The patient profile document provides information about a 27 year old woman, Nisha, who was admitted to the labor ward on December 5, 2010 at 8am for labor. Her chief complaints were amenorrhea for 9 months and labor pains since 4am. On examination, her cervical dilation was 2cm and effacement was 30%. Her labor progressed normally over 7 hours with full dilation at 3pm and she delivered a healthy male child at 4pm.

1. PATIENT PROFILE:-
PATIENT PROFILE :
Name of patient Nisha
Husband’s name Lokesh
Age 27 years
Religion Hindu
Occupation House wife
Education 10th
Address Shastri Nagar, Jaipur
Duration of marriage 6 years
Ward Labour Room
Date of admission 05.12.10 8 A.M
Registration No. 30343
Obstetrical score G1P0 A0 L
L.M.P. 02.03.2010
E.D.D. 09.12.2010
A. CHIEF COMPLAINTS :-
(i) Amenorrhoea from 9months
(ii)Having Labor pain since 4A.M
(iii) Back ache
B. HISTORY COLLECTION
(i) HISTORY OF PRESENT ILLNESS: - Patient was admitted on 05-12-2010 at 8.A.M. with
complain of amenorrhoea from 9 months, pain in lower abdomen since 4.A.M.
(ii) HISTORY OF PAST ILLNESS: -
Medical History:- No H/o D/M, HTN, CAD and T.B.
Surgical History – Not significant.
(III) FAMILY HISTORY: - No history of heretical and genetically disorder.
PERSONAL HISTORY: - Patient is vegetarian. No history of drug allergy or drug addiction. No
use of any type of substances use like smoking, drug abused and alcohol etc.
FUNCTIONAL HISTORY: - Sleep pattern and appetite is normal.
MENSTRUL HISTORY: - Menstrul cycle is regular of 4-5 days. No intermenstrul bleeding
and no coital bleeding.

2. PAST OBSTETRIC HISTORY:- G1P0A0L0
ASSESSMENT OF PATIENT ON ADDMISSION
General
Body built –moderate
Weight- 56 kg
Vital signs (at the time of admission)
Temperature -37.4 degree C
Pulse -94/min
Respiration -24/min
B.P.- 124/80 mm of Hg
Hydration-Adequate
Anaemia –no
Pallor –no
Heart –NAD
Lungs- NAD
Liver- NAD
EXAMINATION:
ABDOMINAL:
On inspection fundal height : below the xyphisternum.
On auscultation : F.H.S. 148/min
On palpitation through GRIP :
Fundal Grip : Sofiter consistency
Lateral Grip : in left lateral Grip felt like a continuous hard, flat surface
Pelvic Grip : heard round part felt it means presenting part is Head.
Paulic Grip : head is fixed.
Uterine contraction : 2contraction/10min, duratrion >20 second
VAGINAL EXAMINATION :
Vulva : normal
Vagina : normal
Cervix
: dilatation 2cm
: effacement 30%
Membrane : intact
Presenting part : Head
Pelvis : seems adequate
INVESTIGATION:
S.N. INVESTIGATION IN PATIENT NORMAL VALUE
1. Sodium 139 mEq/lit 135-145 mEq/lit

3. 2. Potassium 3.9 mEq/lit 3.5 -5.5 mEq/lit
3. Complete blood count-
RBC
Hb
PCV
PLATELET COUNT
Blood group
------------------
5.12 mil/cumm
8.9 gm/dl
36.4%
4.43 lakh /ml
B +ve
-------------------------
4.3-6.3mil/cumm
12-14gm/dl
40-50 %
1.4-4.4lakh/ml
4. Blood glucose 90mg/dl 80-120mg/dl
5. Serum cholesterol
LDL
HDL
242mg/dl
167mg/dl
33mg/dl
120-250mg /dl
<155
<35
6, SGOT
SGPT
219U/L
67U/L
0-40U/L
5-36U/L
Urine examination:
Albumin : Nil
Sugar : Nil
RBC : Nil
WBC : Nil
Litrature view of Normal Labour
.
NORMAL LABOUR
Definition
Series of events that take place in the genital organ in an effort to expel the viable products of
conception out of the womb through the vagina into the outer world is called labour.
Duration of the second stage
Duration of the second stage is difficult to predict with any degree of certainty. In multi gravidae
it may last as little as 5 minitues, in primi gravidae the process may take 2 hours.
Observations during the second stage of labour
 Uterine contraction
 Descent of the presenting part
 Fetal condition
 Maternal condition

4. The transition from the first stage to the second stage is evidenced by the following features:
• Increasing intensity of uterine contraction.
• Appearance of bearing down efforts.
• Urge to defecate with descent of the presenting part.
• Complete dilatation of the cervix as evidenced on vaginal examination.
Principles
1) To assist in the natural expulsion of the fetus slowly and steadily.
2) To prevent perineal injuries.
GENERAL MEASURES:
 The patient should be in bed.
 Constant supervision is mandatory and the FHR is recorded at every 5 minutes.
 To administer inhalation analgesic, if available, in the form of gas N2O and O2 to relieve pain
during contractions.
 Vaginal examination is done at the beginning of the second stage not only to confirm its onset
but to detect any accidental cord prolapse. The position and the station of the head are once
more to be reviewed and the progressive descent of the head is ensured.
PREPARATION FOR DELIVERY:
 Position -Positions of the woman during delivery may be lateral or partial sitting.
Dorsal position with 150
left lateral tilt is commonly favoured as it avoids aortocaval
compression and facilitate pushing effort.
 The accoucherur scrubs up and puts on sterile gown, mask and gloves and stands on the
right side of the table.
 Toileting the external genitalia and inner side of the thighs is done with cotton swabs
soaked in Savlon or Dettol solution. One sterile sheet is placed beneath the buttocks of
the patient and one over the abdomen. Sterilized legging are to be used. Essential
aseptic procedures are remembered as 3'C's:
 clean hands (b) clean surface and (c) Clean cutting and ligaturing of the cord.

5.  To catheterize the bladder, if it is full.
CUNDUCTION OF DELIVERY: The assistance required in spontaneous delivery is divided into
three phases: 1)Delivery of the Head
2)Delivery of the shoulder 3)Delivery of the trunk.
DELIVERY OF THE HEAD
The principles to be followed are 'to maintain flexion of the head, to prevent its early extension and
to regulate its slow escape out of the vulval outlet.
• The patient is encouraged for a bearing down efforts during uterine contraction. This
facilitate descent of the head.
• When the scalp is visible for about 5cm in diameter, flexion of the head is maintained during
contraction .This is achieved by pushing the occiput downward and backward by using
thumb and index finger of the left hand while pressing and premium by the right palm with a
sterile vulval pad. If the patient passes stool, it should be cleaned and the region is washed
with antiseptic lotion.
• The process is repeated during subsequent contractions until the sub-occiput is placed under
the symphysis pubis. At this stage the maximum diameter of the head (biparietal diameter)
sretches the vulval outlet without any recession of the head even after the contraction is over
and it is called "crowning of the head". The purpose of increasing the flexion of the head is
to ensure that the small suboccipito- frontal diameter 10 cm (4") distends the vulval outlet
instead of larger occiputo-frontal diameter 11.5cm (4.5").
• When the perineum is fully stretched and threatens to tear specially in primi -gravidae,
episiotomy is done at this stage after prior infiltration with 10 ml of 1% lingociane. Bulging
thinned out perineum is a better criterion than the visibility of 4-5cm of scalp to decide the
time of performing episiotomy. Episiotomy is done selectively and not as a routine.
• Slow delivery of the head in between the contraction is to be regulated. This is accomplished
by pushing the chin with a sterile towel covered fingers of the right hand placed over the
anococcygeal region while the left hand exerts pressure on the occiput (Ritzen maneuver).

6. The fore head, nose, mouth &chin are thus born successively over the stretched perineum by
extension.
CARE FOLLOWING DELIVERY OF THE HEAD
• Immediately following delivery of the head, the mucus and blood in the mouth and pharynx
are to be wiped with sterile gauze on a little finger. Alternatively mechanical or electrical
sucker may be used. This simple procedure prevents the serious consequence of mucus
blocking the air passage during vigorous inspiratory efforts.
• The eyelids are then wiped with sterile dry cotton swabs using one for each eye starting from
the medial to the lateral canthus to minimize contamination of the conjunctival sac
• The neck is then palpated to exclude the presence of any loop of cord (20-25%). If it is
found and is loose enough, it should be slipped over the head or over the shoulders as the
baby is being born. But if it is sufficiently tight enough, it is cut in between two pairs of
Kocher's forceps placed 1" apart.
PREVENTION OF PERINEAL LACERATION
More attention should be paid not to the perineum but to the controlled delivery of
head.
 Delivery by early extension is to be avoided. Flexion of the sub-occiput comes under the
symphysis pubis so that lesser sub occiputo -frontal 10 cm diameter emerges out of the
introitus.
 Spontaneous forcible delivery of the head is to be avoided by assuring the patient not to bear
down during contractions.
 To deliver the head in between contractions.
 To perform timely episiotomy (when indicated).
 To take care during delivery of the shoulders as the wider bisacromial diameter (12cm)
emerges of the introitus.
DELIVERY OF THE SHOULDER
Do not be hasty in delivery of the shoulder. Wait for the uterine contraction to come
and for the movements of restitution and external rotation of the head to occur. The indirectly

7. signifies that the bisacromial diameter is placed in the antero-posterior diameter of the pelvis.
During the next contraction, the anterior shoulder is born behind the symphysis .If there is delay,
the head is grasp by both hands is gently drawn posteriorly until the anterior shoulder is released
from under the pubis. By drawing the head in upward direction, the posterior shoulder is delivered
out of the perineum. Traction of the head should be gentle to avoid excessive sretching of the neck
causing injury to the brachial plexus, haematoma of the neck or fracture of the clavicle.
DELIVERY OF THE TRUNK After the delivery of the shoulders, the fore finger of each
hand are inserted undue the axillae and the trunk is delivered gently by lateral flexion.
Labour complication
 Mal presentation
 Failure of descent of the fetal head through the pelvic brim
 Poor uterine contraction strength
 Cephalo pelvic disproportion (CPD)
 Shoulder dystocia
Maternal complication
 Vaginal birth injury
 Pelvic girdle pain
 InfectHaemorrhage
 Fetal complication
 Fetal injury
 Neonatal infection
 Rupture of membrane
 Neonatal death
Progress Notes During First And Second Stage Of Labour
Date and
Time.
Interval
&duration
Of pain
Membrane F.H.R Dilatation
&effacement
Of cervix
Station
Of present-
ting part
pelvis Any drugs/
treatment
05.12.10
06Am.
2-3/10 min.
>20 sec
Intact 150/min 1-2cm.
25%
-3 - -

8. 09 AM
1 PM
3PM
4-5/10 min
>20sec
6-8/10 min
>30 sec
6-8/10min
<40sec
Intact
Ruptured
-
140/min
150/min
140/min
6cm.
50%
8 cm
75%
10cm
100%
-2
-1
0
-
Adequate
-
-
Inj.R.L 500ml
+
Inj Oxytocin
2.5 U
-
Date and time of onset of labour pain— ----05.12.2011---8AM-
Date and time of full dilatation of os---3 PM
Date and time of birth of the child—4 pm.
Date and time placental expulsion- 4.15 PM
Total hours 1st
stage----7 hr.------2nd
stage—1 hr. min----- 3rd
stage ---15 min-------Total
hours-8.30 min.------
Delivery Notes-
Mother delivered a normal healthy male child. After 15min placenta and membrane expeld.
Both plecenta and membrane inspected. Episiotomy sutured with aseptic technique.
Post delivery assessment of mother-
- cheked vital sign every 15 min.
- assessed bleeding
- clothes changing
- exertion of labour.
Condition of mother on transfer-
Condition of baby on transfer

10. NURSING CARE PLAN
SN NURSING
DIAGNOSIS
NURSING
OBJECTIVE
NURSING
INTERVENTION
NURSING
IMPLIMENTION
EXPECTED/DE
RED
EVALUATION/
UTCOME
CRITERIA-
PATIENT WILL
1. Impaired gas
exchange (fetal)
r/t altered
oxygen supply
Fetal hypoxia
will be
prevented
-locate the fetal heart by determine fetal
position and presentation
-Ausculate fetal heart through fetal back.
-count and record the fetal heart rate half
an hourly in active phase and every 15
minute during second phase.
-provide the left lateral position to relieve
pressure on inferior vena cava and
improve uterine blood flow.
- Fetal heart sound is
recorded every 30 minutes
through out active stage of
labor.
- left lateral position is given
to patient.
Fetal hypoxia will
be relieved.
2. Altered progress
of labor r/t
physiological
process
Labor will
progress
- Record the frequency and duration of
contraction every half an hourly during
active phase of labor.
- Assess and record the cervical
-uterine contraction is
assessed every half hourly
for 10 minute and duration
of one contraction.
Labor will progre
with in time.

11. dilatation and effacement every four
hourly.
- Assess the station or descend of fetus
every four hrly and record on
partograph.
- Assess the pelvic size during PV
examination.
- uterine contraction’s
frequency and duration is
recorded on partograph.
-recording of cervical
dilatation and effacement
every four hourly.
3. Potential for
injury r/t
physical,
chemical and
external factors
Will be protected
from injury.
- Provide care related to admission
protocol e.g. take nursing history, note
vital sign and laboratory investigation.
- Record temp, pulse, B.p. every two
hourly.
- Encourage to voiding every two hourly
if bladder is distended then empty
bladder by catheteriazation.
- Give enema if ordered by doctor.
- Secure leg in stirrups simultaneously on
delivery table
- Discontinue oxytocin if indicated and
notitfy by doctor. e.g. fetal distress.
-history is taken
-vital signs are recorded two
hourly in active stage of
labor.
- bladder is emptied by K-90
cather.
-enema is given.
Risk of injury wil
be minimized.
4. Potential for To prevent the -wash hands scrupulously - Maintain the strict aseptic - Risk of infection

12. infection r/t
invasive
procedures,
rupture of
amniotic
membrane.
infection -wear cover gown, scrub clothes, hair,
and shoe covers etc. according to
policy.
-use sterile gloves for vaginal
examination
-P/V examination done minimally in
normal labor 4 hrly.
-use antiseptic solution to prepare
perineal area for delivery.
-use sterilized articles .
technique.
- Perineal area is washed
with 50 % butadiene
solution.
- At the time of p/v
examination sterile gloves
are wearied.
- p/v examination is done 4
hrly.
minimized.
5. Anxiety r/t
situational crisis.
To reduce the
anxiety level.
-orient to ward the client.
-explain all the procedure.
-explain reason for protocol e.g.
restriction of food and fluid, side lying
position ect.
-explain about labor progressing.
-encourage expression of feelings and
convey understanding and acceptance.
-do not woman leave alone.
- pt. is oriented about ward
and hospital policy.
-every procedure is
explained before perform.
-attendant or coach is
allowed for full time.
-felling of patient is
assessed.
6. Pain r/t physical
and
To relieved pain -assess pain via verbalization and body
language.
-assessed the pain level by
body language of pt.
Pain is relieved

13. psychological
factors.
-assess coping mechanism verbal and non
verbal expression of fear.
-use touching therapy-stroking, holding
hand, effleurage, massage of back.
-teach or reinforce breathing and
relaxation techniques.
-provide comfortable position.
- touching therapy,
effleurage and back
massage is given.
- reinforced for breathing
and relaxation technique.
- left lateral position is
given.
7. Family coping
r/f basic needs
are sufficiently
gratified,
adaptive task
effectively
addressed.
Family members
participate in
labor process
- assess interest in and preparation for
child birth.
- Encourage partner to help alleviate
discomfort –use of touch technique,
moistening lips, sponging face,
helping with positional changes,
supplement efforts.
- Allow to partner to coach woman in
breathing and relaxation techniques.
- Allow couple to spend time alone
together.
- Support couple’s effort by -offering
praise freely.
- Be nonjudgmental if woman become
-child birth preparation
discuss with spouse and
their relatives.
- spouse given touch
therapy, provide the fluid
and food to patient.
-reassured the family
member about birth
process.
-praised of woman for their
efforts.
-spouse is spent his time
with woman during first
stage of labor.
Family member
participated in
labor process.

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