POST NATAL CASE PRESENTATION

INTRODUCTION
Mrs. Jayanti wife of Mr. Shankar Mali admitted in labor room on 10/4/24 with history of
9 months amenorrhea and complaint of abdominal pain and leaking per vagina.

BIODATA
 Name of patient: Mrs. Jayanti
 Age: 24 years
 Hospital no/IPD: 16510/ 22345
 Date of admission: 10/4/24 at 11 AM
 Religion: Hindu
 Duration of marriage: 5 years
 Address: Jamnipali,Korba
 Diagnosis: no progress of labor with Meconium stained liquor and fetal distress
 LMP: 1/07/23
 EDD: 7/4/24
 MARRITAL STATUS:- married
 OCCUPATION:- home maker
 OCCUPATION HUSBAND - mechanic

OBSTETRICAL SCORE: G2 P2 L2 D0 A0
MEDICAL HISTORY
Past Medical and Surgical History- patient has no any past medical and surgical history
Present Medical History: patient has no any present medical history
Present Surgical History- present surgical history of patient is LSCS (lower segment
cesarean section) done on 10/4/24 because of no progress of labor with Meconium
stained liquor and fetal distress and her post operative day is 2ND DAY

FAMILY HISTORY-
 Type of family- nuclear
 No. of person- 4
 Family medical history of any disease: Hypertension
 History of multiple birth: no

S.N NAME OF RELATION AGE/ SEX HEALTH REMARK

O FAMILY WITH STATUS
MEMBER PATIENT
1 Mr. Shankar Husband 28year/M Healthy -
Mali
2 Mrs. Jayanti Self 24 Year/Fm Unhealthy LSCS
3 Mrs. Submati Mother In 58 Year/Fm Unhealthy Hypertension
Law
4 Ms Renuka Daughter 3year Healthy -

SOCIO AND ECONOMIC WITH BACKGROUND My client husband is the only earning
member and head of family. Monthly income is 15000/- They live in rural area.
They live in semi pucca house they have 4 rooms with separated kitchen with close
drainage system. Have good electrical facilities.
FAMILY INCOME – 15000/-
EDUCATION- HUSBAND - 8th pass WIFE – 12th
OCCUPATION HUSBAND - mechanic WIFE – House wife
MENSTRUAL HISTORY
 Menarche – 14 yr
 Duration – 3-4 days
 Interval – 28 days
 Flow - Normal

MARITAL HISTORY
 Age of marriage-20 years
 Year of marriage-2020
 Consanguineous- no

DIETARY PATTERN
 Vegetarian/non vegetarian: non vegetarian
 Habits- smoking/drinking, chewing pan, tobacco: nil

PERSONNAL HEALTH HISTORY

 Oral hygiene - Good

 Bathing habit - Once Daily
 Grooming - Maintained

SLEEP PATTERN

 Type of sleep - Irregular

 Duration of Sleep - 6 hours with 1 hour of afternoon Nap
 Any Abnormality - difficulty in falling asleep

BLADDER AND BOWEL HABITS

 Regularity - Regular
 Frequency - 3-4 times a day
 Time Interval- - 3-4 hours

ALLERGIES - No any significant history of allergies

 HEALTH HABITS

 Smoking
 Tobacco None of these
 Alcohol
 Drugs

RELIGIOUS HISTORY

 Religion - Hindu

EXERCISE

 Remark- Patient is not aware of any exercises in pregnancy

OBSTETRICAL HISTORY
 G2 P2 L2 D0 A0
 Period of gestation in month: 9 months gestation
No. Of Date of Nature of Conditi Type Condition Conditio Sex/ Nature
pregnan delivery pregnancy on of during labor n of wt of
cy (Preterm/ during delive baby puerperi
post pregnan ry (Alive/ um
term/aborti cy still
on) birth)
1 05/8/2 Full term Normal Norm Normal Alive Male Normal
1 al 2.5
kg
2 10/4/2 Full term Normal LSCS Meconium Alive Fm Normal
4 aspirated 2.6
and fetal kg
distress

DELIVERY RECORD
 Date of delivery: 10/4/24 Time: 1:00 PM
  Onset of true labour date: 9/4/24 time: 6:00 PM
 Membrane of ruptured at: 9:30 AM spontaneous/ artificial/
PROM- PROM
DELIVERY OF BABY
 Baby born at: 1:00 PM
 Male/female: female
 Mode of delivery: LSCS due to no progress of labor with fetal distress and
Meconium stained liquor.
 APGAR score: 7
 Treatment at birth: injection vitamin K 0.5 ml IM given
 Weight of baby: 2.6 kg
DELIVERY OF PLACENTA AND MEMBRANES
 Delivered at: 1:15 PM
 Spontaneously/helped out/ manually removed: manually
 Types of placenta: normal placenta
 Membrane: intact
 Cord insertion: center of the placenta
 Weight: 500 gm
 Any abnormality: no
 Total blood loss: 1000 ml

GENERAL PHYSICAL EXAMINATION

 Height – 154 cm
 Weight – 55 kg
 Temperature – 98.6 o F
 Pulse – 90 beat/m
 Respiration – 26 breath/m
 Blood pressure – 120/70 mm/Hg
  Nourishment : Well Nourished
 Body build : average body build
 Health : Healthy
Activity : Dull

MENTAL STATUS:

 Consciousness : Conscious
 Look : Anxious

BODY POSTURE:

 Body curve : normal curve

 Movement : All range of motion

SKIN CONDITION:

 Color : Dusky skin tone

 Texture : dryness
 Temperature : warm

HEAD & SCALP:

 Hair : Black color

 Scalp : clean, no dandruff
 Any infection : No any infection

EYE:

 Eye brows : Normal

 Conjunctiva : No conjunctivitis
 Sclera : pink

LIP:

 Colour : pink, dry

 Chelitis : No Chelitis

EAR:

 Discharge : No Discharge
  Wax : Present
 Shape : Symmetrical

MOUTH:

 Odor of mouth : No Foul Smell

 Teeth : No Discoloration
 Gum : No Gingivitis
 Tongue : pale

SPECIFIC EXAMINATION (REEDA SCALE)

 Breast: normal healthy breast feeding and no breast engorgement
 Uterus: soft uterus and fundal height is 18 cm
 Bowel: stool passed
 Bladder: empty
 Lochia: Lochia lubra
 Homan’s sign: negative
 Emotional status: normal

EXAMINATION OF THE BABY

1) Anthropometric measurement
 Weight: 2.6 kg
 Length: 51 cm
 Chest circumference: 31 cm
 Head circumference: 34 cm
 Abdominal circumference: 30 cm
2) Breast feeding: 6-7 times
3) Urine: passed
4) Meconium/ stool- passed
5) Reflexes: present
 6) Any abnormalities: nil but baby is shifted to NICU due to Meconium aspiration

INVESTIGATION OF PATIENT
PARAMETER PATIENT VALUE NORMAL VALUE REMARK

HEAMOGLOBIN 11.5 GM% 12-14 %GM Low

BT 2’00’’ 2-9 Minute Normal

CT 4’40’’ 4-10 Minute Normal

BLOOD GROUP “ B” POSITIVE POSITIVE Normal

S. GLUSOSE- 117 Mg/dl UPTO 140 mg/dl Normal

RANDOM

HIV TEST Non - reactive Non – reactive Normal

HBSG Non - reactive Non - reactive Normal

SICKLING TEST SS SS Normal

HBsAg test Non –reactive Normal Normal

VDRL test Non -reactive Normal Normal

USG: Done
  Baby single – live fetus
 Liquor – adequate
 Cord - No twisted cord over neck

FETAL DISTRESS
DEFINITION
Fetal distress is defined as hypoxia that may result in permanent fetal brain damage or
death if not managed immediately.
CAUSES
Book picture Patient picture
Maternal hypoxia Absent
Placental compression Absent
Prolonged labor Present
Vascular anomalies of placenta and Absent
cord
Prolonged compression of head of Present
fetus
Contracted uterus Absent

EFFECTS OF FETAL DISTRESS

Book picture Patient picture
IUGR Absent
Fetal movement decrease Absent
 Meconium aspiration Present
Cerebral palsy Absent
Neonatal seizures Absent
Acidosis Absent

MECONIUM STAINED LIQUOR

DEFINITION
When baby passes Meconium in utero making amniotic fluid light to dark green it gives
rise to a condition of Meconium stained liquor.
INCIDENCE RATE
It is a common obstetric situation occurring in 12-22% of women in labor.
Less than 5% in preterm.
Upto 20% in term
>20% in post term.

CAUSES
Book picture Patient picture
Maternal
Prolonged labor Present
Placental insufficiency Absent
Maternal hypertension Absent
Pre-eclampsia Absent
Oligohydramnios Absent
Maternal drug abuse Absent
Fetal
Response to acute Present
hypoxic events
 Relaxation of anal Absent
sphincter

MEDICAL MANAGEMENT
S Drug Dos Rout Frequ Action Side effects Nursing
N name e e -ency responsibility
1 Inj. 1gm IV BD It is Seizures, - Assess patient for
Ceftriaxon antibacterial Diarrhea, infection at the
e in action and nausea, beginning and
it inhibits the vomiting,, throughout the
bacterial cell phelebitis at therapy.
growth. I/V site. - Obtain specimens
for culture and
sensitivity
- Monitor intake
and output and
daily weight
2 Inj. 40 IV .BD Inhibit the Abdominal  Assess patient
Pantapraz mg secretion of distention, acid routinely for
-ole HCL acid in regurgitation. epigastric pain,
stomach Constipation, frank or occult
nausea and blood in stool or
vomiting emesis.
 Instruct patient to
take full course of
medicine
 Advice patient to
avoid alcohol.
3 Tab. Folic 10 Oral OD Treat a numbness or Monitor Hb level
acid mg deficiency of tingling, mouth before and during
folic acid. To or tongue pain, the therapy.
make DNA weakness, Take folic acid with a
and other confusion full glass of water.
genetic
material and
for the
synthesis of
RBCs.

SURGICAL MANAGEMENT
Cesarean section
It is an operative procedure whereby the fetus after the end of 28 th week are
delivered through an incision on the abdominal and uterine walls.
LSCS is the extraction of the baby is done through an incision made in the lower
segment through a trans peritoneal approach. Transverse incision is made.
In my patient lower segment cesarean section was done on 27/8/18.
Indication: No progress of labor with Meconium stained liquor and fetal distress.
Procedure:
Written and informed consent taken from patient and relatives
Part preparation was done and patient was shifted to operation room.
Stomach was scrubbed down.
Anesthesia given using a spinal block.
Two incisions was made near bikini line one to open the skin and the other to
across the lower part of uterus.
Baby is extracted and handed over to pediatrician before cutting the umbilical
cord.
 Once the pediatrician checks the baby umbilical cord is cut and placenta is
removed.
Suturing is done layer by layer.
NURSING DIAGNOSIS
1. Pain related to caesarian section
2. Deficit fluid volume related to postpartum hemorrhage.
3. Risk for infection related to altered primary defenses during postpartum period
4. Deficient knowledge related to self-care activities during post-partum period.
5. Anxiety related to post-partum period condition as evidenced by client
verbalization.
6. Weakness related to post-partum period condition as evidenced by client
verbalization.

NURSING CARE PLAN

Assessme Diagnosi Goal Planning Implementation Rationale Evaluatio

nt s n
Subjective Pain To To monitor Pain level assess It provides Patient
data related reduc vital signs through visual baseline for expresses
Patients to e analogue pain data relief of
complaint cesarean pain scale. evaluation pain and
s that she incision To examine and also discomfor
is having done at the incision Incision site is helps in t.
pain at lower site for examined for planning
incision abdome redness, redness , edema, treatment.
site. n. edema, drainage and
drainage and approximation Cesarean
approximatio during dressing. incision
 n while heals
dressing. It blocks normally.
Objective Injection pain
data diclofenac transmission
I observed To administer sodium 75 mg and provide
that a prescribed intramuscularly relief from
patient pain is administered pain
facial medications with doctor’s
expression injection. prescription.
is irritable Diclofenac
and sodium 75 It provide
intolerabl mg Provided an support for
e. intramuscular additional pillow abdominal
ly. and teach to muscles
splint the
To provide an incision site
extra pillow when moving or
and teach to coughing for
splint the post cesarean
incision site patient.
when moving
or coughing
for post
cesarean
patient.
Assessment Diagnosis Goal Planning Implementation Rationale Evalua
tion
Subjective Deficit Patien To monitor Color amount It provides Patient
data fluid ts the color and consistency baseline for ’s
Patients volume uterus amount and of Lochia is data blood
complaints related to will consistency of monitored. evaluation. volume
about postpartu remai Lochia. is
bleeding per m n firm It helps in repleni
vagina. bleeding and To count or Sanitary pad are detection of shed.
contra weight counted. blood loss.
Objective ct-ed. sanitary pads. It makes the
data uterus firm.
Assessed To monitor Intake and
vital signs intake and output chart Helps to
and output chart maintained restore lost
observed body fluid.
perineal To administer IV fluid Ringer
pads for fluid or blood Lactate 500 ml
amount of products. and one unit
bleeding. blood transfusion
is given.
To instruct to
take adequate
amount of
fluid and semi Adequate fluid
solid diet.
has given to
client with liquid
diet.
Assessment Diagnosi Goal Planning Implementatio Rationale Evaluation
s n
Subjective Risk for To To observe Incision site is It provides Patient is
data infection prev incision site. observed to baseline for prevented
Client may related ent assess any pus data from
complaint to pati or discharge. evaluation. infection.
that pain altered ent
and pus primary from To monitor Vital sign is
formation defenses infec the vital sign. monitored.
at incision during tion.
site post To maintain Personal It prevents
Objective partum the personal hygiene is from
data period hygiene maintained by infection.
Due to relatives.
presence of To instruct It inhibits
incision site for ice pack ice pack the
patient is at application. application bacterial
risk for done to reduce cell growth.
infection. To provide pain.
the
antibiotics Injection Xone
injection and gentamicin
XONE 1 gm is administered
and with
Gentamicin prescription.
80 mg
Assessment Diagnosi Goal Planning Implementatio Rationale Evaluation
s n
Subjective Deficit To To provide Health It helps to Knowledge
Data knowled impr health education is gain is improved.
Client asks ge ove education provided. knowledge.
about care related kno regarding
to be taken to self wled perineal care Patient is
during care ge. and care of advised to use
postpartum activities incisional pillow while
period. during wound coughing or
Objective postpart sneezing.
data um
I observed period.
that client
having no
knowledge
for care to
be taken
during post
partum
period.
Assessment Diagnosis Goal Planning Implementation Rationale Evalua
tion
subjective Activity To To provide Nutritious food It improves Weakn
health.
data intoleranc reduc nutritious is provided and ess is
Patient e related e food and plan dietary menu is reduce
complaints to weakn dietary menu. planned. d.
that she is weakness. ess.
It improves
feeling To administer Injection iron
hemoglobin
weakness. injection iron sucrose I and provides
strength.
Objective sucrose. ampoule in 100
data ml normal saline
I found is administered.
patient is To administer it increase
the
dull and vitamin C Vitamin C
absorption
lethargy. resource food resource food of iron in the
body
has been given

DIETARY MANAGEMENT (2700 KCALORIE)

MEAL TIME WHAT TO EAT

Early 6:00 am 1 glass of date milkshake
morning 1 katori kheer
1 glass almond milkshake
One gondh laddoo + 1 cup of herbal tea
1 boiled egg
Breakfast 8:00 am Upma with fenugreek seeds
Poha with fenugreek seeds
 1 cup of milk
One apple or banana
Mid-morning 11:00 am Bajara or wheat or suji or singhada
porridge
Lunch 2:00 pm 2 wheat roti
1 cup boiled rice
1 cup green leafy vegetable
1 cup of moong dal
1 cup drumstick soup
Snack 5:00 pm Porridge
1 Sounth laddoo
1 cup kheer
Fruits
1 cup milk
1 boiled egg
Dinner 8:00 pm 1 wheat roti
1 cup boiled rice
1 cup mixed vegetables
1 cup moong dal
Late night 10:30 pm 1 cup milk
HEALTH EDUCATION:-
HYGIENE-
 Explain the client and her relative about to maintain hygiene to prevent the
infection.
 To maintain the personal hygiene.
 To take daily bathing and brushing.
 Teach about perineal hygiene.
DIET-
 To take calories diet eg- 2800kcal\ day.
 To take red and green leafy vegetable and fruits.
 To take high protein and iron rich diets.
 Avoid alcohol and smoking.
MEDICATION
 Advice that without doctor prescription don’t take any medicine.
 Advice to take medicine in proper time.
 Advice patient to take complete dose of prescribed medication.
EXERCISE-
 Encourage for early ambulation
 Teach and encourage patient for post natal exercise.
REST AND SLEEP
 To take proper rest and sleep.
 Teach to support abdomen with pillow while coughing or sneezing.
 Avoid stress and tension.
FOLLOW-UP
 Advice for take proper treatment and proper follow-up.
 Encourage for breast feeding.
CONCLUSION
My client Mrs. Jayanti W/O Mr. Shankar Mali was admitted in Hospital, Korba with
lower segment cesarean section due to Meconium aspirated and Fetal distress on
10/4/24. Now with the help of the treatment and care provided to her, she is able to
cope up with her condition. Her prognosis is good.
BIBLIOGRAPHY
1. Dutta D.C. “Textbook of Obstetrics”, 6th Edition, New Central Book Agency
(P) Limited, 2009, Page no. 374-388

2. Bhaskar Nima “Midwifery and Obstetrical Nursing”, 1st Edition, Emmess

Medical Publishers, 2012, pg. 441-452

3. Dr. Sandhu G.K. “Obstetric and Midwifery”, 1st Edition, Lotus publishers,
2013, Pg. 276-282.

4. Jacob Annamma “A comprehensive Textbook Of Midwifery, 2nd Edition,

Jaypee Brothers Medical Publishers, 2008, Pg. 335-340

5. [Link] distress [Link]

6. [Link] diet [Link]