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Group Project 1 Obg

Obstetrics

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504 views24 pages

Group Project 1 Obg

Obstetrics

Uploaded by

mobashsir1029.don21
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
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ANTENATAL CASE (1)_ ___ Date of Booking —_—— ____——_ Hospital Present Date of Examination _\\04|24 Registration No, 6 Antenatal Visit No, 92 Name __Nuasha. Kamath W/o M4. INeoH04 Karnes Age Adya Religion tHamdas _ Education AA Jpons — Occupation Hourousihe Address “Bino.gest Sungin Lalomay Ht 0, Passed, Pum fa {se Education of Husband _@™”\ Sapa Occupation of Husband _ Lechscacin4 ——§ 12. 000|- | moaatlA Duration of Marriage __ am a Income/month HISTORY OF PRESENT PREGNANCY G_B_P_2_A_@ 1 _B__No.ofMale/Female Children _2-Fenmnole, _ Jo\A\2% eop__\|06\24 poG 50 asielhs. UMP Tick Mark (/), if present Nausea al Vomiting ia Acidity/Heart burn x ‘Ankle Oedema a Backache we) Pain (abdominal) Xx) Constipation &) Discharge (red/yellow/white) Micturition ow Others —— Remarks _NOubeo. Morwulimig —anacl Backscng OBSTETRICAL HISTORY No] Yearand Date | Pregnancy Events | Labour Events | Methods of Delivery | Puerperium | Baby Status a po1g | Sutttaom| rreumat| vaxmnas wonanenlyd devrdba| Varies oa wa eli say wos | jaysurnwe- Ba Kg 2-)2022 | BULL tm Leo Kasey fen ee Rint? B | 2023 | Pasowr 3aKg CONTRACEPTIVE METHOD USED (if any): MENSTRUAL HISTORY Menarche at ___) 2. ae Years of age. Cycle of 2H —______— Days Period Ss Days. Blood flow (aversge/scanty/heayy)_ AVUHmeye. nes Dysmenerinea _ NOL yu enh OU8__ Nab pause, 114 Antenatal Cases 115, PERSONAL HISTORY Dietary habits Ney na Diet/day RAnOpothi, Aatedi = Matha feta, Immunization status Comm plticl, TT. 1 dose __agaay. 2° dose QOL, Any addiction NNO PAST MEDICAL HISTORY [Tick Mark (V))], if present HT val DM Ga TBC Gd Blood Transfusion x Anti-gammaglobulin [3] Others = 8 PAST SURGICAL HISTORY [Tick Mark (V’)] History of previous CS. [A History cf episiotomy [>t Others _ FAMILY HISTORY sro ferully isto of nme tn | EXAMINATION OF PATIENT | General Examination Fos tn General Health: Good/Fair/Poor __Height 5'> Weight Temp._Q3.4°F Pulse 26 blynuin Respiration % b\w _ Blood Pressure _\2.€ —120\B0mm Mg Physical Examination Ear and Nose: y uuitiaC, cancataniuit ate meneame tO (wut 2 afe tu Tonsist Ng Owes gs Breast and Nipple changes:_ Nownas, 1° Heart sounds: _| Lungs: \L_ OAH evalotig enasuinn ae ee = liver:___7 ee eee Skin changes, S. see a es = Chloasma, = Linea Nigra, ue — Striae (Pink/White) ‘Anal Changes (Hemorrhoids): INO YALA Dol ‘Anemic look (Present/Absent): _ PrAthewte, edema (Generalized/Ankle oedema): PAS AR Any Deformity: Nab (yur ee peace eee ee see Others: __ ees ee pee eee Signature of Student pe AS GULab Nama Signature of Teacher . __ ANTENATAL CASE (2) Ieee gee ee ase seer aeRLnEELeEseCL Registration No, 20340324193 __ Present Date of Examination 16 }O4U 2M aa Antenatal Visit No._44__Name_™S @akhWi Wo Aan. Sung, Bae Age Zee Religion Hingit Education _19™ | Occupation Houscuadihe Address £otnasai tye Potala Se et 2 mS as Education of Husband —12™ pars ‘Occupation of Husband Metnwannig Duration of Marriage onsen _Income/month 12.1800 |- wn ew. HISTORY OF PRESENT PREGNANCY G_*% P_O AO L_O© _NoofMale/Female Children : uwp__\t\@\a3 _eoD_16 {08124 POG __ 30. wae 7.6 clogs —___ Tick Mark (V), if present Nausea 4 Vomiting &S Acidity/Heart burn Gd Ankle Oedema 4 Backache S Pain (abdominal) Kk) Constipation wo Discharge (red/yellow/white) [%] Micturition Others Remarks _Naware Vownilivig Pike acon (Mil) Raccoons OBSTETRICAL HISTORY S.No. | Yearand Date | Pregnancy Events | Labour vents | Methods of Delivery | Puerperium | Baby Status or | 2024 | Pussemt Yugrroney 7 CONTRACEPTIVE METHOD USED [if any): MENSTRUAL HISTORY Menarche at __1Usptoted —_— Years of age. Cycle of 20 __ Days. Period 4-8 __ Days. Blood flow (average/scanty/heavy) AVE Quay ie a ai Dysmenorthea ne ous NEF e sae ee 118 Midwifery Casebook with Extra Edge for Viva-Voce PERSONAL HISTORY Dietary habits _v DieVday Rhvmpanii ,fpssials— &ats2i—, Aa Immunization status Comp Ltt TT. 1 dose AAW 2 dose __AOQAL Any addiction_ 1 O PAST MEDICAL HISTORY [Tick Mark (v’)], if present HT X DM Blood Transfusion [] Anti-gammaglobulin Others = TBC x PAST SURGICAL HISTORY [Tick Mark (v}] History of previous C.S. [ History of episiotomy [X] Others notanisg Algnniki fut FAMILY HISTORY EXAMINATION OF PATIENT General Examination [ General Heath: Good/Far/Poor Ly Qc, Height _©' a” Weight__@ 2 eg Temp. 4-226 Puke 94 b\ wna Respiration 21. 6\ynind Blood Pressure 1X01 3 Owmwtng Physical Examination Ear and Nose: Normal, no Ati oa _Jrsured ono din eo sgg —__ Teeth and Gums: _syo SLuLcluing ee LOUAL yo apie gat Tonsils: a Breast and Nipple chang Eianaclasny aola »\° RULOLA movieownuiy Tabet, Heart sounds: momamat $1 S> Soraand Meamd Lungs: Nomad Spleen: ——No_aptamiciod.y NOM a ep Liver: — Nidan None pia tna ee ae Skin changes: - Chloasma, ~ Linea Nigra“, ~ Striae (Pink/White) ‘Anal Changes (Hemorrhoids): __ 9%) YUU LLL Anemic look (Present/Absent):__ PU3&en/xk Oedema (Generalized/Ankle oedema): fakin arolematmabd | Any Deformity: Nok sien dvrk, Others: Nal ony buaynaeat, ass ee peg ets Abdominal Examination 1. Inspection a“ Uterine ovoid (Longitudinal/Transverse/Oblique): Howquiandtinat Head (Flexed/Mobile):___ "Larned = Contour of uterus (Fundal notching/Convex/Flattened anterior wall/CylindricaVSpherical) Cegtiival teat Enlargement of uterus (Undue enlargement/Normal):__ NI Qsamag Skin condition (Ringworm/Scabies/Normal): _ Incisional scar mark (Present/Absent): Antenatal Cases 119. 2. Palpation Height of the uterus BQ __cm_3BO__weeks. Abdominal girth @& cm 3, Obstetrical Grips a. Fundal grip Presentation (Cephalic (Podalic)} Se pluauic cs Lie (LongitudinalTransverse): tow 4 ducal ours b, Lateral/Umbilical grip Back (Smooth curvature Present/Absent):__SWOQtV SUASULOT EL AHS 4rn ft __ Limbs (Irregular parts Present/Absent): Awwurgartare, jnnsel fared — Anterior Shoulder: Le}k acci nite Avtawint, Anteriorly/Transverse/Towards the back: _Prv\A (2440 c. First pelvic grip (Leopold fourth maneuver) Head (Engaged/Not engaged): Non en = Attitude (Flexed/Deflexed): d. Second Pelvic grip (Pawlik’s grip/Third manoeuver of leopold) Head (Flexed/Mobile,_uAcengh 4, Auscultation FHS.=___ 154 __/min LABORATORY INVESTIGATION Hb 10.S9)ah Blood Sugar 46 rg Ad Blood group/Type 0 AVE Urine; Sugar_——"w# Albumin __-Ve VORL “vet HIV. ES Others = RISK FACTORS Risk factors ' ' ' ' ' , Low Risk scoring _2. -r High Risk scoring _O Total scoring _U4 Health Education vt bao Treatment 1 Tak plop” pitts, 1._ ‘Tab Ca S0omgOD 2 Mo oukimak aunty, ___Tals (6M Soomaon 3. Maik 24 pith Gan ell snag 3. Autor 2_folic acta Yom xo 4. Qvdicd tomer Lit 4. mj fem “meg 5 void usvesiing qubing slots © Sn} Ranke, omg BD 6 . ee Remarks ea — a sacle NORMAL DELIVERY (3). Hospital Mnf Keune ye gout nospildes No. of Mother 214 p.4T21602 _ Name Wnt Srusora ° Reg. No. of Baby _ 2.042.129.6422 ____ w/o Mu Sanajeeas ae Date/Time of Delivery 1r}ou [24 et 3:00pm, Age Religion _ nuda Address — tegen Craasssn, Rory 6 La Pung ots ———— Ga pad ao La imp \6\p¥|2 EDD 2B o4jau Date and Time of Admission 11 104 \ay at 124.00 py ______ Date and Time of Transfer to Postnatal ward _4 2 04 {24 ot 206.94, —— eeeeeeaeere ee ADMISSION NOTES General Examination 1. Temperature AD. 6 ° 6. Anemia Aen ie Pulse ad sri 7.,.Heart sounds 1 © Ga taro Respiration 1 Jmin. 8. Lung and chest Ble gais_ematy 2s BR_\2p1%o ss mmHg 9. edema generalized/Ankle oedema AA eves Labour pain Present/Absent) RUULh eat Obstetrical Examination /min. 1. Uterine height __ 3 cm 6, Presentation —Lepnaue Cuviscerges 4 2. Abdominal girth 4 cm 7. Presenting part Wt ouch 3. Lie 8. FHS.__NUO ss 18 | © /min 4. Attitude 9, Time/date of onset of contractions 2.194) 214 a4 “00pm 5. Position Leys Decrpalis ambyWwon 10. Uterine contractions (Present/Absent) _ Ps414 sro Vaginal Examination S.No. | Date & Time Findings 1, | SiMe F009 m Hom Qiaratuoy, 2 | 22) ou {24 +})2'.00 am Sum Aitataton 3. | 12104 (24 | B.00 am lou ditetabhou “if membranes are ruptured color of Amniotic fluid Previous Labour History S.No.| Year &Date | Pregnancy Events | Labour Events | Methods of Delivery | Puerperium | Baby Status ravcmveyousi co. ee ab ——_F 216 investigations | | dL Blood Gro are ii NPPIPE —88¥6 Blood sugar ABvnglAl Urine; Albumin _— suger ——— 7 Vor. — = ; Others = ADMISSION HISTORY bate 8 Time | Pregnancy Complains | Hensal Hany | WMI | LDH Parag fyetes28 Wo wu No wiKlaney) adn | Cunatumms | OME | Myomy feqraru om b-saouy| TN s “9 fyous 5 . Average | PROGRESS NOTES Uterine Contractions ‘Date & Time Stages Frequency Duration 32)04 124 2:00@mM 1 Stage Bu sec | jy 2°30 em) 29 Stage . eae 12) 04 124 3° BO amy 3 stage 2 20 rte 1"' Stage of Labour Date & Time | Membranes Ruptured/ | FHS. Degree of Degree of Station of Not Ruptured Dilatation of Cervix | Effacement Fetal Head | AV [ou \24 NOL bese Mob |e tom 207. ” at soo pa) AP You, " YOHley | gs, S4OtIM | om De ok t y.0 0g fouls Dusywuoed! veep |g uw bo} + by. 000M 12)o4\L4 gaguoud vob | gum 1@07. +“s ipo wn 218 Midwifery Casebook with Extra Edge for Viva-Voce PARTOGRAM Name M2 Swen Gg 2p Name of Hospital sual sauheh ieee Sea Date & Time of Admission Mi} B\\44 at Membrane Status Aur pice S00 pM Date & Time for Membrane Rupture. 12 Joupat_at lr oo awa ‘Onset of Labor : Date _\ lou [att 1 tine 4:90 9 Amniotic Fluid (FS [STC TETE EI iouding t 10 Descent of head [Plot 0} i Urine< Acetone) — 9 8 7 g6 26 le 3 2 1 0 rs Hou! Time| Contractions per 10 mins 3 2" Stage of Labour Normal Delivery 219 Date FHS. 2 Degree of Degree of Episiotomy Newborn L andTime | Cervical Dilatation Effacement (if required) Type V2\oy jr Vo \oy}2N] VG objwd Loum lo ov Yo, Time of birth on 100 om 2g co am NWUWALO LAL Alive/Still 7 at PUA Sex of baby Semag Weight of baby. 3.0 Kg ‘Weight of Placenta (gm 4Usoqm Total hours of Tstage VOVULISWWA 2" stage 30 WM 3% stage 1S Wun Total hours of labour 1 1 Moun Amount of blood loss S00 ml NEWBORN ASSESSMENT AND CARE 1. Airway clearance CALA. 2. Apgar scoring 1 minute__ © 5" minute__ 15 minute LO 3. No. of Umbilical blood vessels a. Arteries a b. Veins fenae 4. Drug administration MUL) Me — 5. First feed started within re bh, Ou ae _______ min/hour 6. Remarks for newborn health status Mag ieee eer ASSESSMENT AND CARE OF MOTHER Immediately After Delivery 1 Uterine behavior Uterine pain/after birth pains ot etseiigContacted/elaed pad — Raison. — ae Blood flow (Rubra) Lactation (Present/Absent) ja HUAR@vh, __ ING mat _ Micturtion and condition of urinary tract Others oA any taceration _— 220 Midwifery Casebook with Extra Edge for Viva-Voce NURSING CARE PLAN ine Nursing Diagnosis Interventions ee % v Porm Leek vaouy4] ACULL pou outatia | PAO Lupavt ae epigictowny ein posto Lo ue fle Sow ancl, a3 wrrdimud tuy ane pymngeng | pauin seousng BCoLL |+ tsvorrtdid Pe eranenenreaite = (|L0) Okt Yet Jip Us Pattee iol iu | SUL 1 UAL Ad NS ama Le LUAUAL POM > Rimi dol rol, ewtowmend Ue Moe bo qo sud OMA RLULD - 2 ULL duck a, Se DATE AND TIME OF SHIFTING TO POSTNATAL WARD Delivery Notes tu. LUA, Wet. 4 fend Health Education for: + Mother &Mustotud yahuoud 4 ya + Newborn baby (oven tcl, ieemeincmommare ag AUS) — Treatment for: + Mother ae tes & Pag o> =e + Newborn baby Signature of Student NORMAL DELIVERY (4) : Hospital vow wena en Moipilates No. of Mother 2.0416 66 2\2 —____ Name MU MOM EK ___Reg. No, of Baby _ 2.14266 319 2. Wo MH BMonnka ___ate/Time of Delivery 14 )o4 J a4 at 24Bam, Age _ 25 yes ____ Religion Hanacly ——_____— address RO, pus, Pung abe SS ae a Gamer A’ A_ OF, Lwp_\ojo4\23 pp JOM [2D Date and Time of Admission \@\ouyaN at, 10 00 ama Date and Time of Transfer to Postnatal ward __1@ Jou \au @ 6:00 am ADMISSION NOTES General Examination 1. Temperature _4%.6 °F 6 Anemia CAs henak 2. Pulbe 9. @ min 7. Heart sounds @\ 9 6. darosich ___ 3, Respiration _\@ min, 8. Lung and chest By. Oui ena Jnday 4. BR 20) 80 mmHg 9. edema generalized/Ankle oedema _ fh eck Labour pain (PreSent/Absent)__@ $end _ Obstetrical Examination 1. Uterine height 2d cm 6. Presentation —Sepnadte valine }— 2. Abdominal girth _ 8S cm 7. Presenting part __-- WtoueA 3. lie & FHS. ta Q Jin 4, Attitude 9, Time/date of onset of contractions 18 [04 J24 oF Spm 5. Position 6 10. Uterine contractions (Present/Absent) @ Seine. Vaginal Examination S\No.| Date &Time | Findings ; 1. | UB]e4)\24 ajooeyh wom 2 1 {ou 124 Wh 009m 6m 3 | 14) pt) ob oo gm Vo ww “if membranes are ruptured color of Amniotic fluid l Previous Labour History SNo.| Year & Date | Pregnancy Events | LabourEvents | Methods of Delivery | Puerperium | Baby Status ~~ — _ ge hae > 222 __ Midwifery Casebook with Extra Edge for Viva-Voce Investigations | AL Urine; Albumin = Ho 12 @q.\ At. Blood Group/Type BAe Blood Sugar WMG LAL Urine; Sugar i HIV Es __ VDRL - Others _ —_—_—_. ADMISSION HISTORY Date & Time | Pregnancy Complaints | Menstrual History | Medical History | Surgical History | Personal History > | No nia Wo untomsy | Patlowrir “Wing ea oomg ae Sustalvoy: HIN Suet | S- Odes ous + ea | VBpoyjay | Laon Earns PROGRESS NOTES Uterine Contractions Date & Time Stages Frequency Duration TO oq ABroopM stage 3 Wo ge | Wlou 24 tg aww 2°4 Stage 5 Ro ate 1A\OU{2U 14S awl 3" Stage ate. 1" Stage of Labour Date & Time | Membranes Ruptured/ FHS. Degree of Degree of Station of Not Ruptured Dilatation of Cervix Effacement Fetal Head heey | ver saxpurud Woblm — Lu 207 ~ | ak Bem NG) ou\a4 re \woum | Yorn oy. +) ok Aen f | | ' nox WB bIM | uw ee a | VOlOH|L tuplasud | Boy | OX AN Om | 1% b\w \owm - 00° rajo4ey | guipured - eee oles] VS, Or Vena Normal Delivery _ 223 es ie a Morale 2 PARTOGRAM Name MUA Moved ¢ Pa ap t_1._—__— Name of Hospital Date & Time of Admission 1% Jouja4 ek 10: ees Stotus — Cuplarud Date & Time for Membrane Rupture_yajoy ys.U @& 12016 on Onset of Labor: Dato AS\nujay Time 3.0.0 PY __ 224 _ Midwifery Casebook with Extra Edge for Viva-Voce 2" Stage of Labour Date FHS. Degree of Degree of Episiotomy Weatorn and Time | | Cervical Dilatation Effacement (if required) Type ral }24 | HS 6] Wy Om \p 0°f yes, gMh | Time ofits eater. jrigoey repos) Gow Alive/Stilt: PUL Sex of baby mole Weight of baby Baty Weight of Placenta (gm): 4So a Total hours of T'stage__ 1OWL BO WUM_2"4 stage __ BOW. 39 stage __\ SW, Total hours of labour My. 1 Syn, Amount of blood loss _ 0.0 ml NEWBORN ASSESSMENT AND CARE 1. Airway clearance __@ CLLMA. 2. Apgar scoring 1 minute & 5" minute__4 15" minute __1. 3. No. of Umbilical blood vessels a. Arteries b. Veins \ = a 4. Drug administration ko) = 5. First feed started within _ Walser AR min/hour 6. Remarks for newborn health status ae ee ee ASSESSMENT AND CARE OF MOTHER Immediately After Delivery 1. Uterine behavior Uterine pain/after birth pains Aaa. Sout Ce Contracted/relaxed Cow, cyetud Blood flow (Rubra) Pashto. Ry lacertion AO 2, Lactation (Present/Absent) _ fie Sk sere eee aM 3. Micturition and condition of urinary tract _ NO@M~wog 4, Others = Normal Delivery 225 NURSING CARE PLAN = Sing Oebonet Interventions Evaluation 4 : Lao a] neste aa a 4] pau ola SALA Jou 2 | oa aa DLOLUM 4 a errickemu fomepuaamid UAL pee cuba: MAY Re rotting | ei owt Uh masun at SL pLLOclnd ig Wav OU, Us WLS - © PLuyrrteled- WL townppner AOU caupint] Norvhiont emel cara & prornide eowmpercor 8 To proride tea el DATE AND TIME OF SHIFTING TO POSTNATAL WARD | Delivery Notes "HLL Juscrma, reaeaeelae ta ieee oe JUHA 2. Bio Health Education for: + Mother wh tetlinoerkich ole uctewannying, rae + Newborn wey fecuatricl Laud mM Coc uA ML Leersb|ycding _ Treatment for: + Mother Tale olLULafonad, 60 7 One eee « Newoom babyee ee ieee Signature of Student ir. Signature of Teacher pe a s C\ POSTNATAL CASE (1) Hospital MORO KOUAM OLY A Masprod Podiatry — —__—— Name Somioe Ausi W/o Bots Kanna — Moe 2 Reg. No. of Mother_2106S4%122 Registration No. of Baby _2OGSUB1442— Address Tanase, Potala, Barajah) __6_2._P_2_ 4 -o_ Type of Delivery _ Nos at dacsaat Gestational Age at Delivery Time 40 Aneake Newborn Condition _niaawwiag_—__§ __ Newborn Sex ___bo Newbom Birth Weight 3.2." _ Total Hous of Delivery Mode of Delivery lasarawo vont No. of Days for Hospital Stay ADMISSION NOTES IN LABOUR ROOM Labour History S.No. | Year & Date | Pregnancy Events | Labour Events | Methods of Delivery 4. [2022 neumde | narumdl) Neural Vvagunat 4 Loy Wow ati oy ‘0 b 2074 Namal | NaUmatl|Nount Naum Huo Vaginal ob Aso) aativeuy GENERAL CONDITION Temp (C)__ 99.42 Respiration/min 2.9. pyM_Pulse/min AL bemBR, \MO\40 mmlig imp) \ 2023 ep0_\S\4\2024 Date and Time of Membrane Rupture Color of Amniotic Fluid _ Ros, DELIVERY NOTES ‘Amount of Blood Loss (ml) UO Ove __ Placental Weight (gm) es Episiotomy Type (if done) __ ____ Any Perineal Laceration = Operation Notes (if any) — Maternal General Condition on Shifting \y. hou. ais 10 Stale. ama ee Date and Time of Shifting (in Postnatal Ward) 16 }O4\ HIM ob 3:00 ner Newborn General Condition on Shifting Nosema Newborn Date and Time of Shifting (in Postnatal Ward) \6 04 | 2024, Bvt ab 400 om POSTNATAL INVESTIGATIONS Hb Blood Group and Type Blood Sugar Others Remacks Vb. Bri IZ\™ aoe Agia i e \mg (do GRY 4 Nounal lew! ave tow $ Lag POSTNATAL ASSESSMENT FOR MOTHER Postnatal day 7 Leas Wayaula> ip Tie Mel wie Tene ale Pulse/min laa | Tea Resp min BP (mm) “Rubra “Serna “Aba " Vaal Signs Lochia *Breast condition (N/E/S/C/IN) ‘Lactation (N/Su) *Stitches condition (N/) Perineal hygiene Bath Remarks ep Zno2z/ 2a + Weight (kg) DCW Ss Others a Remarks J os on r *N-= Normal, B = Buiged out B = Depressed, Ab = Abnormal NURSING MANAGEMENT FOR NEWBORN Day/Date/Time Nursing Diagnosis Implementation Evaluation Riv of Srgabioy — | “MEAL e RISK VFYOA\2024 | Sudeded-ty JOU, VOL Bian uae ampetlon a3 ok nancy seondal Lobes» Saqnupucamllay a SOU 6:20 gw “Bey to Waawp Cat aaktin Parebata ' Jat ce Postnatal Cases 317 CONDITION OF MOTHER AT DISCHARGE > MOM i eOMadOUs, och 2 Whod ws 24 ALU SRLKUALA RELL WA Pondison ~> Wo kigpna mon qutsow sound RIVE ONACC me SN Cee) Myostatin are — CONDITION OF NEWBORN AT DISCHARGE 2 bohy & Malia & aaa, aos ta petal Vea HEALTH EDUCATION ON DISCHARGE For Mother a ay ee eae Ee) PPERER te Sumy Mowatt 4BD- ateatete it oe Taks Nusmos x BR For Baby 7 Ang Cecwiq yu Treatment tea ats AoA CoH - Vit KIM eee = Bi, 0-Swe © anmsd. ae ee =e tena gid pty 0 dose 2 a a rep 9.6 me gm Treatment cS Date and Day for follow up___ we ate Advised/Adopted type of contraceptive method to mother, - Pate WOs OdUiLE bo ULE Seomparorirg POV ARL UAL ALM OL” Signature of Student Signature of Teacher Arpati Rakrrrt POSTNATAL CASE (2) Hospital MOU KOULLMAL pr She ok, pada be a Dos _Wio | : (Lok, RUMniare_ Age 2-9 Reg. No. of Mother 219 UWI2\2. Registration No. of Baby \O.\ 212. bABBUS, oO Address SusiMnad POduota , Purp cto suse G tiogte Pace toe Type of Delivery _NeManas V Gestational Age at Delivery Time Yo Week Canty Newborn Condition Nasnao UME Newborn Sex boy — omens Newborn Birth Weight . __ Total Hours of Delivery _- qauh Mode of Delivery _N) @» (at No. of Days for Hospital Stay/ _O 2. ALLY OY, ADMISSION NOTES IN LABOUR ROOM Labour History S\No.| Year & Date | Pregnancy Events | Labour vents | Methods of Delivery, | Puerperium | Baby Status Noeund Naud N auwel fuotng eed a] 202 Nam o| 2024] Nounail proumagd Nawned | youmaf ae gone joey GENERAL CONDITION Temp (°C) AD-4°E Respiration/min 206 | yum Pulse/min 4. bm 8P M0440 mmHg ump \A\ %& (as EDD 1% AMV ~ Date and Time of Membrane Rupture Color of Amniotic Fluid Lense Amount of Blood Loss (ml) Wo wb - Placental Weight (gm) Rigy Episiotomy Type (if done) MuveLio Lalaniat erty Any Perineal Laceration Operation Notes (if any) = Maternal General Condition on Shifting _ ett gps a Us oyu tabu asad teotay Date and Time of Shifting (in Postnatal Ward) | Newborn General Condition on Shifting epQemals Z Newborn Date and Time of Shifting (in Postnatal Ward) A444 DQM. bad am POSTNATAL INVESTIGATIONS | DELIVERY NOTES | | = | Blood Group and Type Blood Sugar Others Remarks, Mother | 0-A9f0l BeVE Vaden g VA Newborn 3 bive awyids NPUPES | Nomad POSTNATAL ASSESSMENT FOR MOTHER Postnatal day 1 2 pte NAY 14 \ Time mle[me Temp. (F) (a4 |ab6| a8 6] Pulse/min. 92] 90 | 90 Resp/min as'[aolaa BP (mmbg) hab wall Vital Signs “Rubra *Serosa *Alba Uterine Height (cm) *Breast condition (N/E/S/C/IN) “Lactation (N/Su) ‘Stitches condition (N/)) 2 |2 Perineal hygiene Bath Remarks eesnroz|x |Z *N = Normal, C = Cracked Nipples, E = Engorged, Su = Supressed Nipples, ‘Rubra = fil the box with red color, *Serosa = fil the box with pink color *Atba = fill the box with yellow color, NURSING MANAGEMENT FOR MOTHER Postnatal Cases__319 re, = Infected, IN = Inverted Nipples Aidapnar So $ Day/Date/Time Nursing Diagnosis Implementation Evaluation vs l¥ (24 Pru Jou “Pasuasia wat | Pom of Wy ou ae Vihad i qr ef patiova wat O.COM ODOM B.900M | aay a Wdeneud : a xy ol i rt by pou subunrg | ~ beorvided \ Ree. RLpUnt parce \o) A ~ Pree did POW 2 UH Ems north Bowers Lust 320 Midwifery Casebook with Extra Edge for Viva-Voce POSTNATAL ASSESSMENT FOR BABY Day 1 2 [ee 3 4 5 6 Date ely\aye [aly | Time mle;mMle;mye;mM]e;M|e| |] € Newborn age (in days) a a Temp.) haa 494 als Heart Rate/min \dQ 6 Respiration/min Urine (times/day) Stool (times/day) Bath/Sponge Eyes Care Cord Care *Fontanelles (N/B/D) ‘Reflexes (N/Ab) Activity No. of Feeds/day Physical Parameters/Day [2 + Length (cm) u> Ur + Head circumference (cm) 2a a3 | + Chest circumference (cm) 2S as | ‘+ Abdominal circumference (cm) 2 2 + Weight (kg) zm 2.90 Others tf Remarks oun Noumad +N = Normal, B= Bulged out D= Depressed, Ab = Abnormal NURSING MANAGEMENT FOR NEWBORN Day/Date/Time ‘Nursing Diagnosis Implementation Evaluation + Roe Song htot © PAULA isha basil fous Yaad Rapwd of on f ‘ 410 0 OM” Varennes LreOvelangy UAL Leatsey re. i HO Wanpilal aot | - ALslpkscl ou’ Postnatal Cases 321 CONDITION OF MOTHER AT DISCHARGE MOLLY is covscous 2 heotimy 3 vUAU wou st ie 2 Fa ee ee AKDUMA SAA AKL SD nagaiiast_us04 nw CONDITION OF NEWBORN AT DISCHARGE 2 & iw Enews aula see —— a oo sce pin wal — — nan mol pap pital comaraaitial plsanians HEALTH EDUCATION ON DISCHARGE For Mother Treatment pba sada woe ec aie a eet nt ae eee 2 For Baby Treatment afin lis cq arti ¢ ‘Advised/Adopted type of contraceptive method to mother, Pcthewt wor adwitod Wo ube Bowparasy Koveracep toys MUM Od, Signature of Student \ Signature of Teacher

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