University of Malawi KAMUZU COLLEGE OF NURSING

CASE STUDY
OF MRS. JIKA

TO
MATERNAL & CHILD HEALTH NURSING DEPARTMENT

MRS. KADANGO FROM BOB FAQUE

YEAR OF STUDY FOUR

COURSE LOW RISK MIDWIFERY

1|Page

TABLE OF CONTENTS Item page number

Acknowledgements.i Introduction.1 Subjective data..2 Objective data5 Problems identified7 Care plans.8 Progress notes12 Description of second stage..13 Description of third stage15 Initial assessment of the baby..17

Discharge plan/health education...19 Analysis of the case study.22 Impression24 References25 Appendix (antenatal visits page)...26

2|Page

ACKNOWLEDGEMENTS Firstly, I would like to thank the almighty Allah for the gift of life and strength that I have up date. Praise be to you! Successful completion of this case study is as a result of generous contributions and assistance of some individuals worth mentioning. I would like to express my heart felt appreciation to my midwifery lecturers for the midwifery knowledge imparted in me. Mrs. Kadango should receive my special thanks for the support and guidance when I was in labor ward.
I would also like to extend my appreciation to Mrs. Jika and her guardian for accepting to be

my case study client as part of my learning. I also thank them for the good gestures shown to me and for their cooperation throughout hospitalization. The sister in charge, Mrs. Kafansiyanji with all the staff of labor ward at Bwaila should also receive my thanks for the guidance and support offered to me during the time I was conducting the case study. Many thanks should also go to my fellow fourth year students for the support and assistance offered to me.

3|Page

INTRODUCTION As per clinical practice requirement, a midwifery student is supposed to do a case study of normal delivery and submit the write up to the clinical department. As partial fulfilment of this requirement, I identified one patient in labour ward by the name of Mrs. Jika. Therefore, this document presents the details of the case done on Mrs. Jika, 27 years old. She is a gravida 3 para 2 and hails from Chiwalo village, Traditional Authority Chikapa in Machinga district. She is a Yao by tribe and married. She has been attending antenatal clinic at Bwaila family health unit and she attended 3 visits in total. She was admitted in labour ward on 31st January 2011 at 4:30PM with complaints of lower abdominal pain and backache following 9 months amenorrhea. Upon assessment it was discovered that she was in latent phase of labour since the cervix was 4 cm dilated. After my expression of interest to take her as my case study she accepted and history taking was done right away. Using midwifery process, comprehensive care was provided to Mrs. Jika from admission until discharge. According to her, labour started on 31st January at 10:00PM. At 11:16 her cervix was fully dilated and at 11:33 labour progressed to a live full term male infant with an APGAR score of 9/10 at 1 minute and 10/10 at 5 minutes, and birth weight of 3400 grams. Third stage was complete without any complications with an estimated blood loss of 180 mls. She sustained a first degree tear which was sutured using chromic 2-0 suture and health education on care of the sutured area was given. After two hours of observation in labour ward they were sent to postnatal ward where they stayed 2 days before I discharged her following series of health talks on various topics.

4|Page

SUBJECTIVE DATA

PERSONAL PARTICULARS Name : Jamila Jika Age : 27 Years Gravidity :3 Parity :2 Residential address : A/24 Home Address : Chikapa Village, Traditional Authority Chiwalo, Machinga. Religion : Islam Tribe : Yao Marital status : Married Level of education : Form 2 Next of kin : Mrs. Bakali (her mother)

MENSTRUAL HISTORY An accurate menstrual history helps determine the expected date of delivery, enables the midwife to predict a bath date and subsequently calculate gestational age at any point in the pregnancy ( Myles, 2009). However, Mrs. Jika was not able to recall her last day of menstrual period such that it was almost impossible to calculate gestation by dates and the expected day of delivery. Mrs Jika experienced menarche at the age of 11 years when she noted blood draining from her vagina. Since then, she has been having menstrual cycles that are regular, moderate and lasts 4 to 5 days. She also complained of dysmenorrhoea associated with the menstruation.

PSYCHOLOGICAL HISTORY A history of psychiatric disorders, especially postnatal depression or puerperal psychosis is of significance because such conditions may reccur following a subsequent pregnancy. Mrs jika has never had either of the two conditions. According to Mrs. Jika, the pregnancy was not planned. It just came when she decided to have a break with family planning {Depo-Provera}. However she accepted the pregnancy too with her spouse. She also said that together with her husband, they have decided that this should be the last pregnancy and wants tubal ligation to be done as soon as possible to prevent another pregnancy.

5|Page

SEXUAL HISTORY This is asked to determine if there are any sexual adjustments that can put the client at risk of contracting Sexually Transmitted diseases. Mrs jika said there was no any adjustment in sexual activities, they have been having sex until 3 days ago and they will resume six weeks after delivery if there will be no problem. She said that there are no cultural restrictions in relation to sexual activities. She did not complain of dysparenia during sexual intercourse.

MEDICAL/SURGICAL HISTORY Medical and surgical history includes inquiry about any illness, operation or accident which could complicate pregnancy (Myles, 2009). During pregnancy, both the mother and the foetus may be affected by a medical condition, or a medical condition may be altered by the pregnancy, if untreated there may be a serious consequences for the womans health (Lewis, 2007). Mrs. Jika has no previous history of the major diseases like blood sugar, diabetes mellitus, Epilepsy, Hypertension, asthma or renal disease. However she said that she has some attacks of malaria may be twice a year. She has also never undergone any surgical procedure or never had any surgical injury.

FAMILY HISTORY Certain conditions are genetic in origin, others are familial or related to ethnicity, and some are associated with the physical or social environment in which the families lives. There are no hereditary conditions nor medical diseases in her family. She is the second born in a family of 3 females and 1 male. All of them are alive. She also said that there is no one in her family who has suffered or being diagnosed with mental illnesses.

SOCIO-ECONOMIC HISTORY Socioeconomic data including information about family adjustment and living conditions, and unusual stresses, smoking, alcohol or drug addiction is important for it has got an impact on the outcome of pregnancy. Mrs. Jika neither smokes, drinks nor is addicted to drugs. She does business of selling second hand clothes. She said that she is the first and only wife to her current husband who also happens to be his first wife. According to her, she went to school up to form 2 and that she stopped because she was impregnated by her current husband.

6|Page

IMMUNIZATION HISTORY Immunization history is of significance in as far as a pregnant woman is concerned. it is asked to determine the safety of the foetus to risks of infections, such as Tetanus, if not fully protected (immunized). Mrs. Jika received 2 doses of Tetanus Toxoid Vaccine (TTV). She said she has been receiving the vaccine for the previous pregnancies but could not finish all the scheduled 5 doses.

NUTRITIONAL HISTORY This is asked to determine the effects of poor nutrition in the mother which may also affect the foetal growth, resulting in low birth weight babies, preterm babies or preterm delivery, possibly due to low placental weight or other obstetric complications such as maternal induced hypertension, (Mayers, pp 185, 1997). Throughout this pregnancy she has been taking almost all the six food groups. She said that she learnt about the six food groups and its relevance in pregnancy during antenatal visits she has been having. According to Mrs. Jika, during the previous 24 hours, she took nsima with fish(with vegetable and bananas) as yesterdays supper, bread (with peanut) and milky tea as todays breakfast, nsima, meat, vegetables as todays lunch. She also said that she usually has snacks in between meals and takes about 1000mls of water in a day. Since she operates a business of selling second hand clothes, Mrs. Jika said she does not have problems in finding money to buy food and other necessities for herself and her family. On food preparation, she said that she tries not to overcook vegetables because she learnt that overcooking vegetables does not preserve nutrients. However she reported some episodes of vomiting during the first 2 months. She also said she has been having a strong desire to take clay soil at times and that she could reach an extent of taking it sometimes.

PAST OBSTRETRIC HISTORY

Accurate details of all previous pregnancies (not just living babies) must be obtained, including the year , period of gestation, duration of labour, nature of labour, and outcome, including sex and birth weight of the baby: also complications arising during pregnancy, labour and the puerperium. According to Myless 2009, previous childbearing experiences have an important part to play in possible outcome prediction of the current pregnancy. It includes history about miscarriages and pregnancy terminations. Mrs. Jika said that she has not had miscarrieges nor abortions. The table below summarises the details of the previous births she has had.
7|Page

Breakdown of deliveries
METHOD YEAR PLACE GESTATION DURATION OF LABOR OF DELIVERY CONDITION AT BIRTH WEIGHT OF THE BABY ALIVE NOW?

2004

Bwaila hospital

9 months

Cannot remember

SVD

Good, cried

2900

Yes

2006

Bwaila hospital

9 months

Cannot remember

SVD

Good, cried

3000g

Yes

PRESENT OBSTRETRIC HISTORY Mrs. Jika is a gravida 3 para 2. She could not recall her last menstrual period because she said she had been previously on depoprovera since 2008 and the pregnancy came when she missed the date for her next visit for the method. Such being the case, it was difficult to estimate her expected date of delivery. She attended 3 antenatal visits, the first one at 26 weeks.

OBJECTIVE DATA Laboratory investigations HIV test results came out negative during antenatal period. Haemoglobin test result was not done antenatally too with Venereal disease research (VDRL) and Urinalysis.
GENERAL APPEARANCE

Mrs Jika looked well nourished and well kempt. She was putting on long dress (a robe). She looked a little bit distressed, anxious and the gait was not normal. She could lean forward and groaned when she has a contraction.

VITAL SIGNS Blood pressure : 120/80 mmHg Pulse rate Temperature

8|Page

: 72 beats per minute : 36.6 C

Respiration rate : 22 breaths per minute Weight : 62 kg Height : 162 cm

HEAD TO TOE ASSESSMENT Head: Hair normally distributed with a good texture, no lumps palpated or sores seen Face: Symmetrical, no oedema, no scars Eyes: Pink conjunctiva, no discharges seen, symmetrical. Mouth: No sores seen, no kopliks spots, no halitosis, no gingivitis pink membranes and well brushed and complete dental formulae. Neck: Symmetrical, no goitre palpated, no distended jugular vein, and no swollen lymph nodes palpated. Breasts: No lesions seen, no dimpling or visible lumps seen or palpated, no tenderness and swellings, areola and nipple well developed. Chest: Symetrical, on auscultation, equal air entry, no wheezes or cracks heard, the chest was clear with normal breath sounds. Upper extremities: Symmetrical, no deformities, no palmar pallor, capillary refill less than 3 seconds, no oedema. Lower extremities: Symmetrical, no deformities, no varicose veins seen or palpated, and no oedema. Abdominal examination Inspection : o o o o o No scars seen, oval in shape, linea nigra seen, striae gravidarum seen, foetal movements seen

Palpation : o No splenomegally and hepatomegally o Fundal height : 37 weeks,32 cm (from symphisis pubis to the fundus) o Presentation :Cephalic
9|Page

o Lie o Position o Descent Auscultation:

: Longitudinal : Right Anterior Occipital : 4/5

o Foetal heart rate: 142 beats per minute. VAGIVAL EXAMINATION o Show : seen o soft tissues : warm and moist o cervix state : thin and soft o effacement : 100 % o dilatation : 4 cm PELVIC ASSESSMENT o Shape of the brim not followed o Well curved sacrum o Sacral promontory not tipped at 13 cm o Flexible sacrospinous ligaments o Blunt ischial spines o 90 degrees sub pubic arch o Intertuberous diameter admits 4 nuckles o Greater sciatic notch allows 2 fingers Conclusion about pelvis o Feels adequate for this vaginal delivery Anticipated course of labour and delivery o May deliver vaginally Impression A low risk multigravida, at term, with a live foetus in active phase of labour and may deliver vaginally. PROBLEMS IDENTIFIED 1. Altered comfort, pain, related to uterine contractions as evidenced by patient verbalization 2. High risk for altered nutrition related reduced oral intake secondary labour pains. 3. Ineffective individual coping mechanism, anxiety, related to labouring in an unfamiliar environment, knowledge deficit on labour. 4. High risk for infection related to possible increased number of vaginal examinations during labour and after delivery.
10 | P a g e

CARE PLANS DATE NURSING DIAGNOSIS GOAL INTERVENTION RATIONALE EVALUATION

01-02-11 Altered comfort, pain, related to uterine contractions as evidenced by patient verbalization.

Mrs. Jika will verbalise reduced pain after nursing intervention and throughout hospitalization.

Explain the pathophysiology of To equip her with pain to her. knowledge. Do backrubs during a contraction. Back massage stimulates the parasympathetic nervous system to send messages to the brain therefore reducing the sympathetic transmission of pain to the pain centers in the brain. Warmth has a soothing effect thereby reducing pain. As part of diversional therapy to distract her from concentrating to the pain. This provides some form of relaxation therefore muscle tension is released. To facilitate blood circulation (oxygen supply) to the uterus hence reduced pain.

Mrs. Jika verbalised reduced pain after

midwifery interventions.

Advise her to take a shower Chat /encourage guardian to chat with the client.

Teach her slow rhythmic deep breathing. Encourage Mrs. Jika on frequent change of positions.

11 | P a g e

DATE

NURSING DIAGNOSIS High risk for altered nutrition related reduced oral intake secondary to labour pains.

GOAL

INTERVENTION

RATIONALE

EVALUATION

01-02-11

Mrs. Jika will not develop nutrition related complications after nursing intervention and throughout hospitalization.

Explain to her the need for more energy to maintain good uterine contractions. Provide Mrs. Jika with small frequent meals like porridge.

To gain cooperation

It is easily digested hence provides urgent energy. to maintain her hydration status.

Nutritional status of Mrs. Jika did not deviate after midwifery interventions.

Give her sips of water

Smear her lips with Vaseline jelly

To retain moisture thus preventing insensible loss of water.

Commence an intravenous line of 5% dextrose.

Dextrose will provide fluids and increase blood glucose to Jika.

12 | P a g e

DATE 01-02-11

NURSING DIAGNOSIS Ineffective individual coping mechanism, anxiety, related to labouring in an unfamiliar environment, knowledge deficit on labour.

GOAL Mrs. Jika will express minimised anxiety.

INTERVENTION Explain to Mrs. Jika the process of labour Explain all the procedures to Mrs. Jika.

RATIONALE To equip her with knowledge To allay anxiety

EVALUATION Mrs. Jika expressed reduced anxiety

after midwifery interventions.

Orient her to the ward including the toilets and bathrooms.

To keep her oriented to the set up the labour ward.

Allow her to ask questions and To determine verbalise concerns. misconceptions and deal with them necessarily. Answer questions calmly and honestly. Reassure her that she will be assisted on her raised concerns. To ensure good understanding. To inspire hope in her.

13 | P a g e

DATE

NURSING DIAGNOSIS High risk for infection related to possible increased number of vaginal examinations during labour.

GOAL

INTERVENTION

RATIONALE

EVALUATION

01-02-11

Mrs. Jika will not develop infection during labour and delivery and throughout hospitalization.

Maintain aseptic technique when performing procedures

This will prevent introducing infection to the client Unnecessary invasive procedures can introduce infection. Dirty linen is a media for growth of disease causing micro-organism This will control and prevent entry of microorganisms that can cause infection. This will reduce microorganisms that can cause infection. This will cover for infections A rise in temperature of more than 37.2C will indicate infection.

Mrs. Jika did not develop infection after midwifery interventions.

Minimise invasive procedures and avoid unnecessary ones.

Provide a clean working area and clean linen.

Provide a sterile pad when membranes rupture.

Swab/clean the perineum when it gets dirty.

Give antibiotics to client if membranes have ruptured for more than 12 hours. Monitor vital signs more especially temperature every 2.

14 | P a g e

PROGRESS NOTES 16:30 : I admitted Mrs. Jika and findings on admission as baseline data were: Descent 4/5, 142 beats per minute Foetal heart rate, Moderate Contractions (3 in 10 minutes), Intact membranes, No moulding. maternal Vital signs: temperature, 36.6, blood pressure, 120/80, pulse rate, 74 beats per minute and respirations, 22 breaths per minute. I explained to her that she is going to be admitted in the labour ward because she has established labour. I took her to one of the cubicles in the company of her guardian who happened to be her mother. I oriented her to the room and showed her where the toilets and bathrooms were. Advised her to be urinating frequently. Voiding every 2 hours should be encouraged to every woman since a distended bladder may impede descent of the presenting part, inhibit uterine contractions, and lead to decreased bladder tone or atony after birth (Perry, 2006) 17:00 : Foetal heart rate was 140 beats per minute. 17:05 : I advised her to walk around the room and explained to her how this is going to benefit her. Studies carried out on ambulation, mobility and position during labour confirm that mobility during labour improves both womans experience and outcome of labour ( Deakin, 2001, Downe etal 2001, Heines & Kimber 2005). According to Myles 2009, ambulation helps uterine contractions more effective, labour is shortened, there is reduced need for pharmacological analgesics and oxytocin augmentation and the risk of foetal compromise is lowered. 17:13 : I encouraged her to have a shower to refresh herself. 17:30 : Foetal heart rate was 140 beats per minute, membranes intact, 3 moderate contractions in 10 minutes and descent was 4/5. Maternal findings were : blood pressure 117/82, pulse rate 72 beats per minute, respirations, 20 breaths per minute. I provided a bed pan and she Urinated 25ml of urine. I explained to her the findings. 18:00 : foetal heart rate 142 beats per minute. I explained the findings to her. 18:07 : I gave porridge to Mrs. Jika and explained to her that she needs it for energy more especially in the second stage for uterine contractions to be persistent and strong. 18:30 : foetal condition findings were: foetal heart rate 140 beats per minute, membranes intact. Maternal findings were: temperature 36.4C, blood pressure 122/80, pulse rate 76 beats per minute, respirations, 22 breaths per minute. Uterine contractions were 3 moderate in 10 minutes. Explained the findings to her. 19:00 : foetal condition findings were: foetal heart rate, 140 beats per minute. Provided bed pan and she urinated 25 ml urine. Explained the findings to her and the gurdian.

15 | P a g e

19:30: foetal condition findings were: foetal heart rate, 138 beats per minute, membranes intact. Maternal findings were: blood pressure, 120/80, pulse rate, 70 beats per minute, respirations 20 breaths per minute. 3 moderate Uterine contractions in 10 minutes. I explained the findings to her and the guardian. 20:00: foetal condition findings were: foetal heart rate, 138 beats per minute. Explained the findings to her. Provided porridge to Mrs. Jika. 20:20: provided a bed pan and she urinated 30 ml urine. 20:30: foetal condition findings were: foetal heart rate 138 beats per minute, membranes intact, neither moulding nor calput. Maternal findings were: temperature 36.6C, blood pressure 120/84 mmgh, pulse rate 72 beats per minute, respirations 18 breaths per minute. 3 moderate Uterine contractions, Cervical dilatation was 8cm. Warm and moist soft tissues, thin and soft cervix. Explained the findings to her. 21:00: foetal condition findings were: foetal heart rate 140 beats per minute. Explained the findings to her and the guardian. 21:30: foetal condition findings were: foetal heart rate 140 beats per minute, membranes intact. Maternal findings were: blood pressure 122/78, pulse rate 76 beats per minute, respirations, 22 breaths per minute. 3 moderate Uterine contractions. Explained the findings to her and the guradian. She urinated 35 mls of urine. 22:00: foetal condition findings were: foetal heart rate 142 beats per minute. Explained the findings to her. 22:30: foetal condition findings were: foetal heart rate 142 beats per minute, membranes intact. Maternal findings were: temperature 36.5, blood pressure 120/80, pulse rate 76 beats per minute, respirations 20 breaths per minute. 3 strong Uterine contractions, Cervical dilatation was 9cm. Warm and moist soft tissues, thin and soft cervix. Explained the findings to her. 23:00: foetal condition findings were: foetal heart rate 134 beats per minute. Explained the findings to her. 23:16: spontaneous rupture of membranes. Vaginal examination was done and cervical dilatation was 10cm, descent 2/5. No moulding or calput. Cord not felt. Explained the findings to her. A delivery trolley was prepared with the following equipments: delivery pack, suturing pack, lignocane.

16 | P a g e

DESCRIPTION OF SECOND STAGE The second stage of labour has traditionally been regarded as the phase between full dilatation of the cervical os, and the birth of the baby (Myles, 2009). The physiological changes which take place are now concerned with the descent of the foetus through the birth canal and its expulsion (Mayes, 1997). It lasts up to 30 minutes for multiparas and up to one hour for primigravida. When I noted that the cervix was fully dilated, I went to a nearby tap and washed my hands and dried them with a clean towel. Then I put on sterile gloves on top of surgical gloves. I reminded Mrs. Jika on the bearing down technique and advised her to do as advised. I then opened the delivery pack and cleansed the perineum with chlorahexiden solution using 6 swab techinique. I noted that the contractions were now becoming expulsive, there was gaping of the anus and vulva and bulging of the perineum which are some of signs of second stage. I placed a sterile pad on the anus and asked her to bear down when she feels the edge to push. I placed the pad so that I have a clear view of the perineum for signs of tears so that episiotomy can be done if necessary. After few minutes, the vertex started to appear on the vulva. I then placed my left fingers on the occiput flexing the head allowing small diameters to distend the perineum until crowning occurred. Then I told Mrs Jika to pant, while the other hand was supporting the perineum allowing the head to born slowly to prevent tears. When the head was out, I wiped the mucus from the babys mouth, nose and eyes with a clean gauze. I felt for the umbilical cord around the babys neck and slipped it around the neck since it was loose. I waited for restitution and external rotation of the head to occur. When it turned 45 degrees anticlockwise, I placed my palms on each side of the babys head by the parietal bones and asked rs. Jika to push while I was applying slow, gentle downward pressure and outward until the anterior shoulder slipped under the pubic bone. When the arms fold was exposed, I guided the head upward towards the mothers abdomen as the posterior shoulder was born over the perineum. I then lifted the babys head anteriorly to deliver the posterior shoulder. I noted time of delivery (23:33) and the sex of the baby (it was a baby boy). I placed the baby on the abdomen of the mother (skin to skin contact). I then dried the baby and covered him with a dry piece of cloth (chitenje). I assessed the APGAR score at 1 minute, and it was 9/10. I clamped and cut the cord after pulsations had ceased. I then palpated Mrs Jikas abdomen to rule out the presence of additional baby before active management of third stage. I removed the soiled gloves and disposed them in the bin. 23:36: Third stage management done

17 | P a g e

DESCRIPTION OF THIRD STAGE OF LABOUR The third stage of labour lasts from the birth of the baby until the placenta is expelled (Perry, 2006). The goal in the management of the third stage of labour is the prompt separation and the expulsion of the placenta, achieved in the easiest, safest manner. It is the most hazardous for the woman because of the possibility of complications such as haemorrhage. According to World Health Organisation, 2008, haemorrhage is the commonest cause of maternal death in the world and good antenatal, intranatal and postnatal care can decrease this serious complication. The method of conducting the third stage of labour will be influenced by many factors, including, the womans informed preference, the midwifes skill, the absence of a previous history of third stage complications and the normality of the present pregnancy and labour (Mayes, 1997). After ruling out the presence of another baby, I drew oxytocin 10 units and administered it to Mrs. Jika intramuscularly. I explained to her the reason for giving her the drug and explained how it works that it enhances contractility of the uterus thereby preventing severe bleeding. I clamped the cord close to the perineum and held the clamped cord with my right hand. With my non-dominant hand, I felt for a contraction. When I felt a contraction, I gently applied a counter traction, pushing the uterus upwards while using the non-dominant hand to stabilize the uterus and prevent uterine inversion. With the dominant hand, I applied film and sustained downward traction on the cord following the birth canal until the placenta was expelled. Then I delivered the placenta with both hands while twisting it slowly so that the membranes could be expelled intact. I used the forceps to clamp on the membranes and delivered them slowly in a downward, outward and upwards traction Since some membranes teared. I placed the placenta and membranes in a kidney dish and noted the time of delivery (23:39). Then I rubbed for a contraction and expelled the clots until I was sure that the uterus was well contracted. I held the cord up allowing the placenta and membranes to hang down; I inserted the fingers of my right hand inside membranes, with finger spread out and checked for the completeness of the membranes and the cord insertion point. I then held the placenta in palms of hands, with maternal side facing upwards, and checked whether all lobules were present and fitted together. I put the placenta back into the kidney dish and continued with examination of the vagina and perineum for tears. I swabbed the vulva with chlorahexiden solution using the six swab technique. Then I inserted a tampon while inspecting the cervix and vaginal wall for tears and lacerations that may need repair to prevent blood loss and facilitate healing process. I noted that there was a first degree tear. I explained to her that she has sustained a tear which needs to be repaired because it was bleeding and that it was very dangerous for her. Then I applied a cotton pad on the vulva.

18 | P a g e

I removed the soiled linen from the delivery bed and cleaned Mrs. Jika. I put a clean Chitenje on the bed and covered her with another Chitenje. I advised her to lie on her sides so that she should breastfeed her baby while I was preparing for suturing.

23:44 Checked the vital signs for the mother and they were; blood pressure 105/70 mmHg, pulse rate 80 beats per minute, respirations 20 breaths per minute and temperature 36.5C. drained 20 mls of urine. Baby vital signs were; temperature 37.0C, pulse rate 112 beats per minute and respirations were 38 breaths per minute and heartrate was 142 beats per minute. 23:52 examined the placenta thoroughly and the findings were: o Average size, round in shape and no abnormalities were noted o 3 blood vessels; 2 small (arteries) and 1 big (vein). o Whartons jelly was neither excessive nor few but was of average, no knots, the cord was laterally inserted and measured 45 cm long. o Fetal surface was grayish in colour and blood vessels radiated to the edge of the placenta without extending to the membranes. o No infarcts nor calcifications noted o Complete membranes and placenta (lobes) o Weighed 610gram (Findings were recorded on the labour chart) 00:59 suturing done followed by a health talk care of the sutured area. I advised her on: o o o o o o Frequent change of pads Cleaning of anal area from front to back Sitz bath three times a day Avoid strenuous activities Balanced diet with high proteins Increased roughages and water

00:20 checked vital signs, and findings were: blood pressure, 107/70, temperature, 36.4C, pulse rate 78 beats per minute and the uterus was below the umbilicus. Baby vital signs were; temperature 36.8C, pulse rate 116 beats per minute and respirations were 34 breaths per minute and heart rate was 136 beats per minute.

00:35 monitored vital signs and they were: : blood pressure, 110/72, temperature, 36.6, pulse rate 78 beats per minute and the uterus was still below the umbilicus. Baby vital signs were; temperature 36.9C, pulse rate 114 beats per minute and respirations were 36 breaths per minute and heart rate was 138 beats per minute.
19 | P a g e

00:40 initial assessment of the baby done Findings of the initial assessment of the baby Temperature-36.8C General appearance Active, alert and normal muscle tone, pink skin colour, no apparent injury nor abnormality. No cyanosis, no palmar pallor , no jaundice, skin not meconium stained. Slight vernix caseosa and lanugo on the face and the upper arms. Head Round, bones slightly movable at sutures, open, flat and soft fontanelles. No moulding nor caput. Intact scalp and good scalp growth, no bruising, no abrasions, no cuts, no lacerations. Head circumference was 34cm. Eyes Symmetrical, normal size and shape, correct placement, no sub-conjunctival hemorrhage. No discharge, no corneal ulceration, bright and shinny cornea, white sclera. Pupils reacting evenly to light stimulation. Nose Midline positioned, flat, wide and patent,no bloody nor purulent discharge, no nasal flaring. Mouth Symmetrical lips pink in colour, normal size and shape, pink tongue and horse shoe shaped gums. No gingivitis, no cleft palate, no false teeth. Pink, moist and shinny mucus membrane. Ears Symmetrical to each other, no extra auricles, well formed ears, upper ear in line with outer corner of the eye. No foreign body or discharge. Well formed auricles. Neck Average, symmetrical, with skin folds, no webbing. Head in midline position, no masses, some head control, side to side movement, extension and flexion. No fractured clavicles no swelling nor creptus. Lanugo seen.

20 | P a g e

Chest Barrel shaped chest, prominent end of ximphsternum, symmetrical movements with respirations, no chest in-drawings, no rib recession, no involvement of abdominal muscles during breathing. No abnormal breath sounds on auscultation. 46 breaths per minute, regular heart beat. Palpable breast nodules. Abdomen Symmetrical, no signs of organomegally, no tenderness, non-distended abdomen, bowel sounds present. Clean and moist umbilicus. Liver and spleen non-palpable.Two arteries and one vein present on the umbilical cord, no bleeding on the umbilicus. Upper extremities Symmetrical, full range of motion exercises, well formed hands, no extra digits, no webbed fingers, well formed palmar creases, no fracture of long bones. Lower extremities Symmetrical, semi-flexed hips and legs. Full range of motion exercises including abduction. Normal size of long bones. Femoral pulses felt. Well developed plantar creases. No extra digits, no webbed feet, no clubbed feet no talipes. Ortolans test was negative ie no congenital hip dislocation. Genetalia Well developed testes palpable in a sac. Patent urethral opening at center of glans penis correctly positioned. The baby had passed meconium already 30 minutes after delivery. Back and spine Straight, easily flexed, no spinal bifida nor meningocelle nor sacral dimple sinus. Neurological assessment o Moro reflex present- gave a startled response by flinging out arms o Grasp reflex present: Palmar- baby firmly grasped tip of the finger Plantar- toes curled downwards when finger was placed at the base of the toes. o Walking reflex- infant attempted walking by lifting and placing one foot in front of the other. o Rooting and sucking reflex- upon touching at the infants cheek corner of the mouth, infant turned head towards stimulus, while openning his mouth. o Swallowing reflex- sucking co-ordinated with swallowing without gagging, coughing or vomiting.
21 | P a g e

00:50 blood pressure, 110/70, temperature, 36.4C, pulse rate 76 beats per minute, respirations, 22 breaths per minute and the uterus was below the umbilicus. Baby vital signs were; temperature 37.0C, pulse rate 114 beats per minute and respirations were 36 breaths per minute and heart rate was 140 beats per minute. 1:05 blood pressure, 110/75, temperature, 36.6C, pulse rate 78 beats per minute and the uterus was below the umbilicus. Drained 35 mls of urine. Baby vital signs were; temperature 36.8C, pulse rate 116 beats per minute and respirations were 34 breaths per minute and heart rate was 138 beats per minute. 1:23 blood pressure, 110/74, temperature, 36.5C, pulse rate 74 beats per minute and the uterus was below the umbilicus. Baby vital signs were; temperature 36.9C, pulse rate 116 beats per minute and respirations were 34 breaths per minute and heart rate was 134 beats per minute. 1: 40 blood pressure, 110/75, temperature, 36.6C, pulse rate 78 beats per minute and the uterus was below the umbilicus. Baby vital signs were; temperature 36.8C, pulse rate 116 beats per minute and respirations were 38 breaths per minute and heart rate was 142 beats per minute. Maternal and babys Vital signs were within the normal ranges since she was discharged from the labour ward to low risk postnatal until discharge. Blood pressure was ranging from 100 to 125 systolic, 70 to 85 diastolic, temperature 36.1C to 36.9C, pulse rate 70-82 breaths per minute and respirations 18-22 breaths per minute. No complications developed. For the baby; Heart Rate 130140 beats per minute, pulse rate 80-90 beats per minute, temperature 36.0C-37.1C and respirations 30-40 breaths per minute.

DISCHARGE PLAN/HEALTH EDUCATION Nutrition The postnatal mother should continue having good, mixed diet as advised in pregnancy (Belly, 2008). I advised her on the importance of eating the 6 food groups namely: proteins (the sources include, fish, meat and beans), carbohydrates (sources include, potatoes, cassava and nsima), fats (sources include: groundnuts, oil ) , vitamins (all vegetables), fruits (like mangoes, bananas, etc) and water at least 2 litres in a day .

22 | P a g e

Danger signs After a normal delivery, mothers or babies if may develop some complications that if not identified and managed early, may lead to loss of life. To prevent such incidences, I included this part as part of my health education. I told her that if she comes across the following sign she has to rush to any nearest hospital for medical attention: persistent heavy vaginal bleeding, fever, severe abdominal pains, blurred vision and persistent headache. On the danger signs for the baby, I told her of signs like: uncontrollable crying, refusing to breastfeed, fever and pus on the umbilicus. Hygiene/Perineal Care I advise Mrs. Jika to taking bath at least twice a day so that she should be clean and reduce the number of pathogens on her body. This will benefit her and the baby since the chances of the baby coming in contact with pathogens that could lead him to being infected. I also advised her to be washing her hands after visiting the toilet or before breastfeeding the baby. On perineal care, I reminded her of sitz bath three times a day. I also advised her to be wiping from front to back after defecation to prevent introduction of infections to the vagina and the sutured vaginal mucosa. Rest and Sleep For may mothers, insufficient sleep is the most common and distressing problem in the post partum period and indeed during the first few months of motherhood (Turton, 1980). A study by salzarulo and Rigoard (1987) found that sleep problems associated with childbirth may be the starting point of long-lasting sleep disturbances in women. It is, therefore, important to consider rest and sleep and priority on the discharge plan so that women should be advised on the steps that can be taken to have undisturbed sleep. Family Planning The capacity to enjoy and control sexual and reproductive behaviour is a key element of sexual health (WHO, 1999). Contraception is an important factor in many womens lives. The midwife must be able to facilitate clients knowledge and choice by providing sound family planning information and advice (UKCC 1998).
23 | P a g e

I advised her on the available family planning methods that she can find at various government hospitals which included, Depo-Provera, mini pills, implants, intra-uterine device and condoms. I advised her to go to any nearest health facility to access the above mentioned family planning methods. Exclusive Breast Feeding It is defined as giving the baby only breast milk from birth up to six months. Breastfeeding should be a happy, satisfying experience for both the mother and the baby. The mother who is keen to breastfeed and has the support of her partner is most likely to succeed, especially if she has the skilled help and support of the midwife (Mayes, 1997). I explained the advantages of exclusive breastfeeding which include: it has antibodies that protects the baby from infections, meats infants nutritional needs, its fresh and easily digested, enhances uterine contractions (involution) and that it inhibits ovulation. I also advised her on good positioning of the baby during breastfeeding and that she has to be breastfeeding the baby not less than 8 times a day (every three hours). I told her that even if the baby is sleeping and 3 hours has elapsed, she has to work him up, breastfeed and let him continue sleeping. Cord care On cord care, I advised her not to put anything on the umbilicus. I advised her only to be cleaning the umbilicus with warm salty water three times and a day. I told her that if she notes pus or even blood coming out of the umbilicus she has to seek medical attention.

24 | P a g e

ANALYSIS OF THE CASE STUDY The very young (below 18 years) woman runs an increased risk of developing complications during pregnancy. If she gives birth at term, she has an increased risk of Cephalopelvic disproportion (CPD) due to pelvis that is not well developed (obstetric life skills manual for Malawi, 2000). Looking at the age of Mrs. Jika, 27 years, she was on the safe side. Being below 35 years also prevented her from risks like, prolonged labour and post partum haemorrhage. Mrs. Jika attended 3 visits, all at Bwaila family health unit. According to her antenatal card (appendix 1 attached), had a weight of 55 kg and 62 kg on the last visit. Considering the fact that she attended antenatal at 26 weeks gestation hence it will be difficult to know her initial weight to calculate her weight gain during this pregnancy. However, from 55kg to 62kg at 35 weeks was not worrisome. According to Sellers (2001) a normal weight gain after twenty weeks gestation is 0.5kg per week. It was difficult to correlate gestation age and fundal height since Mrs. Jika could not remember when was her last menstrual period. Knowing the last menstrual period helps in calculating expected day of delivery, and matching fundal height and gestation by dates hence rule out some abnormalities in pregnancy like polyhydraminios or even twin gestation (belles, 2004). There is an association between maternal height and delivery outcome. Women with a short stature (less than 150cm) have an increased risk of Cephalopelvic disproportion due to short pelvic diameters (obstetric life skills manual for Malawi, 2000). Mrs. Jika had a height of 162cm putting her out the possibility for Cephalopelvic disproportion. An HIV test during the antenatal period revealed that Mrs. Jika was HIV negative. According to Beischer N.A, 1997, the majority of paediatric AIDS is prenatally acquired from the HIV mother and this is increasing as both the incidence of the disease increases in females. HIV can be transmitted to the foetus in the utero, to the baby during labour and delivery, and may occur during breastfeeding. So Mrs. Jika being tested negative means that the foetus was not at risk of contracting HIV. However, VDRL was not done during antenatal as it is also determines the condition of the baby in the uterus and at birth. Babies born to a mother with syphilis may have complications like blindness, brain damage, spots on the skin among other complications (coldtz, 2003). Gluconuria or blood sugar test was also not done antenetally hence diabetes in pregnancy could not be detected hence it was difficult to determine possibilities of a big baby. Malaria resistance is reduced during pregnancy (Myles, 2009). Mrs. Jika received two doses of Fansidar SP as it is recommended. She also received 1 mosquito net. This means that she was not at low risk of having malarial attack hence the baby was not at a risk of having malaria at birth.

25 | P a g e

Neonates born with congenital malaria are well at birth but develop fever, jaundice and splenomegally within 10-20 days of birth (Mayes, 2004). The prevention and treatment of maternal anaemia should be part of antenatal care (obstetric life skills manual for Malawi, 2000) Prevention of anaemia is important for normal fetoplacental development, and so that the mother can withstand cardiovascular collapse form postpartum haemorrhage (Beicher N.A, 1997). As part of prevention of such complications, women are give iron tablets every month. Mrs Jika has been receiving and taking iron since 26 weeks gestation. Mrs. Jika received two doses of tetanus toxoid vaccine. This means that she was safe from tetanus infection too with her baby to born. Thousands of babies worldwide die every year due to tetanus, when the infection can be easily and cheaply prevented by vaccinating the mother during pregnancy (obstetric life skills manual for Malawi, 2000). Albendazole is a drug used to fight or prevent worm infestation which gradually leads to anaemia. She received a dose of Albendazole at the first antenatal visit putting her on the safe side of not being attacked by worm infestation which can lead to anaemia. On admission, vaginal examination and pelvic assessment revealed that Mrs. Jika had a roomy pelvis adequate for this vaginal delivery. There was normal progress of labour though the expected time of delivery was delayed by one hour, it crossed to the alert line. Normally, cervical dilatation should remain on or to the left of the alert line and when dilatation crosses to the right, it is a warning that labour may be prolonged (obstetric life skills manual for Malawi, 2000). However the delay did not proceed to action line. Foetal heart rate remained within the normal ranges of 120 to 160 beats per minute. This indicated that foetal condition was good since there was also no calput and moulding or muconeum stained liquor after rupturing of membranes. The second stage lasted 25 minutes which is normal for multiparous women. The birth weight of normal mature should range from 2500g to 3800g (Benty, 2001). Mrs. Jikas baby had a birth weight of 3400grams which is falling within the normal ranges. The weight however, reduced to 3200 grams on discharge 48 hours after delivery. Weight loss of 10% of the birth weight is tolerated during the first 72 hours after delivery (Caghies, 2002). Weight loss is due to among other reasons inadequate breast milk in early days, passing out of muconeum, and insensible water loss.

26 | P a g e

IMPRESSION It feels good having cared for Mrs. Jika from admission until discharge. I feel I provided comprehensive individualised care to her and her foetus/baby. Foetal and maternal monitoring was done throughout first and stage and even after birth. Proper documentation was done for every care on her and her baby. The cooperation that she showed also contributed to the success of this case study.

27 | P a g e

REFERENCES Beischer N.A etal (1997) obstetrics and the newborn : an illustrated textbook 3rd edition, saunders company Ltd, London. Fraser DM, Cooper M.A. (2009) Myles Textbook for Midwives, 15th Edition , Edinburgh, Churchill Livingstone. Fraser MD, Cooper MA, Nolte GWA, (2006) Myles textbook for midwives: African edition Edinburgh, Churchill Livingstone. Sweet RS, Tiran D (1997) Mayes midwifery 12th edition, Harcourt publishers Ltd, London. Perry L (2007) maternity and womens health care 9th edition, Mosby inc, St Louis. Ministry of Health, (2000) Obstetric Life skill Training Manual for Malawi-Safe Motherhood program.

28 | P a g e