PREFACE

Over the years, maternal and infant mortality have increased, and family centered maternity care

has become a care intended to reduce maternal and infant mortality and morbidity rates, improve health

of mother and baby, and also encourage focused antenatal care. Family centered maternity care is

defined as the delivery of safe, quality health care while recognizing, focusing and adapting to both the

physical and psychosocial needs of the client (May & Mehlmeista, 1990).

The student midwife in the course of her training uses the family centered maternity care

method to provide care to a chosen client and her family, and supports the family physically,

psychologically, socioeconomically and spiritually, keeping in mind individuality of care. In the course

of the care, the student uses the scientific approach, that is, the nursing process to provide care for

clients and family.

The nursing process is a systematic approach to care for an individual and it involves

identification of actual and potential problems that might influence the health of the mother and the

baby and implementation of interventions needed to maintain physical spiritual and social health. The

application of the family centered maternity care helps the student midwife to put into practice the

knowledge and skills acquired during her training.

The care study also forms part of the assessment of the Nursing and Midwifery Council of Ghana for

the award of Diploma in Midwifery certificate to the student midwife at the end of her training
 ACKNOWLEDGEMENT

I thank God for giving me the strength to pursue my care study successfully. I could never have

conducted this study without the encouragement and support of my Supervisor. I also want to express

my sincere gratitude to the entire tutorial staff of 37 Military Nursing and Midwifery College, and the

effort of the entire staff of Mother and Child Hospital (Maternity Unit) who assisted me in completing

this project. I again thank my client and her family for their cooperation and for providing me with

adequate information needed for my care study.

My profound gratitude goes to my parents Mr. and Mrs. Arhin for supporting my education, and

to the whole Arhin family for their motivation in making this work a success. I would also like to

express my special gratitude to Dr Benjamin Toboh for his advice and his great attitude and support

throughout this care study. Finally, I thank the authors of the various books I used to make it possible to

write the script successfully.

 TABLE OF CONTENTS

PREFACE....................................................................................................................................................i
ACKNOWLEDGEMENT..........................................................................................................................ii
TABLE OF CONTENTS……………………………………………………………………………..…iii
LIST OF TABLES……………………………………………………………………………………….vi
INTRODUCTION……………………………………………………………………………………....vii
LITERATURE REVIEW……………………………………………………………………………...viii
Pregnancy…………………..……………………………………………………………………...viii
Labour……………………………………………………………………………………………....xii
Puerperium………………………………………………………………………………………....xvi
WHY I CHOSE MY CLIENT..............................................................................................................xviii
CHAPTER ONE
ASSESSMENT OF CLIENT AND FAMILY...........................................................................................1
Personal or Social History...................................................................................................................1
Family History.....................................................................................................................................2
Medical History...................................................................................................................................2
Surgical History...................................................................................................................................2
Menstrual History................................................................................................................................2
Past Obstetric History..........................................................................................................................3
Present Obstetric History.....................................................................................................................3
CHAPTER TWO
REPORT ON ANTENATAL.....................................................................................................................8
First Interaction with Client.................................................................................................................8
First Antenatal Home Visit................................................................................................................11
Subsequent Antenatal Clinic Visit………………………………………………………….……...12
Second Antenatal Home Visit...........................................................................................................13
Subsequent Visits to the Antenatal Clinic.........................................................................................15
Problems identified……………………..…………………………………………………….…….15
Nursing diagnosis……………………………………………………………………………..…...15
Short and long term goals……………………………………………………………………..…...15
Nursing Care Plan During Antenatal.................................................................................................17
CHAPTER THREE
REPORT ON LABOUR AND DELIVERY……………………………………………………………23
Admission and Initial Assessment.....................................................................................................23
Management of first stage of labour……………………………………………………………..23
Management of second stage of labour………………………………………………………….30
Management of Third Stage of Labour........................................................................................31
Immediate care of the baby………………………………………………………………………33
Management of the Fourth Stage of Labour…………………………………………………….33
Problems identified during labour……………………………………………………………….38
Nursing diagnosis………………………………………………………………………………..38
Short and long term goals………………………………………………………………………..38
Nursing Care Plan During Labour………………………………………………………………40
CHAPTER FOUR
REPORT ON PUERPERIUM………………………………………………………………………46
Baby's first bath………………………………………………………………………………….46
Subsequent care in the lying in ward…………………………………………………………….49
Preparation of client for discharge……………………………………………………………....49
First Day Post-delivery Home Visit…………………………………………………………….51
Second Day Post-delivery Home Visit.........................................................................................52
Third Day Post-delivery Visit to the Clinic……………………………………………………..59
Third Day Post-delivery Home Visit……………………………………………………………59
Fourth to Seven Day Post Natal Home Visit……………………………………………………60
Seventh Day Post Natal Clinic Visit……………………………………………………………62
Continuity of Care……………………………………………………………………………..63
Problems Identified…………………………………………………………………………….64
Nursing Diagnosis……………………………………………………………………………….64
Short term Objectives…………………………………………………………………………...64
Long Term Objectives……………………………………………………………………………65
Nursing Care Plan During Puerperium…………………………………………………………..66
SUMMARY AND CONCLUSION………………………………………………………………….72
BIBILOGRAPHY …………………………………………………………………………………..74
Appendix I: Antenatal Progress Record………..…………………………………….………………77
Appendix IIA: Pharmacology of Drugs Used In Antenatal…………………………..…...………….78
Appendix IIB: Pharmacology of Drugs Used In Labour Mother……...………………….……….…79
Appendix IIC: Pharmacology of Drugs Used In Puerperium Mother………………………..……....80
Appendix IIC: Pharmacology of Drugs Used In Puerperium Baby….…………………….…….…..81
Appendix IIIA Antenatal Laboratory Investigations…………………………………….…….…….82
Appendix IIIB Laboratory Investigations in Labour...……………………………………………...83
Appendix IV: Partograph………….………………………………………………………………..84
Appendix V: Duration of Observation of Labour….……………………………………………….85
Appendix VI: Examination of Placenta…………………………………………………………….86
Appendix VII: Apgar Score of The Baby…………………………………………………………..86
Appendix VIII: Observation of The Fourth Stage of Labour……………...……………………….87
Appendix IX: Observation of The Baby……………………………………………….…………..88
Appendix X: Report on Baby (Graph)……………………………………………………………..89
Appendix XI: Report on Mother…………………………………………………………………...90
Appendix XIIA: Summary of Labour/Delivery Outcome………………………………………….91
Appendix XIIB: Summary Labour/ Delivery Outcome……………………………………………92
Signatories………………………………………………………………………………………....93
 LIST OF TABLES

TABLES PAGE

Table 1: Nursing Care plan on Antenatal……………………………………………..……....17

Table 2: Nursing Care Plan on Labour…….…………………………………….……….........40

Table 3: Nursing Care Plan on Puerperium………………………………….…………..........66

 INTRODUCTION

The family centered maternity care study is an ordered approach to care rendered to the

expectant woman and her family from the time of conception, through labour and puerperium,

and her family obtaining optimal level of wellbeing. For confidentiality reasons, I will be using

abbreviations for my client’s name and any other name in this document. This formal document

was written on Madam V.O. G3P2A. The care was given throughout pregnancy, labour and

puerperium at Mother and Child Hospital (MCH), Kasoa. This care study enabled the student

midwife to put into practice the knowledge and skills acquired in her 3 years of training.

My initial interaction with Madam V.O. was on the 17 March 2021 at the antenatal clinic

of MCH, Kasoa. Madam V.O. had started her antenatal clinic visit on 3rd September 2020 after

testing positive for pregnancy 2 months after missing her period from the forgotten LMP date. I

looked through her antenatal book and she fitted the criteria needed for the care study. The

education given that morning was about danger signs in pregnancy, their causes and how to

respond to them. She looked a bit worried because she thought she doing all the house chores

could cause her to experience some of the danger signs in pregnancy.

I decided to use her as my client and educate her more about the causes and prevention of

the dangers. I established rapport with her, asked how she was coping with pregnancy and also

about her health, and her response was positive. I then told her my intention and explained the

concept of family care study to her.

This family centered maternity care study has 4 chapters. Chapter One talks about client

history, Chapter Two talks about antenatal period, first and subsequent visits to the clinic, Chapter

Three talks about all the 3 stages of labour, and Chapter 4 talks about the baby’s first bath and

puerperium. Our interaction officially ended on 20th April 2021. However, she calls whenever

necessary.
 LITERATURE REVIEW

A literature review is an academic paper that offers up-to-date information including

current findings as well as theoretical and methodological contributions to a particular issue.

Pregnancy

Pregnancy or gestation, is the period during which an offspring or more grow inside a

woman. Pregnancy usually forms after a sexual intercourse, nevertheless can also ensue through

assisted reproductive technology procedures. A pregnancy may result in a live birth, a stillbirth,

an induced abortion or a spontaneous miscarriage. Childbirth naturally occurs about week 40

counting from the last menstrual period (LMP) of the mother. This is only over nine months

(gestational age) — where each month numbers 31 days.

Referencing fertilization age, it is approximately 38 weeks. An embryo refers to the

offspring growing inside the mother at the initial eight weeks after fertilization. The term fetus, is

then used to refer to the growing baby until time of birth. Early pregnancy may include these

signs and symptoms; missed periods, morning sickness (nausea and vomiting), recurrent urination

and tender breasts. Most women use a home urine pregnancy test strip to determine their

pregnancy status before seeking professional health care. (AM et al., 2012) . Women are more

likely to have a healthy pregnancy and have a healthy baby when they receive a timely pregnancy

diagnosis and prenatal care. Pregnancy is separated into three stages termed trimesters, each stage

lasting roughly 3 months.

The first stage/trimester consists of conception, which is the period the sperm and the egg

meet and fertilization occur. The fertilized egg at this time moves and attaches itself to the walls

of the uterus from the fallopian tube and starts to form the embryo as well as the placenta (WHO,

2019). The first stage of the pregnancy ends after 12 weeks of conception.

The second stage/trimester is identified as starting, between the beginning of week 13 and

end at the end of week 28. According to Shapiro et al (2012), during the second trimester, the

uterus expands to make room for the developing baby the belly grows and the breast will also
gradually continue to increase in size. At this period the woman may feel Braxton Hicks

contractions i.e., mild, irregular contractions and some trivial tightness in the abdomen.

The third stage/trimester starts between the beginning of week 28 and lasts until

childbirth. Development of the fetus continues in this trimester. The fetus opens his or her eyes,

gain more weight, and prepare for delivery through painful contractions of increasing intensity

and frequency. Despite the movement of the fetus during the first trimester, it is only during the

second trimester that movement, known as quickening, can be felt.

This usually happens in the fourth month after conception, more precisely at week 20 and

week 21, or by week 19 if the woman has previously been pregnant. The mother may also

experience nasal problems as her hormone levels increase and her body produces more blood, this

may cause her mucous membranes to swell and bleed easily resulting in nasal bleeds. Other

problems like dental issues, dizziness, leg cramps, vaginal discharge, and urinary tract infections

among others may be noted at this final trimester of the pregnancy.

Maternal Physiological Changes in Pregnancy

These are the anatomical and physiological adaptations during pregnancy that the pregnant

woman's body undergoes to adjust to the growing embryo or fetus in the womb. These

physiologic changes affect almost all the systems of the body, and are completely normal

anticipated changes that help a pregnant woman's body to facilitate the appropriate growth

and development of the embryo or fetus during the pregnancy (Soma-Pillay et al., 2016). The

pregnant woman and the placenta also create other numerous hormones that have a wide range of

impact during the pregnancy.

The pregnant woman’s uterus plays a remarkable role in pregnancy by stretching and

expanding to accommodate and nurture the growing fetus (Shapiro et al., 2012). This expansion

and activation take place on the middle muscle layer of the uterine wall, the myometrium, which

is partly because covered and protected by an outer layer of peritoneum. An inner layer, the

endometrium, lines the uterine wall (Tavakoli et al., 2011).

 The perimetrium is a thin layer of peritoneum composed of connective tissue that

comprises collagen and elastic fibres, which is draped over the uterus and uterine tubes and is

continuous laterally with the broad ligaments (Impey & Child, 2017). During pregnancy, the

peritoneal sac is greatly deformed as the uterus enlarges and rises out of the pelvis.

The myometrium is the middle muscle layer of the uterus that undergoes dramatic

remodeling during pregnancy to provide support for the developing fetus and ultimately to expel

it during labour (Ciarmela et al., 2011). It is composed mainly of bundles of smooth myometrial

cells (myocytes) embedded in a supporting extracellular matrix (ECM).

Remodeling of the endometrium begins spontaneously in stromal cells adjacent to spiral

arterial arterioles during the mid-secretory phase of the menstrual cycle. If implantation occurs the

endometrial cells undergo a transformation known as the decidual reaction which extends into the

junctional zone and forms the decidua of pregnancy (Marshall & Raynor, 2020). The primary

function of the decidualization is to provide nutrition and an immunologically privileged site for

the early embryo (Torres-Mapa et al., 2011).

The cervix is known as the gatekeeper of pregnancy as it is transformed from a closed,

rigid, collagen-dense structure with a closed Os in early pregnancy to one that is soft, distensible

and effaced at the time of birth (Larsen & Hwang, 2011). The initial softening phase of the cervix,

which is due to action of progesterone, begins at conception and continuous until approximately

32 weeks. This softening in early pregnancy was first described by Hegar in 1895 and became

known as Hegar's sign.

Increased flow of blood to the vagina results in a bluish-purple discoloration of the vagina

known as Chadwick's sign (Geraghty & Pomeranz, 2011). There is increased volume of vaginal

secretions due to high levels of oestrogen which results in thick, white discharge known as

leucorrhoea (Cunningham et al., 2010).

Pregnancy causes a variety of common changes in skin, hair and nails, which in majority

of cases is a normal physiological response modulated by hormonal, immunologic and metabolic

factors. Changes in hormones during pregnancy arouse an increase in pigment-bearing cells

(melanin) in the skin of the pregnant woman. Pigmentation of the face affects up to 50-70% of

pregnant women and is known as chloasma or melasma or mask of pregnancy. There might also

be a dark line down the abdomen (linea nigra) of the pregnant woman. This skin changes are

common and generally fade away after delivery (Bolanca et al., 2008).

During the period of pregnancy, the plasma volume upsurges by 40-50% and the red blood

cell capacity increases only by 20–30% leading to haemodilution. The aforementioned changes

usually occur in the second stage/ trimester and prior to 32 weeks gestation period. As a result of

the dilution, there is a reduction in the hematocrit/ hemoglobin level. The erythropoietin, which

excites red blood cell production, surges throughout gestation period and reaches approximately

150% of their pregnancy levels at term. The slight drop in hematocrit or hemoglobin is most

pronounced at the end of the second trimester and slowly improves when reaching term

(Kaushansky et al., 2015).

Some degree of weight gain is expected during pregnancy (Kumari, 2017). This weight

gain results from growing fetus, expanding uterus, placenta and amniotic fluid formation, and

increase in water consumption among others. The weight gained ranges from 5 pounds (2.3 kg) to

over 100 pounds (45 kg) depending on the factors mentioned.

A lot of changes may be caused to the genitourinary system resulting from the

progesterone hormone. Some pregnant women may experience an enlarged uterus and kidneys

resulting from upsurge vasculature and blood volume. Approaching labor, the pregnant woman

might produce physiological hydroureter and hydronephrosis, which are common. The

progesterone hormone causes vasodilatation and amplifies the flow of blood to the kidneys,

resulting in about 50 percent increase in glomerular filtration rate (GFR), and coming back to

normal around week-20 postpartum.

There is a surge in the excretion of glucose, albumin and protein resulting from the

increase in GFR. The increased GFR results in more urinary output, the woman may observe as

frequent urination. Progesterone as well creates reduced motility of the ureters that can lead to

stasis of the urine and therefore result in and increased risk of urinary tract infection.
 Due to the numerous anatomical and physiological variations that occur during pregnancy,

focused antenatal care has been proposed by the World Health Organization (WHO) to give care

to the pregnant women from the time conception is confirmed till labour begins. The midwife

facilitates woman-centered care by providing her with accessible and relevant information to help

her make proper decisions throughout pregnancy. The foundation of this process is the

development of a trusting relationship in which tells midwife engages with the women and listen

to their story.

Labour

A human pregnancy is considered to last approximately 40 weeks, with labour usually

occurring between 37 and 42 weeks gestation (Yunis et al., 2007). Labour is the steady

contractions of uterine with progressive cervical expansion and effacement. During the final 4

weeks of pregnancy, several physical changes pave the way to the onset of labour. The

relationship between new baby and the mother may be influenced by happenings during labour

and these happenings can affect the likelihood and/or experience of future pregnancies.

Normal labour is the form of labour with minimum risk throughout the period,

spontaneous in onset with the fetus presenting by the vertex, culminating in the mother and baby

being in an excellent condition following birth (WHO, 1999). (Burvill, 2005), however stated that

a labour where the fetus is presenting by the breech with zero other risk factors can also be

considered normal.

Physiological Changes in Labour

Universally, there is no accepted sequences of events that elicits the commencement of

human parturition. Despite this position, a number of mechanisms have been assumed, the

following is a recent literature finding that includes most of the factors that have been identified

as a likely causes of the beginning of labor. During the last trimester of pregnancy, the process of

cervical growth and remodeling is accelerated. This process is under the influence of the placental

hormones and relaxin (Harrington, 2009). Prostaglandin E2 (PGE2) acts synergistically with these

substances to promote cervical change.

 At the end of gestation there is increased production of PGE2. Concurrently, there is an

upsurge in the formation and concentration of oxytocin receptors. The quantity of receptors

increases with uterine distention. This therefore leads to a rise in the quantity of myometrial gap

junctions. There is an increased response to the oxytocin pulses by the myometrium that is

secreted by the posterior pituitary, which then causes an increase in the intensity and occurrence

of the contractions resulting from these events. This creates greater tension and pressure on the

cervix, which leads to rise in the production of PGE2. The decidua then responds to the oxytocin

by releasing PGF2a, which increases the response to oxytocin by the myometrium.

At this point, maturational changes in the placenta and fetus cause the release of a diverse

number of substances from several organs. At this point, maturational changes in the placenta and

fetus cause the release of a diverse number of substances from several organs. This includes

epidermal growth factor, platelet-activating factor, adrenocorticotropic hormone, stress hormones,

vasopressin, and increased amounts of oxytocin (Harrington, 2009). The release of some of these

substances is caused by the stress of the transient decrease in foetal oxygenation due to the

increased frequency of uterine activity. As a result of the release of these substances, additional

mobilization of arachidonic acid from

First Stage of Labour the uterine phospholipids occurs (Harrington, 2009).

This results in an increased release of prostaglandins from the placental membranes at the

time of contractions. This results in a further stimulation for increased uterine activity. Therefore,

the process creates an unceasing cycle of activity that consequently leads to the development of

labor. There are four stages of labor.

During this stage of labour, contractions aid the cervix to thin and initiate to open. This is

what is termed effacement and dilation. As the cervix dilates, the birth attendant provider then

measures the opening of the cervix. At this stage, the cervix will enlarge to approximately 10

centimeters. The first stage of labour typically lasts roughly 12 to 13 hours for a first baby, and 7

to 8 hours for a second child. The first stage of labor has three parts (Cunha, 2021):
 The cervix starts to widen. The cervix then opens to about 4 centimeters. Pregnant women

usually start labor at home. Pregnant women are advised to keep doing their usual activities, relax

and rest more, drink clear fluids, eat light meals if you want to, and keep track of your

contractions. Contractions may go away if activities change, but over time they'll get stronger.

When pregnant woman notices a distinctive variation in how long, how frequent and how strong,

their contractions have become, and when they cannot talk during a contraction, they are

doubtless moving into active labor.

During the active stage of labor, the cervix begins to dilate. The cervix expands from 4 to 7

centimeters. This is the period when the pregnant woman has to visit the hospital. The cervix is

opening faster; about 1 centimeter per hour, when the pregnant women experiences contractions

every 3 to 4 minutes and they each lasting approximately 1 minute. She may not want to talk as

others become more of her energy is used in dealing with the contractions. As the labor

progresses, the bag of waters breaks, making the fluid spurt. After the bag of waters breaks, the

woman can expect contractions to quicken up.

At this moment, breathing easy and slowly is very important. Observing positive and

relaxing images or listening to music may be very assistive. Massages, changing positions, and

cold or hot compresses can make women in labor feel better. Sitting upright, walking or standing

can help labor progress. The cervix opens properly when the person in labor relaxes during and

between contractions and helps women in labor relax and ease their discomfort.

The cervix begins to dilate. It generally opens from 7 to 10 centimeters. Most women

attest this cervix dilation as the utmost painful part of labor. This is period when the cervix

expands to its fullest. The contractions last approximately 60 to 90 seconds and reoccur every 2 to

3 minutes. There is very little time to get rest and the woman in labor may feel overwhelmed by

the strength of the contractions. You may feel tired, frustrated, or irritated, and may not want to be

touched. You may feel sweaty, sick to your stomach, shaky, hot, or cold. Although you may find

slow, easy breathing to be most effective throughout labor, you may also find an uneven breathing

pattern most helpful at this time. (Hariyanto, 2020)

Second Stage of Labour

This stage of labor initiates only when the cervix is completely dilated, and terminates

with the birth of your baby. During this stage, contractions drive the baby down the birth canal,

and the women in labor may feel forceful pressure, similar to an impulse to have a bowel

movement.

Birth attendants at this stage advice the woman in labor to push with each occurring

contraction. The contractions progress in intensity, but spreads out a bit to give the woman in

labor time to rest. Numerous factors determine the duration of the second stage, some of these

include; size of the baby, whether or not you've given birth before and how many times, and the

position of the new baby. The severity at the end of the first stage of labor will continue in this

pushing phase (West, 2008). Women in labor tends to be irritable during a contraction and vary

between wanting to be touched and talked to, and wanting to be left alone. It is normal for a

woman to wail or moan when the contractions reach their topmost.

Third Stage of Labour (Afterbirth)

After the birth of the baby, the uterus maintains the contraction to push out the placenta.

The placenta usually falls out approximately 5 to 15 minutes after the baby is delivered.

Fourth Stage of Labour (Recovery)

At this stage the baby is born, the placenta has been successfully delivered. After delivery

many babies are ready to nurse within a short period, others become ready after a while. Mothers

and birth attendants are strongly advised to try to nurse as soon as possible after the baby is born.

Nursing immediately after birth will help the uterus contract faster and will also reduce the

amount of bleeding (post-partum haemorrhage) (Kaiser Permanente, 2021).

Partograph is a graphic record of essential observations during the course of labour to help

assess its advancement and carry out tailored interventions as and when necessary. Correct use of

the partograph can help avoid and manage prolonged or obstructed labour and serious
complications, such as; obstetric fistula, ruptured uterus and stillbirth. The partograph was

developed in 1970 in Zimbabwe and has been globally adopted because of its significance.

Puerperium.

The period of adjustment after childbirth during which the mother’s reproductive system goes

back to its normal prepregnant state. It usually lasts six weeks. Expects advocate for immediate

skin to skin following birth and during the postnatal period as literature portrays significant

evidence of benefit to the mother and father (Widström et al., 2019).

Physiological Changes During Puerperium

Puerperal changes commence almost immediately after delivery, elicited by a sharp fall in

the levels of estrogen and progesterone hormones produced by the placenta during pregnancy.

The uterus contracts back to its normal size or near normal and returns to its pre-birth position by

the week six after delivery. The intricate relationships between physiological, emotional, cultural

and sociological factors are all encompassed in the remit of caring for the postnatal woman and

her newborn (WHO, 2015).

During a process called involution, the extra muscle mass of uterus formed during

pregnancy is reduced, and the lining of the uterus (endometrium) is regenerated latest by week

three. As the uterus returns to its normal state, lactation begins in the breast. At the second day of

birth, a protein-rich form of milk, is produced called colostrum which is steadily converted to

normal breast milk; that has less protein and more fat, usually at the middle of the second week.

Stages of Puerperium

The initial puerperium (acute period) comprises the first 6-12 hours postpartum. This is a

period of swift changes with a potential for abrupt crises such as amniotic fluid embolism,

postpartum hemorrhage, uterine inversion, and eclampsia. Some maternal units have recently

introduced an early warning score to help deal with some of these complications (Lewis, 2012). If

the woman has had a home birth the midwife must not leave the new mother’s home until she is

satisfied the vital signs are stable. The body has to reabsorb a quantity of excess fluid following
the birth and for majority of women this results in passing large quantities of urine, as diuresis is

increased (Cunningham et al., 2010).

The second phase of puerperium is termed the subacute postpartum period, which lasts 2–

6 weeks. During this phase, the new mother’s body undergoes major changes in terms of

genitourinary recovery, hemodynamics, metabolism, and emotional status. However, these

variations are less rapid than they do happen in the acute postpartum phase and here the mother is

usually capable identifying problems herself. (Harrington, 2009) These may run the gamut from

usual distresses about perineal discomfort to peripartum cardiomyopathy or more severe

postpartum depression.

The third phase is the delayed postpartum period that may span up to 6 months. Changes

happening at this phase are extremely steady, and pathology is possible but very sporadic. This is

the period where muscle tone and connective tissue to the prepregnant state are restored to what

they use to be. Though changes are subtle during this phase, it behooves caregivers to recall that a

woman’s body is not fully reinstated to prepregnant physiology up until about 6 months post-

delivery.

Most women will complain of tiredness and fatigue during the puerperium period and lack

of sleep at the end of pregnancy, giving birth and establishing breastfeeding can take its toll.

Tiredness and fatigue can have an adverse effect on the mother’s health and well-being status.

Being tired and fatigued will inevitably have a negative effect on a woman’s ability to care for her

newborn (Troy & Dalgas-Pelish, 2016).

Due to all these physiological changes during puerperium, the need for women-focused

and family-centered postpartum care has been established to assist physical and psychological

recovery of the women (Mathai et al., 2008).

 WHY I CHOSE MY CLIENT

On the 17th of March 2021, I met Madam V.O. at the antenatal clinic of MCH, Kasoa.

When I arrived, I told the midwife in charge my mission and how I would need her assistance in

choosing my client. She assigned me to a duty post where I was in charge of the mothers’ vital

signs. Whilst checking the vital signs I went through their antenatal booklets and came across this

woman whose information fitted my care study criteria. During that morning, health education

was given on danger signs in pregnancy.

After the presentation, I emphasized to her the need to report immediately to the hospital

for prompt treatment if she experienced any of the danger signs mentioned earlier, as well as any

other thing she did not understand. She told the midwife in charge that she had been doing all the

house chores by herself. as I listened to her, I developed more interest and decided to stick to her

as my client and enlighten her more on effects of strenuous activities on herself and the unborn

baby. I called her to my table and told her my intention to use her for my care study. She needed

some explanation as to what a care study was, and why her. I explained everything to her and she

consented.
 CHAPTER ONE

ASSESSMENT OF CLIENT AND FAMILY

This chapter talks about the client and her family which includes personal or social

history, medical history, surgical history, menstrual history, past obstetric history and present

obstetric history. This history taking helps in providing quality care to the client.

Personal or Social History

Madam V.O., a 32-year-old woman who was born on 25th July 1989, hails from Obuasi in

the Ashanti Region of Ghana and lives at Bortianor Israel in the Greater Accra Region. She is

dark in complexion and is 168 cm tall. She ended her education after Senior High School and is

currently a pupils’ teacher in a private school. She speaks Twi and English, and lives with her

husband at Bortianor.

She is a Christian and attends the Church of Pentecost at Bortianor. Her husband, Mr. IA

who is 36 years old and is a native of Agona Swedru in the Central Region of Ghana and a driver

by occupation. They have been married for 7 years and are blessed with 2 children. The firstborn,

SA is 4 years old and a female. The second born is MA, a male who is 2 years old. Madam V.O.

and her family are all fine. Her husband is the main support person and next of kin. She neither

smokes or drinks alcohol, nor does she abuse drugs.

Her usual meal on a typical day consists of Hausa koko with koose or hot tea with milk

and bread for breakfast. A typical lunch consists of Banku with Okro stew, rice and fish stew or

yam with Palava sauce. Her supper is mainly Banku and sometimes Fufu with light soup. For

recreation she watches telenovelas, news and movies. Apart from the usual night sleep times, she

also sleeps during the afternoons on days she does not go to teach. On a typical day, she moves

her bowels once a day, and sometimes twice. She empties her bladder whenever she has the urge

to, but it rarely exceeds six times within 24 hours.

Family History

Madam V.O. said there is no history of chronic illnesses like hypertension, diabetes,

epilepsy, sickle cell, jaundice, mental illness or heart disease in her family and her husband’s

family, but there is a history of multiple pregnancies in both families, of which her husband is a

twin himself. Both of her parents are alive; her mother is 60-year-old Mrs CA and her father is

67-year-old Mr. EA. She is the second of four siblings, all of whom are alive and well. Her elder

brother is a welder living in the Eastern Region with his family. Her younger brother is an auto

mechanic living in Accra. He is single. The youngest sibling (also single) lives with him and she

is a trainee seamstress who runs a mobile money vending business during her free time.

Medical History

Madam V.O. had never been admitted to the hospital on account of hypertension, diabetes

mellitus, asthma, jaundice, sickle cell disease, epilepsy or mental illness, except when she was in

labour. She has no known allergies to food or drugs. She has never had problem with anaemia

prior to getting pregnant, and her blood group is B Rh Positive.

Surgical History

She has not had any surgery done before, and has not gone through any caesarean section

because she delivered her previous babies vaginally. Madam V.O has not had any accident that

will affect her pelvic.

Menstrual History

Madam V.O. does not remember her age at menarche. She had an irregular menstrual

cycle, but it was often 28 days long with moderate flow for about 5 days. According to her, she

experienced dysmenorrhea during this period. She did not remember her last menstrual period

before her current pregnancy except that it was somewhere between June and July 2020. She

resumed her menses 3 months after delivery of her first baby, and 6 months after her second baby.
Past Obstetric History

Madam V.O., G3P2A, carried both previous pregnancies to term. She did not have any

complications like hyperemesis gravidarum, antepartum haemorrhage, and pregnancy induced

hypertension in her first pregnancy, but had malaria which was treated by her midwife. She

attended her antenatal clinic regularly at MCH Hospital, Kasoa, and had the full course of

sulfadoxine-pyrimethamine (SP) in both pregnancies. She had 2 tetanus toxoid injections in her

first pregnancy (at first antenatal visit at 16 weeks and then a month later at 20 weeks gestation),

took the 3rd injection when her baby was about 2 months old, the fourth injection when she was 1

year 4 months old. She took the fifth injection approximately a year after the previous one, during

the first antenatal visit of her second pregnancy, at 14 weeks gestation.

According to her, labour lasted 12 hours and 7 hours in her first and second pregnancies

respectively. She delivered her first baby per vaginam at MCH, Kasoa with the help of an

episiotomy, but had no assisted delivery for the second baby born at the same place. The first

baby was a girl weighing 3.2 kg at birth, and the second was a boy weighing 3.3 kg at birth. She

had no retained placenta or postpartum haemorrhage in both deliveries. Estimated blood loss was

300 mls and 250 mls respectively. The babies had no congenital abnormalities, and she did not

have any puerperal problems.

Her support persons in the puerperal period during both deliveries were her mother and

her husband who assisted with the house chores and in the caring of both babies. She practiced

exclusive breastfeeding for 6 months after which she introduced complementary feeds and

weaned each baby completely at one and half years old. The children received all their routine

immunizations for children below the age of 5 years. Madam V.O. said she attended her postnatal

clinic regularly, and practiced natural family planning using the breastfeeding method, and

resumed her menses in 3 months 3 days and six months respectively.

Present Obstetric History

Going through her antenatal record, Madam V.O., G3P2A started her antenatal clinic on

3rd September, 2020 when she was about 8 weeks pregnant. Her exact last menstrual period
(LMP) date was unknown, hence her expected date of delivery (EDD) by ultrasound scan later at

20 weeks gestation was determined to be 9th April 2021. All personal, social, family, medical,

surgical, menstrual, past and present obstetric histories were obtained and recorded in her

antenatal record book. Examinations performed during the first visit had been recorded as

follows:

 Blood pressure 102/65 mmHg

 Temperature 36.7 °C

 Pulse 88 bpm

 Respiration 20 cpm

 Weight 88 kg

On physical examination during the first visit, she looked well nourished, appeared neat

and well groomed. A head-to-toe examination procedure had been explained to her and she had

granted consent for it to be carried out. On that physical examination, no abnormality was

detected and findings were recorded accordingly. Urine check via dipstick was negative for

protein and glucose. She was then registered into the hospital patient records system at Kasoa.

Results of initial laboratory investigations done were as follows:

 Haemoglobin 11.1 g/dL

 Blood group and Rhesus Factor Group B Rh Positive

 Malaria parasites None seen

 Sickling test Negative

 Hepatitis B screen Non-reactive

 Venereal Disease Research Laboratory Non-reactive

 Urine R/E (protein and sugar) Negative

 Stool R/E No ova seen

 HIV status Non-reactive

 G6PD status No defect

Routine antenatal drugs that were prescribed were:

 Tablet ferrous sulphate 200 mg TDS x 30 days

 Tablet folic acid 5 mg once daily x 30 days

 Tablet Multivitamin 200 mg once daily x 30 days

 Tablet Vitamin C 200 mg once daily x 30 days

Madam V.O. was educated on diet and nutrition, malaria prevention, mother to child

transmission of HIV, rest and exercise, how to use the antenatal red book, its importance and the

purpose of antenatal visits. She was also educated on the danger signs of pregnancy and to report

to the clinic if she experienced any. She had no further questions and her next visit was scheduled

for 23rd December 2020 with a request for obstetric ultrasound scan to determine her actual

gestational age and the EDD.

Madam V.O. had her second antenatal visit to the clinic on 23rd December 2020. She had

done the obstetric ultrasound scan a month earlier and it put her gestational age by scan at 24

weeks 2 days on the day of her second visit, and her EDD by scan to be 9th April 2021.

Examinations performed during this visit had been recorded as follows:

 Blood pressure 108/70 mmHg

 Temperature 36.4 °C

 Pulse 90 bpm

 Respiration 20 cpm

 Weight 94 kg

All routine examinations were performed. Urine was collected and tested for protein and

glucose and it was all negative. Symphysiofundal height was 25 cm. Vital signs were checked and

recorded. She had a repeated haemoglobin test and it was 10.5 g/dL. She had no new complains

and her next visit date was scheduled for 21st January 2021.

On 21st January 2021, Madam V.O. had her 3rd visit at 28 weeks 2 days gestation and all

routine examinations were performed. Examinations performed during this visit had been

recorded as follows:
 Blood pressure 110/70 mmHg

 Temperature 36.8 °C

 Pulse 94 bpm

 Respiration 20 cpm

 Weight 96 kg

Symphysiofundal height was 29 cm. Presentation was cephalic. She had no complaints.

She was educated on sexual activity and safe sex, diet and nutrition, pregnancy induced

hypertension, after which a head-to-toe, breast and abdominal examination was performed on her

and details recorded that day.

On 18th February 2021, she had her 4th visit at 32 weeks 2 days gestation and after the

education was given, all examinations were performed. Vital signs were checked and recorded as

follows:

 Blood pressure 109/57 mmHg

 Temperature 36.7 °C

 Pulse 90 bpm

 Respiration 18 cpm

 Weight 98 kg

Symphysiofundal height was 33 cm. Presentation was cephalic. Foetal heart activity was

present. She had no questions or complaints, and her next visit date was planned for 4th March

2021.

On 4th March 2021, my client had her 5th visit at 34 weeks 2 days gestation and after

routine education, all examinations were performed uneventfully. Vital signs were checked and

recorded as follows:

 Blood pressure 118/70 mmHg

 Temperature 37.0 °C

 Pulse 92 bpm

 Respiration 20 cpm
 Weight 99 kg

Symphysiofundal height was 35 cm. Presentation was cephalic. Foetal heart activity was present.

She had no complaints and was therefore booked for the next visit scheduled for 17th March

2021.

On the 6th visit on 17th March 2021, I got to meet her and I examined her after seeking

her consent. Her gestational age was then 36 weeks 1 day. Her general appearance was

satisfactory, the head and neck were without any abnormality and breast palpation detected no

lumps. Vital signs were checked and recorded as:

 Blood pressure 113/54 mmHg

 Temperature 36.9 °C

 Pulse 90 bpm

 Respiration 22 cpm

 Weight 101 kg

The abdomen was inspected and foetal movements were visible. Symphysiofundal height

was 37 cm and foetal heart activity was present, with cephalic presentation. Both upper and lower

extremities were examined and they were normal. The vulva was inspected and no varicose veins,

warts and any swelling were detected. The back was well aligned and she had a normal gait. I

thanked her, assisted her out of the examination bed and helped her to dress up. Disposable

materials used in the examination were discarded. I washed my hands and communicated the

physical examination findings to her. She had no complaints, but I alerted her to the possibility of

heartburn and encouraged her to take small frequent meals when it occurs, and to sit up for a

while before lying down after eating. Her next visit date was planned for 24th March 2021.
 CHAPTER TWO

REPORT ON ANTENATAL

Antenatal care is a type of preventive health care provided in the form of medical

checkups, consisting of recommendations on managing a healthy lifestyle and the provision of

medical information such as maternal physiological changes in pregnancy, biological changes,

and prenatal nutrition including prenatal vitamins, which prevents potential health problems

throughout the course of the pregnancy and promote the mother and child’s health alike. This

chapter talks about my first interaction with the client, client antenatal visits, home visits,

problems identified and nursing care plan during the antenatal period.

First Interaction with Client

I met Madam V.O. at MCH, Kasoa during her 6th antenatal clinic visit on 17th March

2021 at 8:00 am when she was 36 weeks 1 day pregnant. Madam V.O. walked into the health care

facility before daily duty had commenced and I approached and asked her how she was coping

with her pregnancy, to which she said she was fine. I explained the concept of family care study

to her and the need to choose her as my client upon going through her antenatal book.

A health talk on danger signs in pregnancy was given that morning and I realized she kept

asking questions about the topic. She told the midwife that she had been doing all the house

chores and wondered whether that posed a threat to her pregnancy. Upon hearing this, I decided to

stick to her and educate her more on these danger signs and what she needed to do to keep her

pregnancy safe. Her positive response prompted me to take her as my client for my care study in

order to educate her more on the danger signs in pregnancy, as well as other equally important

topics like malaria prevention, personal and environment hygiene.

After the education, I introduced her to the midwife in charge and she helped me explain

everything about family centered maternity care study to Madam V.O., who then agreed to be my

client and promised her maximum cooperation and support. I then looked through her antenatal

booklet and realized it was her 6th visit to the clinic. She had no danger signs such as vaginal
bleeding, severe headache and others I inquired about. Vital signs were checked and recorded as

follows:

 Blood pressure 113/54 mmHg

 Temperature 36.9 °C

 Pulse 90 bpm

 Respiration 22 cpm

Other measurements taken as well as laboratory investigations carried out and recorded were:

 Weight 101 kg

 Haemoglobin level 10.7 g/dl

 Urine protein Negative

 Urine of glucose Negative

I sought her permission to examine her physically from head to toe. I explained the motive

for the examination and the areas to be examined were discussed with her and she agreed. I

observed her emotional status throughout our interaction and it was good. She had no physical

deformity and had a good gait. I asked her to empty her bladder. I continued with the

examination under the supervision of the midwife in charge. I assured her of total privacy and

helped her to change into the examination gown. I assisted her unto the examination couch to lie

down in a supine position. I washed my hands with soap under clean running water and dried

them with a clean towel, after which I stood at her right side for the examination.

Quick examination from head to toe revealed no abnormality. Her hair was braided neatly

with no dandruff or lice. Her face was smooth with no rashes or pimples. Her conjunctiva was

pink with a clear sclera with no abnormality. There were no discharges from her eyes, nose and

ears. She had dark lips without any cracks, clean mouth with white, well maintained teeth and

clean pink tongue. I inspected and palpated the neck for any swellings or distended neck veins –

there were none. The breasts were well situated on the chest, equal in size with darkened areola

and Montgomery’s tubercles. Client was asked to support her occiput with her left palm for left

breast to be examined. The pad of the palm was used to palpate her left breast quadrants in a
clockwise manner with circular motions. After that, the nipple was squeezed for any discharge –

none was present. The same procedure was done to the right breast and I detected no abnormality.

She was taught how to care for the breast with regular self-breast examination, and was

encouraged to report any abnormality to the midwife or health care provider. Her upper and lower

extremities were of the same size and length with no abnormalities. No abnormalities were seen

on inspection of her nail beds.

On abdominal examination, the abdomen was globular in shape with striae gravidarum,

linea nigra and foetal movement present without any scar or rashes on inspection. I warmed my

palms and palpated her abdomen. The gestation was 36 weeks 1 day; symphysiofundal height

measured 36 cm. On lateral palpation, the lie was longitudinal, position was right occipitoanterior

and presentation was cephalic. In assessment of the descent of the foetal head, the anterior

shoulder was located below the mother’s umbilicus at about 2.5 cm from the linea nigra, where

the limbs were located. Two fingers were kept over the anterior shoulder after which the

symphysis pubis was located. The ulnar border of the right hand was placed just above the

symphysis pubis and the anterior shoulder. Five fingers were accommodated indicating head

descent of 5/5th palpable abdominally.

On auscultation, the foetal heart rate was 134 beats per minute with a regular rhythm.

Permission was sought to do vulva inspection after explanations were given for the examination. I

draped her again with her knee flexed to expose only her genital area. The vulva was inspected for

vulval warts, sores, varicose veins or vaginal discharge but none was found. The groin area was

palpated for swollen lymph nodes, open sores or swelling but none was detected.

I also inspected the lower extremities for tenderness in the calf, oedema, varicose veins,

size and equality but nothing abnormal was present. I inspected her back and no abnormalities

like rashes, oedema or scoliosis were detected on her sacral region. I helped her out of the couch

and assisted her to dress up. I then thanked her for her cooperation throughout the examination.

All these examinations were done under close supervision of the midwife in charge. I washed my

hands with soap and clean water and dried them with clean towel. I made sure all findings were
communicated to Madam V.O., and I reassured her of safe delivery. She had her third dose of

malaria sulphadoxine pyrimethamine on that day. I recorded all observations in her antenatal book

and her routine drugs were prescribed as follows

 Tablet Fersolate 200 mg TDS x 30 days

 Tablet Vitamin C 200 mg once daily x 30 days

 Tablet Folic acid 5 mg once daily x 30 days

 Tablet Multivite 200 mg once daily x 30 days

I asked her if she had any problem or question to ask, she then complained of having

heartburn for the past 3 days after eating. I explained to her that heartburns in pregnancy occur

due to congestion and relaxation of the oesophageal cardiac sphincter, and regurgitation of gastric

contents causing burning sensation in the throat. She was encouraged to eat in bits at frequent

intervals and avoid over eating and highly spicy foods.

I educated her on good nutrition, rest and sleep, personal hygiene and the use of

insecticide treated net to prevent malaria. I documented my findings and I told her there were no

abnormalities. I took Madam V.O.’s home address details and exchanged contact numbers with

her. I escorted her out of the maternity unit and bade her goodbye.

First Antenatal Home Visit

On Monday 22nd March 2021 around 2:50 pm, I made my first visit to Madam V.O. and

her family at Bortianor Israel. My motive for the visit was to know where she stayed, how she and

her family were coping with the pregnancy and know her home environment. On my arrival at her

home, I met Madam V.O. preparing food. She warmly welcomed me and offered me a seat. She

was preparing one of her Banku meals.

I asked about the health of the family to which she replied that they were doing well. I

asked about her health and she confirmed her condition was quite better as she had not

experienced heartburn since I advised her on her eating habits. However, she complained of

inability to move her bowels for the previous three days. I then explained the physiology of
constipation in pregnancy to her, that it was a result of slow intestinal peristalsis from relaxing

effect of progesterone on smooth muscles. I also advised her to eat high fibre diets, take in

adequate fluids, fruits, vegetables, and also can take a glass of warm water in the morning to help

improve her bowel movement.

Madam V.O. lives at Bortianor Israel with her husband and their two children. They live

in a single room in a compound house. The house was built with cement and was painted beige.

Her room was painted light blue and the furniture were neatly arranged. There were two doubled

windows which were opened during day time to improve ventilation and closed during evening,

and a door with mosquito proof net to prevent mosquitoes from coming into the room. They slept

under a treated mosquito net. Their source of water was pipe borne and source of light was

electricity. She stored water in a barrel outside with a well-fitting lid. But her surroundings were

well maintained by tenants of the compound house.

I therefore took the opportunity to comment on the clean environment and commend her

and her co-tenants on their good sense of hygiene since it helps prevent diseases like malaria and

makes one feel comfortable in the environment. Her garbage was stored in a dustbin with a well-

fitting lid behind her house and she emptied in the public down the road every 2 days. Madam

V.O. and her family were ready to receive the baby. I thanked her, her neighbours asked to take

my leave. I bid them goodbye after reminding her of her next antenatal clinic visit in next 2 days.

Subsequent Antenatal Clinic Visit

At 10:00 am on 24th March 2021, Madam V.O. reported to the antenatal clinic at 37

weeks 1 day gestation where she was welcomed and offered a seat. I asked how she was feeling

and she said she was fine and had no complaints. Consent was given for head-to-toe examination,

revealing no abnormalities.

Her vital signs were checked and recorded as follows:

 Temperature 37.0℃

 Pulse 90 bpm
 Respiration 18 cpm

 Blood pressure 100/60 mmHg

 Weight 102 kg

Urine was tested for glucose and protein and it was negative. Abdominal examination was

done and on inspection, the abdomen was globular shape with no scar or rashes. She had striae

gravidarum, linea nigra well as foetal movements, and symphysiofundal height was 38 cm. I

palpated her abdomen with warm hands; the lie was longitudinal, and the back of the foetus was

to her right side, limbs facing the mother’s left side, position was felt at the right occipitoanterior,

presentation was cephalic and decent of 5/5th palpable abdominally.

On auscultation, the foetal heart rate was 144 bpm with regular rhythm. All findings were

communicated to her and recorded in her antenatal book. I reminded her of the signs of labour and

escorted her out of the Unit since she had no complaints.

Second Antenatal Home Visit

My second visit to Madam V.O. was on the 29th of March 2021 at 12 noon. The visit was

to see how she was doing and her preparations towards delivery since her pregnancy was almost

getting to term. On my arrival, I met my client and other relatives who welcomed me and offered

me a seat. We exchanged greetings after which I enquired about her health, which she said she

was urinating frequently and that it even interrupted her sleep. I reassured her and told her that

this is as a result of the presenting part of the baby pressing on her bladder and that when she

delivers, it will go.

She also complained of pain at the back especially when sitting. I therefore explained to

her that it was due to decent of the foetal head, and I encouraged her relatives to assist her in the

household chores. I also asked whether she had items ready for delivery and she said yes. I

therefore asked for her permission to inspect the items and they were intact. I encouraged her to

gather and pack all purchased items together in a bag with her insurance and antenatal card. I also
reminded her about signs of true labour which include blood-stained vaginal discharge, regular

painful rhythmic contractions and severe lower abdominal pains.

I reminded her on the need to take in adequate diet and to have enough rest in order to

maintain her general health. Madam V.O. followed all instructions that were given her on

previous visits to the antenatal clinic, therefore, she had no complaints. I thanked her and relatives

and asked permission to leave.

Subsequent Visits to the Antenatal Clinic

At 38 weeks 1 day gestation Madam V.O. reported to the antenatal clinic on 31st March

2021 at 10:09 am. She was warmly welcomed and offered a seat. I asked how she was feeling and

she complained of lower abdominal pains which I reassured her and explained the physiology to

her. Consent was given for head-to-toe examination which revealed no abnormalities.

Her vital signs were checked and recorded as follows:

 Temperature 37.0 ℃

 Pulse 80 bpm

 Respiration 20 cpm

 Blood pressure 120/60 mmHg

 Weight 103 kg

On 7th April 2021 Madam V.O. reported to the antenatal clinic at 10:00 am at 39 weeks 1

day maturity. She was warmly welcomed and offered a seat. I asked how she was feeling and she

and she replied with a smile that she was fine. Routine examinations were performed with no

abnormality detected. She had no complaints and was informed that labour could set in at any

time, therefore she was educated on birth preparedness and complication readiness whiles she

waited for labour to set in. She was also encouraged that during the waiting, if she experienced

any problems she should report to the clinic.

Nursing Care Plan During Antenatal

Problems Identified

1. Inadequate knowledge on malaria prevention (17/03/21 at 8:30 am)

2. Heartburn (24/03/21 at 11:30 am)

3. Constipation (22/03/21 at 2:50 pm)

4. Frequency of micturition (29/03/21 at 12 noon)

5. Lower abdominal pain (31/03/21 at 12 noon)

6. Lower back pain (29/03/21 at 12 noon)

Nursing Diagnosis

1. Knowledge deficit related to inadequate information on malaria prevention.

2. Impaired comfort (heartburns) related to relaxation of the cardiac sphincter by

progesterone

3. Risk for dysfunctional gastrointestinal motility (constipation) related to the effect of

progesterone acting on smooth muscle.

4. Stress urinary incontinence (frequency of micturition) related to decreased capacity

associated with descent of the foetal head

5. Impaired comfort (lower abdominal pain) related to descent of foetal head

6. Acute pain (backache) related to physiological changes in pregnancy.

Short Term Objective

1. Client will gain adequate knowledge on malaria prevention within 1 hour

2. Client will be relieved of heartburns within 24 hours

3. Client will be able to have free bowel movement within 48 hours

4. Client will be able to cope with frequency of micturition within 24 hours

5. Client will be able to cope with lower abdominal within 48 hours

6. Client will be able to cope with backache in pregnancy within 48 hours.

Long Term Objectives

Madam V.O. will go through pregnancy successfully without any complication to herself and her

foetus.
Date/ Nursing Nursing Nursing Nursing Date/
Time Diagnosis Objectives Time
Orders Intervention Evaluation Sign

17/03/21 Knowledge Client will gain 1. Ask client what she 1. Client was asked what she knows about 17/03/21 Goal fully
at 8:30 deficit related adequate knows about malaria malaria prevention and was educated on at 9:30 met as client
MA
am to inadequate knowledge prevention the importance of malaria prevention. am was able to
information on within 1 hour as answer
malaria evidenced by questions on
prevention client ability to 2. Educate client on the 2. Client was educated on the importance malaria
answer importance of personal of personal hygiene to her and the unborn prevention
questions hygiene. baby. correctly.
correctly on
malaria
prevention 3. Educate client to clean 3. Client was told to let her husband help
choked gutters and clear choked gutters and stagnant water
stagnant water around her around her environment to prevent
environment. mosquitoes from breeding in it.

4. Encourage client to 4. Client was encouraged to wear brightly

wear brightly coloured coloured clothes at night because
clothing at night. mosquitoes like to hide in dark areas.

5. Ask client questions on 5. Client was asked whether she sleeps

malaria prevention. under treated mosquito net and she said
yes.

Table 1: Nursing Care Plan on Antenatal

Table 1: Nursing Care Plan during Antenatal Continued
Date / Nursing Nursing Nursing Nursing Date / Time
Time
Diagnosis Objectives Orders Intervention Evaluation Sign

24/03/21 Impaired Client will be 1. Reassure client that she 1. Client was reassured that she will 25/03/21 at Goal fully MA
at 11:30 comfort relieved of will be relieved of heart- be relieved of heart-burns. 10:30 am met as client
am (heartburns) heart-burns burn affirmed that
2. Physiology of heart-burns was
related to within 24 hours she has been
2. Explain the physiology of explained to client as the effect of
relaxation of as evidenced by relieved of
heart-burns to client as the cardiac sphincter being relaxed by
the cardiac client’s cardiac heart burns
effect of cardiac sphincter progesterone causing reflux of gastric
sphincter by sphincter
relaxation by progesterone contents
progesterone relaxed

3. Educate client to avoid 3. Client was educated to avoid highly

highly fatty and spicy foods fatty and spicy foods such as beef,
fried eggs, because they take longer to
digest .

4. Encourage client to eat

4. Client was encouraged to eat meals
meals in bits at frequent
in bits at frequent intervals to reduce
intervals
reflux

5. Encourage client to avoid

5. Client was encouraged not to bend
bending in her household
when preforming her household
activities.
activities as there is a reflux.
Table 1: Nursing Care Plan during Antenatal Continued

Date/ Nursing Nursing Nursing Nursing Date/

Time Diagnosis Objectives Time
Orders Intervention Evaluation Sign

22/03/21 Risk for Client will have 1. Reassure client that she 1. Client was reassured that her 23/03/21 Goal fully met MA
at 2:50 dysfunctional free bowel will be relieved of constipation will be relieved at 3:30 as client
pm gastrointestina movement constipation to allay fear and pm verbalized that
l motility within 48 hours anxiety she was able
(constipation) as evidenced by 2. Physiology of constipation was to empty her
related to reduced explained to client as effects of bowel freely
effects of progesterone 2. Explain physiology of progesterone acting on the smooth at least once
progesterone acting on the constipation to client on the intestinal muscles making them reduce daily
acting on the smooth effect of progesterone acting in muscle contraction.
smooth intestinal muscle on the smooth intestinal
intestinal muscles
muscle 3. Client was encouraged to take in
3. Encourage client to take in
more fruits, fluids and rich fiber foods
more fruits, fluids and food
such as oat meal, banana, to aid in free
rich in fiber.
bowel movement.

4. Educate client to do
4. Client was educated to do antenatal
antenatal exercise.
exercise like the kegel’s exercise and
brisk walking.

5. Encourage client to empty 5. Client was encouraged to adopt

her bowel whenever she has regular bowel emptying habit to
the urge to do so prevent constipation.
Table 1: Nursing Care Plan during Antenatal Continued

Date/ Nursing Nursing Nursing Nursing Date/ Evaluation

Time Diagnosis Objectives Time
Orders Intervention Sign

29/03/21 Stress Client will be able 1. Reassure client that her 1. Client was reassured that her condition 31/03/21 Goal fully MA
at 12 urinary to cope effectively condition can be managed can be managed and that she is in a safe at 2 pm met as client
noon incontinence with frequency of hand. verbalized
(frequency micturition within that she has
of 24 hours as 2. Explain the physiology of been able to
micturition) evidenced by client frequency of micturition to 2. The physiology of frequency of cope with
related to understanding and client. micturition was explained to client as due frequency of
decreased coping with to decreased capacity of the bladder micturition
capacity of frequency of associated with presenting foetal head
the bladder micturition. 3. Encourage client to empty
3. Client was encouraged to empty her
associated her bladder with each urge to
bladder with each urge to void to prevent
with void
leakage of urine
presented
4. Educate client to always
foetal head 4. Client was educated to clean her vulva
clean her vulva from front to
from front to back after each void to
back after each void
prevent infection.
5. Educate client on good
5. Education on good perineal care was
perineal care.
given to client to prevent infection
Table 1: Nursing Care Plan during Antenatal Continued

Date/ Nursing Nursing Nursing Nursing Date/

Diagnosis Objectives Time
Time Orders Intervention Evaluation Sign

31/03/21 Impaired Client will be 1. Reassure client that pain 1. Client was reassured that 03/04/21 Goal fully met as MA
at 12 comfort (lower able to cope with will subside. her pain will subside after at 2 pm client verbalized
noon abdominal lower abdominal delivery that she has been
pain) related to pains within 48 able to cope with
2. Explain the physiology of 2. Physiology of lower
descent of hours as the pain
lower abdominal pain to abdominal pain was explained
foetal head evidenced by
client. to client as due to the effect of
client
descent of the foetal head
understanding the
physiology of the 3. Client was encouraged to
3. Encourage client to adopt
descent of foetal adopt good sitting and lying
good sitting and lying down
head. down positions to prevent
positions
severity of the pain.
4. Client was asked to grade
4. Assess client’s level of pain level of pain from 0-10 and
rating 0-10 she rated 4.
5. Client was encouraged to
let her mother assist her in
5. Encourage client to allow
household chores like
relatives assist her in
washing, cleaning and
household chores
fetching of water.
Table 1: Nursing Care Plan during Antenatal Continued

Date/ Nursing Nursing Nursing Nursing Date/

Time Diagnosis Objectives Time
Orders Intervention Evaluation Sign

29/03/21 Acute pain Client will be able 1. Reassure client that pain 1. Client was reassured that her 31/03/21 Goal fully met MA
at 12 (back pain) to cope with will be subside after delivery pain will subside after delivery at 11 am as client
noon related to backache in verbalized that
2. Explain the physiology of 2. Physiology of backache was
physiological pregnancy within she has been
backache to client. explained to client as due to the
changes in 48 hours as able to cope
relaxation of the sacroiliac joint
pregnancy evidenced by with the pain
client being able 3. Client was encouraged to assume
3. Encourage client to adopt
to cope with pain. good sitting and lying down
good sitting and lying down
positions to prevent severe pain.
positions
4. Client was assessed using the
4. Assess client using the
pain rating scale from 0-10 and she
pain rating scale 0-10
rated 5.
5. Encourage client to allow
5. Client was encouraged to allow
relatives assist her with
her mother help assist her with
household chores
household chores like cleaning and
washing.
 CHAPTER THREE

REPORT ON LABOUR AND DELIVERY

This chapter gives details on admission and management of labour of Madam V.O.

Labour; this is the process by which the fetus, placenta and membranes are expelled through the

birth canal. Normal labour is a labour which occurs at term, spontaneous in onset and fetus

presenting with vertex which is completed within 18 hours with no complications resulting in the

mother and baby in good health.

Admission and Initial Assessment

Madam V.O. reported to the Mother and Child Hospital on 13 th April, 2021 at 2:10 am with

her mother with the history of labour pains. They were warmly welcome and offered a seat. I took

her antenatal card and quickly looked through to recheck her obstetric history and any antenatal

problems for confirmation. History of labour was taken by inquiring about foetal movement,

vaginal bleeding, ruptured membranes, and any medication taken before coming and last bowel

action. I asked whether she had seen blood-stained mucus discharge from her vagina and she said

yes. Then I asked her if she had eaten and she said she drunk tea with bread around 8:30 pm. I

rechecked her expected date of delivery and verified her HIV status. Her vital signs were also

checked and recorded as follows;

 Temperature 37.0℃

 Respiration 22 cpm

 Pulse 90 bpm

 Blood pressure 100/70 mmHg

Management of First Stage of Labour

I explained head to toe examination to her and she was asked to empty her bladder into a

bedpan for it to be measured. Urine sample was collected and tested for sugar, protein concentration

and smell which were all negative. The amount of urine passed was approximately 150 mls.
I provided privacy and assisted Madam V.O to undress and wear a gown and I helped her into a

comfortable bed in the first stage room. She was assisted to lie in the left lateral position. I washed

my hands and dried them with a clean towel. General examination from head to toe was done and

no abnormalities were detected.

Abdominal examination was conducted and on inspection, the abdomen was globular in

shape. Linea nigra, striae gravidarum and foetal movement were present with no scars. On fundal

palpation, the gestational age was 40 weeks and the symphysiofundal height was 37 cm above the

umbilicus. The foetal buttocks occupied the upper pole of the fundus. On lateral palpation, the

foetal back was felt at right of the mother and the limbs on the left. The position was right

occipitoanterior, lie was longitudinal.

On pelvic palpation, the head descent was 3/5 th above the pelvic brim. On auscultation,

foetal heart rate was 148 bpm with good volume and regular rhythm. I then washed my hands under

running water with soap and dried with clean towel. I sat at the right side of the client, warmed my

palm and placed my palm at the fundus to time uterine contractions. Uterine contractions were 2 in

10 minute each lasting between 20 to 40 seconds.

I explained vaginal examination to client, sort her consent and she agreed. I set a sterile tray

for the procedure. Which I ask her to empty her bladder and also assisted her to assume the

lithotomy position and she was draped. I washed my hands and dried with clean towel. I put on

sterile gloves, removed the soiled pad with my left hand and discarded it. I asked her to separate her

leg and she did. On inspection, the vulva was neatly shaved and healthy with no swelling, edema,

warts hematoma, varicose vein, sore, redness, scar or offensive discharges. I asked her whether she

feels any intense irritation but she said no.

I picked a swab with my right hand from a gallipot and dipped it in a Savlon solution in a different

gallipot and squeeze, then dropped the swab from my right hand into the left hand. With the left

hand, the labia majora, minora and the vestibule were separated and swabbed using one swab per

stroke and wiping from anterior to posterior and disposed off. With the labia minora still separated,
I gently inserted my right middle finger into the vagina, firmly pressing downwards and added the

index finger gently. I felt for the condition of the vagina and the vagina was warm and moist.

The cervix was soft, thin, centrally located, effaced and well applied to the presenting part.

The cervical dilatation was 4 cm at 2:30 am on 13th April, 2021, membranes were intact. The

examining fingers were withdrawn and ‘show’ was noticed on the fingers with no offensive odour.

A sterile perineal pad was applied to the vulva. I discarded the tray and immersed my gloved hands

into 0.5% chlorine solution and removed the gloves.

I then washed my hands with soap under running water and dried them with a clean towel. I

helped my client out of the examination bed and all findings were communicated to her with the use

of the cervical dilatation board. All findings were plotted on the partograph and recorded in her

antenatal record book. She was encouraged to walk around to aid descent or lay on her left lateral

side, empty her bladder frequently to aid descent of the foetal head and practice deep breathing

relaxation exercise in between contractions to prevent her from bearing down prematurely.

I also encouraged her to ask questions and I prepared tea for her with items bought by her

husband and took about 200 mls of malt. She was given constant emotional and physical comfort

throughout to gain enough strength throughout the delivery. I asked her to change the sanitary pad

when soiled and use a new pad when falls down to prevent infection to the genital tract. Maternal

pulse, uterine contractions and foetal heart rate checked every 30 minutes while vaginal

examination, temperature checked every 2 hours and maternal blood pressure were also checked

every 4 hours and urine checked any time she passes urine. Client looked anxious; I therefore

reassured her of competent care and explained the physiology of labour to her.

At 2:30 am

1. Cervical dilatation was 4cm, membranes were intact, cervix was thin and elastic and no

moulding.

2. Descent was 3/5th palpable abdominally.

3. Contractions were 2 in 10 minutes with each lasting between 20-22 seconds

4. Foetal heart rate was 148 bpm

Vital signs checked include;

 Temperature 37.0 °C

 Respiration 22 cpm

 Pulse 90 bpm

 Blood pressure 100/70 mmHg

 Urine passed 150

 Protein and acetone Negative

Client exhibited a little form of anxiety by asking me when will her labour end which I did allay her

fears by educating her on the stages of labour and also using the dilatation structure.

Findings were communicated to client and recorded on the partograph.

At 3:00 am

1. Uterine contractions were 2 in 10 minutes with each lasting between 22-24 seconds

2. Foetal heart rate was 136 bpm

3. Maternal pulse 78 bpm.

Findings were communicated to client and recorded on the partograph.

At 3:30 am

Uterine contractions were 3 in 10 minutes with each contraction lasting between 22-24 seconds

1. Foetal heart rate was 144 bpm

2. Maternal pulse was 80 bpm

Client complained of severe lower abdominal pain. I therefore encouraged deep breathing exercise

and involved her in a conversation to divert her mind from pain. Client was sweating profusely. I

cleaned it with a clean face towel and encouraged her to drink adequate fluids. Findings were

communicated to client and recorded on the partograph.

At 4:00 am

1. Uterine contractions were 3 in 10 minutes with each contraction lasting between 24-26

seconds
2. Foetal heart rate was 148 bpm

3. Maternal pulse was 76 bpm

4. Temperature was 37.2℃

Findings were communicated to client and recorded on the partograph.

At 4:30 am

1. Uterine contractions were 3 in 10 minutes lasting between 26-28 seconds

2. Foetal heart rate was 138 bpm

3. Maternal pulse was 78 bpm

Findings were communicated to client and recorded on the partograph.

Client complained of backache. I reassured her that she will be able to cope with it and I gave her

sacral massage to relieve pain.

At 5:00 am

1. Uterine contractions were 3 in 10 minutes with each contraction lasting between 32-34

seconds

2. Foetal heart rate was 136 bpm

3. Maternal pulse was 74 bpm

Findings were communicated to client and recorded on the partograph.

At 5:30 am

1. Uterine contraction was 3 in 10 minutes with each contraction lasting between 38 to 40

seconds

2. Foetal heart rate was 136 bpm

3. Maternal pulse was 76 bpm.

Findings were communicated to client and recorded on the partograph.

Client complained of tiredness. I reassured her of relieve after delivery and assisted her to assume a

comfortable position. A cup of tea was served and she drank about 100 mls.

At 6: 00 am

1. Uterine contraction was 3 in 10 minutes with each contraction lasting between 42-44

seconds

2. Foetal heart rate was 130 bpm and

3. Maternal pulse 80 bpm

At 6:30 am

Vaginal examination was done under aseptic technique and dilatation was 9 cm. Membranes

were intact, cervix was thin and elastic and no moulding, descent was 1/5 th palpable abdominally

and uterine contractions were 4 in 10 minutes with each contraction lasting over 40 seconds, foetal

heart rate was 136 bpm.

Vital signs checked and recorded as follows;

 Temperature 36.8 ᵒC

 Pulse 78 bpm

 Foetal heart rate 134 bpm

 Blood pressure 120/70 mmHg

Urine was tested for protein and sugar and all were negative; volume of urine passed was

140 mls. Findings were communicated to client and recorded on the partograph. Client was

transferred to the second stage room after I had prepared all items needed for delivery. I helped her

onto the bed to lie in the left lateral position to improve placental perfusion.

Findings were communicated to client and recorded on the partograph.

At 7:00 am

1. Uterine contractions were 4 in 10 minutes with each contraction lasting over 40 seconds.

2. Foetal heart rate was 140 bpm and

3. Maternal pulse was 80 bpm.

Since client was almost due and complained that her anus feels heavy and has the urge to

push. I reassured her not to push because she can obtain a perineal tear. I did set up of delivery. The

delivery trolley and resuscitation table were in set up in preparation for delivery. All sterile and

non- sterile items needed for the delivery were arranged neatly on the trolley. oxygen and suction

apparatus were all checked and tested and all were safe and functioning. I also checked if the

radiant heater was working and cleaned and later came back for Madam V.O. I took all necessary

items needed for the delivery such as perineal pad, cot sheet, baby cloth, etc.

At 7:30 am
Membranes ruptured spontaneously and vaginal examination was done to rule out cord

prolapse and confirm full cervical dilatation. Liquor was clear, cervical OS was fully dilated (10

cm), descent was 0/5th and moulding was one plus.

Client complained of having the urge to bear down when uterine contractions were more

frequent and stronger; 4 in 10 minutes lasting over 40 seconds. Descent was 0/5th palpable

abdominally, foetal heart rate was 141 bpm and maternal pulse was 78 bpm.

Client was reassured that the baby will soon be born unto her abdomen so she should help

hold the baby to promote bonding. She was encouraged to continue with deep breathing and

relaxation exercise with each contraction. All findings were recorded on the partograph sheet.

About 120 mls of urine was passed.

Management of Second Stage of Labour

The second stage of labour begins when the cervix is fully dilated and the complete

expulsion of the fetus out of the vaginal canal. During this stage a delivery boot and apron were

worn as protective clothing. Client was encouraged to assume a comfortable position such as

lithotomy on the delivery bed, I washed my hands with soap under running water, dried with a

clean towel and sterile gloves were worn. The procedure was explained to her and she was

reassured. The midwife in-charge who was my assistant checked the foetal heart rate and maternal

pulse after each contraction.

The abdomen and thighs were covered with a warm clean towel exposing only the vulva and

the perineum. The anus was gaping and perineum bulging. The anal orifice was covered with

perineal pad to prevent contamination of the delivery field with faecal matter. I encouraged and

reassured her to push or bear down with contraction and rest in-between by deep breathing. Foetal

heart rate was checked after every uterine contraction by my assistant. As the foetal head advanced

with good uterine contraction and maternal effort, I placed the fingers of my right hand on the

occiput of the advancing head to maintain good flexion. This was to enable the smallest diameter of

the foetal head, suboccipitobregmatic diameter of 9.5 cm of the skull to distend the perineum and

the vulva thereby preventing any injury to the mother and baby.

As crowning of the foetal head took place, she was asked to stop pushing and pant with each

contraction to avoid rapid expulsion of the foetal head which could lead to perineal tear. The

occiput escaped under the symphysis pubis and the sinciput, face and chin swept the perineum and

the head was delivered by extension. I checked for cord around neck and there was none. The eyes

were cleaned with sterile swabs from the inner cantus outwards to prevent eye infection to the baby

and the face was cleaned. Restitution and external rotation of the head took place and internal

rotation of the shoulder into the anterior posterior diameter of the pelvic outlet. She was reminded

that the baby would be delivered unto her abdomen.

The anterior shoulder was delivered by a downward movement towards the perineum and

the posterior shoulder, also delivered by an upward movement towards the mother’s abdomen, and
the rest of the body was delivered by lateral flexion onto the mother’s abdomen at 8:01 am on 13th

April, 2021. A live female baby who cried immediately was delivered. Apgar score assessed in the

first minute was 7/10. Madam V.O. was congratulated for her effort and cooperation.

Management of Third Stage of Labour

The third stage of labour is that of separation and complete expulsion of placenta and

membranes and involves the control of bleeding. It lasted from the birth of the baby until the

placenta and membranes were expelled. The procedure was explained to client and reassured. The

soiled linen under her was replaced with a new sheet to make her comfortable and she was

remained in that position assumed during delivery of the baby.

Madam V.O.’s bladder was emptied with a urinary catheter which was inserted into the

urethral os, and her abdomen was gently palpated to exclude undiagnosed twin. 10 units of

Oxytocin were administered intramuscularly on her thigh. A sterile receiver was placed

longitudinally in between her thighs near the vulva with the cord of the placenta clamped resting in

it to receive the placenta and blood clots. The uterus was felt for contractions and was well

contracted. The left hand was placed above the symphysis pubis towards the abdomen with palm

facing the umbilicus exerting pressure in an upwards direction (counter-traction). The right hand

was used to hold the cord using the artery forceps. The clamped cord and the end of the forceps

were held horizontally to apply controlled cord traction (CCT) following the curve of the birth

canal.

The placenta was delivered by counter pressure and controlled cord traction. Once the

placenta was out, I teased it with my hand with gentle upward and downward movement, the

placenta and membranes were delivered at 8:25 am. I examined the placenta immediately to rule

out missing lobes or membranes, and placed it into the receiver for thorough examination later. The

uterus was rubbed up for contractions and blood clots were expelled. I then wrapped a gauze swab

around my two index fingers and examined the cervix, vaginal walls and vulva for tears but there
were none. 600 mcg of Cytotec® (misoprostol) was inserted in the anus to prevent postpartum

haemorrhage.

I cleaned my client and applied a perineal pad to the vulva. Estimated blood loss was

approximately 150 mls. I made her comfortable in bed, reassured and thanked her for her

cooperation. She was asked to empty her bladder frequently to prevent postpartum haemorrhage.

Delivery field and trolley were tidied up with 0.5% chlorine solution.

The placenta was placed on a flat surface and examined for any missing lobes or membranes. I held

the placenta by the cord allowing the membranes to hang with a gloved hand. The other hand was

placed within the hole of the membranes and spread out the membranes to aid inspection. Only one

hole from which the fetus had passed through was present, no blood vessels travelled across the

membrane. Which shows that the membranes were intact.

The foetal surface of the placenta was bluish grey in colour with smooth and shiny surface.

The cord was centrally inserted. The cut end of the cord was cleaned with gauze and inspected; one

umbilical vein and two umbilical arteries were also visible. The amnion covered the foetal surface

of the placenta, continues throughout the total length of the cord and was peeled from the chorion

right up to the umbilical cord which allowed the chorion to be fully viewed. The blood vessels that

were seen radiating from the umbilical cord appeared to be lost deep into the placenta tissues before

reaching the circumference. The length of the cord was 48 cm.

The maternal surface was dark red in colour with several lobes (about 18-20 lobes). All the

lobes were intact with no infarcts. Any clot on the maternal surface was removed and kept for

measuring. The placenta weighed 0.6 kg, and it was complete and healthy.

The delivery instruments were immersed into 0.5% chlorine solution for 10 minutes, rinsed, washed

with detergent, rinsed, dried and packed for sterilization and storage for next use. I immersed my

gloved hand into 0.5% chlorine solution, removed the gloves and washed my hands under running

water with soap and dried with a clean towel. Madam V.O. was encouraged to breastfeed

immediately. All findings were recorded on the partograph sheet and in her antenatal book.
Immediate Care for the Baby

Immediately the head was born, the face of the baby was cleaned with sterile gauze and the

eyes were also cleaned with sterile gauzes from the inner cantus outwards. The mouth and nose

were not suctioned since the airway was patent. The umbilical cord was clamped 3 cm away from

the baby’s umbilicus and a second one, 2 cm away from the first clamp. Sterile gauze was placed in

the middle to prevent splashing when cutting and ligatured by a cord clamp. The baby was dried

with a clean towel and wrapped with warm towel to provide warmth and to prevent hypothermia.

Apgar scores in the 1st and 5th minute were 7/10 and 9/10 respectively.

APGAR SCORE 1ST MINUTE 5TH MINUTE

Appearance 1 1
Pulse 2 2
Grimace 1 2
Activity 1 2

Respiration 2 2
Total 7/10 9/10

The baby was shown to the mother to identify and confirm the sex. An identification band

bearing the mother’s name, date of birth, birth weight, time, and sex was placed on the hand. The

baby was active and pink in colour. All findings were recorded on the partograph sheet and in the

mother’s antenatal book.

Management of the Fourth Stage of Labour

The fourth stage of labour is a period for critical observation of the mother and baby closely

for the first six (6) hours following the delivery of the placenta and membranes. One hour in the

labour ward and five hours in the lying-in room. This is to detect any abnormal condition like

postpartum haemorrhage and bleeding from the cord. These were done by my assistant; injection

Vitamin K was given intramuscularly to prevent bleeding from the stump of the umbilical cord and

aid in blood clotting. The female baby weighed 3.0 kg, head circumference was 33 cm, chest

circumference was 32 cm and baby’s length 50 cm.

 The general condition of Madam V.O. was observed by checking and recording her vital

signs every 15 minutes for the first 1 hour, every 30 minutes for the next 2 hours and hourly for the

next 3 hours. Findings were recorded as follows:

Findings for the first hour:

 Temperature 37.0 °C – 37 .2 °C

 Pulse 74 bpm – 78 bpm

 Respiration 18 cpm – 22 cpm

 Blood pressure 110/60 mmHg – 120/70 mmHg

 Lochia Rubra

Findings for the next 2 hours:

 Temperature 36.1 °C – 36.5 °C

 Pulse 78 bpm – 82 bpm

 Respiration 17 cpm – 20 cpm

 Blood pressure 100/70 mmHg – 110/60 mmHg

 Uterus Well contracted

 Lochia Rubra

Findings for the next 3 hours:

 Temperature 36.6 °C – 37.1 °C

 Pulse 80 bpm – 84 bpm

 Respiration 18 cpm – 20 cpm

 Blood pressure 110/70 mmHg – 120/60 mmHg

 Uterus Well contracted

 Lochia Rubra

Findings on the baby for the first hour

Vital signs and observations made on the baby are as follows;

 Temperature 36.2 °C,

 Apex beat 148 bpm

 Respiration 30 cpm

 Colour Pink

 Cord Not bleeding

 General condition Good

Findings on the baby for the next two hours

 Temperature 36.0℃

 Apex beat 148 bpm

 Respiration 30 cpm

 Colour Pink

 Cord Not bleeding

 General condition Good

36.2 ℃
Findings on the baby for the next 3 hours
 Temperature

 Apex beat 140 bpm

 Respiration 30 cpm

 Colour Pink

 Cord Not bleeding

 General condition Good

The uterus was felt every 15 minutes to ensure that it was well contracted. The fundal height

measured 17 cm, vaginal inspection was done frequently to rule out bleeding (postpartum

haemorrhage) and she was asked to change her perineal pad and was taught how to massage her

own uterus. I encouraged her to urinate frequently, which will aid uterine contraction to prevent
postpartum haemorrhage. She was served with a bottle of Malt, and was also taught how to fix and

position the baby to breast. She did it with ease because she has already breastfed 2 babies before.

I checked the baby’s condition and the baby’s colour was pink, the umbilical cord stump

was well clamped with no bleeding and breathing pattern was well established. Urine and

meconium were passed. I asked about the feeding pattern and Madam V.O. said the baby suckled

well when put to the breast. I also asked about the sleeping pattern and she said the baby sleeps

well. She was transferred to the lying-in ward at 8:10 am. Her husband was then invited to visit her.

She also had a warm bath after resting for some time in the fourth stage room. She was told to

report any bleeding and was also advised to observe the baby’s cord for any bleeding and change in

skin colour..

Observation of the Mother after Delivery

Uterus Well contracted

Symphysio fundal height 17 cm

Perineum Intact

General condition Satisfactory

Temperature 37.1 °C

Pulse 80 bpm

Respiration 20 cpm

Blood pressure 110/60 mmHg

Condition of the Baby

APGAR scores 7/10, 9/10

Sex Female

Birth weight 3.0 kg

Head circumference 33 cm

Chest circumference 32 cm

Full length 50 cm

Temperature 36.4 cm
Apex beat 148 bpm

Abnormalities None

Urine Passed

Meconium Passed

Colour Pink

Cord Not bleeding

General condition Good

Condition of the placenta

Maternal surface Dark red and rough

Foetal surface Bluish grey, smooth and shiny

Cord length 48 cm

Weight 0.6 kg

Diameter 22 cm

Cord vessels One umbilical vein, two umbilical arteries

Cord insertion Centrally

Lobes and membranes Complete and healthy

General condition Complete and healthy

Summary of Labour

Labour progressed normally and a live female infant was delivered.

Date of delivery 13th April, 2021

Time of delivery 8:01 am

Mode of delivery Spontaneous vaginal delivery

Time of placenta and membranes 8:25 am

Perineum Intact

Blood loss Approximately 150 mls

Drugs 10 units of oxytocin and 600 mcg of Cytotec®

(misoprostol)
 Duration of Observed Labour

STAGE TIME RANGE DURATION

First stage 2:30 am to 7:30 am 5 hours
Second stage 7:30 am to 8:01 am 31 minutes
Third stage 8:01 am to 8:25 am 24 minutes
Total duration 5 hours 55 minutes

Problems Identified During Labour

1. Client was anxious (13/04/21 at 2:30 am)

2. Client complained of lower abdominal pain (13/04/21 at 3:30 am)

3. Client complained of backache (13/04/21 at 4:30 am)

4. Client complained of fatigue (13/04/21 at 5:30 am

5. Risk for perineal trauma (13/04/21 at 7:30 am)

6. Risk of dehydration (13/04/21 at 3:30 am)

Nursing Diagnosis

1. Anxiety related to unknown outcome of labour.

2. Acute pain (severe lower abdominal pain) related to uterine contractions.

3. Impaired comfort (backache) related to relaxed pelvic ligament

4. Activity intolerance (fatigue) related to stress of labour

5. Risk for perineal trauma related to over stretching of perineal muscles.

6. Fluid volume deficit related to profuse sweating during labour.

Short Term Objectives

1. Client’s anxiety will be allayed within 1 hour

2. Client will be able to cope with severe lower abdominal pain within 5 hours

3. Client will be able to cope with backache within 5 hours

4. Client will be relieved of fatigue within 24 hours

5. Client’s perineum will remain intact within 7 hours

6. Client will maintain her hydration within 2 hours

Long Term Objective

Madam V.O. will deliver a normal and a live baby without any trauma or complications to both

mother and baby.

TABLE 2: Nursing Care Plan During Labour

DATE/ NURSING NURSING NURSING ORDERS NURSING DATE/ EVALUATIO

TIME DIAGNOSIS OBJECTIVES INTERVENTION TIME N SIGN

13/04/21 Anxiety related to Client will be 1.Reassure client to allay 1. Client was reassured of 13/04/21 Goal fully met A.M
at unknown outcome allayed of her fear and anxiety. competent care to allay her At as client
2:30 am of labour anxiety within 1 anxiety 5:25 am appeared to be
hour as 2. Explain the progress 2. Progress of labour was relaxed as
evidenced by of labour to client. explained to client that her labour
midwife cervix is dilating well. progressed.
visualizing 3. Encourage client to 3. Client was encouraged to
client’s relaxed ask questions and answer ask questions and answered
facial accordingly. accordingly.
expression.
4. Involve in 4. Client was involved in
communication and be communication to serve as
with her throughout a diversional therapy.
labour.
5. Allow the presence of 5. Client’s mother was
support person or allowed to be with her.
partner.
Table 2: Nursing Care Plan during Labour Continued

DATE/ NURSING NURSING NURSING NURSING DATE/

TIME DIAGNOSIS OBJECTIVES ORDERS INTERVENTION TIME EVALUATIO SIGN
N
13/04/21 Acute pain (severe Client will be able to 1. Reassure client that 1. Client was reassured 13/04/21 Goal fully met A.M
At lower abdominal cope with pain within she will be able to that she will be able to At as evidenced by
3:30 am pain) related to 5 hours as evidenced cope with pain. cope with pain and have 5:30 am client verbalized
uterine by client verbalizing 2. Explain the a successful delivery. that she is
contractions. that she is coping with physiology of lower 2. Physiology of lower coping with
pain. abdominal pain in abdominal pain was pain.
labour to client. explained to client that
it was as a result of
uterine contractions and
3. Encourage client to descent of foetal head.
lie on the left lateral 3.Client was encouraged
position. to lie on the left lateral
position to aid
4. Give sacral massage circulation.
to relieve pain. 4. Sacral massage was
5. Encourage deep given by her mother.
breathing exercise. 5. Deep breathing
exercise was
encouraged during
contractions and rest in
between contractions.
Table 2: Nursing Care Plan during Labour Continued

DATE/ NURSING NURSING NURSING NURSING DATE/ TIME EVALUATION SIGN

TIME DIAGNOSIS OBJECTIVES ORDERS INTERVENTION
13/04/21 Impaired comfort Client will be able 1. Reassure client to 1. Client was reassured 13/04/21 Goal fully met as A.M
At 4:30 (backache) related to cope with allay anxiety. that she will be able to At client verbalized
am to relaxed pelvic backache within 5 cope with pain 7:00 am that she is coping
ligament. hours as evidenced 2. Explain the 2. Physiology of with the
by client physiology of backache explained to backache.
verbalizing that she backache to client. client that it was due to
is coping with the presence of foetal
backache. head in the pelvic brim.
3. Give sacral 3. Sacral massage was
massage. given to reduce pain.
4. Involve client in 4. Client was involved
a conversation to in a conversation to
divert her attention divert her attention from
from the pain. the pain.
5. Encourage deep 5. Deep breathing
breathing exercise exercise was
during contractions encouraged during
and rest in between. contractions and resting
in between to help
reduce pain.
Table 2: Nursing Care Plan during Labour Continued

DATE/ NURSING NURSING NURSING NURSING INTERVENTION DATE/ EVALUATIO SIGN

TIME DIAGNOSIS OBJECTIVE ORDERS TIME N

13/04/2 Activity Client will be 1. Reassure client 1. Client was reassured that she 13/04/2 Goal fully met A.M
1 intolerance(fatigue relieved of that she will be will be relieved of fatigue after 1 as client had
at ) related to stress fatigue within relieved of ftigue. delivery. At energy to bear
5:30 am of labour 24 hours as 2. Client was assisted to assume 8:00 am down during the
evidenced by the 2. Assist client to a comfortable position like the second stage of
release of stress assume a comfortable left lateral position. labour.
of labour. position 3. Quiet environment was
3. Provide quiet provided for client by the
environment for midwife.
client 4.Nursing care was planned to
4. Plan care to minimize interference
minimize 5. Client was served with hot tea
interference to nourish her.
5. Serve client with
nourishing food and
fluids
Table 2: Nursing Care Plan During Labour Continued

DATE/ NURSING NURSING NURSING NURSING DATE/ EVALUATIO SIGN

TIME DIAGNOSIS OBJECTIVES ORDERS INTERVENTION TIME N
13/04/21 Risk for Client’s perineum 1. Encourage client to 1. Client was encouraged to keep 13/04/2 Goal fully met A.M
at perineal will remain intact keep her buttocks still her buttocks still during the 1 as midwife
7:00 am trauma related within 7 hours as during the delivery delivery process to prevent at visualized
to over evidenced by the process. perineal tears. 8:01 am client’s intact
stretching of midwife 2. Encourage client to 2. Client was encouraged to pant perineum.
perineal visualizing that pant after crowning after crowning of the foetal head to
muscles. client perineum is of the head. be able to assess for cord around
intact during neck.
inspection. 3. Maintain good 3. Good flexion of foetal head was
flexion of foetal head maintained during delivery to
during delivery. allow the smallest diameter to
distend to the perineum.
4. Allow restitution to 4. Restitution was allowed to take
take place before place before delivery of the body
delivering the body. to be able to deliver the anterior
shoulder first.
5. Deliver the anterior 5. Anterior shoulder was delivered
shoulder then the before posterior shoulder to
posterior shoulder. prevent perineal trauma.
Table 2: Nursing Care Plan During Labour Continued

DATE/ NURSING NURSING NURSING NURSING DATE/ EVALUATION SIGN

TIME DIAGNOSIS OBJECTIVES ORDERS INTERVENTION TIME
13/04/21 Fluid volume Client will 1. Reassure client to 1. Client was reassured that she 13 /04/21 Goal fully met A.M
at deficit related maintain her fluid allay fear and will retain her fluid volume. At as evidenced by
3:30 am to profuse volume within 2 anxiety. 2. Client was assessed for signs of 5:30 am midwife
sweating hours as evidenced 2. Assess client for dehydration and there was no observing no
during labour. by absence of signs signs of sign. signs of
and symptoms of dehydration. 3. Sweat from client’s face was dehydration.
dehydration. 3. Clean client’s cleaned with a wet clean towel
sweat with a wet and comfort ensured.
clean towel. 4. Client was given sips of water
4. Encourage client to moisten her mouth.
to take in more 5. Adequate ventilation was
fluids. maintained by opening nearby
5 Ensure adequate windows.
ventilation.
 CHAPTER FOUR

REPORT ON PUERPERIUM

This chapter talks about the care of mother and baby during the puerperium, advice on discharge,

post-delivery home visit for seven days, puerperium, preparation of client and family towards discharge,

first postnatal clinic visit review and nursing care plan.

Puerperium is the period of six (6) weeks or 42 days following childbirth during which the uterus

and other reproductive organs return to their non-pregnant state. During this period, the puerperal

mother is being given some essential care and education which aids in; promoting the development of

good mother-child relationship, physical well-being of mother and baby, encouraging sound method of

infant feeding, supporting the mother’s confidence to enable her fulfil her motherly role.

Baby’s First Bath

Around 2:00 pm Madam V.O was informed that the baby was going to be bathed. The baby was

then wrapped with a cloth. Preparation for baby’s bath was made which include a well set trolley with

baby’s sponge, face towel, baby soap, powder, baby dress, and cotton wool swabs soaked with

methylated spirit for cord cleaning. Warm water and cold water were mixed and its temperature was

tested with the elbow. Plastic apron was put on. Hands were washed and dried, surgical gloves were put

on and baby was placed on protected flat surface and undressed.

Baby was wrapped with a big cot sheet. The eyes were clean with a clean cotton wool swabs

soaked in clean water from inner cantus to the outer cantus. The baby’ face was cleaned with a dump

face towel and dried. The nape of the baby’s neck was supported with the left hand. The ears were

plucked with two fingers of the left hand.

The head was washed with soapy sponge. The baby was lifted off the flat surface, supporting the nape of

the neck and the baby resting in the elbow, to the edge of the bowl. The head was rinsed off soap and

dried with a clean towel.

 The baby was put back on the flat surface. The baby’s body was exposed. The arms and front

trunk were washed paying attention to the skin folds. The baby was turned with one arm supporting the

chest with hand holding the distal arms of the body. The back was washed down the feet, paying

attention to the skin folds. The baby was supported firmly and immersed in a bath of warm water, with

head above water and baby was rinsed thoroughly. The baby was placed on a flat surface covered with a

clean sheet. A small towel was used to dry the baby paying attention to the skin folds. The gloves were

removed and discarded; hands were washed and dried with a towel. I therefore dressed the baby up.

Surgical gloves were worn for the cord dressing. The cord was exposed. It was inspected for bleeding

but there was none.

The tip of the cord clamp was held with a cleaned swab. About 2cm away from the base of the

umbilicus was cleaned using a swab soaked with a methylated spirit one stroke at a time. The whole

cord cleaned with sterile swab soaked in methylated spirit. The cord clamp was clean with a fresh wet

cotton wool swap. I wrapped her in a clean cot sheet, baby was powdered, dressed and giving to mother

to breastfeed again. I tidied up the working surface and decontaminated the items in 0.5 chlorine

solution for 10 minutes. Gloves were removed, hands were washed and dried.

Observations made on the baby were as follows;

 Apex beat 140 bpm

 Respiration 44 cpm

 Temperature 36.4 °C

 Weight 3.0 kg

Examination of Baby

After 6 hours of delivery Madam V.O was informed that the baby will be examine and bathed.

She told me she had breastfed the baby that morning. Procedures were explained to her and she was

asked to sit by as the procedures went on. Examination was done in a clean room with nearby windows
and doors closed under a good source of light at 2:00 pm on 13th April, 2021. The baby was placed on a

protected flat surface. On inspection, the baby looked generally good. It was observed that the baby has

passed her first stool so she was cleaned up.

The baby’s skin was pink with vernix caseosa with no birth mark; there was good muscle tone

with no birth injuries. The scalp of the head was without any caput succedaneum or cephalohaematoma.

The fontanelles were not widely space; the face was round and small. The eyes were open, the

conjunctiva was pink and sclera was white in colour with no discharge. There was no cleft palate or lip,

false tooth and tongue tie. Suckling and rooting reflexes were present.

The nose was evenly placed in relation to the eyes. The nasal septum was intact with no

discharge. The ears were well placed. The neck was free from enlarged lymph nodes. The chest was

symmetric in its movements and expansion. Position of the nipples on the chest was normal. Breast was

free from any false milk. The upper extremities were of equal length and size with no extra digits. The

palmer creases as well as the grasping reflexes were present.

There was no webbing of fingers. The abdomen was soft. The umbilical cord was free from

bleeding. The genitalia were also examined. There was no hip displacement. The lower extremities were

also equal in length and shape with no extra digits. The back was examined and no dimple or swellings

were found. The anus was patent since the meconium had been passed.

Observations made on baby are as follows:

 Temperature 36.8 °C

 Apex beat 142 bpm

 Respiration 40 cpm
Subsequent Care in the Lying In Ward

Madam V.O and her baby were observed for 1 hour in the labour ward after which they were

transferred to the lying-in ward. Baby was wrapped in a warm cot sheet and placed by mother’s side.

Mother was served with malt. Her vital signs were checked and recorded as:

Temperature 37.10C

Pulse 84bpm

Respiration 20cpm

Blood pressure 110/60mmHg

On palpation, fundal height was 19cm above the symphysis pubis and uterus was well

contracted. The amount of lochia was rubra in colour when the perineal pad was inspected. I then told

her to change the perineal pad when soiled and also, pass urine frequently to prevent bleeding.

Preparation of Client for Discharge.

After examination, findings were communicated to the mother and I encouraged her to

breastfeed the baby on demand. On 13th April 2021 at 5:00 pm, Madam V.O. and her baby girl were

doing well. She was educated on the importance of exclusive breastfeeding for 6 months and its benefit

to the baby and the mother, I also educated her on how to position and fix her properly to the breast,

making baby empty one breast before putting her to the other breast and break wind after feeding.

Madam V.O. was asked to demonstrate it to me and she did as exactly how I taught her. The in-

charge then looked into Madam V.O.’s folder and found no abnormalities or complications so she

discharged her home for continuity of care. I sent her folder to the billing office of the Hospital for

billing. Her drugs were collected from the pharmacy. The following medications were given to her on

discharge:
1. Tablet Paracetamol 1 g TDS x 5 days

2. Tablet Folic Acid 5 mg daily x 30 days

3. Tablet Fersolate 200 mg daily x 30 days

4. Tablet Metronidazole 400 mg TDS x 5 days

5. Tablet Multivitamin 200 mg x 30 days

Madam V.O. was educated to bath at least twice daily and change her pad whenever soiled. She

was informed to clean the perineum from front to back after visiting the toilet. She was educated on the

need for frequent hand washing with soap and water especially after visiting the toilet, before handling

the baby or breastfeeding her. Madam V.O. was educated on how to care for the baby, by avoiding the

use of hot compresses and the application of herbal preparation on the posterior and the anterior

fontanels since they would close by the sixth (6th) week and eighteenth (18th) month respectively. She

was also told to keep the cord dry and avoid the application of herbs and other things on it such as

(Pepsodent® or clay).

Madam V.O. was also told to dress the cord with methylated spirit after baby bath. She was

further educated to keep her environment clean to prevent diseases from occurring. She was again

educated to sleep in insecticide treated mosquito net with her baby to prevent malaria.

Madam V.O was also educated on breastfeeding baby on demand and exclusively for six months’ day

and night, without any other food or water. She was taught how to fix the baby to breast. She was

encouraged to have time for the baby when breastfeeding.

She was also educated to feed baby on one breast at time for it to be emptied before giving the

other breast. She was educated to eat a well-balanced diet to help replace her lost blood, repair worn out

tissues and to nourish her body. She was urging to undertake exercise like walking and Kegel exercises

for pelvic muscles to regain their tone and enhance proper circulation as well as to aid in bowel

elimination.
She was also urged to rest for some time in the day and have enough sleep in the night to relieve her

body and mind off the stress of labour and help relieve her body’s immune system.

Madam V.O. was educated on the importance on birth registration and she was encouraged to

register her baby. I did remind my client of the tenth (10th) day visit to the clinic and six weeks post-

natal visit and to continue the immunization of the baby as scheduled. She was educated on the benefit

of completing the vaccination as it would protect the child from the various vaccine preventable

diseases.

She was urging to continue attending child welfare clinic till baby is 5 years old. She was

informed of my visit to her house the following day on discharge. I documented her discharge into the

admission and discharge book. Her husband who was around helped her to pack her things. Her husband

came with a taxi to the hospital premises around 5:30 pm which they got in and went home safely. Vital

signs were checked and recorded as;

 Temperature 36.6 ℃

 Pulse 78 bpm

 Blood pressure 120/70 mmHg

 Respiration 16 cpm

First Day Post-delivery Home Visit

On 14th April, 2021, I visited Madam V.O. and her baby at 7:00 pm and stayed still 8:30 pm in

her house. Relatives of Madam V.O. welcomed me with joy and with so much of excitement. Madam

V.O. was examined from head to toe and no abnormalities were detected. The symphysiofundal height

measured 18 cm. The lochia was rubra, moderate with no odour. She was looking cheerful and healthy.

After bathing she took mashed kenkey with milk for supper. She was reminded again to allow the baby

to empty one breast completely before the other to prevent engorgement. My client complained of lower
abdominal pain when breastfeeding. I educated client to get enough rest and also, exclusively breastfeed

the baby on demand.

Her vital signs were taken and recorded as follows

EVENING

 Blood pressure 110/60 mmHg

 Temperature 36.8 °C

 Pulse rate 80 bpm

 Respiration 20 cpm

She was encouraged on frequent changing of perineal pad. The baby was also examined from

head to toe with no abnormalities detected. The baby was topped tailed and cord was dressed with

methylated spirit and sterile swap and mother was educated not to apply any herbs on it. The baby’s

vital signs were checked and recorded as follows:

EVENING

 Temperature 36.2 °C

 Respiration 42 cpm

 Apex beat 140 bpm

Meconium and urine were passed, and baby’s colour remained pink. She was dressed and wrapped in a

warm cot sheet and put to breast. Findings were communicated to mother; I thanked her and promised to

visit her the next day

Second Day Post-delivery Home Visit

My second day postpartum home visit to Madam V.O. and her baby was on 15th of April 2021

around 7:10 am in the morning and 5:00 pm in the evening. Both mother and baby were doing well. The

following observations were carried on her during morning and evening visit:
 MORNING EVENING

 Temperature 36.2 °C 37.0 °C

 Pulse rate 80 bpm 78 bpm

 Respiration 20 cpm 18 cpm

 Blood pressure 120/60 mmHg 120/60 mmHg

 Fundal height 17 cm 17 cm

Perineal pad was inspected. Lochia was red and the flow was moderate with no odour and

symphysio fundal height was 16 cm. The breast was heavy and colostrum was expressed. She was

therefore encouraged to put the baby to breast frequently. Postnatal exercise was practiced under

supervision. According to her she had a normal bowel movement. I emphasized on increase intake of

fluids and roughages to prevent constipation. She therefore complained of backache and I encouraged

her to sit on a chair with a back support when breastfeeding.

I washed my hand and examined the baby from head to toe but no abnormalities were detected.

The baby was topped and tailed and cord was dressed with methylated spirit. The baby urinated

frequently and passed meconium two times. All examinations done on the baby were recorded during

the morning and evening as:

MORNING EVENING

 Temperature 36.4 °C 36.6 °C

 Respiration 44 cpm 42 cpm

 Apex beat 142 bpm 140 bpm

 Body weight 2.9 kg 2.9 kg

Madam V.O. was educated to have adequate rest and sleep, breastfeeding baby exclusively and

not to apply herbs on the cord as it can cause neonatal infections. I ask about the pains she experience

during breastfeeding. She told me it had subsided. Before leaving, I informed her about my next visit.
Third Day Post-delivery Visit to the Clinic

On 16th of April 2021, which was on Friday, since I was supposed to visit Madam V.O. in

the morning and she would be coming to the Hospital for her postnatal visit. I met her at home that

morning and we came to the hospital together with her husband. Upon reaching the house at 7:30 am,

Madam V.O. was ready and neatly dressed same as the baby. We took a taxi and reported to the Mother

and Child Hospital at exactly 8:20 am. Morning health education was given that day as usual. Education

was giving on preventing the baby from infection.

The midwives talked about the mothers wrapping their baby with a clean and dry sheet,

changing it as soon as it gets wet or soiled. And also holding baby closely in order to have skin to skin

contact with baby. She also spoke about preventing cord from getting wet, cleaning with methylated

spirit or chlorhexidine until the cord falls off and wound heals and also not applying herbs or other

material to the cord such as Pepsodent®, clay etc. After the education, I escorted my client to the

examination room where she is been assigned. They were warmly welcomed and then offered a seat by

my in charge. Baby was handed to father and my client was asked to empty her bladder and bring urine

for checking of glucose and protein. Upon checking the urine sample, the followings were made:

 Protein Negative

 Glucose Negative

Client’s weight was checked and recorded:

 Weight 101 kg

A procedure to be done on client was explained to her and her husband, and consent sought.

Vital signs and examination trays were set up. Mother vital signs were checked and recorded as:
 Temperature 36.7 ℃

 Pulse 76 bpm

 Respiration 22 cpm

 Blood pressure 110/70 mmHg

 Fundal height 16 cm

The importance of postnatal examination procedures was made known to her. She was then

provided privacy by screening the bed and closing nearby doors. She was then helped unto the bed and

head to toe examination done to detect any abnormality. Her hair was neatly braided and there were no

lice or dandruff. The sclera was clear with no paleness in the conjunctiva and there was no discharge

from the eyes or yellowish discoloration indicating a sign of jaundice. There was no chloasma on the

face. Lips were inspected for sores, cracks, dryness of which there was no such thing. The nose was also

inspected for discharges which was also absent.

Madam V.O. was then asked to open her mouth and upon inspection everything was

normal, there was no thrush, halitosis and tongue was pink and teeth were white. Her neck was

examined and palpated to check swollen lymph nodes and any enlargement of the thyroid glands. Both

extremities were inspected, the upper limbs were inspected for alignment, rashes, edema and capillary

refill was done. Her breasts were examined for a symmetry, engorgement, discharges, sores, cracked

nipples but none of these abnormalities were found and breast were lactating well.

Madam V.O. was then encouraged to continue breastfeeding and proper latching was also

encouraged to prevent sore or cracked nipple. Upon examination of the abdomen, the abdomen was

inspected for rashes, distension, swelling, and scars and there was no abnormality seen. Uterus was well

contracted and fundal height was measured and recorded as 15 cm. Linea nigra was less visible, striae

gravidarum was present. The lower extremities were inspected for alignment, swelling, edema, varicose

veins and no abnormalities found.

 I then assisted my client to turn to her left for her back to be inspected. Everything was

normal. Her back was examined for straightness, swelling, tenderness and pain by running my index

finger along her spine and asked her if she feels pains and She complained of a slight pain at the sacral

region. I then reassured her and told her it can be managed and assured her I will explain the

management to her when we are done with the examination.

Perineal examination was the next procedure to be performed. Explanation was done and

consent was given to carry on; she was then asked to remove her panties and sanitary pad as well, while

I donned my gloves. The pad was then inspected and its colour, odour and amount of lochia were noted.

The lochia was rubra, moderate and not offensive.

The perineum was swabbed with cotton wool soaked in Savlon® solution after which the

perineum was assessed for odour, oedema, redness and pain, but none was detected. She was asked to

cough in order to assess the strength and firmness of the pelvic muscles and as she did that urine did not

bulge out confirming the firmness of the pelvic floor muscles. The vagina was moist, temperature was

warm and absence of laceration of the walls on vaginal examination.

After the procedure, Madam V.O. was cleaned and another sanitary towel was given to her

and she was helped to dress. Materials used for the examination was disposed and tray decontaminated. I

washed and dried my hands. Findings were communicated to the client. She was then allowed to

verbalize her concerns and ask questions which were answered appropriately. I then spoke to her about

the management of the backache, I explained to her the possible cause which can be due to poor

positioning during breastfeeding, I then told her that she should continue positioning the baby well as I

taught at home, also She was then advice to adopt a good position by keeping her back straight and foot

raised on a stool when sitting and breastfeeding.

Also, she was educated on lifting techniques when lifting objects from the floor by flexing

her knees and keeping her back straight and in alignment when light from the ground level. Sacral
massage was also encouraged to reduce the pain and I directed it to her husband to do that of which he

laughed and said okay. I also encouraged her husband to help her with the house activities at home so

my client may have enough rest and sleep.

My midwife in charge also educated Madam V.O. on maintenance of personal hygiene thus,

bathing twice daily and also to change her perineal pads when soaked and also wash hands with soap

and water after changing of perineal pads and diapers to prevent infections, also to clean perineum from

front to back after emptying her bowel and bladder to prevent infections. She was also advised to take

balanced meals containing all the three main sources of food groups; body building, energy giving and

protective foods and also to take in a lot of water and fluid to prevent dehydration and constipation. She

was also advised on adequate rest to aid in recuperation hence to have enough rest when the baby is

asleep, postnatal exercises too were encouraged to keep her healthy, fit and strong and to start with sex

only when she can tolerate.

Client was asked if she had any question of which she answered and she has understood

everything said. Her husband was also encouraged to ask questions of which he answered he is clear.

Baby was next to be examined, and procedure and the importance were explained to both parents.

Madam V.O’s baby was exposed and put on weighing scale and he weighed 2.9.kg and vital signs

checked and recorded as follows:

 Temperature 36.8℃

 Apex heart beat 140 bpm

 Respiration 30 cpm

Baby was placed on the couch and well wrapped with a cot sheet. A quick head to toe

examination was done on the baby to detect any abnormalities such as any rashes on the head, the shape

and size of the head was normal, discharges from the eyes, ears, yellowish discoloration of the skin and
eyes indicating jaundice was also checked and no abnormality was detected. Baby’s upper limbs were

checked for any extra digits, symmetry, pallor, swelling, rashes and no abnormality seen. The abdomen

was inspected for organ perforation, swelling, rashes, and as well as the cord stump. The cord was clean

and dry. The skin of the baby was normal and pink.

The lower limbs were also inspected for symmetry, alignment, extra digits, swelling, fractures of

the hip by using the Ortolani reflex. Baby had no fracture. The back of the baby was also inspected for

any abnormality like overgrowth, swelling, pain, fracture but there was no abnormality. The anus

checked and nappy rash were all absent. After the examination. Baby reflexes were present such as the

rooting reflex, the suckling reflex and the Moro reflex. I dressed the baby up, wrapped her well and gave

her to the mother. I then washed and dried my hands. Madam V.O. was advised to change the baby’s

diapers frequently when soaked or soiled to avoid diaper rash, and also encouraged her to send the baby

to the welfare clinic for immunization as well as to monitor her growth. I took the opportunity to remind

about the baby’s immunization against polio and BCG that day. She was given her next visit to the clinic

which was the seventh day which was on 20th April, 2021 was communicated to her. Her routine

medications were prescribed to her to help build her immunity and also help boost the haemoglobin

level. The drugs were:

 Folic acid 5 g daily x 30 days

 Iron supplement 200 mg daily x 30 days

All findings were communicated to her and record in her book. I told Madam V.O. about my

visit in the evening and then escorted them out of the antenatal clinic. We went to the immunization

centre and the community health nurse was informed about my client being there to immunize the baby.

The nurse came to administer Bacillus Calmette Guerin (BCG) 0.5 mg and 2 drops of oral polio. All

findings were communicated to the mother and recorded. I then escorted my client and her family to the

junction to board a car. My client and her husband thanked me and set off.
Third Day Post-delivery Home Visit

I visited Madam V.O. on 16th April, 2021 in the morning at 9:00 am and 4:30 pm evening on the

third day as scheduled. She was looking cheerful and fine. The following were observations that were

carried on her;

EVENING

 Temperature 36.8 °C

 Blood pressure 110/70 mmHg

 Pulse rate 74 bpm

 Respiration 18 cpm

 Fundal height 16 cm

 Lochia drainage Rubra

She was encouraged to continue with her personal exercise. Madam V.O. perineal pad was inspected

and the lochia was rubra and symphysio fundal height was 14 cm. Lactation has been well established.

Exclusive breastfeeding on demand was emphasized. She complained of backache. On enquires I noted

she use to sit on a chair with no back support when breastfeeding. I then demonstrated to her on proper

feeding techniques such as using a chair with back support and proper positioning of the baby. She also

complained of inability to sleep well in the night as a result of the baby crying in the night. I therefore

educated her on the need to have enough sleep during the day in order to feed the baby well in the night.

Baby was topped and tailed and the cord was cleaned. I examined the baby to see if she was developing

any conditions like skin rashes, oral thrush and jaundice but none was detected. The mother told me that

the baby had been urinating frequently and passing normal stools which were yellowish in colour. The

cord was shrinking gradually. The family were very supportive in caring for the baby as well as doing

the house hold chores. She was reminded on postnatal exercise to maintain the tone of abdominal and

pelvic floor muscles.

Baby’s vital signs during the morning and evening visit were;

MORNING EVENING

 Temperature 36.5 °C 36.8 °C

 Respiration 42 cpm 46 cpm

 Apex beat 146 bpm 148 bpm

The baby was put comfortably to bed after breastfeeding. I communicated all findings to her. I thanked

her and promise to visit her the next day.

Fourth and Fifth Day Post Natal Home Visit

On 17th and 18th day of April, I now did visit my client and her baby once daily from 8:30 to 5:00

pm. Vital signs and other measurement of the mother and the baby were checked and recorded.

MOTHER FOURTHDAY MORNING EVENING FIFTHDAY

 Temperature 37.1 °C 37.2 oC 36.6 °C

 Pulse rate 76 bpm 74 bpm 78 bpm

 Respiration 18 cpm 18 cpm 20 cpm

 Blood pressure 120/60 mmHg 120/60 mmHg 110/70 mmHg

 Fundal height 15 cm 15 cm 14 cm

 Lochia drainage Serosa Serosa Serosa

BABY FOURTH DAY MORNING EVENING FIFTH DAY

 Apex beat 138 bpm 140 bpm 140 bpm

 Temperature 36.4 °C 36.6 oC 36.2 °C

 Respiration 46 cpm 44 cpm 44 cpm

 Weight 3.1 kg 3.1 kg 3.1 kg

 Stool Yellow Yellow

 Urine Frequent Frequent

A physical examination was carried out on the baby which was from head to toe and no

abnormalities were detected. The baby was topped ant tailed, cord was dressed and baby wrapped in a

warm sheet. On the fourth day which was 17th April, 2021, Madam V.O. said the backache had

subsided as she used proper feeding techniques and, on the 18th April, 2021, she said she could also

sleep well when the baby is also asleep.

However, she complained of fullness of the breast which she was encouraged to continue breastfeeding

especially at night to prevent breast engorgement. Adequate information was given on nutritious diet

and roughage intake to prevent constipation. On the fourth day lochia was inspected and it was serosa

and fundal height was 13 cm. On the fifth day lochia was inspected again and it was serosa and fundal

height was measured as 12 cm. I thanked her and promised to visit her the next day.

Sixth Day Postpartum Home Visit

I visited Madam V.O. on 19 th of April, 2021 at 6:30 pm. Examination of mother and baby from

head to toe was done and no abnormalities were detected. The following observations were carried out

on the mother:

 Temperature 36.4 °C

 Pulse 80 bpm

 Respiration 20 cpm

 Blood pressure 110/60 mmHg

 Fundal height 13 cm

 Lochia Serosa

She complained of constipation. I then educated her more on fibre foods, fruits, vegetables and to

drink more water to relieve her of it and prevent reoccurrence. Madam V.O. symphysiofundal height
was measured as 11 cm and lochia was inspected which was serosa. Observations on baby were as

follows:

 Temperature 36.2 °C

 Apex beat 138 bpm

 Respiration 40 cpm

 Weight 3.3 kg

 Urine Frequent

 Stool Yellow

The cord came off on the sixth day, baby was bathed and stump dressed with methylated spirit

and cotton wool swab. The mother was taught how to care for the umbilical stump, bath and groom the

baby. She was educated on the need to send the child for immunization as scheduled. We also discussed

about family planning together with her husband and they agreed to continue practicing the natural

method after six weeks. She was educated on breastfeeding on demand which will help serve as a

natural family planning. I congratulated her and the family for their cooperation and reminded her of my

last visit to their house.

Seventh Day Post Natal Clinic Visit

My last official visit to Madam V.O. and her family was on 20 th of April, 2021 around 7 pm. I

was warmly welcomed. I washed my hands before and after examining her and her baby from head to

toe and no abnormalities were detected. I asked about her constipation and she said she was able to

empty her bowel freely and also complained of headache which I reassured her and encouraged her to

continue to take her prescribed medications.

Observations on mother were recorded as follows:

 Temperature 37.0 °C

 Pulse 76 bpm
 Respiration 20 cpm

 Blood pressure 110/70 mmHg

 Fundal height 12 cm

 Lochia Scanty non offensive serosa

Observations on the baby were recorded as follows:

 Temperature 36.4 °C

 Apex beat 140 bpm

 Respiration 42 cpm

 Stool Normal

 Urine Frequent

Continuity of Care

She was reminded to continue postnatal exercise and to send the baby to postnatal clinic on the

day 6th week postpartum. She was also educated on the need to maintain good personal and

environmental hygiene particularly hand washing before and after changing perineal pad to prevent

cross and ascending infection. I informed madam V.O. and the family that my care ends this day. I

congratulated Madam V.O, her husband and the entire family for their cooperation and time. They were

also grateful to me for all I had done and bade them goodbye.

Exclusive breastfeeding was emphasized and the mother was educated to take adequate and

nutritious diet, and also, have adequate rest and sleep. I also encouraged her to visit the clinic anytime

she felt unwell. She was reminded of the 6 th week postnatal visit and Child Welfare Clinic (CWC) to

complete the subsequent immunization. I also reminded her of the family planning they wished to
practice. She was thanked as well as the entire family for their cooperation, time and support which

enabled me to plan and care for her successfully.

I encouraged the family to support her with the household chores and caring for the baby. She

was then introduced and handed over to the community health nurses for continuity of care. She was

thanked again, escorted to the hospital gate and bade her goodbye.

Problems Identified

1. After pains (14/04/21 at 10 am)

2. Backache (15/04/21 at 5:00 pm)

3. Inability to sleep (16/04/21 at 9:00 am)

4. Inadequate knowledge on how to position baby to breast (17/04/21 at 7:30)

5. Constipation (18/04/21 at 8 am)

6. Headache (19/04/21 at 8 am)

Nursing Diagnosis

1. Acute pain (after pain) related to involution and contraction of the uterus during breastfeeding.

2. Altered comfort (backache) related to poor positioning during breastfeeding

3. Altered sleeping pattern (insomnia) related to frequent demand of the baby

4. Risk for breast engorgement related to improper positioning of the baby to breast

5. Altered bowel elimination (constipation) related to over stretching of the perineum during

delivery.

6. Activity intolerance (fatigue) related to stress.

Short Term Objectives

1. Client will be relieved of pain within 48 hours

2. Client will be relieved of backache within 48 hours

3. Client’s sleeping patterns will be improved within 48 hour.

4. Client will not have breast engorgement within 24 hours

5. Client will have free bowel movement within 24 hours

6. Client will be relieved of headache within 24 hours.

Long Term Objectives

Client will go through puerperium safely without any complication to both mother and baby
Table 3: Nursing Care Plan During Puerperium

DATE / NURSING NURSING NURSING NURSING DATE/ EVALUATIO SIGN

TIME DIAGNOSIS OBJECTIVES ORDERS INTERVENTION TIME N
14/04 /21 Acute pain Client will be 1. Reassure client that 1. Client was reassured that her pain will 16/04/21 Goal fully met A.M
at (after pain) relieved of pain her pain will be be relieved within some few weeks. At as client
10:00 am related to within 48 hours relieved. 2. Client was told that the pain was as a 4:30 pm cheerfully
involution as evidenced by 2. Explain the result of involution of the uterus. verbalized
and client physiology of pain to absence of pain.
contraction of verbalizing the client. 3. Client was encouraged to adopt proper
the uterus absence of pain. 3. Encourage client to and comfortable position during
during adopt a proper and breastfeeding
breastfeeding comfortable position.
4. Client was encouraged to exclusively
4. Encourage client to breastfeed on demand to aid involution.
breastfeed
exclusively. 5. Adequate rest and sleep was encouraged
5. Encourage to help relieve pain.
adequate rest and
sleep.
6. Tablet Paracetamol 500mg t.d.s was
6. Serve prescribed served.
analgesics
Table 3: Nursing care plan during puerperium continued

DATE/ NURSING NURSING NURSING NURSING DATE/ EVALUATION SIGN

TIME DIAGNOSIS OBJECTIVE ORDERS INTERVENTION TIME
S
15/04/2 Altered Client will be 1. Reassure client that her 1. Client was reassured that her pain will be 16/04/2 Goal fully met A.M
1 comfort relived of pain pain will be relieved. relieved. 1 as client
at (backache) within 48 hours 2. Explain the cause of 2. Client was told that the pain was because At verbalized relief
5:00 pm related to as evidenced pain to client. she does not sit well when breastfeeding. 8:40 am of pain.
poor by client 3. Encourage client to sit 3. Client was encouraged to sit on a chair
positioning verbalizing on a chair with a back with back support when breastfeeding to
during absence of pain support when prevent back pain.
breastfeeding breastfeeding. 4. Education on how to fix and attach baby
4. Educate client how to to breast was done to prevent engorgement.
fix and attach baby to
breast. 5. Client was encouraged to elevate legs on a
5. Encourage client to stool when breastfeeding to prevent pain in
elevate her legs on a stool the leg and back.
when breast feeding. 6. Paracetamol 500mg was prescribed.
6. Serve prescribed
analgesic
Table 3: Nursing care Plan during puerperium continued

DATE/ NURSING NURSING NURSING NURSING DATE/ EVALUATIO SIGN

TIME DIAGNOSIS OBJECTIVES ORDERS INTERVENTION TIME N
16/4/21 Altered Client’s 1. Reassure client to ease 1. Client was reassured that her sleeping 18/04/21 Goal fully met A.M
At sleeping sleeping pattern her anxiousness. pattern will improve. At as client
9:00 am patterns will be 2. Educate mother to 2. Mother was told to change baby’s wet 4:50 pm verbalized
(insomnia) improved change baby’s wet diapers frequently to help the baby sleep improved
related to within 48 hours diapers frequently. well. sleeping pattern
frequent as evidenced 3. Encourage mother to 3. Mother was encouraged to breastfeed at night.
demand of the by client breastfeed baby baby adequately in the evening before bed
baby. verbalizing that adequately in the time to aid baby sleep soundly.
she can sleep at evening.
least 6-8 hour 4. Encourage client to 4. Client was encouraged to rest and sleep
at night. rest and sleep during the during the day when baby sleeps.
day.
5. Encourage husband 5. Husband and other support persons
and other support persons were encouraged to help in the care of the
to also help in the care of baby to enable the mother sleep well.
the baby
Table 3: Nursing care plan during puerperium continued

DATE/ NURSING NURSING NURSING NURSING DATE/ EVALUATION SIGN

TIME DIAGNOSIS OBJECTIVES ORDERS INTERVENTION TIME
18/04/21 Risk for Client will not 1. Reassure client to reduce 1. Client was reassured that she will 19/04/21 Goal fully met A.M
At breast have breast fear. not have breast engorgement. At as evidenced by
7:30 am engorgement engorgement 2. Client was educated on proper 8:30 am midwife
related to within 24 hours 2. Educate client on proper positioning and attachment of baby to observed client’s
improper as evidenced positioning and attachment of breast during breastfeeding to prevent healthy breast
positioning of by midwife baby to breast. breast engorgement and sore nipple. through
the baby to observing 3. Client was encouraged to support puerperium.
breast. client’s healthy 3. Encourage client to support breast with a well-fitting brassiere to
breast through her breast with a well-fitting prevent breast from hanging.
the puerperium. brassiere. 4. Client was educated to empty one
4. Educate client to empty one breast completely at a time to prevent
breast completely at a time. breast engorgement.
5. Manual expression of milk when
5. Encourage manual expression full and leaking was encouraged to
of milk when full and leaking. prevent painful breast.
Table 3: Nursing Care Plan During Puerperium continued

DATE/ NURSING NURSING NURSING NURSING DATE/ EVALUATIO SIGN

TIME DIAGNOSIS OBJECTIVE ORDERS INTERVENTION TIME N
S
19/04/21 Altered Client will 1. Reassure client that 1. Client was reassured that she will be 20/04/2 Goal fully met A.M
At bowel have free she will be free from relieved of constipation. 1 as client
8:00 am elimination bowel constipation. 2. Physiology of constipation was explained to At verbalized that
(constipation) movement 2. Explain the client that it was due to the pain she went 8:30 am she has been
related to within 24 hours physiology of through during labour. able to pass
over as evidenced constipation to client. 3. Client was encouraged to take a lot of fruits, stool at least
stretching of by client 3. Encourage client to roughages and vegetables of her choice. once a day.
the perineum verbalizing, eat lots of fruit. 4. Client was encouraged to drink about 1-2
during she has been 4. Encourage client to glasses of water early in the morning.
delivery. able to pass drink more water. 5. Client was encouraged to maintain good
stool at least 5. Encourage client to habit of emptying her bowel at least once a day
once a day. maintain good habit of to prevent constipation.
emptying her bowel.
Table 3 Nursing care plan during puerperium continued

Date & Nursing diagnosis Outcome Nursing orders Nursing intervention Date Evaluatio Signatur
time criteria &time n e

19/04/2 Activity Client will 1 Reassure client to alleviate 1 Client was reassured to allay her fear 20/04/2 Goal fully A.M
1 intolerance(fatigue be relieved fear and anxiety. and anxiety. 1 met as
) related to stress of fatigue evidenced
at 2 Educate client to sleep when 2 Client was educated to sleep when at
within 24 by client
baby sleeps. her baby is sleeping to relief fatigue.
8 am hours as 8 am verbalizing
evidenced 3 Counsel client to minimize 3 Client was counselled to minimize a relief
by client visitors. visitors in order to get enough rest and from
verbalizing sleep. headache
the absence 4 Husband and relatives were advised
4 Advise husband and relatives
of pain to help with the care of the baby
to help with the care of the baby.
especially at night

5 Client’ s husband was advised to

5 Advice client’s husband to help in performing the household
help in performing the chores to prevent her from over
household chores. working.
 SUMMARY AND CONCLUSION

This care study was carried out on Madam V.O. Gravida 3 Para 2 all alive. A 32 years

old woman, and her family under my care during antenatal, labour and puerperium with no

complications. She started her antenatal clinic visit on the 3rd of September, 2020 when she

was 8 weeks pregnant. I first met her on 17 th of March, 2021. Various laboratory

investigations were carried on her to help in her care and to be able to give appropriate

treatment when there are any deviations from normal. She went through antenatal with some

minor disorders which were managed effectively.

Her labour and delivery were managed carefully without any complications to herself

and her baby. She delivered an alive healthy female infant of 3.0 kg weight on 13th April

2021 at 8:01 am.

Her successful antenatal care, labour and puerperium were due to quick analysis of facts,

good counselling, understanding and cooperation involving the family. Since she was given

adequate and quality care, she went through a normal late pregnancy, labour and puerperium

and follow up visits were carried out during that period.

From the first day postpartum to the seventh day, she and her baby were examined but

no abnormalities were detected. Madam V.O. was encouraged to breastfeed the baby and

send her to the child welfare clinic for immunization against the vaccine preventable diseases

and also register the baby at the birth and death registry. She was handed over to the

community health nurses for continuity of care on the Seventh day postnatal visit

(20/04/2021).

The family centered maternity care study has helped me to identify every pregnant

woman and her family as an individual whose peculiar problem could be solved with good
data collection. It has also given me the opportunity to render efficient and comprehensive

care to Madam V.O. and recognized her as a unique individual with peculiar problems.

Through data collection and setting of objectives, I was able to achieve my goal of caring for

her and her family during the late pregnancy, labour and puerperium successfully.

I therefore hope to care for other pregnant women, families and communities in the practice

of my midwifery profession, to reduce morbidity and mortality rate of the mothers and their

babies.
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 APPENDIX I

ANTENATAL PROGRESS RECORD

 APPENDIX IIA

PHARMACOLOGY OF DRUGS USED IN ANTENATAL

Date Drugs Dosage Route of Classification Mechanism of action Side effect Remarks
administration

Tablet 3 tablets Orally Anti-malaria Destroys malaria parasite. Vomiting, seizures, Protected
sulphadoxine abdominal cramps, client from
03/09/20
pyrimethamine anorexia and tremors. malaria.

03/09/20 Folic acid 5 mg Orally Haematinic 1. Helps in formation General malaise,

daily x 30 of red blood cells. nausea, flatulence
2. Increases
haemoglobin level

03/09/20 Fersolate 200 mg Orally Haematinic 3. Helps in production of Dizziness, chills, fast No adverse
daily x 30 haemoglobin heartbeat nausea and effect
vomiting reported.
 APPENDIX IIB

PHARMACOLOGY OF DRUGS USED IN LABOUR FOR MOTHER

Date Drugs Dosage Route of administration Classification Mechanism Side effect Remarks
of action

13/04/21 Injection 10 units Intramuscularly Oxytocic agent Contract the uterus, Nausea and No side effect
Syntometrin prevent bleeding. vomiting reported

13/04/21 Misoprostol 600 mcg Per rectum Prostaglandin Contract the uterus, abdominal No side effect
prevent post-partum pain reported
(Cytotec)
haemorrhage.

13/04/21 Paracetamol 100 mg Per rectum Non-opioid analgesics To relieve pain No side effect
suppository reported
 APPENDIX IIB

PHARMACOLOGY OF DRUGS USED FOR BABY

Date Drugs Dosage Route of Classification Mechanism Side effect Remarks

administration
of action

13/04/21 Injection 0.5 mg Intramuscularly Anti-haemorrhage Promotes formation Pain, swelling and No reaction
vitamin K of prothrombin hematoma at reported
injection site

13/04/21 Tetracycline 50 g (0.5%) Ophthalmic Anti-microbial Prevent infection of Irritation on the No side effect
eye ointment on the eye the eye eye, blurred vision reported.

16/04/21 Polio ‘o’ 2 drops Orally Vaccine Prevention of Mild fever No side effect
poliomyelitis reported
crying

16/04/21 Bacillus 0.05 mg Intramuscularly Vaccine Stimulate body to Local reaction, No side effect
Chalmette produce antibodies abscess, reported
Guerin enlargement of
axillary lymph
nodes
 APPENDIX IIC
PHARMACOLOGY OF DRUGS USED IN PUERPERIUM FOR MOTHER

Date Drugs Dosage Route of Classification Mechanism of action Side effect Remarks
administration

14/04/21 Tab paracetamol 1 g TDS 5 Orally Non-Opioid 1. It helps reduce pain Vomiting, seizures, Protected
days analgesic and abdominal cramps, client from
antipyretic anorexia and tremors. malaria.

14/04/21 Folic acid 5 mg daily Orally Haematinic 1. Helps in formation of red General malaise, No adverse
x 30 days blood cells. nausea, flatulence effect
2. Increases haemoglobin reported.
level

14/04/21 Fersolate 200 mg Orally Haematinic 1. Helps in production of Dizziness, chills, fast No adverse
daily x 30 haemoglobin heartbeat nausea and effect
days vomiting reported.

14/04/21 Multivitamin 200mg Orally Vitamin 1. Boost up the immune Dizziness No adverse
daily x 30 supplement system effect
days reported
 APPENDIX IIIA

ANTENATAL LABORATORY INVESTIGATION

DATE SPECIMEN INVESTIGATION RESULT NORMAL REMARKS

VALUES
03/09/20 Stool Worm infestation Not seen No abnormality detected
Ova Not seen No abnormality detected
Larvae Not seen No abnormality detected
Protozoa Not seen No abnormality detected
03/09/20 Urine Protein Negative Normal
Glucose Negative Normal
Ketones Negative Normal
03/09/20 Blood Haemoglobin level 11.0 g/dl 11.2 g/dl-18.2 g/dl Normal
VDRL COOMBS Non-reactive Normal
HBsAg Negative Normal
HIV Negative Normal
Blood group B+ No abnormality detected
G6PD No defect No abnormality detected
Sickling Negative No abnormality detected.
BF for malaria parasite No MPs seen Normal
18/02/21 Blood Haemoglobin 10.7 g/dl 10.7 g/dl Normal
 APPENDIX IIIB
LABORATORY INVESTIGATION DURING LABOUR

Date Specimen Investigation Result Normal Value Remarks

17/03/21 Blood Haemoglobin level 11.9 g/dl 11.0-18.0 g/dl Normal

Urine Protein Negative Negative Normal

Acetone Negative Negative Normal

Glucose Negative Negative Normal

APPENDIX IV
 APPENDIX V

Duration of observation of labour

STAGE TIME RANGE DURATION

First stage 2:30 am to 7:30 am 5 hours

Second stage 7:30 am to 8:01 am 31 minutes

Third stage 8:01 am to 8:25 am 24 minutes

Total duration 5 hours 55 minutes

 APPENDIX VI

EXAMINATION OF PLACENTA

Upon examination and observation of placenta, the following findings were recorded:

PLACENTA AND MEMBRANES CONDITION

Maternal surface Healthy

Foetal surface Healthy

Lobes and membranes Complete

Cord situation Central

Number of vessels 2 arteries and 1 vein

APPENDIX VII
APGAR SCORE OF BABY

1 MINUTE 5 MINUTE

APPEARANCE 1 1

PULSE 2 2

GRIMACE 1 2

ACTIVITY (MUSCLE TONE, FLEXION) 1 2

RESPIRATION 2 2

TOTAL SCORE 7/10 9/10

 APPENDIX VIII

OBSERVATION OF THE FOURTH STAGE OF LABOUR

N/B: Assess ¼ hourly for 1 hour, ½ hourly for 2 hours and hourly for 3 hours.

Date /time Temperature Blood Pulse Respiration Fundal Colour of Bleeding Condition of the uterus
pressure height lochia
(0C ) /bpm /cpm
/mmHg /cm

13/04/21 36.5 130/70 82 20 16 Red Slightly Heavy Firm and well contracted
09:30 am

09:45 am 36.7 120/80 84 24 16 Red Slightly heavy Firm and well contracted

10:00 am 36.3 120/70 80 22 16 Red Slightly heavy Firm and well contracted

10:15 am 36.3 110/80 78 20 16 Red Slightly heavy Firm and well contracted

10:45 am 36.4 110/70 81 23 16 Red Slightly heavy Firm and well contracted

11:15 am 36.2 110/80 83 24 16 Red Slightly heavy Firm and well contracted

11:45 am 36.5 110/80 80 22 16 Red Slightly heavy Firm and well contracted

12:15 pm 36.6 110/80 82 24 16 Red Slightly heavy Firm and well contracted

01:15 pm 36.2 110/70 80 23 16 Red Slightly heavy Firm and well contracted

02:15 pm 36.4 110/70 80 22 16 Red Slightly heavy Firm and well contracted

03:15 pm 36.5 110/70 80 22 16 Red Slightly heavy Firm and well contracted
 APPENDIX IX
OBSERVATION OF THE BABY

N/B: ¼ hourly for 1 hour, ½ hourly for 2 hours, hourly for 3 hours

Date/time Temperature/ Apex Heart Rate Respiration Skin colour Cord General activity
O
13/04/21 C /BPM /CPM

09:30 am 37.0 140 40 Pink Not Bleeding Active

09:45 am 36.8 136 36 Pink Not Bleeding y Active

10:00 am 37.0 138 38 Pink Not Bleeding Active

10:15 am 36.6 138 40 Pink Not Bleeding Active

10:45 am 38.0 140 36 Pink Not Bleeding Active

11:15 am 37.6 136 38 Pink Not Bleeding Active

11:45 am 37.2 138 36 Pink Not Bleeding Active

12:15 pm 36.7 136 36 Pink Not Bleeding Active

01:15 pm 36.5 140 38 Pink Not Bleeding Active

02:15 pm 36.6 136 40 Pink Not Bleeding Active

03:15 pm 36.7 136 38 Pink Not Bleeding Active

APPENDIX X
APPENDIX XI
 APPENDIX XIIA
SUMMARY OF LABOUR/ DELIVERY OUTCOME
 APPENDIX XIIB
SUMMARY OF LABOUR/ DELIVERY OUTCOME
 SIGNATORIES

Name of Candidate: _____________________________________________

Signature: _____________________________________________

Date: _____________________________________________

Name of Clinical Supervisor: _____________________________________________

Signature: _____________________________________________

Date: _____________________________________________

Name of Supervising Tutor: _____________________________________________

Signature: _____________________________________________

Date: _____________________________________________

Name of Principal: _____________________________________________

Signature: _____________________________________________

Date: _____________________________________________