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High Risk Case - Docx 1

This case study examines a patient with premature rupture of membranes (PROM) at 38 weeks and 2 days of gestation. PROM occurs when the amniotic sac breaks before the onset of labor and can increase risks for the mother and baby. The objectives of the case study are to provide holistic nursing care using various nursing theories and processes, identify risks, educate the patient and family, and minimize stress during hospitalization. Data collection includes a thorough history and physical examination to assess the mother's condition and monitor for complications of PROM. Nursing care focuses on monitoring for infection, maintaining fluid balance, and preparing for delivery.

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0% found this document useful (0 votes)
20 views48 pages

High Risk Case - Docx 1

This case study examines a patient with premature rupture of membranes (PROM) at 38 weeks and 2 days of gestation. PROM occurs when the amniotic sac breaks before the onset of labor and can increase risks for the mother and baby. The objectives of the case study are to provide holistic nursing care using various nursing theories and processes, identify risks, educate the patient and family, and minimize stress during hospitalization. Data collection includes a thorough history and physical examination to assess the mother's condition and monitor for complications of PROM. Nursing care focuses on monitoring for infection, maintaining fluid balance, and preparing for delivery.

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MUNA N
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Manamohan Memorial Institute of Health Sciences

(Affiliated to Tribhuvan University)

Soalteemode Karthmandu

CASE STUDY ON "Premature Rupture Of Membrane(PROM)"

Submitted by: Submitted to:

Anjana Maharjan Coordinator, Poojan Sharma

Roll No.: 1 Lecturer ,Indira Adhikari

BNS 2ndyear Lecturer ,Sabitri Giri


Submitted On: 2077/

1
ACKNOWLEDGEMENT
This case study is prepared during the practicum of midwifery in Janakpur provincial
hospital . The report is prepared as the partial fulfillment of Bachelor of Nursing Science (BNS)
curriculum in Midwifery Practicum.

I would like to express my sincere gratitude towards Janakpur provincial hospital for
providing me such an wounderful opportunity to carry out this case study on “Intrauterine fetal
death.”

I would like to give sincere gratitude for our co-ordinater maam mrs. Nilam Jha of Madhesh
institute of health sciences for providing this opportunity to learn about midwifery condition.

Likewise, my sincere gratitude goes to my respected teachers: Mrs. Punita Yadav, and Mrs.
Srijana mahato for their proper and regular guidance, valuable feedback, encouragement and
suggestions throughout developing the case study. Likewise, I am also thankful to all the staffs
of Maternity ward, Bhaktapur Hospital for their support in fulfilling my objectives of doing case
study. I am equally thankful to my patient and visitor of patient for co-operation and for the
needed information that she had provided for me to accomplished the study.

Aggregately, I am thankful to my family, Friends and to everyone who have directly and
indirectly provided me their kind support, co-operation for successful completion of my case
study as a partial fulfillment of educational curriculum on Midwifery .

Thanking you

Muna Nepal

BNS 2nd year

1st batch

MIHS

2
Table of Contents
BACKGROUND.............................................................................................................................................4
SELECTION OF CASE:....................................................................................................................................4
WHY MY PATIENT IS IN HIGH RISK?.............................................................................................................5
OBJECTIVES..................................................................................................................................................6
HISTORY TAKING..........................................................................................................................................7
PHYSICAL EXAMINATION...........................................................................................................................11
ANTENATAL...........................................................................................................................................11
POSTNATAL EXAMINATION...................................................................................................................11
NEONATAL ASSESSMENT:..........................................................................................................................14
DEVELOPMENTAL TASK.............................................................................................................................17
PROM (Prmature Rupture Of Membrane)................................................................................................18
NURSING THEORY APPLIED IN MY PATIENT..............................................................................................27
Assessment according to the Virginia Henderson’s components..........................................................28
NURSING CARE IN MY PATIENT................................................................................................................29
DRUG CARDS.............................................................................................................................................36
DAILY PROGRESS NOTE:.............................................................................................................................44
DISCHARGE TEACHING..............................................................................................................................45
WHAT I LEARNED??.................................................................................................................................46
CONCLUSION.............................................................................................................................................47
REFERENCES..............................................................................................................................................48

3
BACKGROUND
According to the MIHS curriculum requirements , we have clinical posting as a part of
Midwifery major practicum for three weeks .During this period we are responsible to perform
one high risk case .So , I have selected the high risk mother of "Premature Rupture of Membrane
".

Premature rupture of membranes (PROM) is a rupture (breaking open ) of the membranes


before labor begins.Spontaneous rupture of membrane at any time beyond 22weeks of pregnancy
but before the onset of labour is called PROM. Approximately 5-10% of labour preceded this
problem.Rupture of the membranes near the end of pregnancy may be caused by a natural
weakening of the membrane or from the froce of contractions. Keeping this in mind I had
selected PROM case to do details study about it.

This case study show the case of Sunita Tamang ,24years female pregnant women.The
gestational age was 38+2week of gestation.History revealed that rupture of membrane occurs
before onsent of true labour pain.

This case study was done during my maternity posting in BHAKTAPUR HOSPITAL .

SELECTION OF CASE:
I had select this PROM case during my maternity posting because of following reason:

 To do details study of case


 To learn about PROM causes , sign and symptoms,pathophysiology,management .
 To learn how it is diagnosed.
 To learn about its complication.

4
WHY MY PATIENT IS IN HIGH RISK?
High risk pregnancy is defined as those pregnancies that are complictaed by a disease or
disorder that may endanger the life , or affect the health of the mother , the fetus or
newborn .High risk pregnancy may required emergency obsteric care before , during and after
pregnancy .

Health problems that occurs before a woman becomes pregnant or during pregnancy may also
increase the likelihood for high risk pregnancy .

Etiology of high risk pregnancies:

 Physical characteristics : such as obesity , height below 147cm puts a woman in higher
risk pregnancy.
 Exposure that harm fetus : cigarette smoking , alcohol consumption ,use of illict
drugs ,exposure to harmful radiations can causes high risk pregnancy leading to the harm
of fetus.
 Social charactristics :low sociooeconomic condition , nutrition pattern
 Problems in previous pregnancy

So ,Every pregnant women come under high risk when conception starts.But some condition
makes mother and fetus in high risk .Such as maternal condition like medical issues, previous
abortion ,PPROM ,PROM nutritions status of patient ,etc.Fetal condition like :congenital
anomalies, fetal distress, etc.

In the same way my patient who was admitted with provisional diagnosis of Primigravida
38weeks+2days revealed history of early membrane ruptuure before true labour pain /onset of
labour this condition may leads the consequences like fetal distress, maternal and fetal
death ,placental abruption ,cord compression ,etc..

So this case come under high risk and I had selected this case for futher details study , by co-
relating the problems according to book and the patient in real practical situation and provide
proper adequate care to the patient during hospitalization and also to provide health teaching
during discharge .

5
OBJECTIVES
General Objective:

To study depth about PROM , to provide holistic care to the patient, newborn and her family
through nursing procesing in that conditions and also considering patient’s socio-cultural
background and traditional philosophy to find out underlying causes and utilize the learned
knowledge from basic science ,midwifery and fundamental nursing in order to give proper and
holistic care with managemnet during PROM.

Specific Objectives:
 To select a case for study and apply in real practical situations.
 To perform physical examination and obstetrical examination correctly and
systematically way.
 To collect information about the antenatal, postnatal and newborn care as per the cultural
background.
 To provide holistic care using nursing process and nursing theories.
 To collaborate with the patient, family and other health personnel.
 To identify risk for patient for early management.
 To strengthen the knowledge on theory as well as practical.
 To compare patient condition with book picture.
 To provide health education to patient and family as per their need.
 To minimize stress of the patient and family during hospitalization
 To recognize developmental tasks of different age group in planning nursing actions.
 To provide correct information to the patients and family.
 To assess the mother condition proprely and record it for details study.
 To provide discharge teaching to the patient as well as visitors.
 To evaluate the total case study.
 To organize the study in systematic manner.

6
HISTORY TAKING
A. BIODEMOGRAPHIC DATA
Name : Sunita Tamang
Age/ Sex : 24years/Female
Address : Sindhupalchowk ( Permanent) /Bhaktapur( Temporary)
Education : Secondary level
Occupation : Housewife
Age of marriage : 23years
Husband’s name : Kumar Tamang
Religion : Hindu
Date of Admission : 2077/08/29
I.P no. : 777800900
Bed no. :7
Diagnosis : Primigravida @38weeks+2days
Date of Delivery : 2077/08/30 at 2:16pm
Date of discharge : 2077/09/01
Information obtained from:
 Patient
 History taking & physical examination
 Radiology & laboratory investigations
 Patient’s chart & record book

B. CHIEF COMPLAINS
Lower back pain since 1day
Abdominal pain since 1day
Nausea since 3hours

C. History of present illness

The patient was apparently well a day back. She came for regular checkup in outpatient as she
had abdo pain and back pain with 3cm cervix opening on 2077/08/29.

7
D. History of past illness
Childhood immunization : Yes
Childhood illness : No
History of previous hospitalization/surgery/ chronic illness : No
History of any special treatment (e.g. blood transfusion)/ medications : No

E. Personal history
Smoking/ Alcohol consumption : No
Drug addiction : No
Working hours : 8-10hrs a day
Rest : 2 hrs a day
Sleep : 6-9 hrs a day
Bowel and bladder pattern : Normal

F. Dietary habit
No. of meals in a day : 4 times a day ( Breakfast ,Launch , Tiffin /Snacks, Dinner)
Food dislikes : None
Food allergies : No any history of allergies till history time
Non-vegetarian/ Vegetarian : Non-vegetarian
Appetite : Good

G. Menstrual history
Age of menarche : 13yrs
Dysmenorrhea : Sometime
Last Menstrual Period : 2076/12/01
Menstrual flow : Medium flow
Pattern : Regular

H. Present obstetrical history


No. of ANC visits : 4 ANC visits
Last Menstrual Period : 2076/12/01
Expected Date of delivery : 2077/09/08
Weeks of gestation : 38 weeks +2days
Gravida :1
Parity :0
Abortion :0
Methods of family planning : Condom

I. Home environment

8
No. of rooms in the house : 4rooms
Separate kitchen : Yes
Type of fuel used : Gas ,Wood
Source of drinking water : Tap water
Type of toilet used : Water sealed latrine
Drainage method : Closed
Method of water purification : Boiling

J. Psychosocial history. She is well oriented with her society cultural ,rituals and
activities .She has good relation with family members as well as other relatives and member
of society. She takes part in social activities, relative’s ceremonies and rituals which shows
that she is interested to be involved in social activities.

K. Cultural and traditional beliefs


She belongs to Hinduism family, she follows Hindu rituals and ceremonies. She beliefs in
traditional and modern health care facilities.

L. Health seeking behavior


Patient belief to seek traditional and modern health care equally.

M.Socio economic status


She is from Nepali middle class family. She had passed only SLC . They use gas for cooking.
They have separate room, kitchen and well ventilation. They use water sealed latrine.
Source of income :- Husband works in resturant as waiter
Average monthly income: - approximately above Rs 17,000
Housing and environment: - Separate room, kitchen and well ventilated
Electricity :- Adequate
Family support :- Good support from family member

N. Family history
Type of family : Nuclear
No. of family members :4
There is no any history of chronic illness in family members. There is no communicable disease
and psychiatric illness.

9
FAMILY TREE

INDEX:

Female death

Male death

Male

Female patient

Female

10
PHYSICAL EXAMINATION
ANTENATAL
I was not able to perform antenatal examination because of her pain during antenatal time I
collects information from history taking, laboratory investigations and regular antenatal health
checkup card.
According to that she had no any history of disease condition and no any problems in body
systems .

POSTNATAL EXAMINATION
General Appearance
 General condition : Patient was calm and alert
 Level of consciousness : Conscious
 Orientation : Oriented to time, place and person
 Gait : Balanced gait
 Hygiene : Maintained
 Nutritional status : Well nourished
 Dehydration : Not present
 Edema : Not present
 Hair : Uniform distribution, black color, no alopecia
 Nails : Normal shape, normal capillary refill time( i.e. <3sec)
 Facial expression ; Cheerful ,Happy

Anthropometric measurement:
Height : 158cm
Weight (Antenatal period) : 62 kg
BMI- 24.84 kg/m2
Vital signs:
Pulse : 88 beats/min
Respiration : 22breaths/min
Temperature : 98 .20F
Blood pressure : 120/70 mm of Hg

Skin : Inspection
 Color: Fair color all over the body
 Linea nigra :Absent
 Itching : Absent
 Eruption : Not present
 No pallor, icterus, lymph node, cyanosis, oedema and dehydration
Head

11
1. Inspection
 Size, shape, contour: Normal
 No visible lumps, swelling and scars
 Head hygiene maintained
 Hair: Black hair
2. Palpation
 No palpable swelling or lumps
 No tenderness on palpation

Eyes
Inspection:
No sign of anemia or jaundice present.
Eyebrows: Equally distributed
Color of conjunctiva: Pink
Pupil size and reaction: Equal and symmetrical, react to light
Visual aquity: Normal vision
Eye movement: Co-ordinated is good

Ear
 Location: The top of the pinna crosses the eye-occiput line
 No lumps or lesions found, no discharge, redness, tenderness, mass and foreign body
found
Nose
 Size : Normal
 Location : Centrally located
 Smell : Can smell all odors
 Nasal flaring : Not present
Mouth
Inspection
 Lips are light pink in color and dry
 Foul smell present
Neck
Inspection:
 No enlargement of thyroid gland and jugular veins
 No stiffnessor swelling or lumps

Respiratory system
 Normal breathing pattern
 No masses or tenderness

Cardiovascular System

12
 Capillary refill time: back within a second
 No clubbing and cyanosis present

Abdominal examination
Inspection:
 No prominent veins striaegravida ,linea nigra absent
Fundal height :13cm above the symphysis pubis.
Uterus is well contracted.
Nervous System
 Coordinated movements
 Sensation present

Breast examination

Inspection:

 Both breast were symmetrical in shape and size


 Both nipples were directed in the same direction
 Nipples were dark brown in color
 No cracks or discharge from the nipples

Palpation:
Tenderness but no lumps or masses

OTHERS:

Bladder and bowel habbits were normal. Lochia rubra was present.Perineum , vulva and

anus :1st 0tear ,No any sign of infection in vulva

SUMMARY OF POSTNATAL EXAMINATION:

-Bad breathing smell from mouth .

Baby’s condition after delivery

13
Sex : Male
APGAR score : 7/10 in one minute, 8/10 in 5minute.
Weight : 2800gram
Feeding : Baby was breastfed after 2 hours of delivery

NEONATAL ASSESSMENT:
Anthropometric measurement:
Head circumference : 33cm
Chest circumference : 31cm
Length : 47cm
Weight : 2800gram
Respiration : 40breaths/ minute
Heart rate : 136 beats/minute
Temperature : 98.6oF

General appearance
 Baby was active and alert.
 Baby posture was well flexed.
 Color of the face, chest, tongue, lips was pink.
Skin:
 Skin was smooth, no signs of dehydration.
 Skin color was pink.
 Vernix caseosa present
 Lanugo present
Head:
 Round & symmetrical in shape.
 Anterior & posterior fontanels were open
 Suture lines were palpable
Eyes:
 Symmetrical in shape & size.
 No any signs of infection, discharge,
 Corneal reflex was present.
Ears:
 Both ears are symmetrical in shape & size
 No lumps or polyps
 No any discharge
Nose:
 Centrally located.
 No any nasal blockage.
Mouth &throat:

14
 No any cleft lip or cleft palate.
 No any oral thrush.
Abdomen:
 No any umbilical hernia present.
 Cord tied and dry
 No any discharges.
Genitourinary system:
 No any visible abnormalities or discharge.
Musculoskeletal system:
 No any congenital defect of extremities.
 No dislocation of hip.

Nervous system:
 All neonatal reflexes were present.

Findings: No any visible physical deformities

LABOUR DETAILS

Type of delivery:SVD with 1st degree tear


True labour pain starts : 2077/8/30 at 1am

15
Membrane ruptures : 2077/8/29 at 4 am
Cervix fully dilated : 2077/8/30 at 2pm
Baby born : 2077/8/30 at 2:16pm
Placenta expelled 2077/8/30 at2:23pm

Duration of Labour

First stage of labour:10hr


Second stage of labour: 16min
Third stage of labour: 7min

Total hour: 10hrs 23min

This labour details shows that early membrane rupture occur before onset of labour.In
my patient no specific management had done because staff got this information only
during the time of delivery.

Method of delivery of placenta: Control cord traction

- Completeness: Placenta completely out


- Placenta weight: 500gm
- Abnormalities: Not present
- Membrane: Completely out
- Umbilical cord: 2 arteries and 1 vein
- Total blood loss: 90 ml
- Uterus: contracted
- Suturing is done by using catgut (2,0)

DEVELOPMENTAL TASK
1.According to Freud ,my patient is on PUBERTY ONWARDS age with psychosexual stage

16
of Genital.
2.According to Erik Erikson my patient is in stage VI with Psychosocial crisis "INTIMACY
VERSUS ISOLATION "
3.According to Havighurst's Developmental task of young adulthood are:
i. Selecting a mate
ii. Learning to live with a partner
iii. Starting a family
iv. Rearing children
v. Managing a home
vi. Getting started in an occupation
vii. Taking on cicic responsibility
viii. Finding a congenial social group
IN MY PATIENT :all are met according to havighurt's ,Freudand Erik Erikson
developmental tasks.

PROM (Prmature Rupture Of Membrane)

17
Spontaneous rupture of membranes at any time beyond 22weeks of pregnancy but before the
onset of labour is called premature rupture of membrane(PROM). Premature rupture of
membranes may occur in term (37 completed weeks of gestation ) called term PROM and
before 37 completed weeks of gestation is called preterm PROM.

Epidemiology
At term, PROM complicates approximately 8% of pregnancies . Preterm PROM complicates
about 1% of deliveries overall.
Approximately 5-10% of labour are preceded by rupture of membranes ,in a further
25%,rupture ocuurs before the onset of second stage of labour. It is only in the 2-4% that
occur before 34weeks.

CAUSES
Exact causes unkonow.

18
According to book In my patient

A. Increase intra uterine pressure Not applicable in my patient


Multiple pregnancy
Polyhydramnious
Coitus in late pregnancy
Trauma
B. Incompetence cervix
C. Faulty application of the presenting
parts
Malpresentation
Placenta previa
Disproportion
D. Intrinsi cmembrane weakness
Infections
Smoking
Malnutrition
Collagen Deficency
E. Others:
Lower socio-economic status
Poor nutrition

PATHOPHYSIOLOGY

Rupture of membranes results from a variety of factors that ultimately lead to accelerated
membrane weakening. This is caused by an increase in local cytokines, an imbalance in the
interaction between matrix metalloproteinases and tissue inhibitors of matrix metalloproteinases,
increased collagenase and protease activity, and other factors that can cause increased
intrauterine pressure.

Clinical features

19
According to book In my patient

1. History of sudden gush of fluid per Present


vaginum or constant leaking of fluid
per vagina
2. Signs of intrauterine infection as
Absent
maternal pyrexia ,maternal tachycardia
,fetal tachycardia ,uterine tenderness ,
foul smeeling discharge ,dirty blood
stain discharge Present
3. Early signs of labour as painful uterine
contraction Absent
4. Presence of show
5. Constant wetness in underwear

Diagnosis

1. History of leakge of clear fluid per vagina.

2. Speculum examination : Liquor escaping out through the cervix , Collection of liquor in

posterior fornix

3. Investigation:

-Complete blood count

-Ultrasound is not used routinely, but may facilitate diagnosis in cases where it remains unclear.

-In all cases of premature membrane rupture, a high vaginal swab should be taken. It may grow
Group B Streptococcus (GBS) which would indicate antibiotics in labour, or give information as
to a potential cause for PPROM (bacterial vaginosis is commonly implicated).

-Other tests include:(For conformation of diagnosis)

 Place a vaginal pad over the vulva and examine it (visual and odor ) one hour later.
 Ferning test – placing cervical secretion onto a glass slide and allowing it to dry (forming fern-
patterned crystals if there is PROM/PPROM). The false positive rate is around 6%.
 Nitrazine testing – measures the pH of vaginal fluids and has previously been used to diagnose
PROM and PPROM (amniotic fluid pH is higher than vaginal fluids). However, this test carried

20
a high false positive rate (17%), due to contamination with urine, blood or semen – and is no
longer routinely used.
 Less than 6-6.2 ph detected.
 Methylene blue test

IN MY PATIENT:

1.History of clear fluid loss per vaginum.

2.Urine test

3.Complete blood count

4.USG : Impression

a) Cephalic presentation
b) Posterior placentation
c) Fetal H/R 132beats /minutes
d) Fetal age by USG 35weeks 3days
e) Maternal : Left mild hydronephrosis

URINE EXAMINATION

Date:2077/08/29

Colour : Light Yellow


Transparency : Slightly turbid
PH : Acidic
Albumin : Nil
Sugar : Nil
Epithelial cells : 2-4
Pus cells : 1-2
RBC : Nil
Cast : Nil , Crystal : Nil
Date:77/08/29

21
TEST RESULT UNIT NORMAL RANGE

Hematology report
Blood grouping A POSITIVE
CBC
HB 12 gm/dl 11-11.5

TC 10400 /cumm 4000-11000

DIFFERENTIAL LEUCOCYTE
COUNT
Neutrophil 70 % 40-80

Lymphocyte 30 20-40

Monocyte 05 2-10

Eosinophil 01 1-6

Basophil 00 0-1

PCV 39 36-46
x 1000/cumm
Platelets 440 150-450

SEROLOGY REPORT
HBsAG
HIV1and 2AB NON-REACTIVE

VDRL TEST

MANAGEMENT
22
 General Management :
 Hospitalization
 Bed rest with bathroom privilege
 Wearing of clean vulval pad
 Broad spectrum antibiotics
 Maternal and fetal monitoring
Maternal ( temperature , pulse , BP , odor of liquor , uterine tenderness)
Fetal monitoring( FHR 4hrly ,CTG daily , Biophysical profile weekly)
 Assess for sign of intrauterine infection:
If there is no sign of infection:
>37weeks :if membrane rupture is more than 18hours
If the cervix is unfavorable then used prostaglandin ,oxytocin ,augmentation
If the cervix is favorable induce with oxytocin

<37weeks :

Prophylactic antibiotic
Refer to higher centere
Complete bed rest
Continuous assessment for early signs of labour , sign of infection
Give corticosteroid if no frank infection
Women should deliver at 37 weeks
Discontinue antibiotic if women deliver vaginally
If non –cephalic presentation then plan for caesarean section
If there is sign of infection then :
-Start antibiotics: Ampicillin 2gm I/V 6hrly
-Gentamicin 5mg perkg body weight for 24hrs
-If woman has previous CS , continue above anitibiotic and metronidazole 500mg IV
every 8hrs continue until fever free for 48hrs.
-If women deliver vaginally , discontinue anitibiotic.

23
IN MY PATIENTS
Induce with oxytocin
Normal vaginal delivery

24
NURSING MANAGEMENT

1. Prevent infection and other potential complication

-Make an early and accurate evaluation of membrane stauts, using sterile speculum examination
and determination of ferning.

-Determine maternal and fetal status , including estimated gestational age. Continually assess for
sign of infection.

-Maintain the client on bed rest if the fetal head is not engaged . This method may prevent cord
prolapse .

-Once fetal head engaged ambulation can be encourage.

2. Provide client and family education

-Inform the client , if the fetus is at term , that the chances of spontaneous labor beginning
are excellent , encourage the client anad partner to prepare themselves for labor and birth.

-If labor doesnot begin ,explain treatment that are likely to be needed according to week of
gestation.

-Explain about intensive care needed after delivery .

3.Others:

-Monitor FHS every 2-4hrly.

-Monitor maternal vital signs.

-Provide comfort to the patients.

-Encourage patient to verbally express what is being felt at this time .

25
COMPLICATION
The majority of women at term will enter spontaneous labour within 24 hours after membrane
rupture, but there is a greater latency period the younger the gestational age. This pre-disposes
to a greater risk of maternal and fetal complications:

 Chorioamnionitis – inflammation of the fetal membranes, due to infection. The risk increases the longer
the membranes remain ruptured and baby undelivered.
 Oligohydramnios – this is particularly significant if the gestational age is less than 24 weeks, as
it greatly increases the risk of lung hypoplasia.
 Neonatal death –  due to complications associated with prematurity, sepsis and pulmonary
hypoplasia.
 Placental abruption 
 Umbilical cord prolapse

26
NURSING THEORY APPLIED IN MY PATIENT
Henderson’s first (1995) definition of nursing is “ Nursing is primarily assisting the
individual sick or well in the performance of those activities contributing to health, or its
recovery or a peaceful death that he would do unaided if he had necessary strength, will or
knowledge. It is likewise the unique contribution of nursing to help the individual to be
independent of such assistance as soon as possible.”
Later in 1996, Henderson clarified her definition of nursing as “The unique function of
the nurse is to assist the individual, sick or well, in the performance of those activities perform
unaided if he had the necessary strength, will or knowledge.
Four major concepts

Person
Person is viewed as an individual requiring assistance to achieve health and independence or
peaceful death: person and family are viewed as a unit. Person is affected by both body and
mind. Person consists of biological, psychological, sociological and spiritual components. Person
needs strength will or knowledge to perform activities necessary for healthy living.
Health
Health refers to an individual’s ability to function independently in relationship to the fourteen
basic needs. Health is a quality of life that is basic to human functioning. Health requires strength
will or knowledge.
Environment
Environment is not specifically defined by Henderson. Environment involves the relationship on
shares with one’s family. Environment also involves the community and its responsibility for
proving health care. She believes that society wants and expects nurses to provide a service for
individuals incapable of functioning independently, but in return she expects society to
contribute to nursing education. Environment can affect health, personal factors (age, cultural
background, physical capacity, and intellectual capacity) and physical factors (temperature) play
a role in a person’s well-being.
Nursing
She gives definition of nursing and the fourteen components of basic care. The nurse is expected
to carry out the physician’s therapeutic plan. Nursing helps a patient to meet the fourteen basic
needs through the formation of nurse patient relationship; Henderson identifies three levels of
nursing function- substitute (making up for what the patient lacks to be whole), helper(instituting
medical interventions), or partner (fostering a therapeutic relationship with the patient and
functioning as a member of the health care team). Henderson advocates the use of a written
nursing care plan. The goal of nursing is to practice autonomously in helping patients who lack
knowledge, physical strength or strength of will in growth toward independence.

Assessment according to the Virginia Henderson’s components


S HENDERSON’S COMPONENTS ASSESSMENT IN MY PATIENT
N
1 Breathe normally Within normal range .

27
2 Eat and drink adequately Her eating and drinking pattern is normal.
3 Eliminate body wastes She had regular bowel and bladder pattern.
4 Move and maintain desirable postures She was able to maintain desirable position by
support.
5 Sleep and rest Unable to sleep well in night due to false labour
pain.
6 Select suitable clothes-dress and undress She was able to dresse and undresse herself alone.

7 Maintain body temperature Within normal range.


8 Keep the body clean and well-groomed and Hygiene was maintained,
protect the integument.
9 Avoid danger in the environment She was alert and aware of dangers in the
environment.
10 Communication She was anxious, worried about situtional crisis
i.e. non progess of labour and baby care after
delivery.
11 Worship according to one’s faith My patient followed Hinduism. She had strong
faith on god.

12 Work accomplishment I was able to build good interpersonal relationship


with them.

13 Play or participate in various forms of Spend time in household work.


recreation

14 Learn, discover or satisfy the curiosity She was curious to know about the management
done to her and curious to know about
breastfeeding techniques.

So, according to her needs, I have applied some components of Virginia Henderson’s theory to
make nursing diagnosis which are given below down.

28
NURSING CARE IN MY PATIENT
ACTUAL DIAGNOSIS:

1. Anxiety releted to situitional crisis as evidenced by increased tension and non progress of

labour.

2.. Acute pain releted to progress of labour as evidenced by cervical dilation i.e.3cm.

3. Knowledge deficit releted to breast feeding techniques as evidenced by wrong technique

during feeding.

POTENTIAL DIAGNOSIS

1.Risk for Infection releted to loss of protective barrier as evidenced by early membrane rupture.

2.Risk for infection in genitial area releted to 1st degree tear.

Baby

1. Risk for imbalanced nutrition related to mother’s knowledge deficit about breastfeeding.

29
S.N. Date Assessment Nursing Goal Planning Implementation Rational Evaluation
diagnosis
1. 77/8/30 Subjective Anxiety Patient 1.Assess the 1.Reason behind 1.Helps to My goal was
data: releted to will patient anxiety was detect causes met fully as
Patient said situitional verbalize anxiety assessed . of anxiety. patient
that she is not crisis as d relief reason. verbalized
feeling well evidenced from 2.Knowledge reduced of
because of by anxiety . 2.Labor 2.Patient was and anxiety after
non progress increased process informed about information clear
of labour. tension and explained to during of helps to information.
Objective non patient . labour ,true reduced
data: progress of labour pain in anxiety .
Patients labour. primigravida.
seems 3.Provision of
anxious ,restl 3.Answer the 3.Question clear
essness ,mem question regarding information
brane rupture arises by contraction , helps couple
but no any patient time duration to understand
progress in honestly and and fetal what is
labour. clearly. condition was actually
asked by them happening
and answer and reduce
honestly. anxiety.
4.Relaxation
technique
4.Encourage 4.Deep helps to
patient to do breathing was improve
deep encouraged to blood
breathing perform. circulation ,pr
during ovide
anxiety. maximum rest
and reduce
anxiety.

5.Stabilization
may reflect
5.Monitor 5.Maternal vital reduced
maternal and and fetal FHS anxiety.
fetal heart was measured .
rate.

30
S.N. Date Assessment Nursing Goal Planning Implementation Rational Evaluation
Diagnosis
2. 77/8/30 Subjective Acute Patient will 1.Assess 1.Patient 1.Helps to
My goal
data: pain able to cope patient attitude towards identify was
Patient said releted to with labor attitude pain was perception of
partially met
that she had progress pain within towards assessed.(feeling patient as patient
excessive pain of labour an hour pain. of sever pain towards labor
was able to
after use of as after than in others pain. cope with
medication . evidenced intervention. was replied by labor pain
by patient) partially
Objective data: cervical after some
Augmentations dilation 2.Maintain 2.Patient was 2.Help patient intervention.
started to i.e.3cm. poisition of putted in left to have
progress client. lateral comfort even
labor.Facial position ,or during
expression patient contrcationand
looks comfortable reduce pain
flushing ,irrita position. because of
ble when we comfortness.
talk.
3.Provide 3.Helps to
quite 3.Excesive diminish stress
environment visitor was and anxiety
. encouraged to from other
stay out . sources.
4.Provide 4.Helps to
medicine for 4.Injection reduce labour
early epidosin+ pain.
delivery. buscopan was
provided for
effective
cervical
5.Encourage dilation . 5.Helpful in
relaxation pain
technique. 5.Deep management.
breathing was
encouraged
during
contraction.

31
S.N Date Assessment Nursing Goal Planning Implementatio Rational Evaluatio
. diagnosis n n
3. 77/8/30 Subjective data:Knowledge Patient’s 1.Assess 1.Asked about 1.Helps to
Patient said that
deficit will be patient how to feed the understable
her baby is releted to able to knowledge baby. the level of
crying breast feed her about knowledge
continuously breastfeeding in patient.
feeding baby
during feeding. .
techniques properly
Objective data: as with
Patient evidenced proper 2. Explain 2. Patient was 2.Helps
looks confused by wrong breast about the explained about them to
technique feeding techniques of gain
while techniques
during technique breastfeeding. knowledge
breastfeeding, feeding. s. and about it.
wrong positions of
technique breastfeedin
while feeding g.
and providing
care to the
3.Teach 3.Mother was 3.Helps to
baby. explained about gain
mother about
signs of good how to know knowledge
attachments whether baby is for mother.
and suckling. having good
suckling and
attachment .

4.Demonstrat
e how to put 4.Demonstrated 4.Helps
baby durinng about position of mothers to
breastfeeding baby during learn about
. breastfeeding. positioning
.

32
S.N Date Assessment Nursing Goal Planning Implementation Rationale Evaluation

diagnosis

4. 77/8/30 Subjective Risk for Mother 1.Asssess 1.Vital signs was 1.Helps to My goal was
data: Infection will show general taken and collects met fully as
Patient said releted to free of condition of showed baseline patient
that she feel loss of signs of patient (i.e. normal ,Vaginal data. doesnot
loss of whitish protective any vital examination show any
discharge barrier as infection signs ,vaginal show rupture of sign of
excessively on evidenced before examination). membrane. infection
77/8/29 at by early delivery. even early
4am without membrane 2.Assess for 2. Urine color 2.This are rupture of
any pain. rupture. discharge from and vaginal the membrane
vaginal ,temper discharge ,temp indicators occurs.
Objective ature and urine erature was that shows
data : color. assessed. for need of
Early rupture (Tem: 99.4oF) antibiotic
of therapy.
membrane ,no
true labour 3.Encourage for 3. Warm soup 3.Proper
pain ,no inatke of fulid , was given. nutrition
contraction . protein helps to
containing boost the
diet . immunity
system.

4. Sterile gloves 4. Prevent


4.Use of Sterile was used for PV from cross
gloves during examination . infection.
vaginal
examination.
5.Vital signs4. Helps to
5.Re- taken .All were identify
assessment in normal early sign
done especially condition. of
vital signs. infection.

33
S. Date Assessmen Nursing Nursing Planning Implementatio Rational Evaluation
N. t diagnosi goal n
s
5. 77/9/1 Objective Risk of Patient 1.Assess the 1.Perineal 1.Helps to My goal was
Data: infection will not condition and hygiene was identify the fully met as
“Patient of develop hygiene of assessed. risk of patient had
has 1st perineal infection perineal tear. infection. not developed
degree tear area during 2.Maintain 2.Personal and 2.Helps to any sign of infection.
and lochia related to hospitaliz good personal perineal prevent the
rubra perineal ation. and perineal hygiene was organisms to
discharge." tear.i.e.1st hygiene. maintained. enter the
degree incision area.
tear.
3.Provide 3.Pericare was 3.To prevent
pericare. provided. growth of
organisms.
4.Monitor vital 4.Monitored 4.To know the
signs regularly. vital signs baseline data .
regularly, and it
was in normal
range.
5.Watch the 5.To detect the
suture sites for 5.Watched the wound
redness, suture sites, infection.
swelling, lochia redness,
and discharge. swelling, lochia
and discharge.
6.Teach patient
how to clean 6.Health 6.Helps
perineal area in teaching about patient to do
home after care of prienal self in home .
discharge. was given.
7.Encourage
for pad changes 7.Frequently
frequently. pad was 7.Prevents
changed. from cross
infection of
pad .

34
Nursing Planning Implementation Rationale Evaluation
N. Assessment diagnosis Goal

6. Objective Risk for Mother will 1.Assess the 1.Assessed the 1.To gain Mother was
data: nutritional be able to breastfeeding breastfeeding knowledge about able to
Improper imbalance breastfeed technique. technique. breastfeeding breastfeed in a
breastfeeding related to properly methods. proper
techniques improper within an 2.Assess urine 2.Urine was light 2.To gain technique and
and timing. breast hour. color. yellow in color. knowledge about timing was
feeding. sufficiency of maintained .
feeding to the child.

3.Provide 3.Informal teaching 3.To provide basic


informal teaching to the mother about need of baby
to the mother breastfeeding properly, prevent
about techniques , timing complications from
breastfeeding and assisted while improper breast
techniques , breastfeeding and feeding
timing and assist breast care.
while
breastfeeding,
breastcare.

4.Provide 4.Provided 4.To prevent from


informal teaching
informal teaching complications due to
about importanceabout importance insufficiency of
breatfeeding. of exclusive breast feeding,
breatfeeding..
5.Teach patient 5.Urine of baby 5.Help to confrom
about to watch was watched. whether baby is
urine of baby. getting enough
breast milk or not.

6.Teach mother 6.Teached about 6.Helps to provide


about good good suckling and adequate breast milk
suckling and attachment. for baby with good
attachment. attachment.

35
DRUG CARDS
1.Ferro care
Generic Name:Ferrous sulphate

Trade name:Ferro care

Category :Iron product

Ferro-Care Capsule is composed of the following active ingredients (salts)

Ferrous Fumarate

Folic Acid

Riboflavin - Vit. B2

Cyanocobalamin - Vit. B12

The above medicine may be available in various strengths for each active ingredient listed
above.Composition of ferocare capsule

Cyanocobalamin 5 MCG+Elemental iron 60 MG+Elemental zinc 15 MG+Folic acid 1 MG

Mechanism of action
Ferro-Care Capsule works by producing blood cells and platelets in the body; acting on
megaloblastic bone marrow to produce a normoblastic marrow; reducing prostaglandin thus
helping blood thinning and prevents clotting; normalizing the formation of red blood cells and
nerve tissues;

Uses
Ferro-care capsule is used for the treatment, control, prevention, & improvement of the following
diseases, conditions and symptoms:
 During pregnancy
 Treatment of anemias of nutritional origin, pregnancy, infancy, or childhood
 Anemia
 Treatment of megaloblastic anemias due to a deficiency of folic acid
 Cervical cancer

36
 Migraine
 Muscle cramps
 Acne
 Carpal tunnel syndrome
 Vitamin b 12 deficiencies
 Malignancy of pancreas or bowel
 Folic acid deficiency
Side effects
 Constipation
 Dark or green stools
 Diarrhea
 Loss of appetite
 Nausea
 Stomach cramps
 Vomiting
 Anorexia
 Abdominal distention
Contraindication
 Allergic reactions
 Atrophic gastritis
 Child younger than 4 months old
 High levels of iron
 Hypersensitivity
 Intolerance to the drug
 Kidney infection
 Low amount of potassium in the blood
 Operation to remove stomach

37
Nursing implication
Ask patient not to miss the dose
Inform patient to report to the doctor if there is any hypersensitivity to the drug.

2. Calcium supplement
Generic name: Calcium sulphate
Trade name:
Category:
Action:
Caution needed for maintenance of nervous, muscular skeletal systems enzyme reactions, normal
cardiac contractions, coagulations of blood.
Uses:
Prevention and treatment of hypocalemia
Hypermaganesemia
Hypothyroidism
nEonatal tetani
Vit-D deficiency.
Dose:
Adult: 500 mg /day, Expectant and lactating mother’s requirement: 1000 mg day.
I/V – 500mg - 1gm
Adverse effects:
- Anorexia, Vomiting, nausea, constipation
- Hypocalcaemia, muscle weakness,
- Drowsiness, lethargy, headache, coma, polyuria and thirst.
Contraindications:Hypocalcaemia, digitalis toxicity, ventricular fibrillation, renal calculi
Nursing management:
- Monitor ECG for decreased QT and T wave inversion, on hypercalcemiak drug should be
reduced or discontinued.
- Monitor calcium levels during treatment (9 - 10 mg / U normal lvel)
- Advice to increase fluid intake.

Patient teaching:
- Teach the patient &amp; family the name, dose, frequency, action &amp; adverse effects of the
prescribed iron preparation.

38
- Inform patient of daily iron requirement (for more information ask the patient to see daily
requirement)
- Help the patient explore possible cause of anemia such as inadequate diet or excessive
menstrual bleeding o prevent recurrence.
- Advice the patient to include iron rich foods in the diet.
- Teach the patient to take liquid preparation with straw to prevent tooth stains.
- Inform the patient that iron preparations normally darken, stool however the patient should
notify the physician if bloody stool or abdominal cramping or pain occurs.

3.OXYCTOCIN
Generic Name:Oxytocin
Trade name:Pitocin ,Syntocinon
Category:Uterine stimulants (Posterior pituitary hormone)
Mechanism of action:
Oxytocin is thought to bind to estrongen dependent receptors on myometrial cell membranes
activate the contractile protein . Oxytocin is also thought to relase prostaglandin from the
decidua. These both hormones causes fundal contraction with relaxation of the cervix.
Preparation used:
Synthetic oxytocin is available in ampoule contain 5IU/ml ampoule.
Syntometrine :combination of syntocinon 5units and ergometrine 0.5mg
USES:
-Active management of third stage of labor
-Induce/augument labour\-Uterine interia
-Post partum haemorrhage
-Breast engorgement
SIDE EFFECTS:
-Strong uterine contraction
-Hypotension
-Water intoxication
-Occasional anginal pain

39
-Fetal distress
-Fetal death
-Asphyxia
CONTRAINDICATION
In later month of pregnency
-Grand multipara
-Contracted pelvis
-Previous history of caesarean section
-Mal presentation
During labour
-Above all including,Obstructed labour ,Incordinate uterine contraction ,Fetal distress
Others:
-Hypovolameic state
-Cardiac diseae
-Placenta previa
-Placenta abruption
-hypersensitivity reaction
ROUTE :
IV/IM
Buccal tablet or nasal spray
NURSING CONSIDERATION:
-Increase oyctocin drops in every half an hour .
-Monitor uterine contraction and FHR at least every 15-30min.
- Regular checkup of maternal vital signs.
- Observe for the signs of fetal distress.

40
4.EPIDOSIN
Generic Name : Epidosin
Trade Name:Valethamate
Category :Uterine stimulant

Mechanism of action:
Increase cervical dilation and effacement.
USES:
-Cervical dilatation
-Ureteric Colic
-Gastrointestinal tract spasm
-Biliary colic
SIDE EFFECTS:
-Fast heartbeat (Tachycardaia)
-Blurred vision
-Constipation
-Chest pain
Diarrhoea
-Headache
-Rash
CONTRAINDICATION:
-Allergy
-Liverimpairement
-Renal impairement
-ulcerative colitis
Preparation :
Administered maximum three dosages (8mg/mi) through IM/IV at 1/2hour interval

41
Route:
Tablet ,solution ,injection
Nursing consideration:
1.Repeat upto 3doses ,1doses in each half an hour interval.
2.Maintain temperature of medicine.
3.Caution should be exercised in patients with history of severe liver or kidney disease ,any
allergy ,during pregnency and breastfeeding.
4.Avoid patient not to walk alone after using this medicine because this may causes blurred
vision .
5.Monitor FHS of fetal every half hourly .
6.Monitor vital signs of mothers.
7.Pelvic examination should in every does to assess the cervical dilataion .If full dilatation is
achieved or going to achieved after next dose then third dose should stop to prevent side effects.

5. BUSCOPAN
Generic Name : Hyoscine/Scopolamine
Trade Name: Buscopan
Category:Anticholinergic drugs

Mechanism of action:
Block action of Ach on autonomic effectors and CNS excreted through muscarinic receptor in
the GI tract .
Relax the GI system and bladder .

USES:
-Abominal ramp
-Spastic constipation
-Irritable colon
-Gastritis
-Dysmenorrhoea
-Pylorospasm

CONTRAINDICATION
-Urinary retention
-Myasthenia gravis
-Paralytical or obstructive ileus
-Hypersensitivity

42
-Megacolon
-Narrow angle glaucoma

SIDE EFFECTS
-Dizzeness
-Impaired cognition
-Tachycardia
-Dyspepsia
-Constipation
-Retention
-Dry moth ,eyes

Route:Oral ,injection ,parental

Nursing consideration
1. Monitor vital signs because it can causes high grade fever ,alerted bp .
2. Drug compatibility should be monitored closely in patient requiring adjunctive therapy
3. Avoid driving and operating machinery after parental administration.
4. Avoid stict heat.
5. Always keep emergency equipements available and ready because this drugs may causes
respiratory paralysis.
6. Re-orient patient as needed, Tolerance may develip when therapy is long

43
DAILY PROGRESS NOTE:
DATE VITAL SIGNS PROGESS NOTE
077/08/30 Bp= 130/70 mmof hg Patient is well oriented to place ,
Temperature=97.8OF person and time. Patient had
Pulse=90beats /minutes dilatation of cervix 3cm at 8am and
Respiration=24breathe /minutes 6cm at 11am with effacement
SPO2=97% 70% ,station 0.
Weight=62kg Injection epidosin+buscopan had
FHS=136beats/minutes started at 8am with 3doses half
hourly .After PV on 11am Injection
syntocin 2.5IU had started in order
to improve labour .

After using of synotic (2.5 hour )


normal vaginal delivery was done .
BABY:
Male alive baby of weight 2800gram
was born on 2:16pm with apgar
score 7/10 and 8/10.
Baby condition was normal.
MOTHER:
Spontaneous vaginal delivery with
1st degree tear .Reapirement done.
As per requirement third stage
management was done .Vital sign
monitor.History taking was done
through help of visitor.

077/09/01 MOTHER: Mother:


Bp=120/70mm of hg Patient condition is fair.Patient was
Temperature=98.20F encourage for ambulation and
Pulse=82beats/minutes breastfeeding .
Respiration=20breathe/minutes Lochia rubra was present.Patient was
SPO2=96% on RA. in normal diet.

BABY: Baby:
Pulse=128beats/minutes Baby condition is fair.Stool ,urine
Respiration =44Breath /minutes and meconium passed.Baby was in
Temperature=98.80F breatfeeding.

44
DISCHARGE TEACHING
In midwifery it is responsibility of mifewife to give health education for every postnatal mother
before discharge .In the same way on the following topic dischare teaching was provided:
1. Nutrition
-Most essential basic needs of everybody especially for lactating mother.So I
adviced her to have nutritious diet containing fibers, vitamins ,protein .
-Adviced her to intake jawano ko soup ,meat ,dal soup ,chakku .
-Advice her not to consume alcohol ,tobacco.
2. General cleanliness
-Maternal and infant child hygiene should be maintained to prevent infection .
-Mother was thought how to clean the vulva area .
-Mother was adviced to change pad frequently.
3. Breastfeeding
-Encouraage for exclusively breastfeeding for 6months.
-Encourage to feed child from both breast .
-To prevent breast engorgement ,mother was tought to breastfeed the infant in
every 2-3year.
-Teach about cleaniness in nipples as well.
4. Rest ,Sleep and Activity
-Encouged to have 10hrs sleep at night and 1-2hour sleep at afternoon .And also
advice to give peace ,silent and relax sleep for baby as well.
5.Immunization
-I had adviced mother to bring baby for next immuzation ( that is for DPT ) after
4months .BCG had already taken o adviced was given for next immunization
schedule.
6.Follow up
-Mother was adviced for follow up visit with baby .I told her why it is important.
According to doctor order I inform her to visit after 7days in order to detect
complication early for motheer and after 2days for baby.
7.Discharge medication
For mother:
Tab FerocareXT 1tab PO X OD X 6weeks
Tab Shekal 1tab PO X OD X 6weeks
Tab Meftal 500mg PO X TDS X 3days
Tab Amoxy 5OOmg PO X TDS X 5days
For baby
Baby D3Cap 1 cap PO X OD X upto 1year
After 2weeks Syp Feromax XT 1.25ML XPO XOD 6months

8.Danger signs : explained about the danger signs of mother and baby (such as heavy
vaginal bleeding ,shortness of breath or chest pain in mother and convulsion , not feeding
well , ictures ,etc in baby ). She was advised for prompt visit to health care centre incase
any of these symptoms occurs.

45
WHAT I LEARNED??
I GOT AN

• opportunity to know about the disease process, its management in detail.

• to know about the patient’s condition in detail and how to deal with this kind of cases in
coming future as well.

• opportunity to learn general attitude of family and their socio-cultural environment,


educational, religious and economic status of patient.

• opportunity to strength my knowledge

• chance to detect the stressful factors and different therapy to overcome these stress.

• opportunity to recall newborn care and aware mother as well as family about newborn
care.

• opportunity to earn how to handle the PROM case with nursing care.

• opportunity to develop habits to study in details .

• opportunity to lear present the case systematically.

46
CONCLUSION
As a high risk case I got an oportunity to learn about PROM . Case of Primigravida
@38weeks+2days was admitted in maternity ward on 77/08/29 with complain of
abdominal pain , back pain.

During hospitalization early membrane was ruptured .Due to no progress in


labour ,inducation was done and after inducation of 2 1/2 half hour patient cervic fully
dilated and delivered on 8/30 .Male baby weight 2.8gram baby was born .

During hospitalization and discharge, I provided informal teaching to her and care taker
about different topics like: nutrition, medication, health checkup, personal hygiene,
diversional therapy and follow up .

This condition /case helped me to learn brief information about PROM and its
management ,specific test that is done in PROM to identify /conform the PROM . Along
these this case study build up my confident level in antenatal and postnatal settings.

47
REFERENCES
Bhattarai ,S.&Prasai,D.(2013).Midwifery Nursing Part I(2nd
edition).Jamal ,Kathmandu:Medhavi Publication,PP:354-356.

Tuitui,R.& Suwal,S.(2015 A.D.).Manual of Midwifery II (11th


edition).Bhotahity ,Kathmandu:Vidyarthi Pustak Bhandar,PP:275-276.

Tuitui,R.& Suwal,S.(2015 A.D.).Manual of Midwifery III (11th


edition).Bhotahity ,Kathmandu:Vidyarthi Pustak Bhandar,PP:333-339.

Marun ,M.(2018). PROM -Slideshare.Retrived from www.slideshare.net


>EngidawAmbelu >prom-97838920

Thompson,L.(2016). Premature Rupture of Membranes and PPROM-


TeachMeObGyn.Retrieved from teachmeobgyn.com>delivery>pre...

48

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