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Analysis of the Case

This paper presents an analysis of care rendered to baby Amina Ngwira who developed asphyxia neonaturam soon after extraction from the uterus on a caesarean section that her mother underwent due to eclampsia on 26/07/2011 at Ethel Muntharika Maternity Theater, Kamuzu Central Hospital. The baby was cared for from the time of delivery through admission into nursery ward up to fourth day of stay in nursery ward. This case was conducted as partial fulfillment of the clinical placement requirements for the neonatology module (practice). Mrs. Mchere is a 26 years old which is the child bearing age that does not associate with so many obstetric complications such as prolonged labour and post partum hemorrhage (Safe Motherhood 2000). She has the gravidity of two and parity of one with one child alive, born in 2006 a term baby with birth weight of 3400 grammes through vagina without any complication. According to Mrs. Mcheres measured height (antenatal) of more than 150 cm she is not at risk of cephalo-pelvic disproportion due to contracted pelvis that is most common in women below 150 cm. This is because it is believed that most mothers with height of less than 150cm are physiologically at risk of developing the said condition (Fraser, 2010). Mrs. Mchere has been receiving paramount social support from the husband and the relatives throughout the pregnancy. This was good because it ensures availability of basic needs like food and clothes thus fostering mothers health and proper development of the fetus. Mrs. Mchere neither smokes nor drinks just as the husband does and this is a good behaviour for the wellbeing of both the mother and the fetus. Nicotine substance in tobacco causes interference with oxygen exchange in lung alveoli. The end result will be reduction of oxygen in circulating blood. Alcohol reduces appetite thus leading to malnutrition in the mother which in turn may also lead to fetal intrauterine growth retardation (Myles, 1989). Progress of fetal growth was normal according to the weight gain of the mother. On initial visit she weighed 68 kg whilst on second visit she weighed 74 kg thus a weight gain of 6 kg. Gestation age on the first visit was 26 weeks one day and 33 weeks and 6 days on the second. According to Fraser (2009), from the weeks 28 to 33 the fetus approximately gains 25g/day and

28 the grand weight gain by Mrs. Mchere correlates to this fact thus a normal weight gain. During the third visit Mrs. Mchere weighed 77 kg According to Sellers (2001), in normal pregnancy, 2 kg is supposed to be gained in the first trimester while in the second trimester she is supposed to gain at least 0.5kg every week. The summary of the weight gains and other findings have been attached to the case note. She had not tested for hemoglobin. This was unfortunate because knowledge of hemoglobin level in pregnancy helps a midwife to estimate how essential nutrients are transported to the fetus for fetal growth and wellbeing of the mother. This also helps to indicate whether the Mrs. Mchere would be anaemic or not. Anemia is present if haemoglobin level is less than 10g/dl which is a result of deficiency in the quality and quantity of red blood cells (Safe Motherhood, 2000). However, Iron tablets 200mg orally once a day for one month throughout the antenatal period was given to improve haemoglobin level so as to prevent anaemia. Urinalysis was never done throughout antnatal period which was also unfortunate to Mrs Mchere. Urine albumin test helps to rule out cardiac disorders and possibility of developing pregnancy induced hypertension if positive. Proteinuria in the absence of urinary tract infections is indicative of glomerular endotheliosis while a significant increase in proteinuria coupled with diminished urinary output indicates renal impairment. All these were not considered by mere omission of urinalysis antnatally. Venereal Disease Research Laboratory (VDRL) was not done. It is important to do this test because it is good for the fetus and the mother since presence of syphilis in pregnancy may lead to abortions, preterm labour and stillbirths if not treated. This is so because syphilis impairs the integrity of the placenta (Fraser, 2009). Fansidar 3 tablets were provided as a prophylaxis for malaria in the first and second visits to prevent Mrs. Mchere and the fetus from malaria. Malaria resistance is reduced during pregnancy (Fraser, 2009). Neonates born with congenital malaria may develop fever, jaundice and spleenomegally within 10-20 days of birth (Myles, 1989). Therefore it shows that Mrs. Mchere was excellently protected from malaria during pregnancy. Tetanus Toxoid vaccine was given on

29 initial antenatal visit and one month later in order to prevent the mother and the fetus from tetanus. Mrs. Mchere started having labour pains at around 15:00 hours on 27/01/2011 at home. She reported at Chatinkha labour ward at around 21:45 hours on the same day and it shows that she chose the right decision other than just staying at home. On abdominal examination her fundal height was 40 weeks gestation, three fingers below the ximphesternum. Lie was longitudinal, presentation was cephalic, and position was right occipital anterior. Fetal descent was 5/5. Fetal heart rate was 134beats/minute and her bladder was empty. This justified the case as a possible low risk multigravida. Only two vaginal examinations were done throughout first stage of labour. This indicated that she was not exposed to too many and unnecessary vaginal examinations which could predispose her to infections and result in puerperal sepsis postnatally (Fraser, 2009). Pelvic assessment records indicated that the sacropromontory was not tipped at 8cm, the pelvic brim was not followed at 8cm, the sacrum was curved, sacrospinous ligaments were flexible, ischial spines were palpable and not prominent, the sub pubic arch was 90 degrees and the intertubelous diameter admitted 4 knuckles. According to Fraser (2009), if a client has the pelvis with the above findings is said to have a roomy pelvis adequate for spontaneous vaginal delivery. Mrs. Mchere therefore was eligible for vaginal delivery. She was having 3 moderate contractions in 10 minute for the first three hours after admission and was having three strong contractions in 10 minutes for the next three hours leading to successful second stage of labour. Her vital signs were fluctuating on normal ranges and this showed that she was responding well to labour progress. Membranes were ruptured artificially 01:45 hours on 28/01/2011 and liquor was clear but after 30 minutes the liquor became meconeum stained (first grade meconeum) which indicated that there was risk of fetal distress due to meconeum aspiration. However soon after delivery it was revealed that the baby never encountered fetal

30 distress since he got an Apgar score of 9/10 at a minute then 10/10 at five minutes. This was actually a good outcome of all. The second stage of labour for Mrs.Mchere was successful as it has already been stipulated. In other words, the cervical os was fully dilated at 01:45 hours and she started having strong contractions of four in ten minutes at 02:45 hours. She therefore became more restless as her anus started to gape and the perineum bulging. According to Adams (1983), these are some of the signs that Mrs. Mchere could be in second stage of labour. This was therefore the time when the delivery was prepared and at just 03:15 hours Mrs. Mchere successfully delivered a live full term male infant with no complications. Third stage of labour was also completed without a single complication. After delivery the mother was examined for any tears. She sustained first degree perineal tear which was sutured using chromic 2-0 suture with prior administration of 2% lignocaine diluted with corresponding water for injection as a local anaesthesia. After suturing the mother was advised to be cleaning the area with salty water to prevent infection. The baby was also examined for trauma. There was no apparent injury. Two hours post-delivery the baby had been having a normal cry, no convulsions and did not develop jaundice. This was an indication that the baby did not sustain any injury. The baby and the mother were given nursing care in the postnatal ward for two hours as part of forth stage management of labour. During this period Mrs. Mchere and her baby were doing fine and never developed any complications.

Conclusion
Her labour lasted for 12 hours. This was not prolonged labour because prolonged labour is when it exceeds 24 hours. The fetus did not experience fetal distress as indicated by a normal fetal heart rate. The contractions were progressing quite well. The vital signs for the mother were also within the normal ranges throughout labour. The spontaneous vaginal delivery was conducted within the recommended time and the appropriate maneuvers were used to deliver the baby and

31 that is why the baby did not sustain any injury. The mother adjusted well to the non- gravid state two hours postnatally and the baby also adjusted well to the extra-uterine life.

Personal Impression
Mrs. Mchere did not experience any significant problems antenatally. Upon admission into the labour ward a good rapport was established and that is why she co-operated very well throughout the labour process. The maternal and fetal condition was monitored thoroughly throughout labour and there was no deviation from the normal ranges. The spontaneous vaginal delivery was successful with good outcome for the mother and the baby. The mother and the baby did not develop any complication after delivery. But few weaknesses were identified. On laboratory investigations, VDRL and other vital laboratory investigations were not done antenatally because she was attending antenatal care at a Health center or merely because of health personnel omissions. These are important investigations that are supposed to be conducted on each and every antenatal woman. So I feel there is need to put in mechanisms that will ensure that the investigations are done on each and every antenatal mother. However, I still feel Mrs. Mchere received the appropriate physical and psychological care upon admission, during labour and delivery and finally two hours postnatally.

Recommendations
I recommend that Laboratory investigations should be done on each and every antenatal woman to protect the mothers and the unborn babies from syphilis and other pertinent diseases.

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References
Adams, M. (1983) Baillieres Midwives Dictionary 7th Ed: Bailliere Tindall.London Frazer, D.M. Copper, M.A. & Nolte, A.G.W. (2009) Myles Textbook for Midwives 15th Ed: Churchill Livingstone. Philadelphia. Ministry of Health (2000), Obstetric Life skill Training Manual for Malawi: Safe Motherhood Program: Ministry of Health, Lilongwe. Myles, M. (1989), Textbook for midwives: Longman, London. Sellers, P.M. (2001), Midwifery vol.1: Juta & Company. Capetown.