ACKNOLEDGEMENTS

Successful completion of this case study is as a result of generous contributions

and assistance of some individuals worthy mentioning.

I would like to express my heart felt appreciation to Rhoda Chatha for consenting
to be the subject of this study. The difficulty of conducting this study was largely
eased by her enthusiasm, understanding and cooperation.

I would like to extend my appreciation to Mrs. Galilea the acting Chief Nursing
Officer and all labor ward staff at Zomba Central Hospital for support and
contributions that enabled me smoothly carry out this study.

I would also like to acknowledge the contribution of Mrs. Kamanga my clinical

supervisor without whose guidance this study should not have been conducted.

Lastly but by no means the least I thank God for the gift of life.

1
 INTRODUCTION

This paper presents a case study done on Mrs. Rhoda Chatha (in this paper
referred to as Rhoda), aged 26, Para 2. She was admitted in the labour ward at
Zomba Central Hospital from home on 23/12/08 at around 11am with complaints
of lower abdominal pain and backache. Assessment revealed that the foetus was
presenting with breech and she was in active stage of labour. An informed
consent was obtained for her to be the subject of my case study. She was
monitored throughout labour. At 8pm a breech delivery of a live full term male
infant was conducted. Baby and mother were taken to post-natal ward where
they were cared for, for 3 days. On 25/12/08 mother and baby were discharged
after meeting the discharge criteria.

2
 SUBJECTIVE DATA

PERSONAL PARTICULARS
Name: Rhoda Chatha
Age: 26years
Home address: Chidzaro village, T/A Chikowi, Zomba.
Occupation: Housewife
Religion: S.D.A.
Tribe: Lomwe
Marital status: Married
Educational level: Standard 8
Next of kin: Malita Bandawe (mother)

CHIEF COMPLAINT
Rhoda reported in the labour ward from home with complaints of labour pains.
She was experiencing lower abdominal pain and backache. She reported that
she had been in pain since morning of 23/12/06.

MEDICAL HISTORY
Rhoda stated that she had never suffered from any of the following disease:
Tuberculosis, asthma, diabetes mellitus, epilepsy, hypertension, renal diseases,
heart disease or mental illness.

SURGICAL HISTORY
Rhoda had never been operated and had never been involved in any serious
accident.

FAMILY HISTORY
She stated that there are no disease conditions that run in her family and there is
no family history of multiple gestation.

NUTRITIONAL HISTORY
Rhoda was on a well balanced diet. Her 24 hour dietary recall was composed of
all the six food groups. She takes three main meals a day i.e. breakfast, lunch,
and supper. She also snacks in between meals. She takes approximately 2 liters
of fluids in a day. She did not experience any pica nor excessive salivation during
the entire period of her pregnancy. She however experienced nausea and
vomiting during the first three months of her pregnancy. In her culture there are
no food restrictions for pregnant women.

SOCIAL HISTORY
She was the first wife to her first husband Mr. Chatha whom she had been
married to for 5years. She did her education up to standard 8 while her husband
did his education up to form 4. The husband works as a sales man at a bakery.
She is a house wife. The husband earns enough money to afford basic needs at
home. She reported that she had been receiving enough social and financial

3
support from her husband and significant others during her pregnancy. She is in
good relationship with her husband and significant others. Both Rhoda and her
husband neither smoke nor drink.

PSYCHOLOGICAL HISTORY
Rhoda stated that the pregnancy was planned and they had both accepted it.
They planned to be on family planning method after delivery so that they can
prevent unplanned pregnancy. They also planned to have one more child.

GYNAECOLOGICAL HISTORY
She attained menarche at the age of 14. She experiences regular menstrual
cycles. She menstruates for 3 days. She has had no abortions before. She had
been using depo provera since the birth of her first child until November, 2007.
She has been on this method for 2 years.

SEXUAL HISTORY
She reported that she did not experience any sexual discomfort like dyspareunia
during pregnancy. They stopped coitus at 8 months gestation because in their
culture it is believed that coitus after 8 months causes wide fontanels. They are
also expected to resume coitus six months after delivery.

PREVIOUS OBSTETRIC HISTORY

Rhoda was gravida 2 para1. Her first born is a girl whose delivery was
spontaneous vertex. She was born in 2005 at Zomba Central Hospital and had
weighed 2600g at birth. Her daughter was reported to be in good health. During
her antenatal period for her first pregnancy she did not experience any problems.
Neither did she experience any complications after delivery.

PRESENT OBSTETRICAL HISTORY

Her Last Normal Menstrual Period (LNMP) was 13/03/08 and her Estimated Date
of Delivery (EDD) was 20/12/08. Her gestation by dates was 40 weeks. Since
being pregnant she had not drained liquor nor experienced any vaginal bleeding.
She had been taking Iron tablets daily since the day she started attending
antenatal clinic. She also took two doses of Fansidar. She also received two
doses of Tetanus Toxoid Vaccine. She had been attending antenatal clinic at
Zomba Central Hospital. She had been feeling fetal movements throughout
pregnancy. She experienced nausea and vomiting during the first three months
of pregnancy. She started experiencing labour pains in the morning of 23/12/08
around 4 am.

4
 OBJECTIVE DATA

LABORATORY INVESTIGATIONS
HIV test results came out negative during antenatal period. The test was
repeated in labour ward and came out negative. Her haemoglobin test result
was 11.8gm/dl antenatally. Venereal disease research laboratory came out
negative. Urinalysis revealed negative presence of albumin.

PHYSICAL EXAMINATION

GENERAL APPEARANCE
Healthy looking lady, of medium size with no obvious deformity of the pelvic area.
She had poor gait probably due to labour pains. She was well kempt in body and
clothes and was well nourished and hydrated.

Body weight-68 kg
Height-155 cm

VITAL SIGNS
Temperature-37 degrees Celsius
Pulse rate- 68 beats per minute
Respirations-16 breaths per minute
Blood pressure-120/80 mm/Hg

HEAD TO TOE ASSESSMENT

HEAD
Proportional to body size. Clean and well plaited hair. No dandruff, no scars, no
sores nor lacerations.

NOSE
Symmetrical, in midline position, wide and patent nostrils. No purulent nor
bloody discharge.

EARS
Symmetrical with no growths, nor discharge. Pre-auricular lymphnodes were
non-palpable.

EYES
Symmetrical in size and shape with pink conjunctiva no discharges, no opacities,
clear cornea and no lesions.

5
MOUTH
Lips were of normal size and shape with pink colour and no cracks nor sores.
Had pink gums, no gingivitis, no dental caries. Pink and moist oral mucosa
membranes. Pink and symmetrical tongue. No oral thrush.

NECK
Symmetrical in shape. No distended nor visible jugular veins. Non-palpable
lymph nodes, no swelling nor masses. Normal thyroid gland. Able to turn head
both sides.

CHEST
Symmetrical and barrel shaped. Symmetrical respiratory movements. No
abnormal breath sounds like crackles and creptations.

BREASTS
Symmetrical, no visible masses, no sores nor cracks on the nipple. Prominent
and erectile nipple. No palpable masses on the breasts. Colostrum expressed.

UPPER EXTREMITIES
Symmetrical, capillary refill time was less than 2 seconds, no palmar pallor, no
oedema of arms.

LOWER EXTREMITIES
Symmetrical with no varicose veins nor oedema. No swelling nor tenderness of
calf muscles.

ABDOMEN
Symmetrical and oval shaped. Had linea nigra and striae gravidarum. No hepato-
splenomegally. Fundal height was 33 cm which indicates 38 weeks gestation.
The fundus was 2 fingers below xiphisternum. Had longitudinal lie, breech
presentation and Right Sacro-anterior position. Was experiencing 3 moderate
contractions in 10 minutes. Her urinary bladder was empty and her fetal heart
rate was 130 beats per minute.

GENETALIA

Vaginal Inspection
Clean with no sores, no lacerations nor warts. It was non-oedematous, had no
varicose veins, no bleeding, no show and no abnormal vaginal discharge.

Vaginal Examination
Warm and moist vagina, thin cervix, 100% cervical effacement and cervix was 4
cm dilated. The presentation was breech and the presenting part was not well
applied to the cervix. Membranes were intact and cord was not felt.

6
Pelvic Assessment
Shape of brim could not be followed, sacrum was curved, sacro promontory was
not tipped, sacrospinous ligaments were flexible and ischial spines were not
prominent. Sub-pubic arch was more than 90 degrees and intertuberous
diameter could admit 4 knuckles.

IMPRESSION
A high risk multi-gravida with breech presentation in active stage of labour

NURSING DIAGNOSES

 High risk for haemorrhage related to maternal soft tissue injury secondary
to delivery manouvres.
 Altered comfort pain related to uterine contractions and malpresentations
manifested by patient’s own verbalisation and strained facial expressions.
 High risk for altered fluid balance and nutrition related to hyperventilation,
slowed digestive function and emptying time of the stomach and reduced
food intake.
 High risk for infection related to possible increased number of vaginal
examinations during labour and early rupture of membranes.
 Ineffective individual coping anxiety related to labouring in an unfamiliar
environment, knowledge deficit on labour and delivery process and
outcome of breech presentation
 High risk for fetal hypoxia related to compression of the placenta during
uterine contractions, compression of the cord during delivery of the trunk
and inadequate food in take by the mother

7
 PROGRESS NOTES

23/12/08

11am
Vital signs: Temperature- 36.4 degrees Celsius, Pulse rate- 66 beats/minute,
B/P-120/70 mmHg, Respirations- 16 breaths/minute

Abdominal assessment
Fundus – 38 weeks
Presentation - breech
Position - RSA
Lie - longitudinal
Contractions – 3 moderate in 10 minutes
Fetal Heart Rate – 132 beats per minute
Urinary bladder – empty

Vaginal inspection
Clean and dry
No warts, no sores, no lacerations
No bloody discharge
Show not seen

Vaginal examination
Warm and moist tissues
Thin cervix 100% effaced and 4cm dilated
Presenting part not well applied to the cervix
Intact membranes
Cord not felt

11:10 am
Rhoda was oriented to labour ward.
She was also reassured that she will not be left alone throughout all the stages of
labour.
She was also taught relaxation techniques to make her relax and maintain
adequate supply of oxygen to the fetus.
She was advised to always lie in lateral position unless advised otherwise to
prevent compression of inferior vena cava and aorta which can compromise
supply of oxygen to the fetus.
An intravenous infusion of 5 % dextrose was commenced at 15 drops per minute
in order to promote adequate hydration status.

8
11:30 am
Fetal Heart Rate was 130 beats per minute
Rhoda was taught relaxation techniques like deep breathing.

12 noon
Assessments
Temperature: 37 degrees Celsius.
Pulse: 67 beats per minute
Respirations: 19 Beats per minute
B/P:120/80 mmHg
Fetal Heart Rate128 beats per minute.
3 moderate contractions in 10 minutes.
Urinary bladder was empty

12:15 pm
Rhoda complained of severe lower abdominal pain and severe backache. Rhoda
was observed bearing down prematurely. She was discouraged from bearing
down. Pethidine 100mg was administered after assessment of vital signs which
were stable and were as follows:
Temperature: 37 degrees Celsius
Pulse: 67 beats per minute
Respirations: 18 Beats per minute
B/P:120/80 mmHg
Fetal heart rate was checked as well and was 130 beats per minute.
Pethidine 100mg was given intramuscularly.

12:30 pm
Fetal heart rate was 135 beats per minute

1pm
Assessments
Rhoda reported reduction in pain.
Pulse rate: 70 beats per minute
B/P: 120/80 mmHg
Fetal heart rate: 138 beats /minute
3 moderate contractions in 10 minutes
Rhoda was encouraged to ask questions and air out concerns.
Her lips were moistened with Vaseline to prevent excessive drying.
Back rubs were provided to reduce pain.

9
1:15 pm
Rhoda went to the toilet to urinate and she reported to have managed to urinate.
Upon return from the toilet she was taught and advised to do pelvic rocking
exercises to promote descent of the presenting part.

1:30 pm
Fetal heart rate was 130 beats per minute
Mother took porridge.

2 pm
Assessments
Temperature: 37 degrees celcius,
Pulse rate: 66 beats/minute
Respirations: 18 breaths/minute
B/P: 110/80mmHg
Fetal heart rate:140 beats per minute
Contractions: 4 moderate in 10 minutes
Bladder: empty

Vaginal examination
Warm and moist vagina
Thin cervix, 100% effaced and 7 cm dilated
Presenting part poorly applied to the cervix
Membranes intact and cord not felt.
Show was seen which was not blood stained.
The findings were communicated to the client.
Rhoda was advised to change positions frequently to release tension.

2:15 pm
Rhoda was advised to get off the bed and perform pelvic rocking exercises.

2:30 pm
Fetal heart rate was 136 beats/minute
She was encouraged to frequently ambulate and empty her bladder.

3 pm
Fetal heart rate was 138 beats per minute.
Pulse rate: 64 beats per minute
Respirations: 18 breaths/minute
B/P:110/80 mm/Hg
She was experiencing 3 strong contractions in 10 minutes
Findings were communicated to the client.

3:30 pm
Fetal heart rate was 128 beats per minute
Her mother brought porridge which the patient took.

10
She was given a bedpan to urinate in. She urinated about 100mls.
She was advised not to bear down unless advised to do so when cervix is 10cm
dilated.

4 pm
Assessment
Pulse: 66 beats/minute
Respirations: 20 breaths/minute
B/P:110/80mmHg
Fetal heart rate: 126 beats per minute
Contractions: 3 strong in 10 minutes
Her urinary bladder was empty.

4:30 pm
Fetal heart rate was 134 beats per minute
Back rubs were provided to minimize pain.

5 pm
Membranes ruptured spontaneously. Liquor was meconium stained. A vaginal
examination was done. The cervix was 9 cm dilated. Cord was not felt and the
presenting part was not well applied to the cervix. It was a complete breech.
Fetal heart rate was 133 beats / minute.
Temperature:37 degrees Celsius
Pulse rate: 67 beats per minute
Respirations:20 breaths per minute
B/P-120/80 mmHg
She was told of the findings.

5:20 pm.
A delivery trolley was prepared with the following equipments:
delivery pack, suturing pack, lignocane.
Resuscitaire was also prepared in readiness for an asphyxiated baby

5:30 pm
Fetal heart rate was 140 beats per minute
A urinary catheter was inserted and 100ml of urine was drained to ensure that
the bladder was empty.

11
6 pm
Assessment
Fetal heart rate: 140 beats / minute.
Pulse rate: 73 beats per minute
Respirations: 20 breaths per minute
B/P: 120/80 mm/Hg
Contractions: 3 strong in ten minutes.
Findings were communicated to the mother.

SECOND STAGE OF LABOUR

VAGINAL EXAMINATION
Warm and moist vaginal tissues
Cervix thin, 100% effaced and 10 cm dilated
Four fingers inserted into the vagina to confirm cervical dilatation. Cord was not
felt and the presenting part was not well applied to the cervix.
Presenting part was below the ischial spines
Liquor was meconium stained.
Rhoda was informed that she was in second stage of labour but was advised not
to start bearing down unless advised to do so i.e. when the presenting part
becomes visible at the vulva. Mother was instructed to continue deep breathing.
When the presenting part became visible on the vulva she was assisted to
assume supine position with her buttocks on the edge of the bed, legs flexed and
knees abducted.
She was instructed to bear down only with a contraction
Fetal heart rate was checked and there was no sign of fetal distress.
Buttocks and genitalia together with two feet appeared on the vulva.
Rhoda was encouraged to continue pushing. Buttocks and the legs were born. At
6:25pm when umbilicus appeared on the vulva Rhoda was instructed to stop
bearing down. The loop of the cord was gently pulled down to loosen it.
Pulsations on the cord were felt to be regular and strong at 134 beats per minute.

Two fingers were inserted in the vagina. Elbows were not present on the baby ’s
chest but the axilla was felt. The arms were extended. The baby was covered
with a warm cloth. Both thumbs were placed on the sacrum while the fingers
were placed in front of ileac crest. The woman was instructed to push with a
contraction. With a contraction and the woman bearing down the body was
rotated at an angle of 180 degrees keeping the back upper most in order to bring
the shoulder which was more posterior to become more anterior and it was lying
under the symphysis pubis. The index and third fingers were placed over the
shoulder; the upper arm was splinted, flexed and then brought down across the
baby’s face and chest. Then the baby’s body was rotated back 180 degrees;
keeping the back upper most in order to bring the shoulder that was more
posterior to become more anterior until the shoulder was lying under the
symphysis pubis. The index and third fingers of the hand facing the baby ’s back
were placed over the shoulder. Then the upper arm was splinted and flexed and
brought down across the baby’s face and chest.

12
6:28 pm
The body of the baby was left to hang downwards with the head inside the pelvis.
Then the nape of the neck appeared under the pubic arc. Hands were kept near
the baby’s pelvis to prevent the baby from falling down. The baby ’s feet were
firmly grasped with the right hand, exerting firm downward, then outward and
upward traction. When the mouth and the nose were free from the perineum the
airway was gently cleared of secretions. The woman was instructed to continue
breathing deeply until the vault of head was delivered slowly and the body was
drawn upward over the maternal pelvis with the left hand guarding the perineum
to prevent the head from emerging too quickly. The head was delivered at 6:30
pm. The baby was quickly taken to the resuscitaire where it was suctioned and
bagging was done. The baby cried strongly 45 seconds after birth. The baby ’s
apgar score was 9/10 then 10/10.

THIRD STAGE OF LABOUR

10 units of pitocin was administered intramuscularly to promote uterine
contractions and the placenta was delivered 6 minutes later at 6:36pm by
controlled cord traction. Clots were expelled. Upon examination of the perineum
the cervix was intact but she sustained a first degree perineum tear. The mother
was cleaned up and wet linen was replaced with dry linen in readiness for
suturing. Blood pressure immediately after delivery was 110/80mmHg and pulse
rate was 67 beats per minute. Placenta and membranes were complete, weighed
550g and it was a healthy placenta. The cord was 50cm long and had 3 blood
vessels. Blood loss was about 180 ml. A tampon was inserted into the vagina to
absorb blood. Perineal tear was cleaned with chlorhexidine prior to injection of
10ml of 1% lignocaine on both edges of the tear. Then the tear was sutured with
chromic 2-0 in two layers and chlorhexidine was also used to clean the sutured
tear to prevent infection.

FOURTH STAGE OF LABOUR

7:30 pm
Blood pressure was 110/80mmHg, pulse rate was 66 beats per minute,
Temperature was 36.6 degrees Celsius, uterus was in midline position, firm and
well contracted and there was moderate flow of lochia. Intravenous infusion was
stopped and drip was removed. Rhoda was then instructed to take a bath and
wash her cloths.

IMPRESSION
A low risk mother one hour post delivery adapting well to non-gravid state.

MIDWIFERY DIAGNOSIS
 High risk for haemorrhage related to exposed blood vessels at placental
site.
 High risk for infection related to exposed tissues on the sutured perineal
area.

13
 PLAN OF CARE
Encourage Rhoda to breastfeed every 2 hours to stimulate oxytocin production
which promotes uterine contractions
Encourage the client to urinate frequently because a full bladder interferes with
uterine contractions.
Advise the client to lie in supine position with legs crossed. This position
promotes uterine contractions.
Advise the client to report excessive flow of lochia because this can be a sign of
active bleeding
Check blood pressure and pulse rate every 4 hours because increased pulse
rate and decreased blood pressure is suggestive of bleeding.
Advise the client to do sitz bath at least three times a day.
Advise the client to change perineal pads frequently because a moist pad is a
conducive environment for microbial growth.

INITIAL ASSESSMENT OF THE BABY

Temperature: 36.8 degrees Celsius

General appearance
Active, alert and normal muscle tone, pink skin colour, no apparent injury nor
abnormality. No cyanosis, no palmar pallor , no jaundice. Slight vernix caseosa
and lanugo on the face.

Head
Even, 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 seen. No discharge, nor corneal ulceration, bright and shinny
cornea, white sclera.

Nose
In midline position, flattish, wide and patent. No bloody nor purulent discharge,
no nasal flaring.

Mouth
Symmetrical and pink lips of normal size and shape, pink tongue and gums. No
gingivitis, no cleft palate, no false teeth. Pink, moist and shinny mucus
membrane.

14
 Ears
Symmetrical, 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
Short, symmetrical, with skin folds, no webbing. Head in midline position, no
masses present, some head control of side to side movement seen plus
extension and flexion. Neither swelling nor creptus sound found on examination.

Chest
Barrel shaped chest, prominent end of xiphisternum, symmetrical respiratory
chest movement, no chest in-drawings, no rib recession, no involvement of
abdominal muscles during breathing. No abnormal breath sounds on
auscultation. 47 breaths per minute, regular heart beat. Palpable breast nodules.

Abdomen
Symmetrical, no 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 pulse felt. Well developed plantar
creases. No extra digits, no webbed feet, no clubbed feet no talipes. Ortolan ’s
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.

Back and spine

Straight, easily flexed, no spinal bifida nor meningocelle nor sacral dimple sinus.

Neurological assessment
Moro reflex present- gave a startled response by flinging out arms
Rooting and suckling reflex was present: when infant ’s cheek corner of the
mouth was touched, infant turned head towards stimulus and opened the mouth.
Swallowing reflex was present: sucking was coordinated with swallowing with no
gagging, coughing or vomiting.
Grasp reflex was present: baby firmly grasped tip of the finger
Plantar- toes curled downwards when finger was placed at the base of the toes.

15
Walking reflex was present - infant stimulated walking by lifting and placing one
foot in front of the other.

The baby weighed 3100g.

IMPRESSION
A low risk infant one hour post delivery adapting well to extra-uterine life.

NURSING DIAGNOSIS
 High risk for hypothermia related to exposure to cold environments
 High risk for hypoglycemia related to inadequate intake
 High risk alteration in bonding related to fatigue

PLAN OF CARE
Keep the baby thoroughly dried and covered with a warm dry cloth
Prevent the baby from being in contact with cold surfaces
Post-pone bathing for the first 24hours.
Encourage the mother to breastfeed the baby every 2 hours.
Advise the mother to watch the baby’s umbilicus for bleeding.
Monitor body weight daily.
Cover the baby’s head with a hat.
Encourage the mother to cuddle the baby while breastfeeding to promote
bonding through touch.
Encourage mother to maintain eye contact while breastfeeding.
Encourage the mother to talk to the baby while breastfeeding to promote
bonding.

8 pm
Rhoda and her baby were taken to postnatal ward where she was given a bed.
Baby was wrapped in a clean and dry cloth and the mother was advised to keep
the baby always warm and to immediately change soiled linen.
Baby’s head was covered with a hat.
Mother was advised to breastfeed the baby every 2 hours.
Mother was advised to maintain eye contact and talk to the baby when
breastfeeding to promote bonding.
Mother advised to empty the bladder frequently to promote uterine contractions
Mother advised to lie in supine position with legs crossed to promote uterine
contractions.
She was advised to report excessive flow of lochia
She was advised to clean the sutured area with warm salty water to prevent
infection.
She was advised to change perineal pads frequently.
She was also encouraged to ask questions and express her concerns.

8:30 pm
Rhoda and her baby were handed over to night duty staff.

16
 DAY 2 24/12/08

Mother’s assessment
Subjective data
Rhoda reported that she had spent the night well. She said that she was still
having some mild abdominal pain especially when breastfeeding.
She reported that she had been breastfeeding throughout the night every 2 hours
and the baby was sucking well.
She had taken porridge and tea and was not having any problems with eating.
She reported that she had already taken a bath in the morning and had changed
the perineal pad. She reported that she was not having heavy lochia.
She reported that she had passed stools and urine in the morning
She also reported that she was experiencing mild pain in the genitalia due to the
sutured tear but the wound was not bleeding.
She also reported that the baby had passed stools early in the morning.

Objective data
Well kempt in body and clothes.
Vital signs: Temperature:37.2 degrees Celsius, pulse rate: 71 beats per minute,
respirations:18 breaths per minute, B/P:110/70mm/Hg
Pink conjunctiva
Non-oedematous upper extremities, capillary refill time within 2 seconds
Non-engorged breasts, colostrum expressed.
Uterus was 16 cm from the symphysis pubis. It was in midline position, firm and
well contracted. Urinary bladder was empty.
Non-oedematous lower extremities, non tender calf muscles, no varicose veins,
no deep vein thrombosis.
The genitalia was clean, perineal pad slightly soaked, no blood clots, no
offensive smell, no blood nor pus on the sutured tear, no oedema and normal
wound healing process.

Impression
A low risk mother 24 hours post delivery adapting well post-nataly.

Assessment
High risk for haemorrhage related to raw placental site
Altered comfort pain related to uterine contractions (after pains), presence of
sutured tear as evidenced by verbalization.
High risk for infection related to presence of tear in the perineum.

17
Plan
Encourage mother to empty bladder frequently to promote uterine contractions.
Encourage mother to continue breastfeeding every two hours to promote
production of oxytocin that promotes uterine involution.
Check the perineal pad every 4 hours to assess amount of lochia.
Check blood pressure and pulse rate every 4 hours.
Reassure mother that abdominal pain during breastfeeding is due to uterine
contractions secondary to oxytocin production and that pain will subside with
time.
Administer Palacetamol1g every 8 hours orally to reduce pain
Encourage deep breathing and relaxation techniques
Advise the mother be on high fiber diet to promote digestion and minimize
straining during defecation that aggravates pain.
Advise the woman to also be on high protein diet to promote wound healing
Advise the woman to change perineal pads frequently because moist perineal
pad is a conducive environment for microbial infection
Encourage the woman to ambulate in order to promote drainage of lochia thus
reducing the risk of infection.
Advise the woman to have sitz bath in salty water to prevent infection.
Teach the client to clean the perineum from front to back to avoid introducing
microbes on the perineum which can cause infection.
Encourage the mother to follow hand washing technique and observe all infection
prevention measures.

BABY’S ASSESSMENT

Temperature: 36.7 degrees Celsius

General appearance
Active, alert and normal muscle tone, pink skin colour. No cyanosis, no palmar
pallor, nor jaundice.

Head
No sunken nor bulging fontanelles. No bruising, no abrasions, no cuts, no
lacerations.

Nose
No nasal flaring, patent nostrils with no secretions.

Mouth
Pink lips with no sores and no cracks, pink and moist oral mucosa, no oral thrush
nor gingivitis.

Chest
Symmetrical respiratory chest movement, no chest in-drawings, 34 breaths per
minute and heart beat was 123 beats per minute.

18
Abdomen
Symmetrical, no umbilical hernia, no organomegally, dry umbilicus.

Neurological assessment
No convulsions, no abnormal cry, no signs of cerebral irritation.

Baby’s body weight was 2950g

Impression
A low risk baby 24 hours post-delivery adapting well to extra-uterine life

IMPLEMENTATION
9:00 am
Administered 1g of oral palacetamol to mother.
Mother taught on importance of emptying the urinary bladder.
Mother taught on importance of breastfeeding frequently for the first 3 days
because colostrum contains antibodies that protect the baby from infections.
Mother reassured that abdominal pains will go with time and she should continue
breastfeeding despite abdominal pains.

10:00 am
Mother was taught on proper positioning and proper breast attachment during
breastfeeding
Mother was reminded to keep the baby warm and change the nappies whenever
they get wet.
Mother encouraged to cuddle the baby, and to maintain eye contact during
breastfeeding in order to promote bonding.
Baby’s umbilicus was cleaned with surgical spirit and the mother was taught on
how to clean baby’s umbilicus. Mother was advised to watch the umbilicus for
bleeding or any signs of infection and report immediately.
Baby’s head was covered with a hat.

10:30 am
Baby was given BCG vaccine and Polio 0 vaccine to protect the baby from
Tuberculosis and poliomyelitis respectively. The mother was advised not to rub
the injection site on the right hand to prevent reducing the potency of the vaccine.
She was also advised to wait for 30 minutes before breastfeeding the baby to
prevent vomiting because Polio 0 vaccine causes nausea.

11am
Vital signs for the mother were as follows: Temperature:36.8 degrees Celsius,
pulserate:68 beats per minute, respirations:18 breaths per minute, B/P:110/70
mmHg
Vital signs for the baby were as follows: Temperature: 36.8 degrees Celsius,
respirations: 40 breaths per minute, heart beat: 100 beats per minute

19
Mother was advised to always clean perineum from front to back.
Mother was advised to be taking at least 3 liters of oral fluids in 24 hours.
Mother was encouraged to take foods high in fiber content to prevent
constipation which can aggravate pain due to straining when defecating.

1 pm
Mother observed changing the nappies. She was taught to prevent umbilical cord
from coming in contact with urine and stools to prevent introducing infection on
the umbilicus.

Mother was encouraged to ambulate to promote drainage of lochia

1:30 pm
Mother was given health education on family planning. Different methods of
family planning their advantages and side effects were discussed. She was
advised to start family planning 6 weeks after delivery. She was advised not to
fall pregnant in a period of less than 2 years so that she can have enough time to
take care of the baby and also allow the body to fully return to pre-pregnancy
form.
She was also taught that coitus can resume 6months after delivery.

2:30 pm
Mother was taught on six food groups.
Health education on the importance of exclusive breastfeeding was given
Mother was also educated importance adequate rest.

3:00 pm
Mother’s vital signs were as follows: Temperature:37.1 degrees Celsius, pulse
rate:72 beats per minute, respirations:20 breaths per minute, B/P:110/70mm/Hg.

Baby’s vital signs were as follows: Temperature: 37 degrees Celsius,

respirations: 38 breaths per minute, Heart beat:100 beats per minute.

3:30 pm
Mother and baby were observed sleeping.

4:30 pm
Perineal pad was checked and was slightly soaked. Mother was observed
breastfeeding. The baby was well positioned and well attached to breast and
was suckling well.

5:00 pm
Mother and baby were handed over to night duty staff.

20
 DAY 3 25/12/08

8AM

Subjective data
Rhoda stated that she and the baby spent the night well. The baby had been
sucking well during the night. She reported that she had already taken a bath and
had cleaned the sutured perineal tear with warm salty water and she was
experiencing mild flow of lochia. She was able to pass urine and stools and she
was no longer experiencing abdominal pain nor pain on the sutured tear. She
also reported that the baby had passed stools as well

Objective data
Mother
Well kempt in body and clothes.
Vital signs: Temperature:37.2 degrees Celsius, pulse rate: 72 beats per minute,
respirations:19 breaths per minute, B/P-110/70mmHg
Pink conjunctiva
Non-oedematous upper extremities, capillary refill time within 2 seconds
No breast engorgement, no masses felt, colostrum expressed.
Uterus in midline position, 15 cm from the symphysis pubis, firm and well
contracted uterus. Urinary bladder was empty.
Non-oedematous lower extremities, non-tender calf muscles, no varicose veins,
no deep vein thrombosis.
Clean genetalia, perineal pad mildly soaked, no blood clots, no offensive smell,
non-oedematous perineum, normal healing process of the sutured perineal tear.

Impression
A low risk mother 48 hours post delivery adapting well to non-gravid state

Baby

General appearance
Pink skin, alert and active.

Vital signs: Temperature:36.2 degrees Celsius, respirations:32 breaths per

minute, Heart rate:120 beats per minute, body weight:2900g.

Head
Symmetrical, no sunken nor bulging fontanelles. Intact scalp and good scalp
growth, no bruising, no abrasions, no cuts, no lacerations. Head circumference
was 35cm.

Nose
No nasal flaring, patent nostrils with no secretions.

21
Mouth
Pink lips with no sores nor cracks. Pink and moist oral mucosa with no oral
thrush nor gingivitis.

Chest
Symmetrical respiratory chest movement, no chest in-drawings, 34 breaths per
minute and heart beat was 124 beats per minute.

Abdomen
Symmetrical, no umbilical hernia, no organomegally, dry umbilicus and no
omphalitis. No abdominal distension.

Neurological assessment
No convulsions, no abnormal cry, no signs of cerebral irritation.

Impression
A low risk baby 48 hours post-delivery adjusting well to extra-uterine life.

Plan
As per care plan.

8:30 am
The umbilical stump was cleaned with surgical spirit and the mother was asked
to do a return demonstration. She cleaned the umbilicus correctly. She was
reminded to prevent the umbilical area from coming in contact with urine and
stools. She was also warned on the dangers of adding anything on the umbilicus.
She was further reminded on the importance of keeping the baby warm.

9:30 am
Mother was advised to continue cleaning the sutured tear with warm salty water
after being discharged home till the wound heals.
She was counseled on the dangers of inserting traditional herbs into the vagina
The mother was reminded on the importance of adequate rest.
The mother was taught on the importance of eating the six food groups and she
was taught on the importance of breastfeeding the baby exclusively

10:00 am
Rhoda was reminded about exclusive breast feeding. She was also reminded to
allow the baby to suckle empty the breast before given the other breast to
prevent breast engorgement. She was also advised to keep her breasts clean all
the time.

22
10:20am
Mother was advised to report to the hospital immediately if she experiences any
of the following danger signs: severe headache not relieved with analgesics,
heavy lochial flow, foul smelling vaginal discharge, blurred vision, convulsions,
fever, pus or bloody discharge on the sutured perineal tear.

She was also advised to report to the hospital immediately if the baby
experiences any of the following danger signs: fever, laboured breathing,
refusing to breastfeed, distended abdomen and inability to pass stools,
convulsions and purulent or bloody discharge on the umbilicus.

10:50 am
She was advised to report back at the hospital after one week for check-up.
She was further advised to report again at the hospital after six weeks for post-
natal check up, family planning and for baby’s immunization.

11:00am
Rhoda was discharged after health education as per home. Health education as
per discharge plan.

23
 DISCHARGE CRITERIA

MOTHER
 Normal vital signs.
 Mild lochial flow with non offensive smell.
 No pus, no bloody discharge from the sutured perineal tear.
 No breast engorgement, easily expressed colostrum.
 Firm and well contracted uterus, in mid line position.
 Proper positioning and good attachment to the breast
 Ability to describe the six food groups
 Ability to explain the danger signs for the mother and the baby.
 Ability to mention the next appointment date.

BABY
 Normal vital signs.
 Body temperature of less than 37.2 degrees Celsius
 No labored breathing, absence of chest in-drawings, respiratory rate of
less than 60 breaths per minute.
 No convulsions, no abnormal cry, nor any signs of cerebral irritation.
 No pus or bloody discharge on the umbilicus
 Ablility to suckle without any problems

DISCHARGE PLAN
Give health education on the following topics:
 Six food groups.
 Family planning.
 Exclusive breastfeeding.
 Personal body hygiene.
 Importance of adequate rest..
 Danger signs in post-natal mother and baby.
 Perineal care.
 Healthy sexual practices

Discourage harmful traditional practices and encourage beneficial ones.

24
 CASE ANALYSIS

Based on data collected and care rendered to Rhoda, the following are the
pertinent issues.

At age 26 Rhoda fell in a group of women with the lowest obstetric risk as far as
age is concerned (Safe Motherhood 2000). With height of 155 cm Rhoda was
above an average height of 150cm thus a normal vaginal delivery was
anticipated. There is an association between maternal height and delivery
outcome. Women with short stature have an increased risk of cephalo-pelvic
disproportion due to short pelvic diameter.

On social history she said she was the first and only wife to her first husband who
was working and was giving her adequate financial and emotional support. This
is good because a pregnant woman needs adequate support from spouse for her
to effectively cope with pregnancy. She also stated that with the money earned
by her husband they are able to buy basic essential needs like food and clothes
hence fostering mother’s health and proper development of the foetus.

She did her school up to standard eight thus her level of understanding was low
hence the need for comprehensive health education. She was a member of
Seventh Day Adventist church hence needed guidance on alternatives to pork
and some types of fish they are not allowed to take. She was a house wife
hence needed advice on how she could start a business so that she can
eventually become independent financially and be able to support herself and her
family.

Both do not smoke nor drink alcoholic beverages. This is good for wellbeing of
mother and foetus. Nicotine a substance found in tobacco causes interference
with oxygen exchange in lung alveoli resulting in reduction of oxygen in
circulating blood. Alcohol reduces appetite thus leading to malnutrition in the
mother which may lead to fetal growth retardation.

Rhoda did not suffer from any hereditary diseases and no close relative she
knew ever suffered from hereditary diseases such as diabetes, hypertension,
mental illness, epilepsy etc. She however said that was

Rhoda weighed 61kg on initial visit to antenatal clinic. Weight indicates maternal
nutritional status. With a height of 155cm Rhoda had a normal weight for height
ratio. According to Myles (2004), pregnant women are supposed to gain 0.5kg
weekly from 20 weeks gestation. On initial visit she weighed 61 kg and on
second visit she weighed 63 kg. Weight gain of 2 kg is normal and expected in
the second trimester. During her third visit she weighed 65 kg and on the fourth
visit she weighed 67 kg. Maternal weight gain indicates fetal growth; thus
Rhoda’s baby was growing normally.

25
She had a haemoglobin level of 11.8g/dl. This indicates that she was not anemic.
According to Safe Motherhood (2000) anaemia in Malawi is defined as
haemoglobin level of less than 10g/dl. In pregnancy there is an increased
demand for oxygen due to increased demand by the growing fetus.

She tested negative for proteinuria. Proteinuria in pregnancy indicates

pregnancy induced hypertension, pre-eclampsia and renal failure.

She was also tested for Venereal Disease Research Laboratory Test. This is a
test conducted to diagnose syphilis in client’s blood. The results came out
negative meaning that she did not have syphilis. Syphilis can cause intra-uterine
death of foetus or congenital abnormalities hence the need for the test and
treatment.

She tested negative for HIV. HIV can be transmitted to the fetus intrauterine, at
birth or through breast milk hence the need to single out infected mothers and
giving them drugs that reduce the chance of HIV transmission to the foetus.

She also tested negative for gluconuria meaning she did not have diabetes which
is associated with macrosomia which interferes with normal delivery.

She was given Fansidar 3 tablets as a prophylaxis for malaria in the second and
third trimester to prevent the mother and the fetus from malaria. Malaria
resistance is reduced during pregnancy (Myles, 2003). Neonates born with
congenital malaria are well at birth but develop fever, jaundice and
splenomegally within 10-20 days of birth (Mayes, 2004).

Iron tablets 200mg orally once a day was given to Rhoda for one month
throughout antenatal period. Iron tablets improve haemoglobin hence preventing
anaemia.

Tetanus Toxoid vaccine was given on initial antenatal visit and one month later in
order to prevent the mother and the fetus from tetanus.

Assessment on admission confirmed breech presentation. According to Sellers

(2001) there are no known causes of breech presentation. However the following
factors favour breech presentation: preterm babies, multiple pregnancy,
polyhydramnios, grand multiparty, contracted pelvis, placenta praevia, bicornuate
uterus, hydrocephalus and anencephaly. From both subjective and objective data
no predisposing factor was identified. Ultra Sound Scanning was required to rule
out some of the pre-disposing factors but it was not done ante-natally.

26
There was normal progress of labour indicated by progress of contractions from
mild to strong. Fetal heart rate remained within the normal ranges indicating that
there was no fetal distress. Meconium stained liquor is normal in breech
presentation and does not indicate fetal distress (Sellers, 2001). As the breech
descends into the pelvis, meconium is forced out of the colon and anus.

Membranes ruptured spontaneously at 5pm. A vaginal examination was done to

assess for cord prolapse which was ruled out. An hour later she delivered ruling
out need for antibiotics which are indicated when membranes have ruptured for
more than 24 hours before delivery (Myles, 2003).

When the loop of the cord appeared, she was discouraged from pushing and the
loop was gently pulled down and loosened and strong pulsations were present.
Loosening of the cord prevents tension on the cord that can block blood supply to
the fetus.

Time was noted when loop of the cord appeared and delivery of the baby. There
was 5 minute interval. Only 7 to 10 minutes is required before delivery if the
baby is to survive because once the fetal head enters the maternal pelvis blood
supply is cut from the fetus (Sellers 2003).

Extended arms were delivered using Lovset’s manouvre to prevent severe

perineal tears and trauma to the fetus. The head was delivered using Burn ’s
Marshall Manouvre because it was flexed.

After delivery the mother was examined for any tears. She sustained first degree
perineal tear which was sutured using chromic 2-0 suture with prior
administration of 1% lignocaine.

The baby’s birth weight was 3100g. This was within the normal range of 2500g to
3800g and was an indication that the baby was mature (Bennet & Brown1999).
On discharged at age of 3days, the baby weighed 2900g. Weight loss during the
first 3 days of life of up to 10% is normal. Weight is regained by age 10 days.
Weight loss is due to inadequate breast milk in early days, passing out of
meconium, and insensible water loss. Weight is regained later because
production of breast milk becomes well established by day 3 after delivery.

The baby was also examined for trauma. There was no apparent injury.
24-48 hours post-delivery the baby had been having a normal cry, no
convulsions and did not develop jaundice. This was an indication that the baby
did not sustain any injury during birth and was adapting well with extra-uterine
life.

BCG and polio 0 vaccines were administered to the baby before discharge.

27
 CONCLUSION
Her labour lasted for a normal period i.e. about 15 hours. Labour exceeding
24hours is classified as prolonged labour. The fetus did not distress throughout
labour and delivery as indicated by a normal fetal heart rate. Uterine contractions
progressed well. Mother’s vital signs remained within normal ranges throughout
labour, delivery and post-natal periods. Delivery was conducted within
recommended time and appropriate manouvres were used. Rhoda adapted very
well postnatally and her baby also adapted well with extra-uterine life.

PERSONAL IMPRESSION
Rhoda did not experience any significant problems during antenatal, labour,
delivery and post-natal periods. A good client-care provider rapport was
established and maintained throughout her hospital stay. She was well
assessed, monitored and taken care of during her entire hospital stay.

I strongly feel that success of her pregnancy out come was as a result of
individualized care I provided and support I got from other midwives and other
health care providers who continued providing individualized care to Rhoda in my
absence.

RECOMMENDATIONS

It is recommended that haemoglobin test should be done more than once to

ensure anaemia is isolated and treated throughout pregnancy period.

It is also recommended that albendazole should be given to all women attending

antenatal clinic to prevent anaemia that come as a result of worm infestation.

It is also recommended that all pregnant women should undergo ultrasound

scanning antenatally to isolate any problems with the fetus.

CHALLENGES AND LIMITATIONS

Limitation of resources e.g. sterile packs for cleaning cord, basins to demonstrate
bathing of the baby posed a big challenge to care implementation.

There was no auditory privacy because a number of clients were being examined
in the same room at the same time with only covering of screens.

28
Rhoda was counseled alone on all topics because her husband was always at
work.

LESSONS LEARNT
Multiparas women should not be taken for granted that they know a lot about
delivery and child care. They need to be taught as much as primigravidas.

Psychological preparation of the mother is very important as it is the basis for

cooperation.

Comprehensive handover ensures continuity of individualized care provision on

patient.

29
 REFERENCES

1. Bennet, V.R and Brown, L.K (1999) Myles textbook for midwives. (13th
Edition) Edinburgh, Churchill Livingstone

2. Burroughs A (1997), Maternity nursing: An introductory text, (7th

edition), Philadelphia, WB Saunders company.

3. Fraser DM, Cooper M.A. (2004) Myles Textbook for Midwives, (14th
Edition) , Edinburgh, Churchill Livingstone.

4. Ministry of Health, (2000) Obstetric Life skill Training Manual for

Malawi-Safe Motherhood program.

5. Ministry of Health, (2000) Concepts of Antenatal Care and Focused

Antenatal Care

6. Olds,S.B., London, M.L., & Ladewig, P.A. (1999) Maternal newborn

nursing: A family and community based approach. (6th edition)
London, Pretince Hall.

7. Sellers P.M, (2001) Midwifery, (volume 2) Cape Town, Juta and

Company.

8. Sweet, B.R. (1999) Mayes’ Midwifery (12th edition) London, Bailliere

Tinall

30
31