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YEAR OF STUDY—2019
IDENTIFICATION DATA
AGE— 24 years
SEX— Female
RELIGION— Hindu
EDUCATION— Graduation
DISCHARGE DATE—
OCCUPATION— Housewife
HIGHT—5 feet
CHIEF COMPLAINS—
FAMILY HISTORY—
She belongs to a joint family having 6 numbers . Her husband & Brother-in-law are the
supporting person in her family. The monthly income of her family is nearly about Rs 35,000.
There is no history of any disease like TB, HTN, DM & hereditary disease , twin pregnancy in
her family.
There is a CHC in her village at a distance of about 1 km. Transportation facility available like
bicycle & motorcycle.
HOUSING —
She lives in a pucca house having 8 numbers of rooms with adequate ventilation. They use
sanitary latrine for toileting. Electricity supply is available. They use municipality water supply
taps for drinking.
PERSONAL HISTORY—
DIET—She takes both vegetarian & non-vegetarian diet & She takes meals 4 times a
day. she don’t have any addiction of alcohol & tobacco. She drinks about 2-3 lts 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— She has regular walking habits of evening everyday.
MENSTRUAL HISTORY—
She got menarche at 13 year of age with regular cycles of 28-30 days interval & 3-4 days
duration with average amount of bleeding. Her LMP is 25/9/18 and EDD- 2/7/19.
She is married since 1 and 1/2 years & She has satisfactory relationship with her spouse.
General health of her spouse is good.
OBSTETRICAL HITORY—
INVESTIGATIONS—
Hb=11gm%
FBS=83mg/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 18/5/19 showing single live intra-uterine fetus in cephalic presentation.
PHYSICAL XAMINATION—
VITAL SIGN—
Temp –98.2 F
BP—120/70mmhg
Pulse –78beat/min.
Resp –20 braeth/min.
OBSTETRICAL EXAMINATION—
INSPECTION—
P/V EXAMINATION—
INTRODUCTION—
DEFINITION—
Spontaneous rupture of the membranes any time beyond 28th week of pregnancy but before the
onset of labour is called Prelabour rupture of the membranes( PROM ).
It is of 2 types :-
Term PROM –
When rupture of the membranes occur beyond 37th week but before the onset of
labour is called term PROM.
Preterm PROM –
When rupture of the membranes occur before 37 completed week is called
Preterm PROM.
Prolonged rupture of membranes-
When rupture of membranes occur for more than 24 hours before delivery is
called Prolonged rupture of membranes.
INCIDENCE –
IN BOOK IN CLIENT
In majority causes are not known. Idiopathic
Possible causes are - ( Causes are not known)
Increased friability of the membranes
Decreased tensile strength of the membranes
Polyhydramnios
Cervical incompetence
Multiple Pregnancy
Infection – Chorio – amnionitis, Urinary tract infections
and lower genital tract infection
Cervical length < 2.5 c.m
Prior preterm labour
Low BMI ( < 19 kg/m2)
IN BOOK IN CLIENT
Only subjective symptom- Watery discharge in a gush leak
Watery discharge per vagina either in the
form of gush or slow leak
DIAGNOSIS –
IN BOOK IN PATIENT
3)HIV/HbsAg/HCV Nonreactive
COMPLICATION:
IN BOOK IN PATIENT
MANAGEMENT-
PRELIMINARIES-
1) Aspectic examination with a sterile speculum is done confirm the diagnosis ,to note the state
of the cervix,and to detect the cord prolapse
2)patient is put to rest and sterile vulval pad is applied to observe any further leakage.
OBSTETRIC MANAGEMENT-
TERM PROM-
Observed patient carefully If the she is not in labor and there is no evidenced of
infection or fetal distress ,
if labor does not ocurr spontaneously within 24 hour then induction of labor with
oxytocin start.
Caesarean section is performed with obstetric condition.
PRE-TERM PROM-
If gestational age is 34 weeks or more, then wait for spontaneous labor for 24 -48 hour.
If fails then induction with oxytocin or caesarean for non cephalic presentation
If gestational age is less than 34 weeks and absence of maternal and fetal condition,
then provide bed rest ,antibiotic
pelvic rest and antibiotic help to seal leak sponateously and reduce infection ,and
pregnancy continues
USE OF ANTIBIOTICS-
Prophylactic antibiotics are given to minimise maternal and fetal risk of infection
USE OF CORTICOSTEROID-To stimulate surfactant synthesis against RDS in preterm
EXAMINATION EXAMINATION
OPERATION NOTE-
Under all aspectic condition, Parts painted & draped, abdomen opened by pfannesteil
incision in layers. Uterus opened by lower segment transverse incision after pushing the
bladder downwards. A term male child delivered by using ventouse at 1.23 p.m. on 22.06.19.
Baby weight is 2.945 kg . Uterus closed in two layers Abdomen closed in layers and skin
closed by subcuticular sutures layer.
3. Risk for imbalanced nutrition less than body requirement evidenced by decreased urine
output.
SUMMARY-
Mrs. Rojalin Biswal, a primipara having GA 38 week 2 days & with PROM, 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, how to give care to her baby, how to give proper breast
feeding, regular follow up, which makes her more confident & due to this she is now able to
cope to any stressful situation . She was also given health education on nutrition, personal
hygiene, antenatal exercise & regular follow up.
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