A CASE PRESENTATION ON NORMAL VAGINAL DELIVERY

WITH EPISIOTOMY
STUDENT NAME—Miss Itismita Biswal

HOSPITAL—IMS & SUM HOSPITAL , BBSR.

YEAR OF STUDY—2018

IDENTIFICATION DATA

NAME OF THE PATIENT—Mrs.Madhusmita Das

NAME OF THE HUSBAND—Mr. Vikram Das

AGE— 28 years

SEX— Female

MARITAL STATUS— Married

HOPITAL REGISTRATION NO— 190204002

WARD/BED NO— 2(maternity Ward) / Bed No- 3

ADRESS— At- Naripur, P.O – Argul, Dist – Khordha, State - Odisha

RELIGION— Hindu
EDUCATION— Post - Graduation

ADMISSION DATE— 03/02/19

DISCHARGE DATE— 07/02/19

DIAGNOSIS– Primigravida at 38wk Period of gestation in active labour

NAME OF THE DOCTOR— Dr. Pradeep Panigrahi

OCCUPATION— Housewife

MONTHLY FAMILY INCOME— Rs- 30,000

WEIGHT— 62 kg

HIGHT—154 cm

CHIEF COMPLAINS—

 Pain in lower abdomen since 1day ( from 2.00 p.m on 3/2/2018)

 Water leakage per vagina since 9.00 p.m on 3/2/2018

HISTORY OF PAST ILLNESS—

 There is no past medicalhistory of TB, HTN, and DM.

 She has not undergone any surgical procedure.
FAMILY HISTORY—

She belongs to a nuclear family having 4 numbers. Her husband is the only supporting person in her family. The monthly income of her family
is nearly about Rs 30,000. There is no history of any disease like TB, HTN, DM , hereditary disease & twin pregnancy in her family.

HEALTHFACILITYNEAR HOME—

There is a PHC in her village at a distance of about 3 km.Transportation facility available like Bicycle, Auto , Motorcycle & Car.

HOUSING—

She lives in a Pucca house having 6 numbers of rooms with adequate ventilation. They use sanitary latrine for toileting. Electricity supply is
available. They use municipality water supply taps as well as own bore well for drinking.

PERSONAL HISTORY—

PERSONAL HYGIENE –

She is maintaining her oral hygiene by brushing daily & taking bath once daily with soap & normal water.

 DIET—she takes both vegetarian & non-vegetarian diet &she takes meals 4-5 times a day. She don’t have any addiction of alcohol
&tobacco. She drinks about 3-4 litres of water per day. She takes rest of about 2 hrs at day time & 8 hrs during night time. She takes no
drugs for sleep.
 ELIMINATION—She has a regular bowel & bladder habits
 MOBILITY & EXERCISE—No regular walking habits. Only moderate activity with normal house hold work.
MENSTRUAL HISTORY—

She got menarche at 14 year of age with regular cycles of 28-30 days interval & 3-5 days duration with average amount of bleeding. Her LMP is
10/5/18 and EDD- 17/02/19.

SEXUAL &MARITAL HISTORY—

She is married since 2 year & she has satisfactory relationship with her spouse. General health of her spouse is good.

OBSTETRICAL HISTORY—

 PAST OBSTETRIC HISTORY—

Nothing significant as she is Primigravida.
 PRESENT OBSTETRIC HISTORY-
She is a registered case. She had attended antenatal clinic 6 times,
Her LMP was 10/5/18 & EDD- 17/02/19. Thus the Gestational age (GA) is 38 weeks.
 FIRST VISIT—
She missed her menstrual period & went to nearby clinic & tested her urine for pregnancy & become confirm of her pregnancy. On her
examination her weight was 54 kg, BP = 120/70mmhg, pulse = 84bpm. At that time she suffered from minor ailments like nausea,
vomiting & constipation.
 SECOND VISIT-
She went to nearby clinic for 2nd antenatal check-up after 2months at that time her weight was 57 kg, BP = 124/80mmhg,
Pulse = 82 bpm.

INVESTIGATIONS—

 Hb = 11.4 gm%
 FBS = 92 mg/dl
 Urine for HCG = Positive
  Blood group = ‘B’ positive
 Sickling = Negative
 Urine test = Albumin-- Not Present
Sugar--Not Present
 VDRL = Negative
 HIV = Non reactive
 HbsAg = Non reactive
 HCV = Non-reactive
 USG = Done on 12/1/19 showing single live intra-uterine foetus in cephalic presentation.

OBSERVATION & ASSESSMENT—

 Her general appearance is good

 Patient is conscious & anxious
 She has no foul body odour & foul breath

PHYSICAL EXAMINATION—

VITAL SIGN—

 Temp – 98.6of
 BP — 124/80 mmhg
 Pulse – 82 beat/min.
 Resp –22 breath/min.

HEAD TO TOE EXAMINATION—

 Her skin colour is normal

 Hair & scalp are clean &healthy. No dandruff & pediculosis is present
  In eye ,no Jaundice& Pallor is seen
 Mouth is clean
 No glossitis & No stomatitis
 Tongue is hydrated
 Gum is healthy
 Total no. of teeth is 32
 Nose, ear, throat are clear
 In neck no abnormal enlargement of lymph node & glands.
 In breast secondary areola has formed & nipple are normal.
 Liver & spleen are not palpable
 Leg , spine & back are normal
 pedal oedema is present

OBSTETRICAL EXAMINATION—

INSPECTION—

 No undue enlargement of the Uterus .

 Skin condition—healthy & no discolouration.
 Linea nigra is prominent
 Striae gravidarum visible all over the abdomen but mainly on lower part.
 Episiotomy wound present.

PALPATION—

 Uterus is hard, mobile & globular.

 Fundal height is 24 c.m i.e. at the level of umbilicus.
P/V EXAMINATION—

Vulva – Normal, No oedema

Perineal area & Anus – Clean

Lochia rubra present in normal amount

Episiotomy wound - Healthy

DEPENDENCY LEVEL OF PATIENT – Patient is partially dependent.

CLINICAL EXAMINTION & NOTES-

DIAGNOSIS — Vaginal delivery with right mediolateral episiotomy

INTRODUCTION— vaginal delivery is a normal procedure of child birth which due to the changes occurs in the female genital organs that can
able to push the viable products of conception out of the maternal uterus.

DEFINITION—Delivery is the expulsion or extraction of a viable fetus out of the womb.

Labour: Series of events that takes place in the female genital organs in an effort to expel the viable products of a conception out of the womb
through the vagina in to the outer world is called labour.

STAGES OF LABOUR

BOOK PICTURE PATIENT PICTURE

 First stage: It starts from the onset of true labour pain & ends  The duration of 1st
stage is 10hr 30 min.
with full dilatation of cervix. Its duration is 12 hour in
primigravida & 6 hour in multipara.
  Second stage: It starts from full dilatation of cervix & ends  The duration of 2nd stage is 1hr 30 min.
with expulsion of fetus from the birth canal. Its duration is 2
hour in primigravida & 30 min in multipara.
 Third stage: It starts after expulsion of fetus & ends with  The duration of 3rd stage is 15 min.
expulsion of placenta & membrane. Its duration is 15 min in
both primigravida & multipara.
 Fourth stage: It is the stage of observation for at least 1hour  The duration of 4th stage is 1hr.
after expulsion of after birth products.

Book picture Patient picture

Event in first stage - Dilation 10 cm, effacement 100%.
The main events that occur in the first stage are—
(a)Dilatation and effacement of the cervix and
(b) Full formation of lower uterine segment.
EVENTS IN SECOND STAGE-
(1) Propulsive—from full dilatation until head touches the pelvic floor. Mother give bearing down effort. Baby is delivered.
(2) Expulsive—since the time mother has irresistible desire to “bear
down” and push until the baby is delivered. With the full dilatation of
the cervix, the membranes usually rupture and there is escape of
good amount of liquor amnii.

EVENTS IN THIRD STAGE OF LABOR

 Placental separation : central and marginal Placenta is delivered in toto.
 Separation of membrane
 Expulsion of placenta
MECHANISM OF LABOUR-

To accommodate itself to the maternal pelvic dimensions, the fetus must undergo a series of changes in the attitude of its presenting part. This
is required for fetal descent through the birth canal.

Nine discrete cardinal movements of the fetus occur over the course of labor and delivery: engagement, descent, flexion, internal rotation,
crowning, extension, external rotation, restitution, expulsion of trunk & shoulder.

Engagement: Engagement is the descent of the widest part of the fetus through the pelvic inlet. This normally occurs 2-3 weeks before labour
in nulliparous women and may occur any time before or after onset of labour in multiparous women. In this the antero-posterior diameter or
biparietal diameter (9.5cm) of head coinsides with the transverse diameter of maternal pelvis.

Descent: Descent refers to the downward passage of the presenting part through the pelvis. Descent of the fetus is not a steady, continuous
process. The greatest rate of descent occurs during the deceleration phase of the first stage and during the second stage of labor.

Flexion: While some degree of flexion of the head is noticeable at the beginning of labor but complete flexion is rather uncommon. As the
head meets the resistance of birth canal during descent, full flexion is achieved either due to the resistance offered by the unfolding cervix, the
walls of the pelvis or by the pelvic floor.

Internal Rotation: Internal rotation is the 2/8th rotation of the presenting part from its original position (usually transverse with regard to the
birth canal) or 1/8th if the presenting part is in oblique diameter to the antero-posterior position as it passes through the pelvis. As with flexion,
internal rotation is a passive movement resulting from the shape of the pelvis and the resistance of the pelvic floor musculature.

Crowning: In this the biparietal diameter of head stretches the vulval outlet without any recession of head even after the contraction is over.

Extension: Extension occurs once the fetus has descended to the level of the introitus. This descent brings the base of the occiput into contact
with the inferior margin of the symphysis pubis. At this point, the birth canal curves upwards. The fetal head is delivered by extension and
rotates around the symphysis pubis. The forces responsible for this motion are the downward force exerted on the fetus by uterine
contractions and maternal expulsive efforts along with the upward forces exerted by the muscles of the pelvic floor.
External Rotation: After the fetal head deflexes (extends), it rotates to the correct anatomic position in relation to the fetal torso; left or right
rotation depends on the orientation of the fetus. This is again a passive movement resulting from a release of the forces exerted on the fetal
head by the maternal bony pelvis and its musculature and mediated by the basal tone of the fetal musculature.

Expulsion of shoulder & trunk: Expulsion refers to delivery of the body of the fetus. After delivery of the head and external rotation, further
descent brings the anterior shoulder to the level of the symphysis pubis. The anterior shoulder rotates under the symphysis pubis, after which
the rest of the body usually delivers without difficulty.

MANAGEMENT OF THE FIRST STAGE

ACTUAL MANAGEMENT:

GENERAL MEASURES

Book picture Patient picture

 Provide Antiseptic dressing .  Antiseptic dressing done.

 Provide emotional support and assurance to keep up the  Emotional support and assurance given.
morale.

 Constant supervision is ensured.  Constant supervision is ensured.

 An enema with soap and water or glycerin suppository is  Enema not given
traditionally given in early stage.

 Provide Rest and ambulation  Rest and ambulation provided

 Fluids in the form of plain water, ice chips or fruit juice may be  Plain water and fruit juice given
given in early labour. Intravenous fluid with ringer solution is
started where any intervention is anticipated or the patient is
 under regional anaesthesia.

 Patient is encouraged to pass urine by herself as full bladder

often inhibits uterine contraction and may lead to infection.  Urine passed by herself

 The common analgesic drug used is Pethidine 50–100 mg  Analgesic not given
intramuscularly when the pain is well established in the active
Phase of labor
 Partograph  Partograph was maintained

MANAGEMENT OF THE SECOND STAGE

GENERAL MEASURES

Book picture Patient picture

 FHR is recorded at every 5 minutes
 Vaginal examination is done at the beginning of the second
stage
 Positions of the woman during delivery may be lateral,
squatting or partial sitting (45°). Dorsal position with 15° left
lateral tilt is commonly favoured as it avoids aortocaval
compression and facilitates pushing effort
 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 leggings are to be used
 Essential aseptic procedures are remembered as three ‘C’s:
(a) Clean hands
 FHR recorded at every 15 minutes
 Vaginal examination was done at the beginning of the second
stage
 Dorsal recumbent position was given.
 Toileting the external genitalia and inner side of the thighs was
done with cotton swabs soaked in betadine solution.
 One sterile sheet was placed beneath the buttocks of the
patient and one over the abdomen
 Sterilized leggings are not used.
 Three ‘C’ maintained
 (b) Clean surface
(c) Clean cutting and ligaturing of the cord.
 To catheterize the bladder  Catheterization done
 When the scalp is visible for about 5 cm in diameter, flexion of  When the scalp is visible for about 5 cm in diameter, flexion of
the head is maintained during contractions. This is achieved by the head was maintained during contractions. This is achieved
pushing the occiput downward and backward by using thumb by pushing the occiput downward and backward by using
and index fingers of the left hand while pressing the perineum thumb and index fingers of the left hand while pressing the
by the right palm with a sterile vulval pad. perineum by the right palm with a sterile vulval pad.
 If the patient passes stool, it should be cleaned and the region  She did not Pass stool
is washed with antiseptic lotion.
 When the perineum is fully stretched and threatens to tear  Episiotomy was done
especially in primigravidae, episiotomy is done at this stage
after prior infiltration with 10 mL of 1% lignocaine
 Immediately following delivery of the head, the mucus and  Wiping done
blood in mouth and pharynx are to be wiped with sterile gauze
piece on a little finger.
 The neck is then palpated to exclude the presence of any loop  Loop Cord was not present
of cord (20– 25%). If it is found and if loose enough, it should
be slipped over the head or over the shoulders as the baby is
being born.

MANAGEMT OF THIRD STAGE LABOUR:

Expectant management

Book picture Patient picture

 Delivery of baby  Baby delivered
 Clamp, divide& ligate the cord  Cord was clamped, divided & ligated
 Wait & watch:  Continuous supervision was there
 1. Cathertize the bladder if needed 1. Catheterization not done
2. Guard the fundus 2. Fundus was guarded
3. Wait for spontaneous separation of placenta 3. Waiting for spontaneous separation of placenta
 Placenta separated  Placenta separated
Wait for spontaneous expulsion with the aid of gravity Spontaneous expulsion of placenta occurs
If fail assisted expulsion should be done
Injection of oxytocin 5/10 unit slowly iv or im Assistance not given
Methargine 0.2 mg im
To examine placenta and membrane ,inspect vulva ,vagina& perineum Placenta and membrane Examined and was found complete

Active management

Book picture Patient picture

Injection oxytocin 10 unit im or inj. Mithargine 0.2 mg IM to the Placenta is delivered through the general management so no needed
mother with in 1 min of delivary of the baby. of active management.
Clamp, divide and ligate the cord.
To deliver the placenta by control cord traction soon after the delivery
of the baby availing first uterine contraction
If fails repeat after 2-3 min.
If fails again wait for 10 min repeat the procedure
If fails manual removal of placenta and inspection and examine the
placenta.
EPISIOTOMY:

Definition:

Episiotomy, also known as perineotomy, is a surgical incision of the perineum and the posterior vaginal wall generally done by a midwife or
obstetrician. Episiotomy is usually performed during second stage of labor to quickly enlarge the opening for the baby to pass through. The
incision, which can be done at a 90 degree angle from the vulva towards the anus or at an angle from the posterior end of the vulva (medio-
lateral episiotomy), is performed under local anesthetic (pudendal anesthesia), and is sutured after delivery.

Timing: Episiotomy is specially done during contraction just prior to crowning when the head is visible 3-4 cm. in diameter.

INDICATION:

Book picture Patient picture

Inelastic or rigid perineum Rigid Perineum Present
Big baby
Breech delivery
Shoulder distrosia
Ventouse delivery
Previous perineal surgery
Threatened perineal injury in primigravida
TYPES:

 There are 4 main types of episiotomy these are as follows

BOOK PICTURE PATIENT PICTURE

1. Medio-lateral: The incision is made downward and outward
from the midpoint of the fourchette either to the right or left. Right medio-lateral episiotomy was done.
It is directed diagonally in a straight line which runs about 2.5
cm (1 in) away from the anus (midpoint between the anus and
the ischial tuberosity).
 2. Median: The incision commences from the centre of the
fourchette and extends on the posterior side along the midline
for 2.5 cm (1 in).
3. Lateral: The incision starts from about 1 cm (0.4 in) away from
the centre of the fourchette and extends laterally. Drawbacks
include the chance of injury to the Bartholin's duct, therefore
some practitioners have strongly discouraged lateral incisions.
4. J-shaped: The incision begins in the centre of the fourchette
and is directed posteriorly along the midline for about 1.5
centimetres (0.59 in) and then directed downwards and
outwards along the 5 or 7 o’ clock position to avoid injury to
the external & internal anal sphincter.

DEGREE OF EPISIOTOMY:

Book picture Patient picture

First degree: only vaginal and perineal skin are tear First degree episiotomy is done.
Second degree: involve perineal muscle
Third degree : involve anal sphincter
Fourth degree : involve rectal mucosa
REPAIR OF EPISIOTOMY

The repair is done soon after the expulsion of placenta and membrane

Timing of repair: The repair is done soon after expulsion of placenta. If repair is done prior to that, disruption of the wound is inevitable, if
subsequent manual removal or exploration of the genital tract is needed. Oozing during this period should be controlled by pressure with a
sterile gauze swab and bleeding by the artery forceps. Early repair prevents sepsis and eliminates the patient’s prolonged apprehension of
“stitches”.

Preliminaries: The patient is placed in lithotomy position. A good light source from behind is needed. The perineum including the wound area
is cleansed with antiseptic solution. Blood clots are removed from the vagina and the wound area. The patient is draped properly and repair
should be done under strict aseptic precautions. If the repair field is obscured by oozing of blood from above, a vaginal pack may be inserted
and is placed high up. Do not forget to remove the pack after the repair is completed. The repair is done in three layers.

The vaginal mucosa is sutured first. The first suture is placed at or just above the apex of the tear. Thereafter, the vaginal walls are apposed by
interrupted sutures with polyglycolic acid suture (Dexon) or No. “0” chromic catgut, from above downwards till the fourchette is reached. The
suture should include the deep tissues to obliterate the dead space. A continuous suture may cause puckering and shortening of the posterior
vaginal wall. Care should be taken not to injure the rectum.
Day 1 (04/02/2019)

GENERAL CONDITION OF ADVICE NURSING INTERVENTION

MOTHER

Patient conscious Tab.Taxim-O 1tab BD Bed making done

Afebrile Low salt diet
Pallor (- ve) Tab Pan(40mg) 1 tab OD Mouth care given
Pulse= 82bpm Vital sign checked
BP= 100/60mmhg Tab Emanzen D 1 tab BD I/O chart maintained
Chest/CVS = NAD Bleeding P/V checked
P/A= Soft, Uterus Medication given in due
contracted time
P/V= Lochia Rubra Perineal Care given
U/O= Adequate Advice for Exclusive
Breast feeding
DAY 2 (05/02/19)

GENERAL CONDITION OF ADVICE NURSING INTERVENTION

MOTHER
Patient conscious Tab.Taxim-O 1tab Bed making done
Afebrile BD Perineal Care given
Pallor (- ve) Tab Pan(40mg) 1 Mouth care given
Pulse= 82 bpm tab OD Vital sign checked
BP= 120/70mmhg Tab Emanzen D 1 I/O chart maintained
Chest/CVS = NAD tab BD Bleeding P/V checked
P/A= Soft, Uterus Medication given in time
contracted Advice for Exclusive Breast
P/V= Lochia rubra feeding
present
DAY 3 — (06/02/19)

GENERAL CONDITION OF ADVICE NURSING INTERVENTION

MOTHER

Patient conscious Tab.Taxim-O 1tab BD Bed making done

Afebrile Mouth care given
Pallor (- ve) Tab Pan(40mg) 1 tab Vital sign checked
Pulse= 80bpm OD I/O chart maintain
BP= 116/84 mmhg Bleeding P/V checked
Chest/CVS = NAD Tab Emanzen D 1 tab Medication given in
P/A=Soft, uterus BD time
contraction present Advice for Exclusive
BP/V = Lochia Rubra Breast feeding

She has undergone LSCS and delivered healthy baby.

30/11/17 1st POD

GENERAL CONDITION OF ADVICE NURSING INTERVENTION

THE MOTHER
BP- 160/100mmhg NPO Advice to importance
Pulse-80 /mts Inj dynapar 50mg BD of breast feeding.
Chest- NAD Inj ranitidine 150 mg Bed making is done
bd Checked vital signs
Medication given IV.
1/12/17 2nd POD

GENERAL ADVICE NURSING INTERVENTION

CONDITION OF
MOTHER
BP- 130/90 mmhg Inj ranitidine 50 mg iv OD Bed making done.
Pulse- 78/mts Vital sign checked.
Respiration- Assist in breast feeding.
23/mts. Sips of water given.
All medication given in due time.

CARE PLAN OF POSTNATAL MOTHER (NORMAL VAGINAL DELIVERY)

assessment Nursing diagnosis Expected outcome Intervention evaluation

Subjective data Pain related to The patient will Pain intensity, severity, Patient reduced pain after
Mrs.Madhusmita episiotomy incision as experience less pain. duration of pain was assessed 1 days
Das says that I am evidenced by Comfortable position given.
having pain on visualisation of facial Vital sign checked.
episiotomy area. expression Calm and quiet environment
provided.
Objective data Visitors restricted.
Facial expression Infrared light provided.
Diversional therapy provided
Analgesic was given as per the
Physician’s order

The risk of getting

SUBJECTIVE DATA: Risk of infection related To reduce the risk of infection was reduced a
She said I am not to the surgical incision as getting infection Assess the incision site. little.
able to take care evidenced by Advice her to take daily care
of the incision site. observation of the site of the incision site.
Objective data Antibiotic medication is given
Swelling of the site to reduce the risk of infection.
Local tenderness
Subjective data Imbalance nutrition less Patient will have good Assess the level of Patient will regain weight
She said i don’t feel like to than body requirement appetite. nutrition. and have adequate
eating. related to loss of appetite Formulate diet nutrition.
Objective data as evidenced by weight plan in
Weight loss. loss. consultation with
Loss of appetite. Dietitian.
Measure total
intake output
chart.
Health teaching
regarding
contuining
balanced diet.
Teach food
preparation to
lessen fatty food
in menu.

ADVICE ON DISCHARGE :
 Low salt diet
Adequate fluid to drink
Regular health visit
Antenatal foetal monitoring
Be alert for complication like oedema, B p/v, excess weight gain, severe abdominal pain , vomiting , head railing
To seek immediately the medical attention in case any complication arises.
To avoid heavy lifting& climbing upstairs
To maintain personal hygiene
To take highly nutritious diet .
Iron & calcium to be continued

SUMMARY—

Mrs rasmita is a multigravida having GA 36 weeks & with pregnancy induced hypertension, is taken to improve nursing care. The care giver
established a good IPR with the client & her trust & confidence was gained. The client revealed all her problems, thus the care giver was able
provide care to meet the need up to an optimum. During this period she gains knowledge on different aspects like care of herself, regarding
possible complications,regular follow up, which makes her more confident & her anxiety was reduced & due to this she is now able to cope to
any stressful situation . She was also educated on nutrition, personal hygiene, antenatal exercise & regular follow up.

CONCLUSION—

Effect of my care—

After providing nursing care, the client has improved her self confidence .She feels relaxed & no anxiety is there. The client & family members
are very co-operative & they have trust on me.
BIBLIOGRAPHY—

1. DUTTA.DC “ Text book of obstretics “jaypee brothers medical publisher ,new delhi ,(2016).pgno-255-270.
2. Jacob annamma, A text book of midwifery ang gynaecological nursing, jaypee brothers medical publishers, new delhi 3rd edition (2012)
pg no- 572.
SUBMITTED BY : Miss Madhusmita Nayak

M .Sc nursing 1st year

SUBMITTED ON :04/04/2014