ACKNOLEDGEMENTS Successful completion of this case study is as a result of generous contributions and assistance of some individuals worthy mentioning.

I would like to express my heart felt appreciation to Rhoda Chatha for consenting to be the subject of this study. The difficulty of conducting this study was largely eased by her enthusiasm understanding and cooperation. I would like to extend my appreciation to !rs. "alilea the acting Chief #ursing $fficer and all labor ward staff at %omba Central &ospital for support and contributions that enabled me smoothly carry out this study. I would also like to acknowledge the contribution of !rs. 'amanga my clinical supervisor without whose guidance this study should not have been conducted. (astly but by no means the least I thank "od for the gift of life.

INTRODUCTION This paper presents a case study done on !rs. Rhoda Chatha )in this paper referred to as Rhoda* aged +, -ara +. She was admitted in the labour ward at %omba Central &ospital from home on +./0+/12 at around 00am with complaints of lower abdominal pain and backache. 3ssessment revealed that the foetus was presenting with breech and she was in active stage of labour. 3n informed consent was obtained for her to be the subject of my case study. She was monitored throughout labour. 3t 2pm a breech delivery of a live full term male infant was conducted. 4aby and mother were taken to post5natal ward where they were cared for for . days. $n +6/0+/12 mother and baby were discharged after meeting the discharge criteria.

SUBJECTIVE DATA PERSONAL PARTICULARS #ame7 Rhoda Chatha 3ge7 +,years &ome address7 Chid8aro village T/3 Chikowi %omba. $ccupation7 &ousewife Religion7 S.9.3. Tribe7 (omwe !arital status7 !arried :ducational level7 Standard 2 #ext of kin7 !alita 4andawe )mother* CHIEF COMPLAINT Rhoda reported in the labour ward from home with complaints of labour pains. She was experiencing lower abdominal pain and backache. She reported that she had been in pain since morning of +./0+/1,. MEDICAL HISTORY Rhoda stated that she had never suffered from any of the following disease7 Tuberculosis asthma diabetes mellitus epilepsy hypertension renal diseases heart disease or mental illness. SURGICAL HISTORY Rhoda had never been operated and had never been involved in any serious accident. FAMILY HISTORY She stated that there are no disease conditions that run in her family and there is no family history of multiple gestation. NUTRITIONAL HISTORY Rhoda was on a well balanced diet. &er +; hour dietary recall was composed of all the six food groups. She takes three main meals a day i.e. breakfast lunch and supper. She also snacks in between meals. She takes approximately + liters of fluids in a day. She did not experience any pica nor excessive salivation during the entire period of her pregnancy. She however experienced nausea and vomiting during the first three months of her pregnancy. In her culture there are no food restrictions for pregnant women. SOCIAL HISTORY She was the first wife to her first husband !r. Chatha whom she had been married to for 6years. She did her education up to standard 2 while her husband did his education up to form ;. The husband works as a sales man at a bakery. She is a house wife. The husband earns enough money to afford basic needs at home. She reported that she had been receiving enough social and financial

support from her husband and significant others during her pregnancy. She is in good relationship with her husband and significant others. 4oth Rhoda and her husband neither smoke nor drink. PSYCHOLOGICAL HISTORY Rhoda stated that the pregnancy was planned and they had both accepted it. They planned to be on family planning method after delivery so that they can prevent unplanned pregnancy. They also planned to have one more child. GYNAECOLOGICAL HISTORY She attained menarche at the age of 0;. She experiences regular menstrual cycles. She menstruates for . days. She has had no abortions before. She had been using depo provera since the birth of her first child until #ovember +11<. She has been on this method for + years. SEXUAL HISTORY She reported that she did not experience any sexual discomfort like dyspareunia during pregnancy. They stopped coitus at 2 months gestation because in their culture it is believed that coitus after 2 months causes wide fontanels. They are also expected to resume coitus six months after delivery. PREVIOUS OBSTETRIC HISTORY Rhoda was gravida + para0. &er first born is a girl whose delivery was spontaneous vertex. She was born in +116 at %omba Central &ospital and had weighed +,11g at birth. &er daughter was reported to be in good health. 9uring her antenatal period for her first pregnancy she did not experience any problems. #either did she experience any complications after delivery. PRESENT OBSTETRICAL HISTORY &er (ast #ormal !enstrual -eriod )(#!-* was 0./1./12 and her :stimated 9ate of 9elivery ):99* was +1/0+/12. &er gestation by dates was ;1 weeks. Since being pregnant she had not drained li=uor nor experienced any vaginal bleeding. She had been taking Iron tablets daily since the day she started attending antenatal clinic. She also took two doses of >ansidar. She also received two doses of Tetanus Toxoid ?accine. She had been attending antenatal clinic at %omba Central &ospital. She had been feeling fetal movements throughout pregnancy. She experienced nausea and vomiting during the first three months of pregnancy. She started experiencing labour pains in the morning of +./0+/12 around ; am.

OBJECTIVE DATA LABORATORY INVESTIGATIONS &I? test results came out negative during antenatal period. The test was repeated in labour ward and came out negative. &er haemoglobin test result was 00.2gm/dl antenatally. ?enereal disease research laboratory came out negative. @rinalysis revealed negative presence of albumin.

PHYSICAL EXAMINATION GENERAL APPEARANCE &ealthy looking lady of medium si8e with no obvious deformity of the pelvic area. She had poor gait probably due to labour pains. She was well kempt in body and clothes and was well nourished and hydrated. 4ody weight5,2 kg &eight5066 cm VITAL SIGNS Temperature5.< degrees Celsius -ulse rate5 ,2 beats per minute Respirations50, breaths per minute 4lood pressure50+1/21 mm/&g HEAD TO TOE ASSESSMENT HEAD -roportional to body si8e. Clean and well plaited hair. #o dandruff no scars no sores nor lacerations. NOSE Symmetrical in midline position wide and patent nostrils. #o purulent nor bloody discharge. EARS Symmetrical with no growths nor discharge. -re5auricular lymphnodes were non5palpable. EYES Symmetrical in si8e and shape with pink conjunctiva no discharges no opacities clear cornea and no lesions.

MOUTH (ips were of normal si8e and shape with pink colour and no cracks nor sores. &ad pink gums no gingivitis no dental caries. -ink and moist oral mucosa membranes. -ink and symmetrical tongue. #o oral thrush. NECK Symmetrical in shape. #o distended nor visible jugular veins. #on5palpable lymph nodes no swelling nor masses. #ormal thyroid gland. 3ble to turn head both sides. CHEST Symmetrical and barrel shaped. Symmetrical respiratory movements. #o abnormal breath sounds like crackles and creptations. BREASTS Symmetrical no visible masses no sores nor cracks on the nipple. -rominent and erectile nipple. #o palpable masses on the breasts. Colostrum expressed. UPPER EXTREMITIES Symmetrical capillary refill time was less than + seconds no palmar pallor no oedema of arms. LOWER EXTREMITIES Symmetrical with no varicose veins nor oedema. #o swelling nor tenderness of calf muscles. ABDOMEN Symmetrical and oval shaped. &ad linea nigra and striae gravidarum. #o hepato5 splenomegally. >undal height was .. cm which indicates .2 weeks gestation. The fundus was + fingers below xiphisternum. &ad longitudinal lie breech presentation and Right Sacro5anterior position. Aas experiencing . moderate contractions in 01 minutes. &er urinary bladder was empty and her fetal heart rate was 0.1 beats per minute. GENETALIA Vaginal Inspec i!n Clean with no sores no lacerations nor warts. It was non5oedematous had no varicose veins no bleeding no show and no abnormal vaginal discharge. Vaginal E"a#ina i!n Aarm and moist vagina thin cervix 011B cervical effacement and cervix was ; cm dilated. The presentation was breech and the presenting part was not well applied to the cervix. !embranes were intact and cord was not felt.

Pel$ic Assess#en Shape of brim could not be followed sacrum was curved sacro promontory was not tipped sacrospinous ligaments were flexible and ischial spines were not prominent. Sub5pubic arch was more than C1 degrees and intertuberous diameter could admit ; knuckles. IMPRESSION 3 high risk multi5gravida with breech presentation in active stage of labour NURSING DIAGNOSES &igh risk for haemorrhage related to maternal soft tissue injury secondary to delivery manouvres. 3ltered comfort pain related to uterine contractions and malpresentations manifested by patientDs own verbalisation and strained facial expressions. &igh risk for altered fluid balance and nutrition related to hyperventilation slowed digestive function and emptying time of the stomach and reduced food intake. &igh risk for infection related to possible increased number of vaginal examinations during labour and early rupture of membranes. Ineffective individual coping anxiety related to labouring in an unfamiliar environment knowledge deficit on labour and delivery process and outcome of breech presentation &igh risk for fetal hypoxia related to compression of the placenta during uterine contractions compression of the cord during delivery of the trunk and inade=uate food in take by the mother

PROGRESS NOTES %&'(%')* 00am ?ital signs7 Temperature5 .,.; degrees Celsius -ulse rate5 ,, beats/minute 4/-50+1/<1 mm&g Respirations5 0, breaths/minute Abdominal assessment >undus E .2 weeks -resentation 5 breech -osition 5 RS3 (ie 5 longitudinal Contractions E . moderate in 01 minutes >etal &eart Rate E 0.+ beats per minute @rinary bladder E empty Vaginal inspection Clean and dry #o warts no sores no lacerations #o bloody discharge Show not seen Vaginal examination Aarm and moist tissues Thin cervix 011B effaced and ;cm dilated -resenting part not well applied to the cervix Intact membranes Cord not felt 00701 am Rhoda was oriented to labour ward. She was also reassured that she will not be left alone throughout all the stages of labour. She was also taught relaxation techni=ues to make her relax and maintain ade=uate supply of oxygen to the fetus. She was advised to always lie in lateral position unless advised otherwise to prevent compression of inferior vena cava and aorta which can compromise supply of oxygen to the fetus. 3n intravenous infusion of 6 B dextrose was commenced at 06 drops per minute in order to promote ade=uate hydration status.

007.1 am >etal &eart Rate was 0.1 beats per minute Rhoda was taught relaxation techni=ues like deep breathing. 0+ noon 3ssessments Temperature7 .< degrees Celsius. -ulse7 ,< beats per minute Respirations7 0C 4eats per minute 4/-70+1/21 mm&g >etal &eart Rate0+2 beats per minute. . moderate contractions in 01 minutes. @rinary bladder was empty 0+706 pm Rhoda complained of severe lower abdominal pain and severe backache. Rhoda was observed bearing down prematurely. She was discouraged from bearing down. -ethidine 011mg was administered after assessment of vital signs which were stable and were as follows7 Temperature7 .< degrees Celsius -ulse7 ,< beats per minute Respirations7 02 4eats per minute 4/-70+1/21 mm&g >etal heart rate was checked as well and was 0.1 beats per minute. -ethidine 011mg was given intramuscularly. 0+7.1 pm >etal heart rate was 0.6 beats per minute 0pm 3ssessments Rhoda reported reduction in pain. -ulse rate7 <1 beats per minute 4/-7 0+1/21 mm&g >etal heart rate7 0.2 beats /minute . moderate contractions in 01 minutes Rhoda was encouraged to ask =uestions and air out concerns. &er lips were moistened with ?aseline to prevent excessive drying. 4ack rubs were provided to reduce pain.

0706 pm Rhoda went to the toilet to urinate and she reported to have managed to urinate. @pon return from the toilet she was taught and advised to do pelvic rocking exercises to promote descent of the presenting part. 07.1 pm >etal heart rate was 0.1 beats per minute !other took porridge. + pm Assessments Temperature7 .< degrees celcius -ulse rate7 ,, beats/minute Respirations7 02 breaths/minute 4/-7 001/21mm&g >etal heart rate70;1 beats per minute Contractions7 ; moderate in 01 minutes 4ladder7 empty Vaginal examination Aarm and moist vagina Thin cervix 011B effaced and < cm dilated -resenting part poorly applied to the cervix !embranes intact and cord not felt. Show was seen which was not blood stained. The findings were communicated to the client. Rhoda was advised to change positions fre=uently to release tension. +706 pm Rhoda was advised to get off the bed and perform pelvic rocking exercises. +7.1 pm >etal heart rate was 0., beats/minute She was encouraged to fre=uently ambulate and empty her bladder. . pm >etal heart rate was 0.2 beats per minute. -ulse rate7 ,; beats per minute Respirations7 02 breaths/minute 4/-7001/21 mm/&g She was experiencing . strong contractions in 01 minutes >indings were communicated to the client. .7.1 pm >etal heart rate was 0+2 beats per minute &er mother brought porridge which the patient took.

10

She was given a bedpan to urinate in. She urinated about 011mls. She was advised not to bear down unless advised to do so when cervix is 01cm dilated. ; pm Assessment -ulse7 ,, beats/minute Respirations7 +1 breaths/minute 4/-7001/21mm&g >etal heart rate7 0+, beats per minute Contractions7 . strong in 01 minutes &er urinary bladder was empty. ;7.1 pm >etal heart rate was 0.; beats per minute 4ack rubs were provided to minimi8e pain. 6 pm !embranes ruptured spontaneously. (i=uor was meconium stained. 3 vaginal examination was done. The cervix was C cm dilated. Cord was not felt and the presenting part was not well applied to the cervix. It was a complete breech. >etal heart rate was 0.. beats / minute. Temperature7.< degrees Celsius -ulse rate7 ,< beats per minute Respirations7+1 breaths per minute 4/-50+1/21 mm&g She was told of the findings. 67+1 pm. 3 delivery trolley was prepared with the following e=uipments7 delivery pack suturing pack lignocane. Resuscitaire was also prepared in readiness for an asphyxiated baby 67.1 pm >etal heart rate was 0;1 beats per minute 3 urinary catheter was inserted and 011ml of urine was drained to ensure that the bladder was empty.

11

, pm Assessment >etal heart rate7 0;1 beats / minute. -ulse rate7 <. beats per minute Respirations7 +1 breaths per minute 4/-7 0+1/21 mm/&g Contractions7 . strong in ten minutes. >indings were communicated to the mother. SECOND STAGE OF LABOUR VAGINAL EXAMINATION Aarm and moist vaginal tissues Cervix thin 011B effaced and 01 cm dilated >our fingers inserted into the vagina to confirm cervical dilatation. Cord was not felt and the presenting part was not well applied to the cervix. -resenting part was below the ischial spines (i=uor was meconium stained. Rhoda was informed that she was in second stage of labour but was advised not to start bearing down unless advised to do so i.e. when the presenting part becomes visible at the vulva. !other was instructed to continue deep breathing. Ahen the presenting part became visible on the vulva she was assisted to assume supine position with her buttocks on the edge of the bed legs flexed and knees abducted. She was instructed to bear down only with a contraction >etal heart rate was checked and there was no sign of fetal distress. 4uttocks and genitalia together with two feet appeared on the vulva. Rhoda was encouraged to continue pushing. 4uttocks and the legs were born. 3t ,7+6pm when umbilicus appeared on the vulva Rhoda was instructed to stop bearing down. The loop of the cord was gently pulled down to loosen it. -ulsations on the cord were felt to be regular and strong at 0.; beats per minute. Two fingers were inserted in the vagina. :lbows were not present on the babyDs chest but the axilla was felt. The arms were extended. The baby was covered with a warm cloth. 4oth thumbs were placed on the sacrum while the fingers were placed in front of ileac crest. The woman was instructed to push with a contraction. Aith a contraction and the woman bearing down the body was rotated at an angle of 021 degrees keeping the back upper most in order to bring the shoulder which was more posterior to become more anterior and it was lying under the symphysis pubis. The index and third fingers were placed over the shoulderF the upper arm was splinted flexed and then brought down across the babyDs face and chest. Then the babyDs body was rotated back 021 degreesF keeping the back upper most in order to bring the shoulder that was more posterior to become more anterior until the shoulder was lying under the symphysis pubis. The index and third fingers of the hand facing the babyDs back were placed over the shoulder. Then the upper arm was splinted and flexed and brought down across the babyDs face and chest.

12

,7+2 pm The body of the baby was left to hang downwards with the head inside the pelvis. Then the nape of the neck appeared under the pubic arc. &ands were kept near the babyDs pelvis to prevent the baby from falling down. The babyDs feet were firmly grasped with the right hand exerting firm downward then outward and upward traction. Ahen the mouth and the nose were free from the perineum the airway was gently cleared of secretions. The woman was instructed to continue breathing deeply until the vault of head was delivered slowly and the body was drawn upward over the maternal pelvis with the left hand guarding the perineum to prevent the head from emerging too =uickly. The head was delivered at ,7.1 pm. The baby was =uickly taken to the resuscitaire where it was suctioned and bagging was done. The baby cried strongly ;6 seconds after birth. The babyDs apgar score was C/01 then 01/01. THIRD STAGE O+ LABOUR 01 units of pitocin was administered intramuscularly to promote uterine contractions and the placenta was delivered , minutes later at ,7.,pm by controlled cord traction. Clots were expelled. @pon examination of the perineum the cervix was intact but she sustained a first degree perineum tear. The mother was cleaned up and wet linen was replaced with dry linen in readiness for suturing. 4lood pressure immediately after delivery was 001/21mm&g and pulse rate was ,< beats per minute. -lacenta and membranes were complete weighed 661g and it was a healthy placenta. The cord was 61cm long and had . blood vessels. 4lood loss was about 021 ml. 3 tampon was inserted into the vagina to absorb blood. -erineal tear was cleaned with chlorhexidine prior to injection of 01ml of 0B lignocaine on both edges of the tear. Then the tear was sutured with chromic +51 in two layers and chlorhexidine was also used to clean the sutured tear to prevent infection. +OURTH STAGE O+ LABOUR <7.1 pm 4lood pressure was 001/21mm&g pulse rate was ,, beats per minute Temperature was .,., degrees Celsius uterus was in midline position firm and well contracted and there was moderate flow of lochia. Intravenous infusion was stopped and drip was removed. Rhoda was then instructed to take a bath and wash her cloths. IMPRESSION 3 low risk mother one hour post delivery adapting well to non5gravid state. MIDWIFERY DIAGNOSIS &igh risk for haemorrhage related to exposed blood vessels at placental site. &igh risk for infection related to exposed tissues on the sutured perineal area.

13

PLAN OF CARE :ncourage Rhoda to breastfeed every + hours to stimulate oxytocin production which promotes uterine contractions :ncourage the client to urinate fre=uently because a full bladder interferes with uterine contractions. 3dvise the client to lie in supine position with legs crossed. This position promotes uterine contractions. 3dvise the client to report excessive flow of lochia because this can be a sign of active bleeding Check blood pressure and pulse rate every ; hours because increased pulse rate and decreased blood pressure is suggestive of bleeding. 3dvise the client to do sit8 bath at least three times a day. 3dvise the client to change perineal pads fre=uently because a moist pad is a conducive environment for microbial growth. INITIAL ASSESSMENT OF THE BABY Temperature7 .,.2 degrees Celsius General appearance 3ctive alert and normal muscle tone pink skin colour no apparent injury nor abnormality. #o cyanosis no palmar pallor no jaundice. Slight vernix caseosa and lanugo on the face. Head :ven bones slightly movable at sutures open flat and soft fontanelles. #o moulding nor caput. Intact scalp and good scalp growth no bruising no abrasions no cuts no lacerations. &ead circumference was .;cm. Eyes Symmetrical normal si8e and shape correct placement no sub5conjunctival hemorrhage seen. #o discharge nor corneal ulceration bright and shinny cornea white sclera. Nose In midline position flattish wide and patent. #o bloody nor purulent discharge no nasal flaring. Mout Symmetrical and pink lips of normal si8e and shape pink tongue and gums. #o gingivitis no cleft palate no false teeth. -ink moist and shinny mucus membrane.

14

Ears Symmetrical no extra auricles well formed ears upper ear in line with outer corner of the eye. #o foreign body or discharge. Aell formed auricles. Nec! Short symmetrical with skin folds no webbing. &ead in midline position no masses present some head control of side to side movement seen plus extension and flexion. #either swelling nor creptus sound found on examination. " est 4arrel shaped chest prominent end of xiphisternum symmetrical respiratory chest movement no chest in5drawings no rib recession no involvement of abdominal muscles during breathing. #o abnormal breath sounds on auscultation. ;< breaths per minute regular heart beat. -alpable breast nodules. Abdomen Symmetrical no organomegally no tenderness non5distended abdomen bowel sounds present. Clean and moist umbilicus. (iver and spleen non5palpable. Two arteries and one vein present on the umbilical cord no bleeding on the umbilicus. #pper extremities Symmetrical full range of motion exercises well formed hands no extra digits no webbed fingers well formed palmar creases no fracture of long bones. Lo$er extremities Symmetrical semi5flexed hips and legs. >ull range of motion exercises including abduction. #ormal si8e of long bones. >emoral pulse felt. Aell developed plantar creases. #o extra digits no webbed feet no clubbed feet no talipes. $rtolanDs test was negative ie no congenital hip dislocation. Genetalia Aell developed testes palpable in a sac. -atent urethral opening at center of glans penis correctly positioned. The baby had passed meconium already. %ac! and spine Straight easily flexed no spinal bifida nor meningocelle nor sacral dimple sinus. Neurological assessment !oro reflex present5 gave a startled response by flinging out arms Rooting and suckling reflex was present7 when infantDs cheek corner of the mouth was touched infant turned head towards stimulus and opened the mouth. Swallowing reflex was present7 sucking was coordinated with swallowing with no gagging coughing or vomiting. "rasp reflex was present7 baby firmly grasped tip of the finger -lantar5 toes curled downwards when finger was placed at the base of the toes.

15

Aalking reflex was present 5 infant stimulated walking by lifting and placing one foot in front of the other. The baby weighed .011g. IMPRESSION 3 low risk infant one hour post delivery adapting well to extra5uterine life. NURSING DIAGNOSIS &igh risk for hypothermia related to exposure to cold environments &igh risk for hypoglycemia related to inade=uate intake &igh risk alteration in bonding related to fatigue

PLAN OF CARE 'eep the baby thoroughly dried and covered with a warm dry cloth -revent the baby from being in contact with cold surfaces -ost5pone bathing for the first +;hours. :ncourage the mother to breastfeed the baby every + hours. 3dvise the mother to watch the babyDs umbilicus for bleeding. !onitor body weight daily. Cover the babyDs head with a hat. :ncourage the mother to cuddle the baby while breastfeeding to promote bonding through touch. :ncourage mother to maintain eye contact while breastfeeding. :ncourage the mother to talk to the baby while breastfeeding to promote bonding. 2 pm Rhoda and her baby were taken to postnatal ward where she was given a bed. 4aby was wrapped in a clean and dry cloth and the mother was advised to keep the baby always warm and to immediately change soiled linen. 4abyDs head was covered with a hat. !other was advised to breastfeed the baby every + hours. !other was advised to maintain eye contact and talk to the baby when breastfeeding to promote bonding. !other advised to empty the bladder fre=uently to promote uterine contractions !other advised to lie in supine position with legs crossed to promote uterine contractions. She was advised to report excessive flow of lochia She was advised to clean the sutured area with warm salty water to prevent infection. She was advised to change perineal pads fre=uently. She was also encouraged to ask =uestions and express her concerns. 27.1 pm Rhoda and her baby were handed over to night duty staff.

16

DAY 2

24/12/08

M !"#$%& '&&#&&(#)! S,-.ec i$e /a a Rhoda reported that she had spent the night well. She said that she was still having some mild abdominal pain especially when breastfeeding. She reported that she had been breastfeeding throughout the night every + hours and the baby was sucking well. She had taken porridge and tea and was not having any problems with eating. She reported that she had already taken a bath in the morning and had changed the perineal pad. She reported that she was not having heavy lochia. She reported that she had passed stools and urine in the morning She also reported that she was experiencing mild pain in the genitalia due to the sutured tear but the wound was not bleeding. She also reported that the baby had passed stools early in the morning. O-.ec i$e /a a Aell kempt in body and clothes. ?ital signs7 Temperature7.<.+ degrees Celsius pulse rate7 <0 beats per minute respirations702 breaths per minute 4/-7001/<1mm/&g -ink conjunctiva #on5oedematous upper extremities capillary refill time within + seconds #on5engorged breasts colostrum expressed. @terus was 0, cm from the symphysis pubis. It was in midline position firm and well contracted. @rinary bladder was empty. #on5oedematous lower extremities non tender calf muscles no varicose veins no deep vein thrombosis. The genitalia was clean perineal pad slightly soaked no blood clots no offensive smell no blood nor pus on the sutured tear no oedema and normal wound healing process. I#p0essi!n 3 low risk mother +; hours post delivery adapting well post5nataly. Assess#en &igh risk for haemorrhage related to raw placental site 3ltered comfort pain related to uterine contractions )after pains* presence of sutured tear as evidenced by verbali8ation. &igh risk for infection related to presence of tear in the perineum.

17

Plan :ncourage mother to empty bladder fre=uently to promote uterine contractions. :ncourage mother to continue breastfeeding every two hours to promote production of oxytocin that promotes uterine involution. Check the perineal pad every ; hours to assess amount of lochia. Check blood pressure and pulse rate every ; hours. Reassure mother that abdominal pain during breastfeeding is due to uterine contractions secondary to oxytocin production and that pain will subside with time. 3dminister -alacetamol0g every 2 hours orally to reduce pain :ncourage deep breathing and relaxation techni=ues 3dvise the mother be on high fiber diet to promote digestion and minimi8e straining during defecation that aggravates pain. 3dvise the woman to also be on high protein diet to promote wound healing 3dvise the woman to change perineal pads fre=uently because moist perineal pad is a conducive environment for microbial infection :ncourage the woman to ambulate in order to promote drainage of lochia thus reducing the risk of infection. 3dvise the woman to have sit8 bath in salty water to prevent infection. Teach the client to clean the perineum from front to back to avoid introducing microbes on the perineum which can cause infection. :ncourage the mother to follow hand washing techni=ue and observe all infection prevention measures. BABY%S ASSESSMENT Temperature7 .,.< degrees Celsius General appearance 3ctive alert and normal muscle tone pink skin colour. #o cyanosis no palmar pallor nor jaundice. Head #o sunken nor bulging fontanelles. #o bruising no abrasions no cuts no lacerations. Nose #o nasal flaring patent nostrils with no secretions. Mout -ink lips with no sores and no cracks pink and moist oral mucosa no oral thrush nor gingivitis. " est Symmetrical respiratory chest movement no chest in5drawings .; breaths per minute and heart beat was 0+. beats per minute.

18

Abdomen Symmetrical no umbilical hernia no organomegally dry umbilicus. Neurological assessment #o convulsions no abnormal cry no signs of cerebral irritation. 4abyDs body weight was +C61g I(*$#&&+ ) 3 low risk baby +; hours post5delivery adapting well to extra5uterine life IMPLEMENTATION C711 am 3dministered 0g of oral palacetamol to mother. !other taught on importance of emptying the urinary bladder. !other taught on importance of breastfeeding fre=uently for the first . days because colostrum contains antibodies that protect the baby from infections. !other reassured that abdominal pains will go with time and she should continue breastfeeding despite abdominal pains. 01711 am !other was taught on proper positioning and proper breast attachment during breastfeeding !other was reminded to keep the baby warm and change the nappies whenever they get wet. !other encouraged to cuddle the baby and to maintain eye contact during breastfeeding in order to promote bonding. 4abyDs umbilicus was cleaned with surgical spirit and the mother was taught on how to clean babyDs umbilicus. !other was advised to watch the umbilicus for bleeding or any signs of infection and report immediately. 4abyDs head was covered with a hat. 017.1 am 4aby was given 4C" vaccine and -olio 1 vaccine to protect the baby from Tuberculosis and poliomyelitis respectively. The mother was advised not to rub the injection site on the right hand to prevent reducing the potency of the vaccine. She was also advised to wait for .1 minutes before breastfeeding the baby to prevent vomiting because -olio 1 vaccine causes nausea. 00am ?ital signs for the mother were as follows7 Temperature7.,.2 degrees Celsius pulserate7,2 beats per minute respirations702 breaths per minute 4/-7001/<1 mm&g ?ital signs for the baby were as follows7 Temperature7 .,.2 degrees Celsius respirations7 ;1 breaths per minute heart beat7 011 beats per minute

19

!other was advised to always clean perineum from front to back. !other was advised to be taking at least . liters of oral fluids in +; hours. !other was encouraged to take foods high in fiber content to prevent constipation which can aggravate pain due to straining when defecating. 0 pm !other observed changing the nappies. She was taught to prevent umbilical cord from coming in contact with urine and stools to prevent introducing infection on the umbilicus. !other was encouraged to ambulate to promote drainage of lochia 07.1 pm !other was given health education on family planning. 9ifferent methods of family planning their advantages and side effects were discussed. She was advised to start family planning , weeks after delivery. She was advised not to fall pregnant in a period of less than + years so that she can have enough time to take care of the baby and also allow the body to fully return to pre5pregnancy form. She was also taught that coitus can resume ,months after delivery. +7.1 pm !other was taught on six food groups. &ealth education on the importance of exclusive breastfeeding was given !other was also educated importance ade=uate rest. .711 pm !otherDs vital signs were as follows7 Temperature7.<.0 degrees Celsius pulse rate7<+ beats per minute respirations7+1 breaths per minute 4/-7001/<1mm/&g. 4abyDs vital signs were as follows7 Temperature7 .< degrees Celsius respirations7 .2 breaths per minute &eart beat7011 beats per minute. .7.1 pm !other and baby were observed sleeping. ;7.1 pm -erineal pad was checked and was slightly soaked. !other was observed breastfeeding. The baby was well positioned and well attached to breast and was suckling well. 6711 pm !other and baby were handed over to night duty staff.

20

DAY , 23!

2-/12/08

S,-.ec i$e /a a Rhoda stated that she and the baby spent the night well. The baby had been sucking well during the night. She reported that she had already taken a bath and had cleaned the sutured perineal tear with warm salty water and she was experiencing mild flow of lochia. She was able to pass urine and stools and she was no longer experiencing abdominal pain nor pain on the sutured tear. She also reported that the baby had passed stools as well O-.ec i$e /a a Mot er Aell kempt in body and clothes. ?ital signs7 Temperature7.<.+ degrees Celsius pulse rate7 <+ beats per minute respirations70C breaths per minute 4/-5001/<1mm&g -ink conjunctiva #on5oedematous upper extremities capillary refill time within + seconds #o breast engorgement no masses felt colostrum expressed. @terus in midline position 06 cm from the symphysis pubis firm and well contracted uterus. @rinary bladder was empty. #on5oedematous lower extremities non5tender calf muscles no varicose veins no deep vein thrombosis. Clean genetalia perineal pad mildly soaked no blood clots no offensive smell non5oedematous perineum normal healing process of the sutured perineal tear. I#p0essi!n 3 low risk mother ;2 hours post delivery adapting well to non5gravid state %aby "eneral appearance -ink skin alert and active. ?ital signs7 Temperature7.,.+ degrees Celsius respirations7.+ breaths per minute &eart rate70+1 beats per minute body weight7+C11g. &ead Symmetrical no sunken nor bulging fontanelles. Intact scalp and good scalp growth no bruising no abrasions no cuts no lacerations. &ead circumference was .6cm. #ose #o nasal flaring patent nostrils with no secretions.

21

!outh -ink lips with no sores nor cracks. -ink and moist oral mucosa with no oral thrush nor gingivitis. Chest Symmetrical respiratory chest movement no chest in5drawings .; breaths per minute and heart beat was 0+; beats per minute. 3bdomen Symmetrical no umbilical hernia no organomegally dry umbilicus and no omphalitis. #o abdominal distension. #eurological assessment #o convulsions no abnormal cry no signs of cerebral irritation. I#p0essi!n 3 low risk baby ;2 hours post5delivery adjusting well to extra5uterine life. P.') 3s per care plan. 27.1 am The umbilical stump was cleaned with surgical spirit and the mother was asked to do a return demonstration. She cleaned the umbilicus correctly. She was reminded to prevent the umbilical area from coming in contact with urine and stools. She was also warned on the dangers of adding anything on the umbilicus. She was further reminded on the importance of keeping the baby warm. C7.1 am !other was advised to continue cleaning the sutured tear with warm salty water after being discharged home till the wound heals. She was counseled on the dangers of inserting traditional herbs into the vagina The mother was reminded on the importance of ade=uate rest. The mother was taught on the importance of eating the six food groups and she was taught on the importance of breastfeeding the baby exclusively

01711 am Rhoda was reminded about exclusive breast feeding. She was also reminded to allow the baby to suckle empty the breast before given the other breast to prevent breast engorgement. She was also advised to keep her breasts clean all the time.

22

017+1am !other was advised to report to the hospital immediately if she experiences any of the following danger signs7 severe headache not relieved with analgesics heavy lochial flow foul smelling vaginal discharge blurred vision convulsions fever pus or bloody discharge on the sutured perineal tear. She was also advised to report to the hospital immediately if the baby experiences any of the following danger signs7 fever laboured breathing refusing to breastfeed distended abdomen and inability to pass stools convulsions and purulent or bloody discharge on the umbilicus. 01761 am She was advised to report back at the hospital after one week for check5up. She was further advised to report again at the hospital after six weeks for post5 natal check up family planning and for babyDs immuni8ation. 00711am Rhoda was discharged after health education as per home. &ealth education as per discharge plan.

23

DISCHARGE CRITERIA MOTHER #ormal vital signs. !ild lochial flow with non offensive smell. #o pus no bloody discharge from the sutured perineal tear. #o breast engorgement easily expressed colostrum. >irm and well contracted uterus in mid line position. -roper positioning and good attachment to the breast 3bility to describe the six food groups 3bility to explain the danger signs for the mother and the baby. 3bility to mention the next appointment date. BABY #ormal vital signs. 4ody temperature of less than .<.+ degrees Celsius #o labored breathing absence of chest in5drawings respiratory rate of less than ,1 breaths per minute. #o convulsions no abnormal cry nor any signs of cerebral irritation. #o pus or bloody discharge on the umbilicus 3blility to suckle without any problems

DISCHARGE PLAN "ive health education on the following topics7 Six food groups. >amily planning. :xclusive breastfeeding. -ersonal body hygiene. Importance of ade=uate rest.. 9anger signs in post5natal mother and baby. -erineal care. &ealthy sexual practices 9iscourage harmful traditional practices and encourage beneficial ones.

24

CASE ANALYSIS 4ased on data collected and care rendered to Rhoda the following are the pertinent issues. 3t age +, Rhoda fell in a group of women with the lowest obstetric risk as far as age is concerned )Safe !otherhood +111*. Aith height of 066 cm Rhoda was above an average height of 061cm thus a normal vaginal delivery was anticipated. There is an association between maternal height and delivery outcome. Aomen with short stature have an increased risk of cephalo5pelvic disproportion due to short pelvic diameter. $n social history she said she was the first and only wife to her first husband who was working and was giving her ade=uate financial and emotional support. This is good because a pregnant woman needs ade=uate support from spouse for her to effectively cope with pregnancy. She also stated that with the money earned by her husband they are able to buy basic essential needs like food and clothes hence fostering motherDs health and proper development of the foetus. She did her school up to standard eight thus her level of understanding was low hence the need for comprehensive health education. She was a member of Seventh 9ay 3dventist church hence needed guidance on alternatives to pork and some types of fish they are not allowed to take. She was a house wife hence needed advice on how she could start a business so that she can eventually become independent financially and be able to support herself and her family. 4oth do not smoke nor drink alcoholic beverages. This is good for wellbeing of mother and foetus. #icotine a substance found in tobacco causes interference with oxygen exchange in lung alveoli resulting in reduction of oxygen in circulating blood. 3lcohol reduces appetite thus leading to malnutrition in the mother which may lead to fetal growth retardation. Rhoda did not suffer from any hereditary diseases and no close relative she knew ever suffered from hereditary diseases such as diabetes hypertension mental illness epilepsy etc. She however said that was Rhoda weighed ,0kg on initial visit to antenatal clinic. Aeight indicates maternal nutritional status. Aith a height of 066cm Rhoda had a normal weight for height ratio. 3ccording to !yles )+11;* pregnant women are supposed to gain 1.6kg weekly from +1 weeks gestation. $n initial visit she weighed ,0 kg and on second visit she weighed ,. kg. Aeight gain of + kg is normal and expected in the second trimester. 9uring her third visit she weighed ,6 kg and on the fourth

25

visit she weighed ,< kg. !aternal weight gain indicates fetal growthF thus RhodaDs baby was growing normally. She had a haemoglobin level of 00.2g/dl. This indicates that she was not anemic. 3ccording to Safe !otherhood )+111* anaemia in !alawi is defined as haemoglobin level of less than 01g/dl. In pregnancy there is an increased demand for oxygen due to increased demand by the growing fetus. She tested negative for proteinuria. -roteinuria in pregnancy indicates pregnancy induced hypertension pre5eclampsia and renal failure. She was also tested for ?enereal 9isease Research (aboratory Test. This is a test conducted to diagnose syphilis in clientDs blood. The results came out negative meaning that she did not have syphilis. Syphilis can cause intra5uterine death of foetus or congenital abnormalities hence the need for the test and treatment. She tested negative for &I?. &I? can be transmitted to the fetus intrauterine at birth or through breast milk hence the need to single out infected mothers and giving them drugs that reduce the chance of &I? transmission to the foetus. She also tested negative for gluconuria meaning she did not have diabetes which is associated with macrosomia which interferes with normal delivery. She was given >ansidar . tablets as a prophylaxis for malaria in the second and third trimester to prevent the mother and the fetus from malaria. !alaria resistance is reduced during pregnancy )!yles +11.*. #eonates born with congenital malaria are well at birth but develop fever jaundice and splenomegally within 015+1 days of birth )!ayes +11;*. Iron tablets +11mg orally once a day was given to Rhoda for one month throughout antenatal period. Iron tablets improve haemoglobin hence preventing anaemia. Tetanus Toxoid vaccine was given on initial antenatal visit and one month later in order to prevent the mother and the fetus from tetanus. 3ssessment on admission confirmed breech presentation. 3ccording to Sellers )+110* there are no known causes of breech presentation. &owever the following factors favour breech presentation7 preterm babies multiple pregnancy polyhydramnios grand multiparty contracted pelvis placenta praevia bicornuate uterus hydrocephalus and anencephaly. >rom both subjective and objective data no predisposing factor was identified. @ltra Sound Scanning was re=uired to rule out some of the pre5disposing factors but it was not done ante5natally.

26

There was normal progress of labour indicated by progress of contractions from mild to strong. >etal heart rate remained within the normal ranges indicating that there was no fetal distress. !econium stained li=uor is normal in breech presentation and does not indicate fetal distress )Sellers +110*. 3s the breech descends into the pelvis meconium is forced out of the colon and anus. !embranes ruptured spontaneously at 6pm. 3 vaginal examination was done to assess for cord prolapse which was ruled out. 3n hour later she delivered ruling out need for antibiotics which are indicated when membranes have ruptured for more than +; hours before delivery )!yles +11.*. Ahen the loop of the cord appeared she was discouraged from pushing and the loop was gently pulled down and loosened and strong pulsations were present. (oosening of the cord prevents tension on the cord that can block blood supply to the fetus. Time was noted when loop of the cord appeared and delivery of the baby. There was 6 minute interval. $nly < to 01 minutes is re=uired before delivery if the baby is to survive because once the fetal head enters the maternal pelvis blood supply is cut from the fetus )Sellers +11.*. :xtended arms were delivered using (ovsetDs manouvre to prevent severe perineal tears and trauma to the fetus. The head was delivered using 4urnDs !arshall !anouvre because it was flexed. 3fter delivery the mother was examined for any tears. She sustained first degree perineal tear which was sutured using chromic +51 suture with prior administration of 0B lignocaine. The babyDs birth weight was .011g. This was within the normal range of +611g to .211g and was an indication that the baby was mature )4ennet G 4rown0CCC*. $n discharged at age of .days the baby weighed +C11g. Aeight loss during the first . days of life of up to 01B is normal. Aeight is regained by age 01 days. Aeight loss is due to inade=uate breast milk in early days passing out of meconium and insensible water loss. Aeight is regained later because production of breast milk becomes well established by day . after delivery. The baby was also examined for trauma. There was no apparent injury. +;5;2 hours post5delivery the baby had been having a normal cry no convulsions and did not develop jaundice. This was an indication that the baby did not sustain any injury during birth and was adapting well with extra5uterine life. 4C" and polio 1 vaccines were administered to the baby before discharge.

27

CONCLUSION &er labour lasted for a normal period i.e. about 06 hours. (abour exceeding +;hours is classified as prolonged labour. The fetus did not distress throughout labour and delivery as indicated by a normal fetal heart rate. @terine contractions progressed well. !otherDs vital signs remained within normal ranges throughout labour delivery and post5natal periods. 9elivery was conducted within recommended time and appropriate manouvres were used. Rhoda adapted very well postnatally and her baby also adapted well with extra5uterine life.

PERSONAL IMPRESSION Rhoda did not experience any significant problems during antenatal labour delivery and post5natal periods. 3 good client5care provider rapport was established and maintained throughout her hospital stay. She was well assessed monitored and taken care of during her entire hospital stay. I strongly feel that success of her pregnancy out come was as a result of individuali8ed care I provided and support I got from other midwives and other health care providers who continued providing individuali8ed care to Rhoda in my absence. RECOMMENDATIONS It is recommended that haemoglobin test should be done more than once to ensure anaemia is isolated and treated throughout pregnancy period. It is also recommended that albenda8ole should be given to all women attending antenatal clinic to prevent anaemia that come as a result of worm infestation. It is also recommended that all pregnant women should undergo ultrasound scanning antenatally to isolate any problems with the fetus. CHALLENGES AND LIMITATIONS (imitation of resources e.g. sterile packs for cleaning cord basins to demonstrate bathing of the baby posed a big challenge to care implementation. There was no auditory privacy because a number of clients were being examined in the same room at the same time with only covering of screens.

28

Rhoda was counseled alone on all topics because her husband was always at work. LESSONS LEARNT !ultiparas women should not be taken for granted that they know a lot about delivery and child care. They need to be taught as much as primigravidas. -sychological preparation of the mother is very important as it is the basis for cooperation. Comprehensive handover ensures continuity of individuali8ed care provision on patient.

29

REFERENCES 0. 4ennet ?.R and 4rown (.' )0CCC* M/.#& !#0!1 :dition* :dinburgh Churchill (ivingstone 2 3 $ (+45+6#&. )0.th

+. 4urroughs 3 )0CC<* M'!#$)+!/ )7$&+)89 A) +)!$ 47:! $/ !#0!; )<th edition* -hiladelphia A4 Saunders company. .. >raser 9! Cooper !.3. )+11;* M/.#& T#0!1 :dition* :dinburgh Churchill (ivingstone. 2 3 $ M+45+6#& )0;th

;. !inistry of &ealth )+111* O1&!#!$+: L+3# &2+.. T$'+)+)8 M')7'. 3 $ M'.'5+<S'3# M !"#$" 4 *$ 8$'(= 6. !inistry of &ealth )+111* C ):#*!& 3 A)!#)'!'. C'$# ')4 F :7&#4 A)!#)'!'. C'$# ,. $lds S.4. (ondon !.(. G (adewig -.3. )0CCC* M'!#$)'. )#51 $) )7$&+)89 A 3'(+./ ')4 : ((7)+!/ 1'&#4 '**$ ':"= ),th edition* (ondon -retince &all. <. Sellers -.! )+110* M+45+3#$/ )volume +* Cape Town Huta and Company. 2. Sweet 4.R. )0CCC* M'/#&% M+45+3#$/ )0+th edition* (ondon 4ailliere Tinall

30

31