INTRODUCTION. This is a case study for baby Joyce Chitini, born to Mrs. Joyce Chitini, a para 3. Mrs.

Chitini delivered at bwaila hospital on the 26th of October, 2008, and got discharged on the 27th of October 2008. On the 28th, her baby developed jaundice, which, progressed gradually till it was generalized. She brought the neonate to the hospital on the 29 th October. Jaundice is the yellow discoloration of the skin and conjunctivae due to the presence of bile pigment in the blood. In new borns it is usually caused by the breakdown of red blood cells which releases a yellow substance called bilirubin. Bilirubin is processed by the babys body before it is excreted through babys urine and stools (http://nursingcrib.com). This process is normal after birth and it usually does not require treatment. However, in some cases, more severe or pronounced jaundice is a sign that the babys body can not process bilirubin quickly enough and in such cases phototherapy is needed to speed up the process of breaking down bilirubin. This neonate was cared for four days, after which she was discharged. This write up then discusses and criticizes the type of care that this neonate was given throughout hospitalization and it includes It includes the assessments done, the care provided, the discharge plan and analysis of the situation. The first part explains the detailed account of the day-to-day care of this neonate while the last part is the critique of the care that was given. PERSONAL HISTORY. Mrs. J.Chitini is 30 years old and resides at Area 24, near the apostolic church at Miss. Rose Chilomos plot. She is a house wife and married to a salesman at Beco international She is Chewa by tribe and so too is her husband. Mrs. Chitini belongs to Roman Catholic Church and she went to school up to form four but she never attended any tertiary education thereafter because she did not do well in her Malawi school certificate of education examination. PREVIOUS OBSTERTRICS HISTORY. This is the third child for Mrs. Chitini meaning that she has gone through labour three times as well. All the pregnancies were singletons and they were all spontaneous vertex deliveries. The first child was born at a hospital in 2003, while the second born was born at a traditional birth attendant in 2005 and this child was born here at bwaila hospital. They are all girls. She explained that she had antepartum bleeding during the first pregnancy, but had no any other problems during the subsequent pregnancies. Se said all her children cried immediately after birth and were average sized. Mrs. Chitini did not experience any problems related to lactation and breast feeding as she explained that her breast were producing enough milk. PRESENT OBSTETRIC HISTORY. Mrs. Chitini explained that she had her last menses in December, 2007 but she could not remember the exact date and this meant that, her estimated date of delivery in September 2008. Mrs. Chitini drained liquor for two days before the actual delivery, and apart from this, she never experienced any abnormal symptoms like bleeding or abnormal headache.

She also explained that she attended antenatal care three times at bwaila during this pregnancy as follows: Date of visit 25.06.08 06.08.08 03.09.09 Gestation Fundal height 24 26 30 32 35 36 Presentation Weight Cephalic Cephalic Cephalic 67.1kgs 68kgs 70kgs Blood pressure Fetal heart Positive Positive positive

MENSTUAL AND GYNAECOLOGICAL HISTORY. Mrs. Chitini attained menarche at the age of 13 years and since then her menstrual cycle has been regular-28days cycle. She menstruates for 5 days and the nature of her menstrual flow is moderate. She said she does not experience any dysmenorrhoea. Additionally she has never had an abortion or ectopic pregnancy. CONTRACEPTIVE HISTORY. Mrs. Chitini displayed adequate knowledge in family planning by explaining that she knows various methods like pills, injection, condoms and bilateral tubal ligation. She admitted not having adopted any type of family planning method because her church does not allow family planning. PSYCHOLOGICAL HISTORY Mrs. Chitini explained that this was a planned pregnancy, both the client and her spouse have accepted and, are ready for the baby. SEXUAL HISTORY. Mrs. Chitini said nothing changed on her sexual response during pregnancy even right now, however, she said in her culture a woman is not supposed to have sex with her husband soon after delivery until the baby is six months old. MEDICAL HISTORY. The client denied any history of tuberculosis, asthma diabetes renal disease, heart disease, epilepsy, hypertension and mental illness. SURGICAL HISTORY. Mrs. Chitini denied having undergone any type of surgery including uterine surgery, vesical vaginal fistula repair or 3rd degree repair; however she admitted having sustained a small tear during this delivery which was repaired by a midwife.

FAMILY HISTORY. She said she does not have any history of some of the hereditary conditions like tuberculosis, heart disease diabetes mellitus epilepsy and mental illness, but her grand mother is hypertensive. She also denied history of twinning. SOCIAL HISTORY. Mrs. Chitini is the first and only wife to Mr. Chitini. Her husband went to school up to form four after which he pursued a certificate in marketing. None of them smokes nor takes alcoholic beverage. NUTRITIONAL HISTORY. Mrs. Chitini said she has adequate knowledge of six food groups and she said she is able to afford the food sources without any problems from her garden. She explained that even the time she has been in hospital her relatives and friends are bringing her food every meal, For example, a day before she came to the hospital she had tea with milk and doughnuts in the morning, nsima with boiled nkhwani and eggs for lunch and during supper she said she had nsima, beans and cabbage plus banana for supper. This 24 hour dietary recall shows that this client is able to afford all the six food groups, On food preparation, she likes stewed food and salads rather than boiled vegetables. In her culture she said she is not aware if there are any dietary restrictions related to pregnancy and lactation.

PHYSICAL EXAMINATION. General appearance: A healthy looking mother, well kempt in body and clothing well nourished with no significant abnormal feature. She was happy at the time of examination. Vital signs: Temperature: 37.1 degrees celsius. Blood pressure: 126/90 mmHg Respirations: 16 breaths per minute. Pulse rate: 88 beats per minute. Weight: 67 kilograms. HEAD-TO-TOE EXAMINATION. Head: well distributed hair, no dandruff, well combed hair. Face: symmetrical features, no acne seen. Ears: no enlarged lymph nodes palpable. Nose: no nasal stuffiness of discharge. Mouth: pink tongue and mucous membranes, no oral thrush, no Kaposis lesion seen. Neck: no lymphadenopathy, full range of motion. Upper extremities: warm skin, palpable brachial and wrist pulses, full range of motion, no edema of the fingers, good capillary refill.

Chest and lungs: symmetrical chest no retraction or bulging of intercostals spaces during inspiration and expiration, symmetrical expansion. Low pitched resonance of moderate intensity. Breasts: clean nipples, supple, symmetric in size and contour, darker pigmentation of nipple and areola present, superficial veins prominent, milk present. Lower extremities: popliteal artery palpable strong and regular, no edema nor varicosities seen. ABDOMINAL EXAMINATION. Inspection: loose skin on the abdomen seen. No visible scar, striae garvidurum and linea nigra prominent. Palpation: abdomen non tender, liver and spleen non palpable. Uterus palpable just above the symphysis pubis. Vaginal inspection: vulva clean, with mild, pale pink lochia seen on the sanitary pad, no sores seen, no warts or varicose veins. Well done surgical sutures seen on the perineum, tightly sewn and intact. Digital vaginal examination was not done. Conclusion on the physical examination, nothing significant was detected. PHYSICAL EXAMINATION OF THE NEONATE. GENERAL APPEARANCE. The baby was active and alert in a well flexed position, with a yellow skin colour for the whole body including extremities. Soles of the feet and palms were also yellow. Skin texture was smooth and soft with no dry peeling of the hands and feet as in post mature baby. There were no skin pustules or rash. The baby did not have any congenital obvious abnormality. The Gestational age assessment showed that that baby was about 39 weeks. Vital signs were: Temperature: 36.2 degrees celsius Pulse rate: 122 beats per minute Respirations: 42 breaths per minute Her weight was 3200kgs. HEAD -TO -TOE EXAMINATION. HEAD. The head was symmetrical to the body. Head circumference was 35cm.There was no caput or moulding, the fontanels and sutures were normal size. Both the anterior and posterior fontanels were palpable, neither were they sunken nor bulging. EYES. There was moderate whitish discharge on both eyes. Both eyelids were swollen.

There pupil was clear not suggestive of opacities. The sclera was slightly red possibly due to inflammation caused by the neonatal ophthalmic but it was not suggestive of trauma. There was no subconjuctiva heamorrhage. The nose: was patent without discharge or polyps. There was no nasal flaring The ears: the pina was well developed, the ears were patent there was no discharge. The upper corner of the ears was in line with the outer corner of the eyes. The mouth: There were no witch teeth, no oral thrush. There was no cleft lip plate or cleft hard palate. Rooting and suckling reflexes were present. THE NECK There were no lumps, swelling and webbing UPPER EXTREMITIES The arms were symmetrical; there was no fracture of clavicle or bone of the arms. There were no extra digits. Palmer clenses were present.Grasping and moro reflexes were present. THE CHEST The chest had normal barrel shape.There was symmetrical breathing movements.The respiration was normal with 48 breaths per minute without chest indrawin,subcoastal retraction. THE ABDOMEN The umbilical cord was tightly secured and not bleeding.There was no exomphalus.The liver and spleen was not palpable THE LOWER LIMBS The legs were symmetrical.There were no extra digits.There were no fractures.The Otolans sign was negative for congenital hip dislocation.The feet had no talipes and webbing between digits.Grasping reflect was present Walking reflex was present THE GENITALIA The anus was patent but baby had not yet passed meconeum but passed urine. The urethra opening was present at centre of glans penis and the testes were Descended. THE BACK The spine was even not suggestive of meningocele or Spina Bifida Crown to heal length was 38cm. .

ANALYSIS OF THE ANTENATAL CARE In trying to minimize maternal neonatal mortality, the ministry of health and population launched a national safe motherhood initiative with four pillars of services one of which is focused antenatal care. Focused antenatal care is the care where the number of visits to attend antenatal care is reduced but compensates the client by increasing the client-provider time, (Obstetrics Life skills training manual, 2000). As per recommendation by the safe motherhood initiative, every woman is scheduled for four antenatal visits, first at the initial (booking visit), second visit after six weeks if the pregnancy is less than 28 weeks gestation or four weeks if pregnancy is more than 28 weeks, third and fourth visits are scheduled four weeks apart. (Obstetrics Life skills training manual, 2000). However, Mrs. J.C attended only three visits, first one at 24 weeks, then at 30 weeks and finally at 35 weeks. During these visits she received care as follows: intermittent preventive treatment twice and ferrous sulphate supply for a month three times. 1. Laboratory examinations: Frazer et al (2006) emphasizes that knowledge of hemoglobin level, blood group and any systemic infections in a pregnant woman help in planning appropriate care during pregnancy, labor and delivery hence preventing complications. a) Hemoglobin level: this test measures the amount of hemoglobin, the oxygen carrying factor, and red pigment of the blood. As a recommendation by safe motherhood, every pregnant woman is supposed to be tested for anemia at booking and at 36 weeks. This is done to rule out anaemia in pregnancy which is one of the leading causes of maternal mortality in Malawi. Additionally, it brings with it a lot of complications like premature labour, intrauterine growth retardation as well as intrauterine deaths and many more. Obstetrics life skill training manual (2000) defines anemia as a hemoglobin level of less than 10 grames per deciliter which is a result of deficiency in the quality or quantity of red blood cells .Mrs. J.Cs hemoglobin level at booking was 10.2 grammes per deciliter which is the borderline of normality and mild anaemia. This was never repeated at the third visit or any other visit. b) Blood group: this is done to determine the mothers blood group in case of need for transfusion, but also to exclude Rhesus negativity which pre disposes to abortion and fetal rejection especially if the father or fetus is Rhesus positive and vice versa. Mrs. J.Cs group was B positive, which meant that shat she belongs to blood group B type with a positive Rhesus factor. c) VDRL: this is translated to Venereal Disease Research Laboratory test and it is performed for syphilis. However, not all positive results indicate active syphilis. Early testing will allow a woman to be treated in order to prevent infection of the fetus. During the whole antenatal period, Mrs. J.C. was never tested for VDRL. This had negative implications on the mother as well as of fetus because not

knowing the results means depriving both the mother and the fetus of treatment, thus exposing them to abortion, malformation and disfigurement. d) HIV: this is done after pretest counseling to start treatment or administer prophylactic treatment of niverapine which is beneficial in reducing vertical transmission to the fetus. e) Urine for albumin: this was done to exclude albumin in urine which is an indication of abnormalities such as pregnancy induced hypertension or urinary tract infections. This was done at booking visit and it was found to be negative. f) Stool microscopy was not done. g) Fetal presentation analysis: throughout the 3 visits, Mrs. Ndholos fetal presentation has been cephalic. As explained in the obstetrics life skills training manual (2000) the fetal position which is often associated with appropriate progress of labour and delivery is the vertex presentation, hence breech, transverse or oblique presentations during intrapartum is a risk associated with a very high perinatal mortality if delivery is done by people with little training or experience. 2). Prophylaxes. The prevention or treatment of maternal anemia should be part of focused antenatal care (obstetrics life skills training manual 2000). With regards to the level of hemoglobin for Mrs. J.C which was relatively low, ferrous sulphate was supplied to her every time she attended antenatal care. She was also given fansidar 3 tablets which she took under direct observation at the clinic once for prevention of malaria as an intermittent prophylaxis treatment. Focused antenatal care recommends that malaria prophylactic treatment be given to every antenatal mother three times during the antenatal period, after 16 weeks gestation (or after quickening has taken place) and before 36 weeks gestation (obstetrics life skills training manual 2000). This is done to every pregnant woman as per guidelines by the safe motherhood because malaria resistance is reduced during pregnancy and intermittent prophylaxis treatment is used to avoid frequent attacks of malaria which predisposes the mother to haemolysis of red blood cells and anaemia which may lead to premature labour or abortion. Since Mrs. J.C received fansidar only once in the whole antenatal period, it means that she was not fully protected from malaria and she was at high risk for developing malaria at any time. This also put the fetus at risk. Her late attendance to antenatal care could have also contributed to this problem, because she started antenatal care at 24 weeks gestation the time she was expected to have received her second dose of fansidar. Additionally she was also given an insecticide treated net for the same purpose of malaria prevention at the first visit.

Safe motherhood also emphasizes the need for a complete dosage of tetanus toxoid vaccine in order to prevent neonatal deaths due to tetanus, using the cheapest easy to access mode, thus vaccination. Mrs. J.C finished her schedule during the second pregnancy and she was appraised for this. 3). Routine midwifery observations. h) Olds (2000) explains that it is important to note the pattern of weight gain during pregnancy in order to evaluate the need for nutrition counseling, obtain information on eating habits, cooking practices, need for food supplements, pica and other food habits. However for this to be done effectively there is need to note the initial weight to establish baseline for weight gain throughout pregnancy. Throughout the antenatal period, Mrs. J.Cs weight was monitored and it was ranging between 67.1 kgs to 70 kgs with an average of 68.3kgs. Her initial weight gain is not known but on average she was gaining 0.19kgs per week. According to Myles (1998), normal weight gain during the second trimester, is 0.5 kilograms per week, which means that this clients weight at this time was lower than expected. This is very worrisome especially in pregnancy because it could be a warning that something is wrong somewhere. Lack of or reduced weiht gain can be due to excessively low carbohydrate and fat intake which decreases maternal weight and fetal growth that can result to intrauterine growth retardation and/ or intrauterine death in extreme cases. In conclusion, Mrs. J.C. did not receive adequate care during her antenatal period because due to some reasons, she did not undergo some important laboratory examinations like VDRL, blood grouping and stool microscopy. Additionally, some vital observations like blood pressure check was not done throughout her care antenatally. Sellers (2003) emphasizes the importance of checking blood pressure antenatally while following and analyzing its pattern in order to exclude and identify pregnancy induced hypertension, hence early intervention. Throughout the three visits, Mrs. J.Cs blood pressure was not monitored. SUMMARY OF LABOUR AND DELIVERY Mrs. J.C laboured for 22 hours, which was not accompanied by drainage of liquor. She only had one vaginal examination and fetal and maternal response to labour was also monitored once-during admission. She was seen again in her second stage when the head of the fetus was at the vulva. She delivered a live full term female infant weighing 3200g by spontaneous vertex delivery. Apgar score was 8/10 then 10/10. Two hours later she was discharged to low risk post natal ward. During the third and fourth stage nothing abnormal was indicated. Placenta was removed through CCT and it was recorded to be complete.

ANALYSIS OF LABOUR AND DELIVERY Perri and Lowdermilk (2006) explains that labour is considered normal when the woman is at or near term, no complications exist, a single fetus presents by vertex, and labour is completed within 18 hours in multiparas or up to 20 hours in nulliparas. In this case Mrs. J.Cs labour, which took almost 22 hours, could be considered prolonged. Prolonged labour predisposes both the mother and fetus to ascending intrauterine infection during and after delivery (Myles, 2002). This is mainly due to the fact that the cervical os remains and keeps on opening throughout labour. This could be because she was missed out and was not followed up thereafter, because soon after admission, she was sent for ambulation, and to await established labour in the waiting room, where no staff goes to check on the patients. This may also be reason fetal and maternal monitoring never took place thereafter until she was in second stage of labour.

PROBLEMS IDENTFIED FOR BABY Potential for brain damage related to inability to conjugate bilirubin. High risk for infections related to prolonged labour. High risk for altered nutrition less than body requirements related to feeding difficulties High risk for respiratory distress syndrome related to prematurity High risk for jaundice related to prematurity and infections High risk for hypothermia related to prematurity PROBLEMS IDENTFIED FOR MOTHER 1.Actual problem of anxiety related to babys condition 2.Altered baby and parent bonding related to intensive nursery care 3.High risk for infection related to prolonged labour. 4.High risk for breastfeeding problems related to nutrition deficit. 5. Actual problem of knowledge deficit on six food groups related to lack of information 6. Actual problem of knowledge deficit of Sexuality during puerperium related to cultural taboos 7. Actual problem of poor health seeking behaviour related to late attendance for antenatal care. 8. lack of family planning implementation related to religious belief. 8. Non compliance on focused antenatal visits 9. Potential for intrauterine infection or sexually transmitted infection

MIDWIFERY CARE PLAN MIDWIFWER Y DIAGNOSIS Actual problem of eye infection related to prenatal and intrapartum infection of mother GOAL The baby will demonstrat e no signs of infections within 5 days of manageme nt INTERVENTIONS RATIONALE EVALUATIO N prevent Check Nurse baby To spread of condition of in isolation infection to eyes once everyday to Clean eyes other babies To remove eye asses for with normal saline using discharge and improvement clear clean cotton help infection swabs Administer Tetracycline To treat by killing ointment causative 8hourly microorganis Wash hands ms before and To prevent after eye care cross infection Check To rule out mother for congenital VDRL syphilis for prompt management as neonatal opthamia may be as a result of sexually transmitted disease passed on from mother.

MIDWIFER Y DIAGNOSIS Actual problem of anxiety of mother related to babys condition manifested by mother asking questions about baby

GOAL Mrs.F.B should demonstrate understandin g of babys condition and exhibit no signs of anxiety throughout hospitalizatio n

INTERVENTIONS Establish a good nurse client relationship Explain to mother about babys condition,pro gnosis and every intervention Allow mother to ask questions Involve the mother in the care of the baby Explain the routines and protocols of the ward e.g nursing baby in isolation room, handwashing before touching baby,removin g shoes when

RATIONAL E -To promote open communicatio n and verbalization of concerns -To allay anxiety and promote her cooperation -To promote verbalization of her feelings for prompt management -To raise her self confidence on the care of the baby and allay anxiety -To allay anxiety and promote her cooperation in the care

EVALUATIO N

entering nursery

the

MIDWIFER Y DIAGNOSIS Altered mother-baby bonding related to babys condition

GOAL The mother and baby should maintain bonding throughout hospitalizati on

INTERVENTIOS Explain to mother about babys condition and the need to be nursed in isolation nursery Encourage and assist with exclusive breastfeedin g Encourage the mother to cudle baby,talk to him when breastfeedin g or caring for her

RATIONALE -To promote understanding,all ay her anxiety and gain cooperation.

EVALUATIO N

-provides chance for mother to carry her baby for mother and baby to explore each other feeling and promotes closeness -Encourages bonding

MIDWIFER Y DIAGNOSIS Potential problem of altered nutrition less than body requirement related to feeding difficulties

GOAL To maintain the required nutritional needs of the baby throughout hospitilisatio n

INTERVENTION S -Assess babys ability to suckle and swallow -Teach mother and assist with proper breastfeeding attachment and postioning -If unable to suckle from breast discontinue and insert nasogastric tube for feeding for feeding expressed breastmilk -Provide baby with 10% glucose in water if mother unable to express enough breastmilk -Provide feeds calculated based on daily weight -Advise the mother to take 6 food groups with more proteins and more fluids atleast 3litres in day

RATIONAL E -For planning of appropriate feeding measures -To promote exclusive breastfeeding to meet babys body requirement -To provide baby with enough exclusive breastmilk to meet body requirements -To provide baby with adequate glucose to meet metabolism requirements -To meet nutritional requirements for the baby -To promote production of enough breastmilk to meet babys requirements

EVALUATIO N Weighing baby on altenate days to assess weight gain

MIDWIFE RY DIAGNOSI S High risk for infections related to prematurity

GOAL

INTERVENTION S -Follow infection prevention measures:mother and health workers to wash hands before and after contact with baby,mother to remove shoes when entering the nursery -Do umbilical cord care once daily - Encourege and assist with exclusivebreastfeed ing

RATIONA LE -To prevent spread of infection to the baby.

EVALUATION

The baby should not develop infections throughout hospitilisati on

Check vital signs 2 hourly to detect signs of infection e.g hyperthermia or hypothermia,tachycar dia

-To prevent entry of microorganis m through the cord which is a raw wound -For baby to acquire passive immunity through colostrums i.e Ig A,Ig C and additional phagocytic cells which -Take blood sample helps to fight for full blood count infections -To check signs of infection e.g increased white cell count for prompt management

MIDWIFER Y DIAGNOSIS High risk for respiratory distress syndrome related to prematurity

GOAL The baby will not develop complication s of prematurity throughout hospitilisatio n

INTERVENTIONS -Check vital sign hourly for one hourly increasing frequency when condition is stable

RATIONAL E

EVALUATIO N

-For early identification of signs of respiratory distress syndrome for prompt management -Check sign of -For proper respiratory distress and prompt syndrome i.e management cyanosis,grunting,nas al flaring,subcoastal retractions -Provide oxygen -To help meet therapy 2litres/minute adequate if baby develops the gaseous condition exchange to prevent complications -To prevent -Nurse the baby under hypothermia rediant warmer with which can temperature well cause regulated respiratory andmonitored distress syndrome

NURSING PROGRESS RECORD 18TH AUGUST,2008 9.30AM S Received the baby from labour ward nurse who reported that they had brought the baby for admission in nursery baby was born with excessive eye discharge. O: On head to toe assessment of baby there was no significant findings except that the baby had swollen eyelids and purulent eye dischargeand it was premature. Vital signs were temperature 36.6degrees celcius,heartrate 110/minute,respiration 48/minute A : Actual problem of eye infection related to maternal perinatal and intrapartum Infection. Actual problem of prematurity related to premature labour P: As per care plan To take comprehensive antenatal,intrapartum history after admission of baby. I: Introduced myself to the mother and informed her that I had identified her baby as my as my casestudy.Informed the mother about the babys condition and that he would be admitted in Nursery isolation room for proper management.She was also imformed the plan of care ,expectations from her such as infection prevention measures and 2hourly feeding of the baby.The mother demonistrated understanding of the explanations. 9.40AM Baby was properly covered and put under a radiant warmer with temperature set at 26degrees celcius to provide warmth and prevent hypothermia. Washed hands with soap and running water The baby was placed on its back ,eyes cleaned and Tetracycline eye ointment applied 10.00am It was time for feeding the,observed the mother breastfeeding and she was having breastfeeding problems the baby could not suckle and mother was producing less milk. Advised the mother to express and feed with a cup.told to feed baby with 10 ml per feed according babys weight and she was shown how much that was using the feeding cup Advised to altenate cup feeding with breastfeeding to stimulate babys suckling reflex and milk production as it stimulates release of oxytocin The mother was also advised to eat adequately and meals to comprise 6 food groups With plenty of fluids. 11.25 A.M Checked the baby the linen was wet with urine.Provided baby with clean and dry linen And covered baby well to prevent heat loss.

Vital signs were checked temperature 37.2degrees celcius,heartrate 112beats/minute, Respirations 47 breaths per minute. 12 P.M Mother came for breastfeeding she was assisted to express breastmilk in a cup but She only expressed 4mls.She verbalized that she was hungry as she had not eaten since Morning. Told the mother that this could have contribute to poor milk prodiction She was counseled on the importance of taking adequate food to promote milk Production.The plan was to continue monitoring feeding to ensure babys get enough to meet body requirement. 2P.M S : Mother came for breastfeeding,she reported that she was still having difficulities Breastfeeding she had tried to put baby to breast but baby not suckling. O: Observed the mother expressing milk she only expressed about 5 mls.The supply was Inadequate. A :Potntial problem of nutrional deficit related to feeding problems P : As per care plan Take comprehensive history of mother for antenatal,labour and delivery I :Assisted the mother with babys attachment and positioning to breast and Baby managed to suckle . History was taken and records reviewed where it was noted that antenatal mother did Not have blood for VDRL and that she had pronged premature rupture of membranes Plan was to have VDRL done and have clinician to review mother the following day for to assess and treat infection if present.The mother was informed about her condition and plan of care and she accepted. 4P.M Assesed babys vital signs Temperature 37.4 degrees celcius,heartrate110beat/minute, Respirations 46beats/minute.There were normal Baby had some yellowish eye discharge in eyes.Eye care was done and baby left clean. 4:55 P.M Assed the baby there was no discharge in eyes.The linen was dry and clean the baby comfortable.Informed mother about babys condition and informed her I was knocking off.Reminded her about 2hourly feeding and adherences to Infection prevention measures with emphasis on hand washing before breastfeeding the baby. Gave handover to night duty nurses to continue monitoring baby condtition throughout The night and knocked off. DAY 2 :19 AUGUST,2008 8.00 A.M S : Received hand over from the night duty nurses who reported that the babys eye Infection was worsening.The baby was producing excessive eye discharge which was Greenish in colour.The baby was suspected to have congenital syphilis.

The nurses covered the baby on antibiotics :Benzylpenicilln 105,000`IU 12 hourly For 5 days and Gentamycin 10mg once a day for 5 days.She also had Tetracycline Eye ointment in the morning. Mother reported the baby was feeding well and the amount of milk she was expressed Had increased.She reported to have feed baby about 6 times during the night. O : Baby assessed vital signs Temperature 37.3celcius,heartrate 108 beat/minute, Respirations 48breaths /minute.The eyes were clean without any discharge. A : Actual problem of infection. P :As per care plan To continue monitoring baby for infection,feeding problems to prevent complications Of prematurity. Check mother for VDRL and treat her if positive I : Dump dusting done,babys linen changed and baby provided with clean and dry linen And left sleeping in a comfortable environment. Calculated the amount of milk to be given per feed and it was 15ml showed the Mother this quantity using the feeding cup. 8.30A.M Cord care was done,the umbilical cord was cleaned with normal saline,deministrated To the mother on how to do it the cord was and left dry to prevent a good medium for multiplication of microorganisms. Also advised the mother to watch for signs of jaundice in the baby such yellow staining of skin and eyes as preterm babies are at high risk of developing jaundice. 10.00A.M Observed the mother breastfeeding the baby assisted with positioning and Attachment to breast baby was able to suckle a little.Suplemented expressed milk with 10 ml of expressed breastmilk. 10.20 A.M Reminded the mother that she was to be checked for VDRL this day because The baby was demonstrating signs neonatal Opthalmia caused by sexually transmited infection which he might have acquired from her. Checked with the sister in charge on this matter who informed me that the test is not being done at Bwaila as there are no reagents and advised to take the mother to Sexually Transmitted disease clinic for proper management. 11:05A.M Went with the mother to the STI clinic where upon assessment she was Symptomatically treated for Gonorhea.She was given Gentamycin 240mg immediate dose once and Erythromycin 500mg 8hourly for 5 days and was asked to bring her husband for treatment Counseled the mother on drug compliance and need to bring partner for treatment to Avoid reinfection.She reported to inform the husband when he comes for visiting so he Could get treated right at this hospital. 12P.M Checked baby vital signs which were normal temperature was 37.4degrees Celcius, heartrate 110 beats/minute and respiration 50 breaths/minute Mother feed baby with 15 ml expressed breast milk and then put baby to breast and was

able to suckle and swallow. 2.00P.M Assessed the baby and found that the eyes were still swollen, there was moderate purulent discharge. Hand washing was done, Eye care done and the afternoon dose of Tetracycline eye ointment applied. 3:10 P.M The baby was reviewed by the Doctor who ordered the baby to maintain the treatment he was receiving until 5 days. 4.45P.M The baby was assessed the vital signs were normal Temperature 37.3 degrees celcius, heartrate 105beats/minute, respiration 48 breaths/minute. The mother was informed on prognosis of the baby and encouraged her to continue breastfeeding and hygiene to maintain the condition. Reminded her to feed baby 2hourly at night encouraged mother to curdle and chat with bay when feeding to promote bonding. Handed over the baby to night duty nurses to continue monitoring babys condition over the night and I knocked off. 3rd DAY: 20 AUGUST, 2008 7:30 P.M S: Night duty staff reported that the baby had hypothermia and they added extra linen to Keep baby warm. The eyes were improving excreting less discharge .The baby had already received the morning dose of antibiotics and eye ointment. Mother reported that baby was able to suckle from the breast and was feeding well. O: Vital signs were Temperature 35.5 degrees celcius, heartrate 110beats per minute, respirations 52breaths per minute. The eyes were clear without discharge and the eye lids were slightly swollen as swelling was subsiding . The babys linen was wet and soiled with meconeum. A: Altered thermoregulation hypothermia, related to prematurely secondary to exposure to Cold environment manifested by temperature of 35.5 degrees Celsius. P: To increase temperature of radiant warmer to 30degrees Celsius and monitor hourly. Keep baby in dry environment to keep him warm Provide baby with extra linen Promote adequate feeding of baby 20ml per feed 2 hourly according to babys weight Post pone interventions that exposes baby to cold e.g. weighing and cord care until Temperature is stable. Recheck temperature after 1 hour to evaluate effectiveness of interventions. 7:49 A.M I : The baby was wiped off meconeum with a cloth wetted with warm water then its coat was cleaned and baby provided with extra clean and dry linen. Temperature of radiant warmer was increased to 30 degrees Celsius. To inform mother of babys condition when she comes for feeding, discourage Unnecessary exposure and monitor feeding to ensure baby is getting enough to meet metabolic requirements. To recheck temperature after 1 hour at 8.49 A.M

8:49 A.M Temperature checked it was 36.8 degrees celcius; plan was to continue checking hourly And decrease frequency when temperature stabilizes. 10:00 A.M The mother come for breastfeeding and was informed of the babys condition. She was Also the amount of milk to give baby per feed 20ml/per feed. Baby was given 20ml of expressed milk and put on breast was able to suckle. Reminded the mother to inform the husband about need to be treated for STI when he comes visiting. She reported that the husband would come at Lunch break and she was going to inform him. Asked her to tell her husband to meet me for counseling on need for treatment. 12 P.M Temperature was checked it was 37.4 degrees celcius.The temperature of radiant warmer was reduced to 26 degrees Celsius to prevent overheating the baby. 12:20 P.M The mother came for breastfeeding and baby breastfeed well without problems. The mother reported that the husband was around and she had informed him about the treatment and he accepted. Counseled the couple together and arranged for the husband to receive treatment at Bwaila STI clinic after lunch break. 2P.M Checked temperature which was 37.7 degrees Celsius. The baby was weighed and his weight was 2000g.The baby had lost 100g from the birth weight this is normal physiological weight loss which is expected for neonates to lose 10% of birth weight within 10 days afterbirth and then start gaining. Eye care was done using aseptic technique and Tetracycline eye ointment applied. Cord care was also done using normal saline. The cord was not bleeding ,drying well and no signs of infection observed 2.30P.M Mother came for breastfeeding and she reported that the husband had also received treatment as per plan.Comfirmed by checking in her health passport where this was documented. Informed the mother that the babys condition was improving and if this continued she was going to be discharged in 2 days after the baby had finished antibiotic treatment Informed the mother that the following day was going to be last day for the case study this was to gradually terminate nurse-client relationship. The baby was breastfeed without any problems. 4.P.M

Baby assessed there eyes were improving there was no discharge seen swelling was subsiding.Vital signs were temperature 37.5 degrees celcius,heartrate 107beats/minute,repirations 48breaths/minute.No abnormal findings detected. Plan was to continue management as per plan. 4.12Pm Mother came for breastfeeding and baby feed without any problems.The mother was counseled on Family planning and puerperal sexuality as part of discharge plan and she demonistrrated understanding of the lessons by asking questions and answering appropriately. 4.55P.M Temperature was checked it was 37 degrees celcius.Told the mother to cover baby well and ensure he is dry all the time to prevent hypothermia. Gave hand over to night duty nurses and knocked off. 4th DAY:21 AUGUST,2008 8:00 A.M S :Mother reported that baby was fine spent the night well. Was able to breastfeed and feed 7 times during the night. The night duty nurses reported that the baby was improving, was having less eye Discharge and morning temperature was 36.8 degrees Celsius O: Baby was active and alert, vital signs temperature 36.9 degrees celcius, heartrate 112beats/minute and respirations 46 breaths /minute. No eye discharge observed and the eyelid were not swollen slight erythematous.The treatment chart indicated that baby had already received morning dose of antibiotics and eye ointment. A: Baby was improving P: To continue nursing care as per plan Implement discharge care plan Terminate nurse-client relationship 8:10P.M I: Dump dusting done. Babys coat cleaned and linen changed 10:10A.M Mother beast feed baby and baby was able to suckle without problems. Cord care was done using normal saline in the presence of mother the mother was Advised mother to continue doing cord care at home after discharge. 2:00P.M Checked vital signs temperature 37degrees celcius, heartrate 110beats/minute and Respirations. Baby was breastfeed without any problems. The mother was counseled on general care of the baby at home and follow up care including follow up visits at the hospital. The mother was also informed to have the baby immunized at follow up visit since baby could not be immunized while in hospital because his weight was less than 2000grams.According to Bwaila procols

premature babies get immunizations when they are 2000grams and above 2.30P.M Eye care was done and Tetracycline eye ointment. 4.30P.M Gave hand over to night duty nurses. Terminated relationship with mother.

SUMMARY OF THE CASE STUDY I feel I gave comprehensive care to this baby and it was also mother centered did a comprehensive assessment and analysis of the situation in order to provide appropriate and priority care. This baby was diagnosed with opthalmia neonaturum and also had prematurity was able to identify factors during antenantal, labour and delivery period which could have contributed to these conditions. I feel the cause for the Opthalmia neonaturum was maternal undiagnosed and untreated antenatal infections .These infections could also be the contributing factor for preterm labour.This is because Mrs F.B did not have comprehensive history take and laboratory investigation done during antenatal visit. For instance she was not checked for VDRL to detect Syphilis and urinalysis for urinary tract infection as it is required. This is reflects that the mother did not received quality antenatal care as required in focused antenatal care. The babys condition is also associated with factors during labour and delivery as Dulock et al suggest that events during labour and delivery influences the outcome the neonate.Mrs F.B had preterm labour and premature rupture of membrane and these also increases risk of neonatal infections. This neotate was born prematurely at 33 weeks gestation and was at risk of complications This baby received comprehensive care as he did not develop complications of infections and prematurity. I feel I provided quality and mother centered care because I was involved the mother in the care of the baby, encouraged bonding and I also facilitated for the mother and husband to get treated for their infection. DISCHARGE CRITERIA The following were the standards which were used to assess fitness of the mother and the baby for discharge home. THE MOTHER Well established lactation and ability to correctly position and attach the baby to breast. Physically and psychologically healthy and stable mother. Ability to provide good care and safety to baby. Ability to keep the neonate warm. Ability to identify danger signs in the baby.

BABY Stable vital signs within normal range:36.5-37.2 degrees Celcius,neonatal heartrate :120160/minute and respirations :30-60 breaths/minute. Baby able to suckle the breast well. No signs of infections. Baby able to pass urine and stools Baby active and all reflexes present Baby pink not cyanosed or jaundiced Dry umbilical cord without imflamation or any other sign of infection. Baby received BCG and Polio Vaccine. HEALTH EDUCATION AND COUNSELLING EXCLUSIVE BREASTFEEDING AND BREASTCARE The mother was taught the importance of feeding the baby breastmilk only until the age 6 months and introduce supplementary feeding after that. She was told the advantages of exclusive breastfeeding. She was reminded to always wash hand before breastfeeding to avoid spreading infection to baby. She was also reminded o breast positioning and attachment to prevent breastfeeding complications. She was taught to breastfeed the breast alternatively to prevent breast engorgement. Mrs F.B was also taught to clean the breast with piece of cloth and clean water to keep it clean. NUTRITION COUNSELLING Mrs. F.B was taught the importance of eating 6 food groups to help in development of the body for successful lactation. She was told that a good 6 food group diet should comprise of carbohydrates, proteins, fats, oil, vegetables and fruits. She was advised to take iron rich food to such as green leafy vegetables e.g. bonongwe Nkhwani, liver and dry fish as these help in production of hemoglobin and vit c rich food like citrus fruits because it aids absorption of iron. This was to increase her Hb and prevent anemia as she had lost some blood during delivery. She was also advised to take enough fluids at least 3litres in 24 hours as this helps in the production of milk. SEXUALITY Mrs. F.B was discouraged on the taboo of abstinence up to 6 months postnaltally since this promotes unfaithfulness of the partner which increases the risk of acquiring sexually transmitted infections including HIV She was counseled that it was safe to resume sex 6 weeks postnatal because by this time the reproductive system returns to its prepregnant state as long the woman is comfortable and lochia had stopped. FAMILY PLANNING

Mrs. F.B was advised to start family planning 6 weeks after the baby is born because by this time the reproductive system returns to its prepregnant state and ovulation resumes and she could get pregnant if she resumes sex at this time. She was counseled to consider voluntary surgical contraception as she had under gone 4 deliveries as it is risk for a woman to give more than five deliveries. CARE OF THE BABY She was advised to take good care of this baby to avoid neonatal or under five death as it occurred with the other 2 children. She was advised to attend under five clinics up to the time child is 5 years so that the child should get all immunizations and have the weight monitored for early detection of problems and prompt management and the mother to get IEC for health promotion. She was also reminded to keep the baby warm at all times as he was at risk of developing hypothermia due to prematurity. The mother was reminded on cord care and importance of maintaining hygiene to prevent the baby from developing infections since the baby had underdeveloped immune system. DANGER SIGNS Educated the mother on the danger signs to watch the child for at home which included: fever,jaundice,skin pustules, eye discharge, convulsions and pus,redness on the umbilical cord. She was advised to bring the baby to the hospital immediately if these symptoms occur.

REFERENCES Bennet, R. & Brown, L.K (2006) Myles Textbook of Midwifery-The African Edition (14th edition) Edinburg, Churchhill Livingstone Dullock, L. H & Vinten, A.S (1992) Martenal-Newborn Nursing (1st Edition) J.B Lippincot .Philadephia McEwan,D & James,A Elsevier.Churchill,Livingstone (2005) Obsterics in focus (1st Edition)

Sweet, B.R (2002) Mayess Midwifery (13th Edition) London.Baillere Tindal M.O.H ,(2001) Focused Antenatal care M.O.H, (2002) safe motherhood Manual

ss