injection methergine 0.2mg is given by IM. There are no perineal tears. Baby is
cried immediately after delivery APGAR score is 9/10 at 5mins.eye care, Oral and nasal suction was done. Cord clamped and cut. O 2 administered at rate of
3L/min.

Third stage: placenta and its membranes are delivered, completely. Placenta is normal complete and weighs about 560gm. Episiotomy wound is sutured by
layers. No PPH, the blood loss about 530ml during labour. Vitals are monitored, perineal wash and breast care provided. Initiated the breast feeding with 1 hr.
of the delivery. Mother and baby were healthy. They shifted to recovery room and then to postnatal ward.

PHYSICAL EXAMINATION OF MOTHER

General information:
Name: Zubeda
Age: 20yrs
Obstetrical score : G 1P 1L 1A 0D 0
Date of delivery :10/02/2018
Postnatal period : 1day

1) GENERAL OBSERVATION:
a) Constitution : Well body built
b) Stature : Normal
c) State of Nutrition : moderately built
d) Personal appearance : anxious
e) Posture : Good
f) Emotional stage : Anxious
g) Skin : Pallor
h) Cooperativeness : Cooperative

2) VITAL SIGNS:
Temperature : 99oF
Pulse : 70 bpm
Respiration : 20 Bpm
Blood pressure : 120 / 80 mmhg

3) HEIGHT : 154 CMS

4) WEIGHT : 60 KGS

5) SKIN AND MUCUS MEMBRANE:

a) Color of skin : Pallor
b) Edema : Absent
c) Moist Temperature : Normal
d) Turgor : Normal
e) Texture : Moist

6) HEAD :
a) Skull : Has no abnormality noted
b) Hair : Black hair, hair distribution normal
c) Movements of the head : Full range of movement
d) Fore head : No scars or lesion
e) Face : Anxious looking

7) EYES:
a) Expression : Anxious & fear
b) Eye brows : Equal
c) Eye lids : No lesion
d) Lacrimation : Clear fluid
e) Conjunctiva : Pale
f) Sclera : pallor
g) Cornea : Clear and moist
h) Iris : Normal
i) Pupils : PERRLA

8) EARS :
a) Appearance : No mass
b) Discharge : No
c) Hearing : Normal
d) Lesion : Absent
9) NOSE :
a) Appearance : No Septal deviation
b) Discharge : No
c) Patency : Both nostrils are patent
d) Sense of smell : Good

10) MOUTH AND THROAT:

a) Lips : Dry
b) Tongue : coated
c) Teeth : Intact in upper and lower jaw
d) Gums : Pink and moist
e) Buccal mucosa : No lesion
f) Tonsil : Normal
d) Taste : Normal

11) NECK:
a) General appearance : Normal
b) Trachea : Normal in position
c) Lymph node : No enlargement
d) Thyroid gland : Feel smooth and firm
e) Cyst and tumor : Absence

12) CHEST AND RESPIRATORY SYSTEM:

a) Inspection : Size and shape normal, chest
expansion equal in both side and
respiration is normal
b) Palpation : No local swelling, no lymph node
enlarge
c) Percussion : Normal resonance in both lungs
d) Auscultation : Breath sounds are normal, high pitched
in both sides. Respiratory rate 20bpm,S1
and S2 heart normal, heart rate–70bpm
Breast:
 symmetrical in size and shape of the breast. both are enlarged.
 Warm to touch and heavy to feel, filled with milk.
 No masses and no tenderness on palpation

13) ABDOMEN:
a) Inspection :flaccid abdomen, uterine involution is about 15 1/2 cm.
surgical incision is clear, no signs of infection and discharges
b) Palpation : uterus hard and firm and contracted well
c) Percussion : No fluid filled spaces could be found
d) Auscultation : Peristalsis present

14) BACK:
a) Spine and curvature : No abnormalities is noted
b) Movements : All range of movements are normal
c) Tenderness : No tenderness noted

15) perineum:
Vaginal discharges (lochia rubra) are present, perineum is intact,

16) UPPER EXTREMITIES:

 Normal movement
 No deformities
 No lymphnode enlargement

17) LOWER EXTREMITIES:

 Left and right limb is normal
 Normal movement
 No deformities
 No lymph node enlargement
 PHYSICAL EXAMINATION OF BABY

1) General Appearance:
Baby appears healthy and active, good cry, movements are active. Baby appears nourished, baby appears pink color and flexed posture.

2) Anthropometric measurements:
a) Length of the baby : 52cm
b) Head circumference : 33cm
c) Chest circumference : 31cm
d) Weight of the baby : 2.80kg

3) VITAL SIGNS:
Temperature : 99oF
Pulse : 110 bpm
Respiration : 36 Bpm

Head to Foot Examination

Head: hair is equally distributed no micro or macro cephalic,no depressed or elevated fontanels, sutures can be palpated. Head lags back. No birth injuries.

Eyes: normal eyes, no congenital cataract, no congenital abnormalities. Conjunctiva is normal eye brows and eye lashes are normal.

Nose: small stubby nose, no congenital anomalies and no discharges.

Ears: ears are normal, no congenital anomalies,no recoiling of ears, no low set of ears. No discharges from the ears. Hearing acuity is good.

Mouth: mouth is small and lips are normal clearly angles, No cyanosis, No cleft lip and cleft palate. Mucus membrane is normal. Normal tongue. No
supraneemeiory teeth. No other congenital anomalies. No oral thrush.

Neck: no masses, numerory folding arepresent. No congenital hyper and hypothyroidism

Chest and respiratory system:

 a) Inspection : Size and shape normal, chest expansion equal in both side and no retraction of chest. Nipple buds can be seen on
the chest. Witch milk isabsent. respiration is normal34b/min
b) Palpation : No local swelling, no lymph node
c) Percussion : Normal resonance in both lungs enlarge
d) Auscultation : Breath sounds are normal, high pitched
in both sides. Respiratory rate 34bpm,S1
and S2 heart normal, heart rate–110bpm

Abdomen:
a) Inspection:No abnormality, normal abdominal movements. No scaphoid abdomen,fresh umbilical card stump is present , no signs of infection.
b) Palpation : No organomegaly
c) Percussion : No fluid filled spaces could be found
d) Auscultation : Peristalsis present

Back: No spinabifida, no abnormalities are noted, no tenderness noted.

Perineum: Normal development of labia majora and labia minora. Normal urethral and vaginal orifices. no discharges. Baby passing the urine and meconium regularly.

Upper extremities: Normal movement, no resistance to normal movements. No deformities, palmer creases are present. No lymph node enlargement. No poly
dactyl or syndactyly

Lower extremities: Normal movement, no resistance to normal movements. No deformities, plantar creases are present. Left and right limb is normal.

Immunization schedule:
Sr.no Age (time) of vaccination Vaccine Status

1. At birth BCG and OPV- O dose Given

2. At 6 weeks DPT-1 and OPV- 1 Not Given

3. At 10 weeks DPT-2 and OPV- 2 Not Given

4. At 14 weeks DPT-3 and OPV- 3 Not Given

 5. At9 weeks Measles Not Given

6. At 16-24 weeks DPT and OPV Not Given

7. At 5-6 years DT Not Given

8. At 10-16years TT Not Given

New born reflexes

Reflex How Elicited Expected Response Abnormal Response Response

MORO Jar the crib or hold the baby Symmetrical abduction and A slow response might occur Elicited
Present at birth; in a semi sitting position extension of arms and legs, with preterm infants or
disappears and let the head slightly and legs flex up against sleepy neonates.
by 6 months. drop back. trunk. An asymmetrical response
The neonate makes a “C” may be related to temporary
shape with thumb and or permanent birth
index finger. injury to clavicle, humerus,
or brachial plexus.
STARTLE Make a loud sound near Same as Moro response Slow response when
Present at birth; theneonate. sleeping Elicited
disappears Possible deafness
by 4 months Possible neurological
TONIC NECK With the neonate in a The neonate assumes a Response after 6 months
Present between birth supine position, turn the “fencing” position with may indicate cerebral palsy. Elicited
and6 weeks; head to the side so that thechin arms and legs extended in the
disappears by is over the shoulder. direction in which the head was
4 to 6 months turned.
ROOTING Brush the side of a cheek The neonate turns his head May not respond if recently fed. Elicited
 nearthe corner of the mouth. toward the direction of the Prematurity or neurologicaldefects
stimulus and opens his mouth. may cause weak orabsent response.
Instruct mothers who are
lactating to touch the cornerof
the neonate’s mouth with a
nipple and the infant will turn
toward the nipplefor feeding.
SUCKING Place a gloved finger or Sucking motion occurs. May not respond if recentlyfed.
Present at birth; nipple of a bottle in the Prematurity or neurologicaldefects Elicited
disappears neonate’s mouth. may cause weak or
at 10–12 months absent response.

PALMER GRASP The examiner places a finger The neonate grasps fingers Absent or weak response
Present at birth; in the palm of the tightly. If the neonate indicates a possible CNS Elicited
disappears neonate’s hand. grasps the examiner’s fingers defect; or nerve or muscle
at 3–4 months with both hands, the injury.
neonate can be pulled to a
sitting position.
BABINSKI Stroke the lateral surface of Hyperextension and fanning Absent or weak may indicate Elicited
Present at birth; the sole in an upward of toes a possible neurological
disappears motion. defect.
at 1 year
STEPPING OR Hold the neonate upright The neonate steps up and Diminished response may
DANCING with feet touching a flat down in place. indicate hypotonia. Elicited
Present at birth; surface.
disappears
at 3–4 weeks

19) INVESTIGATIONS:
Sr. Investigations Patient’s value Normal value Remarks
No.
1) Blood
  Hemoglobin 9.2 gm/dl 14 – 16 gm/dl Anemia
 Blood group “AB” …………. …………….
 Rh Factor Positive ………….. …………..
CBC ( complete blood count )
 Erythrocyte count 4.47 mil cu.m 4.20- 5.40mil cu. M 150000- Normal
 Platelets 384000 400000/cumr Normal
12400 cu/mm 4000-11000/cu.mr Presence of infection
 Leukocyte count

Normal
Differential count
88% 40 – 75% Normal
 Neutrophil
12% 20 – 60 % Normal
 Lymphocytes
0% 0– 6% Normal
 Esinophills
0% 0-10 Normal
 Monocyte
0% 0 - 1%
 Basophils
Normal
60mm/hr 0 – 20 mm/hr
 ESR
29.7% 37- 47 % Normal
 P.C.V
69.6% 77- 93 %femtolitte
 M.C.V
21.1% 27, Normal
 M.C.H Negative ……………………. Normal
 M.C.H.C Negative …………………… Sickle cell anemia
Positive Negative Normal
HbSAg- Australian antigen
HIV – Spot 10ml
Sickling test for sickle cells Pale Yellow
Urine Examination S.Turbid
Quantity 8.0
Colour Q.N.S
Appearance
pH Trace
Specific Gravity Nil
CHEMICAL EXAMINATION Nil
Urine albumin
 Urine sugar Nil
Urine acetone Nil
Bile salts Nil
Bile pigments Absent
Urobilinogen
Occult blood Nil
MICROSCOPIC EXAMINATION 1-2 / hpf
Red blood cells ( perhpf ) 203/ hpf
Pus cells ( perhpf) Nil
Epithelial cells ( perhpf) Nil
Casts
Crystals Present
Absent
Absent
Nil

USG: single intra uterine viable fetus with vertex presentation. Placenta present at posterior region. Liquor is adequate. No abnormality detected.

MEDICATION:
SR. NAME ROUT DOSE TIME ACTION
NO E
1. Inj. Oxytocin IV 5 units Stimulate Uterine
contraction
2. Inj. Buscopan IV 150mg TDS Antispasmodic
5. Inj.Pantop IV 40 mg Bd Proton pump inhibitor

6. Inj. Cftriaxone IV 1 gm Bd Antiinfective

COMPARISION OF BOOK PICTURE WITH PATIENT PICTURE

Book picture Patient picture

Definition : Pregnancy is the carrying of one or more offspring, known as a fetus or embryo, inside the womb Single fetus is present
of a female. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets.

Initiation
The initial stages of human embryogenesis. Although pregnancy begins with implantation, the process leading to Present
pregnancy occurs earlier as the result of the female gamete, or oocyte, merging with the male gamete,
spermatozoon. In medicine this process is referred to as fertilization; in lay terms, it is more commonly known
as "conception". After the point of fertilization, the fused product of the female and male gamete is referred to as
a zygote or fertilized egg. The fusion of male and female gametes usually occurs following the act of sexual
intercourse, resulting in spontaneous pregnancy. However, the advent of artificial insemination and in vitro
fertilization have also made achieving pregnancy possible in cases where sexual intercourse does not result in
fertilization (e.g., through choice or male/female infertility).

The process of fertilization occurs in several steps, and the interruption of any of them can lead to failure.
Through fertilization, the egg is activated to begin its developmental program, and the haploid nuclei of the two
gametes come together to form the genome of a new diploid organism. At the beginning of the process, the
sperm undergoes a series of changes. As freshly ejaculated sperm is unable or poorly able to fertilize, it must
undergo capacitation in the female's reproductive tract over several hours. This increases its motility and
destabilizes its membrane, preparing it for the acrosome reaction, the enzymatic penetration of the egg's tough
membrane, the zona pellucida, which surrounds the oocyte.

Prenatal period: Prenatal defines the period occurring "around the time of birth", specifically from 22 She is on prenatal period
completed weeks (154 days) of gestation (the time when birth weight is normally 500 g) to 7 completed days
after birth. Legal regulations in different countries include gestation age beginning from 16 to 22 weeks (5
months) before birth.
Perinatal period: The perinatal period is immediately before to after birth. Depending on the definition, it starts
between the 20th to 28th week of gestation and ends between 1 to 4 weeks after birth (the word "perinatal" is a She is on prenatal period
hybrid of the Greek "peri-" meaning 'around or about' and "natal" from the Latin "natus" meaning "birth.").

Duration: The expected date of delivery (EDD) is 40 weeks counting from the first day of the last menstrual
period (LMP), and birth usually occurs between 37 and 42 weeks.

PHYSIOLOGICAL CHANGES:
Physiological and anatomical alterations develop in many organ systems during the course of pregnancy and
delivery. Early changes are due, in part, to the metabolic demands brought on by the fetus, placenta and uterus
and, in part, to the increasing levels of pregnancy hormones, particularly those of progesterone and estrogen.
Later changes, starting in mid-pregnancy, are anatomical in nature and are caused by mechanical pressure from
the expanding uterus.

1.Reproductive System—Breasts:
 Increase of estrogen and progesterone levels: Initially produced
 by the corpus luteum and then by the placenta
 Increased blood supply to breasts. Increase of prolactin: Produced by the anterior pituitary. Present
Clinical Signs and Symptoms
 Tenderness, feeling of fullness, and tingling sensation
Present
 Increase in weight of breast by 400 g
,,
 Enlargement of breasts, nipples, areola, and Montgomery follicles (small glands on the areola around the
nipple) ,,
 Striae: Due to stretching of skin to accommodate enlarging breast tissue ,,
 Prominent veins due to a twofold increase in blood flow ,,
 Increased growth of mammary glands ,,
 Increase in lactiferous ducts and alveolar system ,,
 Production of colostrum, a yellow secretion rich in antibodies, ,,
 begins to be produced by end of 16th week of gestation. ,,

2. Reproductive System—Uterus:
 Increased levels of estrogen and progesterone
 Enlargement of uterus to accommodate developing fetus and placenta
 Expanded circulatory volume leads to increased vascular congestion. Present
 Acid pH of vagina.

Clinical Signs and Symptoms

 Hypertrophy of uterine wall Present
 Softening of vaginal muscle and connective tissue in preparation for expansion of tissue to accommodate ,,
passage of fetus through the birth canal ,,
 Uterus contractibility increases in response to increased estrogen levels, leading to Braxton-Hicks ,,
contractions.
,,
 Hypertrophy of cervical glands leads to formation of mucus plug which serves as a protective barrier
 between uterus/fetus and vagina. ,,
 Hypertrophy of vaginal glands leads to increase in leukorrhea ,,
 Cessation of menstrual cycle (amenorrhea) and ovulation ,,
 Increase in uterine size to 20 times that of nonpregnant uterus ,,
 Weight of uterus increases from 70 g to 1,000 g. ,,
 Blood flow to the uterus is 500–600 mL/min at term. ,,
 Goodell’s sign: Softening of the cervix
 Hegar’s sign: Softening of the lower uterine segment
 Chadwick’s sign: Bluish coloration of cervix, vaginal mucosa, and vulva
 Acid environment inhibits growth of bacteria. ---
 Acid environment allows growth of Candida albicans, leading to increased risk of candidiasis (yeast
infection).

3. Cardiovascular System:
 Decrease in peripheral vascular resistance
 Increase in blood volume by 40%–50% Present
 Increase in cardiac output by 30%–50%
 Increase in RBC count by 30%
 Increase in RBC volume by 17%–30%
 Increase in WBC count
 Increased demand for iron in fetal development
 Hypercoagulability
 Increased venous pressure and decreased blood flow to
 Extremities due to compression of iliac veins and inferior Vena cava

Clinical Signs and Symptoms

Present
 Decrease in blood pressure
 Hypervolemia of pregnancy ,,
 Increased heart rate of 15–20 bpm 14-16 beats/min increased
 Increased stroke volume of 30%
 Systolic murmurs, load and wide S1 split, load S2, obvious S3 S1 & S2 heard
 Increase in heart size ----
 Increase in peripheral dilation -----
 Physiological anemia of pregnancy Present
 Hemodilution is caused by the increase in plasma volume being relatively larger than the increase in RBCs,
 which results in decreased hemoglobin and hematocrit values.
 Values up to 15,000 mm3 in the absence of infection Present
 Iron-deficiency anemia: Hemoglobin <11 g/dL and hematocrit <33%
 Plasma fibrin increase of 40% --------
 Fibrinogen increase of 50% --------
 Decrease in coagulation inhibiting factors Absent
 Protective of inevitable blood loss during birth
,,
 Edema of lower extremities
 Varicosities in legs and vulva
 Hemorrhoids

4. Respiratory System
 Hormones of pregnancy stimulate the respiratory center and act on lung tissue to increase and enhance
respiratory function
 Increase of oxygen consumption by 15%–20%
 Estrogen, progesterone, and prostaglandins cause vascular engorgement and smooth muscle relaxation.
 Upward displacement of diaphragm by enlarging uterus
Present
 Estrogen causes a relaxation of the ligaments and joints of the ribs.

Clinical Signs and Symptoms:

 Increase in tidal volume by 30%–40%
 Slight increase in respiratory rate, Increase in inspiratory capacity Present
 Decrease in expiratory volume ,,
 Slight hyperventilation ,,
 Slight respiratory alkalosis ,,
 Dyspnea ,,
 Nasal and sinus congestion, Absent
 Epistaxis Present
 Shift from abdominal to thoracic breathing --------
 Chest and thorax expand to accommodate thoracic breathing and upward displacement of diaphragm.
 Slight decrease in lung capacity
Present
5. Renal system
 Increased progesterone levels, which cause a relaxation of smooth muscles
 Pressure of enlarging uterus on renal structures
 Alterations in cardiovascular system (increased cardiac output and increased blood and plasma volume) lead
 to increased renal blood flow of 50%–80% in first trimester and then decreases.
 Decreased renal flow in third trimester & Increased vascularity

Clinical Signs and Symptoms:

 Dilation of renal pelvis and ureters leads to increased risk of urinary tract infections (UTI).
 Ureters become elongated with decreased motility, leading to increased risk of UTI.
 Decreased bladder tone with increased bladder capacity Present
 leads to urinary frequency and incontinence and increased risk of UTI. --------
 Displacement of bladder in third trimester leads to urinary frequency and nocturia. Present
 Increased glomerular filtration rate leads to increased urinary output. Present
 Increased renal excretion of glucose and protein leads to glucosuria and proteinuria. --------
 Dependent edema Absent
 Hyperemia of bladder and urethra
,,
6. GASTROINTESTINAL SYSTEM
 Increase levels of hCG and altered carbohydrate metabolism
 Increased progesterone levels lead to decreased muscle tone and slowing of digestive processes.
 Increased progesterone levels lead to decreased muscle tone of gallbladder, resulting in prolonged emptying Present
time. --------
 Changes in senses of taste and smell --------
 Displacement of intestines by uterus Absent
 Increased levels of estrogen lead to increased vascular congestion of mucosa. Present
--------
Clinical Signs and Symptoms:
 Nausea and vomiting during early pregnancy
Present
 Constipation
 Delayed stomach emptying leads to heartburn ,,
 Increased risk of gallstone formation and cholestasis ,,
 Increase or decrease in appetite --------
 Pica: Abnormal; craving for and ingestion of nonfood substances such as clay or starch Present
 Flatulence, abdominal distension, abdominal cramping, and pelvic heaviness Present
 Gingivitis, bleeding gums, increase risk of periodontal disease ,,
,,
7. Musculoskeletal System
 Increased progesterone and relaxin levels lead to softening of joints and increased joint mobility, resulting in Present
widening and increased mobility of the sacroiliac and symphysis pubis.
 Distension of abdomen related to expanding uterus, reduced abdominal tone, and increased breast size ,,
 Increased estrogen and relaxin levels lead to increased elasticity and relaxation of ligaments. --------
 Abdominal muscles stretch due to enlarging uterus

Clinical Signs and Symptoms:

 Altered gait: “Waddle” gait, facilitates birthing process Pelvic tilts forward, leading to shifting of center of
gravity that results in change in posture and walking style, increasing lordosis
 Increased risk of falls due to shift in center of gravity and change in gait and posture Present
 Round ligament spasm ,,
 Increase risk of joint pain and injury Absent
 Diastasis recti ,,
,,
8.Integumentary System
 Estrogen and progesterone levels stimulate increased melanin deposition, causing light brown to dark brown
pigmentation.
 Increased blood flow, increased basal metabolic rate, progesterone-induced increase in body temperature,
Present
and vasomotor instability
 Increased action of adrenocorticosteroids leads to cutaneous elastic tissues becoming fragile.
 Increased estrogen levels lead to color and vascular changes.
 Increased androgens lead to increase in sebaceous gland secretions.

Clinical Signs and Symptoms:

 Linea nigra Present
 Melasma (chloasma) ,,
 Darken of nipples, areola, vulva, scars, and moles ,,
 Hot flashes, facial flushing, alternating sensation of hot and cold Absent
 Increased perspiration
,,
 Striae gravidarum (stretch marks) on abdomen, thighs, breast, and buttocks
Present
 Angiomas (spider nevi)
 Palmar erythema: Pinkish-red mottling over palms of hands Absent
 Increased oiliness of skin and increase of acne ”
Present
9.Endocrine System
 Decreased follicle-stimulating hormone
 Increased progesterone Present
 Increased estrogen
 Increased prolactin ”
 Increased oxytocin ”
 Increased human chorionic gonadotropin (hCG) ”
 Human placental lactogen/human chorionic somatomammotropin
”
 Hyperplasia and increased vascularity of thyroid
 Increased BMR related to fetal metabolic activity ”
 Increased need for glucose due to developing fetus ”
 Increase in cortisol ”
”
Clinical Signs and Symptoms:
 Amenorrhea
 Maintains pregnancy by relaxation of smooth muscles, leading to decreased uterine activity, which results in Present
decreased risk of spontaneous abortions --------
 Decreases gastrointestinal motility
--------
 Facilitates uterine and breast development
Present
 Facilitates increases in vascularity
,,
 Facilitates hyperpigmentation
 Alters metabolic processes and fluid and electrolyte balance ,,
 Facilitates lactation ,,
 Stimulates uterine contractions ,,
 Stimulates the milk let-down or ejection reflex in response to breastfeeding ,,
 Maintenance of corpus luteum until placenta becomes fully functional ,,
 Alters carbohydrate, protein, and fat metabolism ,,
 Facilitates fetal growth by altering maternal metabolism; acts as an insulin antagonist --------
 Enlargement of thyroid
--------
 Nursing Nursing Nursing Interventions Implementations Evaluation
Assessment Diagnosis Goal
Sub data: I)Acute pain Mother will - Assess the general conditions - Assessed the general Sub evaluation:
Mother verbalizes related to have the of the mother. conditions of the mother. Mother
that she is having physiological reduced pain verbalizes that is
changes and discomfort - Assess the pain and - Assessed the pain and
acute pain over felling
postnatal period discomfort. discomfort
the surgical site. comfortable.
and surgical
incision wound - Provide the comfort position, - Provided the comfort position,
Obj data: assist in changing position assist in changing position Objective
She has and provide additional and provide additional evaluation:
restlessness and pillows. pillows. Mother is doing
discomfort by her -self some
- Reduced the anxiety - Reduced the anxiety
activities.
- Use diversional activities - Used diversional activities
such as listening to slow such as listening to slow
music. music.

- Maintain the aseptic - Maintained the aseptic

techniques techniques

- Change the dressings - Changed the dressings

regularly regularly

- Involve the patient in making - Involved the patient in

decisions about care to reduce making decisions about care
the sense of powerlessness. to reduce the sense of
powerlessness.
- Attend the mother`s comfort - Attended the mother`s
and needs to increase her trust comfort and needs to increase
her trust

- Spend as much as time - Spend as much as time

possible with the mother to possible with the mother to
provide comfort and provide comfort and
assistance assistance

- Applied warm applications - Apply warm applications

- Encouraged the mother to use - Encourage the mother to use

the diversional therapy the diversional therapy

- Encouraged the mother to do - Encourage the mother to do

her simple selfcare activities her simple selfcare activities
by her self by her self
 Nursing Nursing Nursing Interventions Implementations Evaluation
Assessment Diagnosis Goal
Subjective data: II)Imbalanced Mother will -Assess the general conditions of the - Assessed the general conditions of Subjective
Mother-in-law nutrition less take the mother the mother evaluation:
verbalizes that that body balanced Husband
she is not taking requirement nutritional -Assess the pain and discomfort. - Assessed the pain and discomfort. verbalizes that
food after related to intake. she is eating
Surgery. increased - Monitored the mother`s vitals. food now.
caloric -Monitor the mother`s vitals.
Objective data: requirement - Provided the comfort position Objective
On physical and anorexia -Provide the comfort position evaluation:
examination secondary to - Found out the her likes and She is looking
Mother is looking lactation. -Find out the her likes and dislikes dislikes of food calm and taking
weak and restless. of food food.
- Planed for balanced diet Playing with
-Plan for balanced diet child.
- Educated the mother about the
-Educate the mother about the importance of the dietary intake
importance of the dietary intake during lactating period.
during lactating period.
- Provided rest and sleep.
-Provide rest and sleep.
- Encouraged the mother to take
-Encourage the mother to take more more fluids.
fluids.
- Reduced the anxiety
-Reduce the anxiety
 - Provided the psychological &
-Provide the psychological & spiritual support.
spiritual support.
- Encouraged the mother to speak
-Encourage the mother to speak out out her fears.
her fears.
- Used the diversional therapy
-Use the diversional therapy
- Modified the attitude of the
-Modify the attitude of the mother mother and make her to accept the
and make her to accept the food food offered.
offered
- Made her understand the needs the
-Make her understand the needs the new born and feed her properly
new born and feed her properly
 Nursing Nursing Nursing Interventions Implementations Evaluation
Assessment Diagnosis Goal
Subjective data: III)Risk for Mother will - Assess the general conditions of - Assessed the general conditions Objective
Client’s infection have the the mother of the mother evaluation:
verbalizes her related to post reduced risk There are no
- Assess the pain and discomfort. - Assessed the pain and discomfort.
pain at incision LSCS wound for infection signs of infection
site. and indwelling - Follow the strict aseptic - Followed the strict aseptic
catheter techniques techniques
Objective data:
Mother is having - Change the dressings regularly - Changed the dressings regularly
surgical wound
and indwelling - Educate not keep hands over - Educated not keep hands over
catheter surgical site, keep clean& dry surgical site, keep clean& dry

- Empty the urinary bag regularly - Emptied the urinary bag regularly

- Provide perineal care - Provided perineal care

- Educate the mother about to - Educated the mother about to

inform if anything happens inform if anything happens.

- Administer the antibiotics - Administered the antibiotics

- Reduce the anxiety - Reduced the anxiety

- Provide the psychological & - Provided the psychological &

spiritual support. spiritual support.

- Encourage the mother to speak - Encouraged the mother to speak

out her fears. out her fears.
 - Record the findings. - Record the findings.

Nursing Nursing Nursing Interventions Implementations Evaluation

Assessmen Diagnosis Goal
t
Sub data: IV)Ineffective Mother will - Encourage the mother to feed the - Encouraged the mother to feed the Mother is
Mother breast- have the feed neonate neonate feeding the
verbalized feedingtechniques the child baby by
- Encourage her to hold the neonate - Encouraged her to hold the neonate
that she has of child related effectively. lying down
pain on the to related to - Encourage the mother to speak out - Encouraged the mother to speak out position with
surgical site difficulty to her feelings her feelings support to
position the baby the baby for
and not able
secondary to - Involve the family in feeding the - Involved the family in feeding the elevation
position the child make them to assist the mother child make them to assist the mother
immediate post
baby to feed. LSCS mother
- Position the child properly and feed - Position the child properly and feed
Obj data: as per the demand of the child as per the demand of the child
Mother is on
- Remind the needs of the new child - Reminded the needs of the new child
bed rest after
and encourage her to feed the child and encourage her to feed the child
immediate
post LSCS - Provide the psychological support - Provided the psychological support

- Involve the husband in the process of - Involved the husband in the process
education and support and care of education and support and care

- Educate the mother about the - Educate the mother about the
importance of breast milk and its importance of breast milk and its
composition composition

- Warn the mother about the effects on - Warn the mother about the effects on
the baby if breast milk is not given. the baby if breast milk is not given.
 Nursing Nursing Nursing Interventions Implementations Evaluation
Assessmen Diagnosis Goal
t
Sub data: V)Deficient Mother and - Assess the knowledge of family and - Assess the knowledge of family and Sub
Mother knowledge, family will mother about family planning. mother about family planning. evaluation:
verbalized family planning, have the husband
- Find a quiet place teach the mother - Find a quiet place teach the mother
that if I use related to knowledge verbalizes
copper–T planning for next about the - Establish a trusting relationship with - Establish a trusting relationship with that he will
how it will be child family the mother and develop mutual goals the mother and develop mutual goals make her to
planning and for learning. for learning. understand
Obj data: attitude to
She is adopt the any - Select the appropriate the teaching - Select the appropriate the teaching Obj
verbalizing methods of methods and material such as methods and material such as evaluation:
discussion and demonstrations using discussion and demonstrations using
that she wants family Husband
AV aids AV aids
one more planning responded
child after - Involve the patient in making - Involve the patient in making actively.
some time. decisions about care to reduce the decisions about care to reduce the
sense of powerlessness. sense of powerlessness.

- Attend the mother`s comfort and - Attend the mother`s comfort and
needs to increase her trust needs to increase her trust

- Spend as much as time possible with - Spend as much as time possible with
the mother to provide comfort and the mother to provide comfort and
assistance assistance

- Educate the family about different - Educate the family about different
methods and uses of family planning methods and uses of family planning
 methods. methods.

- Encourage the family to adopt any - Encourage the family to adopt any
one method one method

Summary:
My Patient Mrs.Zubeda came with labour pain with contractions for4 hours. Patient is full term primi mother. On admission 4 finger tight and labor pains. she
is having acute pain on back and abdominal area. Due to unbearable pain for her she is ready for elective LSCS she delivered a male baby. Bothe mother and
baby are healthy. After providing 5 days care, Patient was maintaining good nutritional status. Patient is maintaining stable vital paramete

Conclusion:
During my clinical posting, I got chance to provide care to, Mrs. Zubeda with diagnosis of Postnatal mother withelective LSCS by this study I learn in detail
about LSCS and its management. I thank my client for his cooperation and my clinical coordinatorfor her valuable guidance.