PATIENTS PROFILE Name Age RN IC Number Marital Status Gravida Parity LMP EDD Race Religion Address Occupation

Date of admission Time of admission Date of clerking Place of clerking POA : Mastura binti Abdul Rahman : 36 years old : HSNZ00177518 : 780329-11-5402 : Married :3 :2 : 30/01/2013 : 06/11/2013 : Malay : Muslim : Panji Alam, Kuala Terengganu : Housewife : 20/10/2013 : 5.30 am : 20/10/2013 :Labour room , HSNZ, KT : 37 weeks 5 days

CHIEF COMPLAINT Contraction pain two hours prior to admission.

HISTORY OF PRESENT ILLNESS Puan Mastura binti Abdul Rahman was admitted into the hospital due to uterine contractions pai. The contractions started two hours prior to admission while was sleeping. She initially thought that it was regular stomach pain and tried going to the toilet t pass motion but unable to do so. The contractions were infrequent and irregular initially lasting only e few seconds and the pain was mild and bearable. However, the contractions become more frequent and regular lasting about 10-15 seconds. The pain was moderate which she gave a pain score of 3 out of 10. There was no pain felt at other part of her body. The contractions were rhythmic and the pain was only felt with the contractions. There was no pain associated when the utrus relaxed. This happened once in every ten minutes and does seemed to be aggravated or relieved by any movement or actions. The pain was associated with the presence of mucus and blood discharge. There were no signs of rupture of amniotic membrane as she did not notice any gushing of warm fluid or dribbling of water. Fetal kick count was normal and fetal movements were felt. SYSTEMIC REVIEW CVS - no chest pain, no shortness of breath, no orthopnea, no PND, no ankle edema - no cough, no wheezing, no haemoptysis - no nausea, no vomiting, no diarrhea, no constipation, no malena, no hematemesis

Respiratory system GIT

Genitourinary system - there is frequency, no urgency, no dysuria, no haematuria, no nocturia CNS - no headache, no dizziness, no blurring vision, no insomnia

PRESENT OBSTETRIC HISTORY The pregnancy was unplanned. She found out about her pregnancy after 1month of delay in her menstruation and she went to the clinic for a check up. A urine pregnancy test was done and the result was positive. At that time, was 5 weeks POA. Then, she did her first booking at the 5 weeks of her pregnancy in Klinik Kesihatan Sri Langkap. On routine check ups at the antenatal clinic, her wight was 48kg,and her height 157 cm. Her blood pressure, blood glucose, urine test and haemoglobine level was within the normal range. She has blood group A rhesus positive. VDRL was negative. Her pregnancy was uneventful. She did her subsequent antenatal follow up monthly till 28 weeks and forthnightly till 36 weeks. Her total weight gain during this pregancy was about 20 kg and increase 0.5 kg per week.

Uterine fundal height was measured and it was correspond to the date. She did her first ultrasound on 16 weeks of POA and did her last ultrasound on 28 weeks od POA. The result was normal on both. Quickening was felt at the 16 weeks of her pregnancy. It was increase in frequency and intensity. Fetal movements were good at ten kick count per day. There was no hisory of fall or trauma. There was no abnormal vaginal or breast discharge. She experienced mild nausea and vomitting in the morning during the first five weeks of pregnancy and said to be similar to the morning sickness she experienced in her previous pregnancies. There was frequency but her bowel habit was normal and no constipation. There was no urinary tract infection symptom There also was no breast tenderness. For immunization, ATT was injected 1 dose and rubella was given during her school time. MENSTRUAL HISTORY She attand her menarche at the age of 13 years old. Her menstrual cycle is 7/28 days and regular. She used 2-3 pads on first and second day and it is fully soaked. But she used 2 pads per day until day 7 and it is not fully soaked. There is no dysmenorrhea, no menorrhagia and no intermenstrual bleed. PAST OBSTETRIC HISTORY Her first pregnancy was in year 2007. This was transverse lie and preterm, LSCS, girl, birth weight 1.9kg. Her second pregnancy was in year 2010, was deliverd by spontaneous vaginal delivery at term, boy, birth wight 2.49 kg. There were no anterpartum, intrapartum or postpartum complication in both of her children. She breast feed both of her children until 2 years old. She is not taking any OCP or IUCD. PAST GYNAECOLOGICAL HISTORY She doesnt has any past gynaecological disease before. There is also no menorraghia, no dysmenorrhea, no intermenstrual bleed, no dyspareunia and no postcoital bleeding. PAST MEDICAL/SURGICAL HISTORY She has no history of hypertension, diabetes mellitus, cardiac problems, thyroid disease, asthma, or any other medical conditions. She had never undergone any surgical procedures. PSYCHIATRIC HISTORY Unremarkable as she did not has any post-natal depression or psychiatry problems.

FAMILY HISTORY She has 9 siblings and all are healthy. Her father has asthma and her mother is healthy. There is no history of multiple pregnancies, congenital abnormalities, or genetic problem in her family. SOCIAL HISTORY She married on 2007 at the age of 30 years old. This is the first marriage and not a consanguinous marriage. Her education level is diploma and her husband works as an enginner. His income is enough to support her family. Her house condition is good and her husband visits her everyday. Her mother was taking care of her children while she was in the hospital. Her husband is nt a smoker and non alcoholic. DRUG HISTORY She does not take any medication other than the iron, folic acid, and vitamins C and B12 given by the antenatal clinic. She is not allergy to any medications and does not take any traditional medicine. DIET HISTORY She eat normal balance adult diet. She has no allergy on any food. PHYSICAL EXAMINATION General Examination The patient appears alert, conscious and well orientated to time and space. She was lying comfortably on the bed propped up with one pillow. There were no sign of pain respiratory distress. Hydrational and nutritional status was good. Vital Signs Pulse rate : 96 beats/minute, rhythm is regular, volume is normal and equal on both sides. Respiratory rate : 22 breaths/minute Temperature : 37 degree celcius Blood pressure : 128/82 mm Hg On examination of hand,hand was warm, no pallor, no palmar erythema, no koilonychias, no peripheral cynosis, no clubbing and capillary refilling time was less than 3 seconds. On examiation of eyes, there was no sign of jaundice on sclera, and no pallor on conjuctiva. On examination of nose, there were no discharge and no nasal polyps.

On examination of mouth, there were no glossitis, no angula stomatitis, no oral thrust, no dental caries and oral hygine was good. The tongue was moist and no central cynosis. On examination of neck, there were no thyroid swelling and no lymph node enlargement. On examination of leg, there were no ankle edema, no dilated veins and no calf tenderness. Abdominal Examination On inspection, abdomen was distended with gravid uterus evidenced by linea nigra and striae gravidarum. There were also striae albicans. Abdomen moves symmetrically with respiration. Umbilical was centrally located and inverted. There was longitudinal c-sec surgical scar for transverse lie on abdomen.The scar was well heal, no redness and no discharge. There also were no dilated veins and no visible fetal movement on that moment. On light palpation, abdomen was soft and non tender. There was no tenderness on c-sec scar. The symphysio-fundal height was at 33 cm which not correspond to the POA. The fundus was palpable one finger breath below xyphisternum. There were fullness of flank. The clinical fundal height was 37 weeks whisch is corresponding to the POA. On fundal grip, a firm, broad, and not ballotable mass was felt which suggestive fetal buttock. On lateral grip, a smooth, firm and continous structure were felt on maternal right side which suggestive fetal back and bulging, irregular knoby structures felt on maternal left side suggestive fetal limbs. On pelvic grip, a round, hard and ballotable structure felt which suggestive fetal head. In conclusion, it was singleton fetus, longitudinal lie, cephalic presentation. The head was 2/5th palpable above pelvic brim,so,fetus is already engaged. Liquor volume was adequate. Estimated fetal wight was 2.8 kg to 3 kg. On aiscultation, fetal heart sound can be heard with Pinnard. It was regular, good volume and heard on maternal right side. Fetal heart rate was 150 beats per minute. Systemic Examnation Review CVS S1 and S2 can be heard . There were no murmur and no added sound. Respiratory system Vesicuar breath sounds can be heard on both side of chest and no wheezing, no crackles and no abnormal sounds heard. CNS All are intact.

PROVISIONAL DIAGNOSIS The patient was in labour. LABOUR 1st Stage (Duration from the onset of labour to the full dilatation of the cervix : 3 hours 50 minutes) Vaginal examination wasdone an hour after admission and her cevical dilatation was 3 cm. The cervical effacement was 40-60% and soft in consistency. She was send into the labou room. Station of the fetus head was -2 and is in left occipital posterior position. Her bishops score was 8 as below: Dilatation Effacement Station Consistency Position 0 0 0-40 3 Firm Posterior 1 1 or 2 40-60 2 Medium Central 2 3 or 4 60-80 1 or 0 Soft Anterior Total 3 5 or more >80 Below

Membranes were felt but no placenta and cord felt. There was no moulding of fetal head. At the labour room, membranes was bulging so no artificial rupture of membrane was done. Fetal monitoring was done via cardiotocograph and progress of labour was recorded on a partogrph. Fetal heart rate was 134 beats per minute. Uterine contractions was 3 in 10 minutes lasting 20-30 seconds each contraction and increased to 4 in 10 minutes lasting 30-45 seconds each time as time elapsed. Oxytocin was not given as the patients uterine contraction was sufficient. The mother vital signs were also monitored. She was planned for four houry reviews. However, 2 hours later, the patient complained of the urge to bear down. Vaginal examination wasdone and the cervix was fuly dilated at 10 cm and fully effaced. Cervix was soft. No membrane, cord or placenta felt. Station of fetus head was +2 and was in the left occipital posterior position. Fetal heart rate was 120 beats per minute. Urinary catherization was done and delivery was anticipated. 2nd Stage (Duration from full dilatation of cervix to the birth of the baby : 13 minutes) The cervix was fully dilated at 10.50 am. Membrane also ruptured spontaneously. Clear liquor was demonstrated. Contractions were good with 4 in 10 minutes and patient was placed in dorsal recumbent position. I encourge her to push when contraction was felt. I positioned my hand at

the vaginal opening and upon crowning of the babys head, I applied light pressure with one hand on the babys head to guard f while it was delivered by extension and guarded the perineum with the other hand. After the head came out, restitution occurred and I proceeded to checked for any cord around the babys neck. The umbilical cord was loosely coiled around the babys nect and I uncoiled the cord before continuing to deliver the shoulders. As the head was being deliverd, there was gushing of hind water. The anterior shoulder was delivered first and then posterior shoulder. At 11.03 am on 20/10/2013, a baby girl was delivered. I proceeded with clamping her umbilical cord and cut it with a pair of umbilical cord scissor. The baby cried immediately and suction of the mouth and nasal cavity was done. After wrpping the baby in a sterile drape, she was brought to the mother for first skin-to-skin contact. Cord blood was taken for TSH and also G6PD test. 10 mg of oxytocin wasgiven intrmuscularly in the thigh to the mother within the first minute of delivery. Apgar score for the baby was 8 in 1st minute , 9 in the 5th minute and 9 in the 10th minute. Her birth weight was 2.5 kg, head circumfrence was 31cm and length was 48 cm.Vitamin K and Hepatitis B were also given. 3rd Stage (Duration from birth of the baby to the delivery of the placenta and membranes : 12 minutes) Following delivery of the baby, the placenta was delivered with signs of placental separation such as lengthening of the umbilical cord, gushing of blood and well contraction of the uterus. Delivery of placental was done through controlled cord traction wich involves traction on the umbilical cord, combined with counterpressure upwards on the uetine body by a hand placed immediately above the symphysis pubis. After complete expulsion of the placental, I examined the placental for the number of opening and examination revealed only one opening in the intact membrane and complete cotyledons in the maternal surface. There were 2 arteries and 1 vein on the fetal surface. The placental and its membrane was washed and returned to the mother. All bood clots were also removed. Total duration of labor was 4 hours 15 minutes. 4th Stage (Duration : 2 hours of monitoring) After delivery of placenta, the vagina was examined for any tear. There was a first degree tear and perineal repair was done through suturing from the apex of the wound by the staff nurse. There was no active bleeding and the uterus was well contracted. The mothers vital signs were stable and within the normal range. There was no rise in temperature and her urine output was normal. After 2 hours. The patient showed no signs of PPH or any other complication. She was sent to the postnatal ward for further monitoring and to recuperate.

SUMMARY Puan Mastura binti Abdul Rahman, a 35 years old Malay housewife, G3 P2, with LMP 30/01/2013 with EDD on 06/11/2013 at 37 weeks POA. She present with complained of contactions pain and show. Physical examination revealed that her blood pressure was normal and it was singleton pragnency. . The symphysio-fundal height was at 33 cm which not correspond to the POA. The fundus was palpable one finger breath below xyphisternum. There were fullness of flank. The clinical fundal height was 37 weeks whisch is corresponding to the POA. The fetus was in longitudinal lie, cephalic presentation. The head was 2/5th palpable above pelvic brim,so,fetus is already engaged. Liquor volume was adequate. Estimated fetal wight was 2.8 kg to 3 kg. Fetal heart sound was regular, good volume, and heard on back of the fetus which was on the maternal right side. A baby girl was delivered through spontaneous vaginal delivery at 11.03 am on 20/10/2013 with the first degree tear but there wereno complications during delivery for both fetal and maternal side. The mother and her baby were discharged 1 day later.

Name : Syamim Syuhada Sazali Student ID : 1000923062 Topic : Normal Labour