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INTRODUCTIONThis paper presents a case study done on Mrs. Rhoda Chatha (in this paperreferred to as Rhoda), aged 26, Para 2. She was admitted in the a!our ward at"om!a Centra #ospita from home on 2$%&2%' at $''pm with compaints of

ower a!domina pain and !ac*ache. +ssessment reeaed that the foetus waspresenting with !reech and she was in actie stage of a!our. +n informedconsent was o!tained for case study. She was monitored throughout a!our. +tpm a !reech deiery of a ie fu term mae infant was conducted. -a!y andmother were ta*en to postnata ward where they were cared for, for $ days. /n26%&2%' mother and !a!y were discharged after meeting the discharge criteria.

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SUBJECTIVE DATA

PERSONAL PARTICULARS0ame Rhoda Chatha

+ge 26years

#ome address Chid1aro iage, T%+ Chi*owi, "om!a./ccupation #ousewifeReigion C.C.+.P.Tri!e omweMarita status Married3ducationa ee Standard 0e4t of *in Maita -andawe (mother)

CHIEF COMPLAINTRhoda reported in the a!our ward from the high ris* antenata ward withcompaints of a!our pains. She was e4periencing ower a!domina pain and

!ac*ache. She reported that she had !een in pain for 6 hours.

MEDICAL HISTORYRhoda stated that she had neer suffered from any of the foowing diseaseTu!ercuosis, asthma, dia!etes meitus, epiepsy, hypertension, rena diseases,heart disease or menta iness.

SURGICAL HISTORYRhoda had neer !een operated on, had neer !een inoed in any seriousaccident and had neer receied any !ood transfusion !efore.

FAMILY HISTORYShe stated that there are no disease conditions that run in her famiy and there isno famiy history of mutipe gestation.

NUTRITIONAL HISTORYRhoda ta*es a we !aanced diet. #er 25 hour dietary reca was composed of athe si4 food groups. She eats three main meas a day i.e. !rea*fast, unch, andsupper. She aso snac*s in !etween meas. She ta*es appro4imatey 2 iters offuids in a day. She did not e4perience any pica nor e4cessie saiation duringher entire period of her pregnancy. She e4perienced nausea and omiting for thefirst three months of her pregnancy. n her cuture there are no food restrictionsfor pregnant women.

SOCIAL HISTORYShe was the first wife to her first hus!and Mr. Chatha whom she was married tofor 7years. t is monogamous famiy. She did her education up to form 2 whie herhus!and did his education up to form 5. The hus!and wor*s as a saes man at a!a*ery. She is a house wife. The hus!and earns enough money to afford !asicneeds at home. She reported that she had !een receiing enough socia and

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financia support from her hus!and and significant others during her pregnancy.She is in good reationship with her hus!and and significant others.

PSYCHOLOGICAL HISTORYRhoda stated that the pregnancy was panned and they had !oth accepted it.

They panned to !e on famiy panning method after deiery so that they canpreent unpanned pregnancy. They aso panned to hae one more chid.

GYNAECOLOGICAL HISTORYShe attained menarche at the age of &6. She e4periences reguar menstruacyce. She menstruates for $ days. She has had no a!ortions !efore. She had!een using depo proera since the !irth of her first chid unti 0oem!er, 2''8.She has !een on this method for 2 years.

SEXUAL HISTORYShe reported that she did not e4perience any se4ua discomfort i*e dyspareunia

during pregnancy. They stopped coitus at months gestation !ecause in theircuture it is !eieed that coitus after months causes wide fontanes. They areaso e4pected to resume coitus si4 months after deiery.

PREVIOUS OBSTETRIC HISTORYRhoda was graida 2 para&. #er first !orn is a gir whose deiery wasspontaneous erte4. She was !orn in 2''7 at "om!a Centra #ospita and hadweighed 26''g at !irth. #er daughter was reported to !e in good heath. 9uringher antenata period for her first pregnancy she did not e4perience any pro!ems.0either did she e4perience any compications after deiery.

PRESENT OBSTETRICAL HISTORY#er ast 0orma Menstrua Period (0MP) was &$%'$%' and her 3stimated 9ateof 9eiery (399) was 2'%&2%'. #er gestation !y dates was 5' wee*s. Since!eing pregnant she had not drained i:uor nor e4perience any agina !eeding.She had !een ta*ing ron ta!ets daiy since the day she started attendingantenata cinic. She aso too* two doses of ;ansidar. She aso receied twodoses of Tetanus To4oid


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LABORATORY INVESTIGATIONS#< test resuts came out negatie during antenata period. The test wasrepeated in a!our ward and came out negatie. #er haemogo!in test resutwas &&.gm%d antenatay. unctia no discharges, no opacities,cear cornea and no esions.

MOUTH

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ips were of norma si1e and shape with pin* coour and no crac*s nor sores.#ad pin* gums, no gingiitis, no denta caries. Pin* and moist ora mucosamem!ranes. Pin* and symmetrica tongue. 0o ora thrush.

NECK

Symmetrica in shape. 0o distended nor isi!e >uguar eins. 0onpapa!eymph nodes, no sweing nor masses. 0orma thyroid gand. +!e to turn head!oth sides.

CHESTSymmetrica and !arre shaped. Symmetrica respiratory moements. 0oa!norma !reath sounds i*e crac*es and creptations.

BREASTSSymmetrica, no isi!e masses, no sores nor crac*s on the nippe. Prominentand erectie nippe. 0o papa!e masses on the !reasts. Coostrum e4pressed.

UPPER EXTREMITIESSymmetrica, capiary refi time was ess than 2 seconds, no pamar paor, nonoedema of arms.

LOWER EXTREMITIESSymmetrica with no aricose eins nor oedema. 0o sweing nor tenderness ofcaf musces.

ABDOMENSymmetrica and oa shaped. #ad inea nigra and striae graidarum. 0o hepato

spenomegay. ;unda height was $$ cm which indicates $ wee*s gestation.The fundus was 2 fingers !eow 4iphisternum. #ad ongitudina ie, !reechpresentation and Right Sacroanterior position. ?as e4periencing $ moderatecontractions in &' minutes. #er urinary !adder was empty and her feta heartrate was &5' !eats per minute.

GENETALIA

Vaginal Inspeci!nCean with no sores, no acerations nor warts. t was nonoedematous, had noaricose eins, no !eeding, no show and no a!norma agina discharge.

Vaginal E"a#inai!n?arm and moist agina, thin ceri4, &''@ cerica effacement and ceri4 was 5cm diated. The presentation was !reech and the presenting part was not weappied to the ceri4. Mem!ranes were intact and cord was not fet.

Pel$ic Assess#en

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Shape of !rim coud not !e foowed, sacrum was cured, sacro promontory wasnot tipped, sacrospinous igaments were fe4i!e and ischia spines were notprominent. Su!pu!ic arc was more than A' degrees and intertu!erous diametercoud admit 5 *nuc*es.

IMPRESSION+ high ris* mutigraida with !reech presentation in actie stage of a!our

NURSING DIAGNOSES

#igh ris* for haemorrhage reated to materna soft tissue in>ury secondary

to deiery manoures.

+tered comfort pain reated to uterine contractions manifested !y patientBs

own er!aisation and strained facia e4pressions.

#igh ris* for trauma to the fetus reated to deiery manoures.

#igh ris* for atered fuid and nutrition reated to sowed digestiefunctioning and emptying time of stomach and reduced food inta*e.

#igh ris* for infection reated to inasie procedure during a!our and

ruptured mem!ranes.

#igh ris* for hypo4ia reated to compression of the pacenta during uterine

contractions.

neffectie indiidua coping, an4iety reated to a!ouring in an unfamiiar

enironment, *nowedge deficit on a!our and deiery process, outcomeand e4pectation of the midwife.

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PROGRESS NOTES

%&'(%')*

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&2 noon+ssessments

Temperature $8 degrees Cesius.Puse 68 !eats per minuteRespirations &A -eats per minute-%P&2'%' mm#g;eta #eart Rate&2 !eats per minute.$ moderate contractions in &' minutes.=rinary !adder was empty

&2&7 pmRhoda compained of seere ower a!domina pain and seere !ac*ache. Rhodawas o!sered !earing prematurey. She was discouraged from !earing down.

Pethidine &''mg was administered after assessment of ita signs which weresta!e and were as foowsTemperature $8 degrees CesiusPuse 68 !eats per minuteRespirations & -eats per minute-%P&2'%' mm#g;eta heart rate was chec*ed as we and was &$' !eats per minutePethidine &''mg was gien intramuscuary

&2$' pm;eta heart rate was &$7 !eats per minute

&pm+ssessmentsRhoda reported reduction in pain.Puse rate 8' !eats per minute-%P &2'%' mm#g;eta heart rate &$ !eats %minute$ moderate contractions in &' minutesRhoda was encouraged to as* :uestions and air out concerns.#er ips were moistened with


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&&7 pmRhoda went to the toiet to urinate and she reported to hae managed to urinate.=pon return from the toiet she was taught and adised to do peic roc*inge4ercises to promote descent of the presenting part.

&$' pm;eta heart rate was &$' !eats per minuteMother too* porridge.

2 pmAssessmentsTemperature $8 degrees cecius,Puse rate 66 !eats%minute

Respirations & !reaths%minute-%P &&'%'mm#g;eta heart rate&5' !eats per minuteContractions 5 moderate in &' minutes-adder empty

Vaginal examination?arm and moist aginaThin ceri4, &''@ effaced and 8 cm diatedPresenting part poory appied to the ceri4Mem!ranes intact and cord not fet.

Show was seen which was not !ood stained.The findings were communicated to the cient.Rhoda was adised to change positions fre:uenty to reease tension.

2&7 pmRhoda was adised to get off the !ed and perform peic roc*ing e4ercises.

2$' pm;eta heart rate was &$6 !eats%minuteShe was encouraged to fre:uenty am!uate and empty her !adder.

$ pm;eta heart rate was &$ !eats per minute.Puse rate 65 !eats per minuteRespirations & !reaths%minute-%P&&'%' mm%#gShe was e4periencing $ strong contractions in &' minutes;indings were communicated to the cient.

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$$' pm;eta heart rate was &2 !eats per minute#er mother !rought porridge which the patient too*.She was gien a !edpan to urinate in. she urinated a!out &''ms.She was adised not to !ear down uness adised to do so when ceri4 is &'cm

diated.

5 pmAssessmentPuse 66 !eats%minuteRespirations2' !reaths%minute-%P&&'%'mm#g;eta heart rate &26 !eats per minuteContractions $ strong in &' minutes#er urinary !adder was empty.

5$' pm;eta heart rate was &$5 !eats per minute-ac* ru!s were proided to minimi1e pain.

7 pmMem!ranes ruptured spontaneousy. i:uor was meconium stained. + aginae4amination was done. The ceri4 was A cm diated. Cord was not fet and thepresenting part was not we appied to the ceri4. t was a compete !reech.;eta heart rate was &$$ !eats % minute.Temperature$8 degrees Cesius

Puse rate 68 !eats per minuteRespirations2' !reaths per minute-%P&2'%' mm#gShe was tod of the findings.

72' pm.+ deiery troey was prepared with the foowing e:uipmentsdeiery pac*, suturing pac*, ignocane.Resuscitaire was aso prepared in readiness for an asphy4iated !a!y

7$' pm;eta heart rate was &5' !eats per minute

+ urinary catheter was inserted and &''m of urine was drained to ensure thatthe !adder was empty.

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6 pmAssessment;eta heart rate &5' !eats % minute.Puse rate 8$ !eats per minuteRespirations 2' !reaths per minute

-%P &2'%' mm%#gContractions $ strong in ten minutes.;indings were communicated to the mother.

VAGINAL EXAMINATION?arm and moist agina tissuesCeri4 thin, &''@ effaced and &' cm diated;our fingers inserted into the agina to confirm cerica diatation. Cord was notfet and the presenting part was not we appied to the ceri4.Presenting part was !eow the ischia spinesi:uor was meconium stained.

Rhoda was informed that she was in second stage of a!our !ut was adised notto start !earing down uness adised to do so i.e. when the presenting part!ecomes isi!e at the ua. Mother was instructed to continue deep !reathing.?hen the presenting part !ecame isi!e on the ua she was assisted toassume supine position with her !uttoc*s on the edge of the !ed, egs fe4ed and*nees a!ducted.She was instructed to !ear down ony with a contraction;eta heart rate was chec*ed and there was no sign of feta distress.-uttoc*s and genitaia together with the two feet appeared on the ua.Rhoda was encouraged to continue pushing. -uttoc*s and the egs were !orn. +t627pm when um!iicus appeared on the ua Rhoda was instructed to stop

!earing down. The oop of the cord was genty pued down to oosen it.Pusations on the cord were fet to !e reguar and strong at &$5 !eats per minute.

Two fingers were inserted in the agina. 3!ows were not present on the !a!yBschest !ut the a4ia was fet. The arms were e4tended. The !a!y was coeredwith a warm coth. -oth thum!s were paced on the sacrum whie the fingerswere paced in front of ieac crest. The woman was instructed to push with acontraction. ?ith a contraction and the woman !earing down the !ody wasrotated at an ange of &' degrees *eeping the !ac* upper most in order to !ringthe shouder which was more posterior to !ecome more anterior and it was yingunder the symphysis pu!is. The inde4 and third fingers were paced oer theshouder, the upper arm was spinted, fe4ed and then !rought down across the!a!yBs face and chest. Then the !a!yBs !ody was rotated !ac* &' degreesD*eeping the !ac* upper most in order to !ring the shouder that was moreposterior to !ecome more anterior unti the shouder was ying under thesymphysis pu!is. The inde4 and third fingers of the hand facing the !a!yBs !ac*were paced oer the shouder. Then the upper arm was spinted and fe4ed and!rought down across the !a!yBs face and chest.

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62 pmThe !ody of the !a!y was eft to hang downwards with the head inside the peis.Then the nape of the nec* appeared under the pu!ic arc. #ands were *ept nearthe !a!yBs peis to preent the !a!y from faing down. The !a!yBs feet were

firmy grasped with the right hand, e4erting firm downward, then outward andupward traction. ?hen the mouth and the nose were free from the perineum theairway was genty ceared of secretions. The woman was instructed to continue!reathing deepy unti the aut of head was deiered sowy and the !ody wasdrawn upward oer the materna peis with the eft hand guarding the perineumto preent the head from emerging too :uic*y. The head was deiered at 6$'pm. The !a!y was :uic*y ta*en to the resuscitaire where it was suctioned and!agging was done. The !a!y cried strongy 57 seconds after !irth.

THIRD STAGE O+ LABOUR&' units of pitocin was administered intramuscuary to promote uterine

contractions and the pacenta was deiered 6 minutes ater at 6$6pm !ycontroed cord traction. Cots were e4peed. =pon e4amination of the perineumthe ceri4 was intact !ut she sustained a first degree perineum tear. The motherwas ceaned up and wet inen was repaced with dry inen in readiness forsuturing. -ood pressure immediatey after deiery was &&'%'mm#g and puserate was 68 !eats per minute. Pacenta and mem!ranes were compete, weighed77'g and it was a heathy pacenta. The cord was 7'cm ong and had $ !oodesses. -ood oss was a!out &' m. + tampon was inserted into the agina toa!sor! !ood. Perinea tear was ceaned with chorhe4idine prior to in>ection of&'m of &@ ignocaine on !oth edges of the tear. Then the tear was sutured withchromic 2' in two ayers and chorhe4idine was aso used to cean the sutured

tear to preent infection.

+OURTH STAGE O+ LABOUR8$' pm-ood pressure was &&'%'mm#g, puse rate was 66 !eats per minute,Temperature was $6.6 degrees Cesius, uterus was in midine position, firm andwe contracted and there was moderate fow of ochia. ntraenous infusion wasstopped and drip was remoed. Rhoda was then instructed to ta*e a !ath andwash her coths.

IMPRESSION+ ow ris* mother one hour post deiery adapting we to nongraid state.

MIDWIFERY DIAGNOSIS

#igh ris* for haemorrhage reated to e4posed !ood esses at pacenta

site.

#igh ris* for infection reated to e4posed tissues on the sutured perinea

area.

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PLAN OF CARE3ncourage Rhoda to !reastfeed eery 2 hours to stimuate o4ytocin productionwhich promotes uterine contractions3ncourage the cient to urinate fre:uenty !ecause a fu !adder interferes withuterine contractions.

+dise the cient to ie in supine position with egs crossed. This positionpromotes uterine contractions.+dise the cient to report e4cessie fow of ochia !ecause this can !e a sign ofactie !eedingChec* !ood pressure and puse rate eery 5 hours !ecause increased puserate and decreased !ood pressure is suggestie of !eeding.

+dise the cient to do sit1 !ath at east three times a day.+dise the cient to change perinea pads fre:uenty !ecause a moist pad is aconducie enironment for micro!ia growth.

7:35 pm ASSESSMENT OF THE BABY

Temperature $6. degrees Cesius

Geneal appeaance+ctie, aert and norma musce tone, pin* s*in coour, no apparent in>ury nora!normaity. 0o cyanosis, no pamar paor , no >aundice, no meconium staineds*in. Sight erni4 caseosa and anugo on the face.

!ead

3en, !ones sighty moa!e at sutures, open, fat and soft fontanees. 0omouding nor caput. ntact scap and good scap growth, no !ruising, noa!rasions, no cuts, no acerations. #ead circumference was $5cm.

E"esSymmetrica, norma si1e and shape, correct pacement, no su!con>unctiahemorrhage seen. 0o discharge, nor cornea uceration, !right and shinnycornea, white scera.

Nosen midine position, fattish, wide and patent. 0o !oody nor puruent discharge,no nasa faring.

Mo#t$Symmetrica and pin* ips of norma si1e and shape, pin* tongue and gums. 0ogingiitis, no ceft paate, no fase teeth. Pin*, moist and shinny mucusmem!rane.

Eas

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Symmetrica, no e4tra aurices, we formed ears, upper ear in ine with outercorner of the eye. 0o foreign !ody or discharge. ?e formed aurices.

Nec%Short, symmetrica, with s*in fods, no we!!ing. #ead in midine position, no

masses present, some head contro of side to side moement seen puse4tension and fe4ion. 0either sweing nor creptus sound found on e4amination.

&$est-arre shaped chest, prominent end of 4iphisternum, symmetrica respiratorychest moement, no chest indrawings, no ri! recession, no inoement ofa!domina musces during !reathing. 0o a!norma !reath sounds onauscutation. 58 !reaths per minute, reguar heart !eat. Papa!e !reast nodues.

AbdomenSymmetrica, no organomegay, no tenderness, nondistended a!domen, !owe

sounds present. Cean and moist um!iicus. ier and speen nonpapa!e. Twoarteries and one ein present on the um!iica cord, no !eeding on the um!iicus.

'ppe extemitiesSymmetrica, fu range of motion e4ercises, we formed hands, no e4tra digits,no we!!ed fingers, we formed pamar creases, no fracture of ong !ones.

Lo(e extemitiesSymmetrica, semife4ed hips and egs. ;u range of motion e4ercises incudinga!duction. 0orma si1e of ong !ones. ;emora puse fet. ?e deeoped pantarcreases. 0o e4tra digits, no we!!ed feet, no cu!!ed feet no taipes. /rtoanBs

test was negatie ie no congenita hip disocation.

Genetalia?e deeoped testes papa!e in a sac. Patent urethra opening at center ofgans penis correcty positioned. The !a!y had passed meconium aready.

)ac% and spineStraight, easiy fe4ed, no spina !ifida nor meningocee nor sacra dimpe sinus.

Ne#ological assessmentMoro refe4 present gae a started response !y finging out armsRooting and suc*ing refe4 was present when infantBs chee* corner of themouth was touched, infant turned head towards stimuus and opened the mouth.Swaowing refe4 was present suc*ing was coordinated with swaowing with nogagging, coughing or omiting.Erasp refe4 was present !a!y firmy grasped tip of the fingerPantar toes cured downwards when finger was paced at the !ase of the toes.?a*ing refe4 was present infant stimuated wa*ing !y ifting and pacing onefoot in front of the other.

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The !a!y weighed $&''g.

IMPRESSION+ ow ris* infant one hour post deiery adapting we to e4trauterine ife.

NURSING DIAGNOSIS

#igh ris* for hypothermia reated to e4posure to cod enironments

#igh ris* for hypogycemia reated to inade:uate inta*e

#igh ris* ateration in !onding reated to fatigue

PLAN OF CAREFeep the !a!y thoroughy dried and coered with a warm dry cothPreent the !a!y from !eing in contact with cod surfacesPostpone !athing for the first 5hours.3ncourage the mother to !reastfeed the !a!y eery 2 hours.

+dise the mother to watch the !a!yBs um!iicus for !eeding.Monitor !ody weight daiy.Coer the !a!yBs head with a hat.3ncourage the mother to cudde the !a!y whie !reastfeeding to promote!onding through touch.3ncourage mother to maintain eye contact whie !reastfeeding.3ncourage the mother to ta* to the !a!y whie !reastfeeding to promote!onding.

pmRhoda and her !a!y were ta*en to postnata ward where she was gien a !ed.

-a!y was wrapped in a cean and dry coth and the mother was adised to *eepthe !a!y aways warm and to immediatey change soied inen.-a!yBs head was coered with a hat.Mother was adised to !reastfeed the !a!y eery 2 hours.Mother was adised to maintain eye contact and ta* to the !a!y when!reastfeeding to promote !onding.Mother adised to empty the !adder fre:uenty to promote uterine contractionsMother adised to ie in supine position with egs crossed to promote uterinecontractions.She was adised to report e4cessie fow of ochiaShe was adised to cean the sutured area with warm saty water to preent

infection.She was adised to change perinea pads fre:uenty.She was aso encouraged to as* :uestions and e4press her concerns.

$' pmRhoda and her !a!y were handed oer to night duty staff.

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DAY 2 24/12/08

Mo!"#$% &%%"%%'"(

S,-.eci$e /aa

Rhoda reported that she had spent the night we. She said that she was stihaing some mid a!domina pain especiay when !reastfeeding.She reported that she had !een !reastfeeding throughout the night eery 2 hoursand the !a!y is suc*ing we.She had ta*en porridge and tea and was not haing any pro!ems with eating.She reported that she had aready ta*en a !ath in the morning and had changedthe perinea pad. She reported that she was not haing heay ochia.She reported that she had passed stoos and urine in the morningShe aso reported that she was e4periencing mid pain in the genitaia due to thesutured tear !ut the wound was not !eeding.She aso reported that the !a!y had passed stoos eary in the morning.

O-.eci$e /aa?e *empt in !ody and cothes.unctia0onoedematous upper e4tremities, capiary refi time within 2 seconds

0onengorged !reasts, coostrum e4pressed.=terus was &6 cm from the symphysis pu!is. t was in midine position, firm andwe contracted. =rinary !adder was empty.0onoedematous ower e4tremities, non tender caf musces, no aricose eins,no deep ein throm!osis.The genitaia was cean, perinea pad sighty soa*ed, no !ood cots, nooffensie sme, no !ood nor pus on the sutured tear, no oedema and normawound heaing process.

I#p0essi!n+ ow ris* mother 25 hours post deiery adapting we postnatay.

Assess#en#igh ris* for haemorrhage reated to raw pacenta site

+tered comfort pain reated to uterine contractions (after pains), presence ofsutured tear as eidenced !y er!ai1ation.#igh ris* for infection reated to presence of tear in the perineum.

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Plan3ncourage mother to empty !adder fre:uenty to promote uterine contractions.3ncourage mother to continue !reastfeeding eery two hours to promoteproduction of o4ytocin that promotes uterine inoution.Chec* the perinea pad eery 5 hours to assess amount of ochia.

Chec* !ood pressure and puse rate eery 5 hours.Reassure mother that a!domina pain during !reastfeeding is due to uterinecontractions secondary to o4ytocin production and that pain wi su!side withtime.

+dminister Paacetamo&g eery hours oray to reduce pain3ncourage deep !reathing and rea4ation techni:ues

+dise the mother !e on high fi!er diet to promote digestion and minimi1estraining during defecation that aggraates pain.

+dise the woman to aso !e on high protein diet to promote wound heaing+dise the woman to change perinea pads fre:uenty !ecause moist perineapad is a conducie enironment for micro!ia infection

3ncourage the woman to am!uate in order to promote drainage of ochia thusreducing the ris* of infection.+dise the woman to hae sit1 !ath in saty water to preent infection.Teach the cient to cean the perineum from front to !ac* to aoid introducingmicro!es on the perineum which can cause infection.3ncourage the mother to foow hand washing techni:ue and o!sere a infectionpreention measures.

BABY$S ASSESSMENT

Temperature $6.8 degrees Cesius

Geneal appeaance+ctie, aert and norma musce tone, pin* s*in coour. 0o cyanosis, pamarpaor, nor >aundice.

!ead0o sun*en nor !uging fontanees. 0o !ruising, no a!rasions, no cuts, noacerations.

Nose0o nasa faring, patent nostris with no secretions.Mo#t$Pin* ips with no sores and no crac*s, pin* and moist ora mucosa, no ora thrushnor gingiitis.

&$estSymmetrica respiratory chest moement, no chest indrawings, $5 !reaths perminute and heart !eat was &2$ !eats per minute.

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AbdomenSymmetrica, no um!iica hernia, no organomegay, dry um!iicus.

Ne#ological assessment

0o conusions, no a!norma cry, no signs of cere!ra irritation.

-a!yBs !ody weight was 2A7'g

I')#"%%*o(+ ow ris* !a!y 25 hours postdeiery adapting we to e4trauterine ife

IMPLEMENTATIONA'' am

+dministered &g of ora paacetamo to mother.

Mother taught on importance of emptying the urinary !adder.Mother taught on importance of !reastfeeding fre:uenty for the first $ days!ecause coostrum contains anti!odies that protect the !a!y from infections.Mother reassured that a!domina pains wi go with time and she shoud continue!reastfeeding despite a!domina pains.

&''' amMother was taught on proper positioning and proper !reast attachment during!reastfeedingMother was reminded to *eep the !a!y warm and change the nappies wheneerthey get wet.

Mother encouraged to cudde the !a!y, and to maintain eye contact during!reastfeeding in order to promote !onding.-a!yBs um!iicus was ceaned with surgica spirit and the mother was taught onhow to cean !a!yBs um!iicus. Mother was adised to watch the um!iicus for!eeding or any signs of infection and report immediatey.-a!yBs head was coered with a hat.

&'$' am-a!y was gien -CE accine and Poio ' accine to protect the !a!y fromTu!ercuosis and poiomyeitis respectiey. The mother was adised not to ru!the in>ection site on the right hand to preent reducing the potency of the accine.She was aso adised to wait for $' minutes !efore !reastfeeding the !a!y topreent omiting !ecause Poio ' accine causes nausea.

&&am


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Mother and !a!y were handed oer to night duty staff.

DAY + 2,/12/08

+M

S,-.eci$e /aaRhoda stated that she and the !a!y spent the night we. The !a!y had !eensuc*ing we during the night. She reported that she had aready ta*en a !ath andhad ceaned the sutured perinea tear with warm saty water and she wase4periencing mid fow of ochia. She was a!e to pass urine and stoos and shewas no onger e4periencing a!domina pain nor pain on the sutured tear. Sheaso reported that the !a!y had passed stoos as we

O-.eci$e /aaMot$e?e *empt in !ody and cothes.unctia0onoedematous upper e4tremities, capiary refi time within 2 seconds0o !reast engorgement, no masses fet, coostrum e4pressed.=terus in midine position, &7 cm from the symphysis pu!is, firm and wecontracted uterus. =rinary !adder was empty.0onoedematous ower e4tremities, nontender caf musces, no aricose eins,

no deep ein throm!osis.Cean genetaia, perinea pad midy soa*ed, no !ood cots, no offensie sme,nonoedematous perineum, norma heaing process of the sutured perinea tear.

I#p0essi!n+ ow ris* mother 5 hours post deiery adapting we to nongraid state

)ab"

Eenera appearancePin* s*in, aert and actie.


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&''' amRhoda was reminded a!out e4cusie !reast feeding. She was aso reminded toaow the !a!y to suc*e empty the !reast !efore gien the other !reast topreent !reast engorgement. She was aso adised to *eep her !reasts cean athe time.

&'2'amMother was adised to report to the hospita immediatey if she e4periences anyof the foowing danger signs seere headache not reieed with anagesics,heay ochia fow, fou smeing agina discharge, !urred ision, conusions,feer, pus or !oody discharge on the sutured perinea tear.

She was aso adised to report to the hospita immediatey if the !a!ye4periences any of the foowing danger signs feer, a!oured !reathing,refusing to !reastfeed, distended a!domen and ina!iity to pass stoos,

conusions and puruent or !oody discharge on the um!iicus.

&'7' amShe was adised to report !ac* at the hospita after one wee* for chec*up.She was further adised to report again at the hospita after si4 wee*s for postnata chec* up, famiy panning and for !a!yBs immuni1ation.

&&''amRhoda was discharged after heath education as per home. #eath education asper discharge pan.

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DISCHARGE CRITERIA

MOTHER

0orma ita signs.

Mid ochia fow with non offensie sme.

0o pus, no !oody discharge from the sutured perinea tear.

0o !reast engorgement, easiy e4pressed coostrum.

;irm and we contracted uterus, in mid ine position.

Proper positioning and good attachment to the !reast

+!iity to descri!e the si4 food groups

+!iity to e4pain the danger signs for the mother and the !a!y.

+!iity to mention the ne4t appointment date.

BABY

0orma ita signs.

-ody temperature of ess than $8.2 degrees Cesius

0o a!ored !reathing, a!sence of chest indrawings, respiratory rate of

ess than 6' !reaths per minute.

0o conusions, no a!norma cry, nor any signs of cere!ra irritation.

0o pus or !oody discharge on the um!iicus

+!iity to suc*e without any pro!ems

DISCHARGE PLANEie heath education on the foowing topics

Si4 food groups.

;amiy panning.

34cusie !reastfeeding.

Persona !ody hygiene. mportance of ade:uate rest..

9anger signs in postnata mother and !a!y.

Perinea care.

#eathy se4ua practices

9iscourage harmfu traditiona practices and encourage !eneficia ones.

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ANALYSIS OF CASE STUDY

-ased on data coected and care rendered to Rhoda, the foowing are thepertinent issues.

She is 2A years od meaning that she is in the chid !earing age and this does notput her at ris* as far as age in concerned. The ery young (!eow & years)woman runs an increased ris* of deeoping compications during pregnancy.?omen aged !etween 2'$' years of age hae the owest o!stetric ris*s, !uta!oe the age of $7 there is aso an increased ris* which is aso com!ined withthe ris* of high parity that may resut in proonged a!our and haemorrhage (SafeMotherhood 2'''). #er height of &7 cm does not put her at ris* !ecause ris* ofcephaopeic disproportion due to contracted peis is common in women !eow

&7' cm.

/n socia history she ac*nowedged that she is receiing ade:uate socia andpsychoogica support from her hus!and and significant others. The famiy is a!eto purchase essentia !asic through the money they get from farming and runninga sma scae !usiness. This is good !ecause it ensures aaia!iity of !asicneeds i*e food and cothes thus fostering motherBs heath and properdeeopment of the fetus. -oth do not smo*e and drin*. This is good as we forthe we!eing of !oth the mother and the fetus. 0icotine su!stance in to!accocauses interference with o4ygen e4change in ung aeoi. The end resut wi !ereduction of o4ygen in circuating !ood. +coho reduces appetite thus eading to

manutrition in the mother which in turn may aso ead to feta intrauterine growthretardation.

Progress of feta growth was norma according to the weight gain of the mother./n initia isit she weighed 65 *g and on second isit she weighed 66 *g D aweight gain of 2 *g which is norma in the second trimester. 9uring the third isitshe weighed 6 *g and on the fourth isit she weighed 8' *g. +ccording toSeers (2''&), in norma pregnancy, 2 *g is supposed to !e gained in the firsttrimester whie in the second trimester she is supposed to gain at east '.7*geery wee*. The summary of the weight gains and other findings hae !eenattached to the case note.

She had a haemogo!in ee of &&g%d. This is a good haemogo!in ee inpregnancy !ecause there is an increased demand of o4ygen for the growingfetus and the mother as we. t is aso essentia for transportation of nutrients forfeta growth and we!eing of the mother. This indicates that the woman was notanaemic !ecause in Maawian setting anaemia is defined as a haemogo!in eeof ess than &'g%d which is a resut of deficiency in the :uaity and :uantity of red!ood ces (Safe Motherhood, 2''').

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/n urinaysis, urine a!umin was negatie thus ruing out hypertensie disordersand possi!iity of deeoping pregnancy induced hypertension. Proteinuria in thea!sence of urinary tract infections is indicatie of gomeruar endotheiosis whiea significant increase in proteinuria couped with diminished urinary output

indicates rena impairment

ectie data doesnot predispose her to !reech presentation. /!>ectiey, =tra Sound Scanning(=SS) was not done so it is difficut to rue out the other causes. +fteresta!ishing that the woman was in a!our she was commenced on intraenousfuids of 7 @ de4trose to maintain ade:uate hydration status and proide energy.There were no signs of materna distress !ecause the ita signs were within thenorma ranges. There was norma progress of a!our in the sense that thecontractions were progressing we from mid to strong contractions. The fetaheart rate aso remained within the norma ranges. The i:uor stained meconiumis norma in !reech presentation and is an indication of feta compromise. +s the!reech descends into the peis, meconium is forced out of the coon and anusand fresh meconium with a deepy engaged presenting part is indicatie of!reech presentation. This is the ony indication in which meconium is notnecessariy a sign of feta compromise.(Seers, 2''&)

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+t $'' pm there was spontaneous rupture of mem!ranes. The i:uor wasmeconium stained. + agina e4amination was done. The ceri4 was A cmdiated. Cord was not fet and the presenting part was not we appied to theceri4. t was a compete !reech. ;eta heart rate was &$' !eats % minute. She

was e4periencing $ strong contractions in &' minutes. She deiered an hourater meaning that she did not need any anti!iotics !ecause anti!iotics areadministered when &2 hours hae gone after rupture of mem!ranes. (Myes,2''$)

The !uttoc*s and the egs were !orn at 52' pm. ?hen the oop of the cordappeared at 522 pm, she was discouraged from pushing and it was genty pueddown and oosened and strong pusations were present. oosening of the cord isimportant !ecause it preents tension on the cord that can !oc* !ood suppy tothe fetus. t was aso important to note the time when the oop of the cordappeared !ecause there is ony 8 to &' minutes aaia!e soon after the cord has

appeared ti deiery if the !a!y is to surie !ecause once the feta head entersthe materna peis !ood suppy is cut from the fetus (Seers 2''$). n this casethe oop of the cord appeared at 522 pm and deiery was competed at 5$' pmDwhich means it too* &' minutes and the !a!y suried with an +pgar score of8%&', &'%&'. The e4tended arms were deiered using osetBs manoure. Thismanoure is important in the deiery of e4tended arms !ecause it preentsseere perinea tears and trauma to the fetus. The head was deiered using-urnBs Marsha Manoure !ecause it was fe4ed.

+fter deiery the mother was e4amined for any tears. She sustained first degreeperinea tear which was sutured using chromic 2' suture with prior

administration of &@ ignocaine as a oca anaesthesia. +fter suturing the motherwas adised to !e ceaning the area with saty water to preent infection.

The !a!y was aso e4amined for trauma. There was no apparent in>ury. 255hours postdeiery the !a!y had !een haing a norma cry, no conusions anddid not deeop >aundice. This was an indication that the !a!y did not sustain anyin>ury.

The !a!y and the mother were gien nursing care in the postnata ward for $days. The mother did not deeop any compications postnatay.The !a!y had!een suc*ing we and has had no pro!ems with eimination. #is !irth weightwas $'''g and was discharged on day $ with a !ody weight of 287'g. Theweight oss was norma !ecause a !a!y is e4pected to ose amost &'@ of the!ody weight for the first $ days and regain it for the ne4t &' days. The weight ossis due to inade:uate coostrum for the eary days, passing out of meconium, andinsensi!e water oss. The weight is regained ater !ecause after $ days ofdeiery !reast mi* production !ecomes we esta!ished.

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t shoud !e a must to do =tra Sound Scanning (=SS) on any antenata womanwhose presentation of the fetus is not cephaic in order to rue out fetaa!normaities.f resources permitting, =tra Sound Scanning (=SS) shoud !e done on eachand eery antenata woman in order to rue out feta a!normaities and to

determine the si1e of the !a!y in reation to the materna peis so as to predictthe appropriate mood of deiery.

REFERENCES

-ennet,


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Sweet, -.R. (&AAA) M&."%$ M*3*"#. (&2thedition) ondon, -aiiere Tina.

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breech hhhh

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