INTRODUCTION This is a case study of Mrs.

Samala village, she was admitted at Ndilande Health Centre due to spontaneous labor pains around 5pm on the 27th of May, 2009. She delivered a live full term female infant on the same day around 9:25am, immediately after delivery she was admitted in the post natal ward at 0950am where she was identified as a client for this case study. Mrs. R.C was taken care of for a period of 48hours before discharging her in consultation with the qualified midwives of Ndilande Health Centre. Postnatal period of peuperium is the period between the third stage of labor and 6 th week after delivery (Dickson, E.J Et al 1993). It is a period where the body regains its prepregnant state through various physiological processes. This write up is about the postnatal care given to Mrs. RC for the period she was admitted in the postnatal ward to the time of discharge. The paper describes a review and an analysis of antenatal and labor and delivery records, any other significant data collected a draft of a care plan and a series of interventions rendered and the discharge plan for Mrs.RC and her neonate.

PERSONAL HISTORY

Name: Rhoda Chimaliro Age: 19 years Address: Makata, Ndilande Home Village: TA Msamala, Balaka. Religion: Baptist NOK: Mai Jera, (Mother) Marital Status: Married Educational Level: Form 2 Date of Admission: 26/05/09. Time of delivery 09:25am, 27/05/09. PRESENT COMPLAINT Mother complained that she is feeling pain on the perineum due to tear, and lower abdominal pains. She is able to pass urine, but has not yet passed stools. She verbalized that she had painful labor and delivery experience because of the tear. Baby is able to breastfeed and eliminate. REVIEW OF AND ANALYSIS OF COLLECTED ANTENATAL, LABOUR AND DELIVERY DATA. The review of antenatal, labor and delivery data is important in the care of a woman in peuperium, this acts as baseline information for which subsequent assessments, care and evaluative measures are based on. The collected data may also help the midwife to provide effective and client centered health education. Antenatally, Mrs. RC stated Antenatal Care (ANC) at 24 weeks gestation, she attended three visits and received two doses of Fansidar for Intermittent Presumptive Treatment (IPT) and three doses of Iron tablets. She had normal blood pressure ranges and she had a steady weight gain. Hemoglobin level and VDRL were not checked, her HIV status was negative. Mrs. RC received two doses of TTV and the third dose is due in September, her height was 160cm,

Obstetric history indicated that this was her first pregnancy, she had no any problem during antenatal period, her last menstrual period was on the 17th of September 08 and her expected date of delivery was on 24th June 5, 2009. Mrs. RC attained menarche at the age of 13 years and since then her menstrual cycle has been regular-28days cycle. She menstruates for 5 days and the nature of her menstrual flow is moderate. She said she does not experience any dysmenorrhoea. Additionally she has never had an abortion or ectopic pregnancy. Mrs. RC displayed adequate knowledge in family planning. She explained that she knows various methods like pills, injection, condoms and bilateral tubal ligation, Bu has never used any family planning method, however she opts to use Depo-Provera after delivery as a family planning method. This was not a planned pregnancy, both the client and her spouse accepted it, that is why they kept this pregnancy up to term. Mrs. RC is the first and only wife to Mr. Chimaliro. Her husband went to school up to form four. None of them smokes nor takes alcoholic beverage. Currently, Mrs. RC stays with her mother in-law because her husband went to South Africa in search of greener pastures when she was 7months pregnant. All the support comes from her mother in-law, she doesnt have any income generating activity. Mrs. RC said she has adequate knowledge of six food groups and she said she is provided with the six food groups without any problems from her mother in- law, the previous day before she came to the hospital she had tea with bread in the morning, oclock, nsima with boiled eggs and vegetables for lunch and during supper she said she had nsima, beans and vegetables plus banana. There is nothing significant about family history, medical and surgical history According to FANC guidelines it advisable for a woman to start ANC as soon as she notices that she is pregnant or between 12 and 16weeks gestation. This is done to detect problems related to pregnancy as early as possible in order to prevent complications. The ANC records also shows that Mrs. RC attended 3 visits, this shows that she had a good number of visits though she stated ANC late, and within these three visits she finished the recommended dose of Fansidar. The records also show that Hemoglobin (Hb) level and VDRL tests were not done. It is important to know the level of Hb in a pregnant woman because it provides the baseline 3

data during labor and delivery and postnatal care. Furthermore, it helps rule out anemia in pregnancy which can bring complications during labor and delivery and postnatal period. VDRL test is done to establish whether the mother has syphilis or not, syphilis is a dangerous infection in pregnancy because it crosses the placenta and infects the developing fetus and this can lead to abortion, fetal defects and premature birth. Therefore early detection of the infection requires prompt treatment to avoid complications. Labor was spontaneous, lasting for 7hours, she had two vaginal examinations, labor was progressing well, with normal fetal heart rate, the time of rapture of membranes was not indicated, there was no caput, no molding, maternal condition monitoring was not done, initial assessment of the neonate was not done, immediate vital were not done. She sustained a second degree tear and it was repaired. Monitoring and recording of observations, examinations and any drug treatment on the partograph is important, because this helps to establish normal from abnormal when labor is established. According to the records on the labor chart, it shows that maternal condition was not monitored during and after delivery. This is dangerous because during labor the mother may develop complications, and his may lead to mismanagement of the mother during labor and after delivery. Fetal condition was being monitored, this is good because it helps to detect complication as early as possible and also to know the response of the fetus to labour. Initial assessment of the baby was not recorded which means it was not done. Initial assessment is important because it helps to identify abnormalities for immediate attention.

INITIAL PHYSICAL EXAMINATION MOTHER

GENERAL CONDITION Health looking, well kempt, energetic, well hydrated, with an anxious face. VITAL SIGNS BP 110/60mmHg, RR 24breaths per minute, PR140beats per minute, T37.2degrees Celsius. HEAD TO TOE EXAMINATION HEAD: black coarse texture, no tinea, no dandruff, no scars seen, no alopecia. EYES: pink conjunctiva, estimated hemoglobin of 9.9g/dl, no eye discharge, no lesions no eye discharge. MOUTH: pink mucus membranes, no oral thrush, no kaposis sarcoma lesions. EARS: no lesions, no eye discharge, pre and post auricular lymph nodes not palpable. NECK: no distended jugular veins no enlarged deep and superficial nodes. CHEST: symerical movement with breathing, no swelling, no scars seen, On auscultation, normal air entry, no wheezes, normal heart sounds. BREAST: symmetrically located, medium size, nipples not inverted, On palpation, nodes not palpable, breast tissue soft and not tender, no lamps felt, colostrums expressed. ABDOMEN: no distention, bladder empty no lesions, strea gravidulum present linea nigra present, bowel sounds present. On palpation, no tenderness, no organomegally, rectus diaastasis-2 fingers. UTERUS: mildline, well contracted, below umbilicus, fundal height 15cm. UPPER EXTREMITIES: no pallor, capillary refill less than 2seconds. LOWER EXTREMITIES: symmetrical, warm, no cuff tenderness, no varicosities, no edema. GENETALIA: no sores, no warts, no hemorrhoids, tear, second degree, not bleeding, Intact sutures, lochia, mild, fresh, not offensive.

IMPRESSION A primi para 4hours post SVD adapting well to pre pregnant state.

MIDWIFERY DIAGNOSIS IDENTIFIED FOR THIS CLIENT 1. Altered comfort pain, related to uterine contraction and tear. 2. High risk for hemorrhage related to raw placental site. 3. High risk for infection related to altered skin integrity (tear). 4. Potential for altered sleep and rest pattern related to pain on tear and new attained motherly role. 5. Knowledge deficit on postpartum, self and baby care, related to inadequate information and experience. INTIAL PHYSICAL EXAMINATION/BABY General condition Health looking baby, active, pink, well flexed, no obvious abnormalities seen. VITAL SIGNS: T36.6degrees Celsius, WEIGHT 4000g, RR33 breaths per minute, HR130 beats per minute. HEAD: proportion to the body, well distributed hair, black in complexion, palpable anterior and posterior fontanelles but not bulging or sunken. Caput present, head circumference 34cm. crown to heal 54cm. EYES: symmetrically located, no discharge seen, pink conjuctiva, clear corneas, well positioned. EARS: symmetrically located, well formed, no septic spots NOSE: well placed, no cleft, no flaring, no growth, no discharge seen. MOUTH: no cleft, no oral thrush, no teeth, pink mucus membranes, well formed gums , no bleeding. CHEST: symmetrical movements with breathing, no central cyanosis, no chest in drawing, no masses no growth seen, two breast present, symmetrically located not engorged, with adequate areola. Clear lung fields and normal heart sounds. Heart rate 133beat per minute. ABDOMEN: round shaped, no distention, bowel sounds present, no organomegally on palpation, cord clean and dry, no redness, no pus and no bleeding seen.

UPPER EXTREMITIES: symmetrical, no fractures, grasping reflex present, no extra digit, no webbing seen. LOWER EXTREMITIES: symmetrical, warm, plantar and walking reflex positive. no extra digit, no webbing seen. GENETALIA: well developed labia mijora and minora, urethra and vaginal orifice Present and patent. Anal orifice present and patent. BACK: no spinal bifida, no growth or deformity observed. IMPRESSION 4hrs old female neonate adapting well to extra uterine life. MIDWIFERY DIAGNOSIS IDENTIFIED 1. High risk for hemorrhage related to exposed blood vessels. 2. High risk for infection related to open would 3. High risk for hypothermia, related to poor wrapping of the baby.

MIDWIFERY CARE PLAN FOR THE MOTHER. 27/05/2009 MIDWIFERY GOAL INTERVENTION RATIONALE 7

EVALUATION

DIAGNOSIS High risk for hemorrhage related to raw placental site.

Mrs.RC. will not develop hemorrhage the first 48hours.

Encourage Mrs. RC to frequently empty her bladder and rectum

To facilitate uterine involution and contraction there by preventing uterine atony. This will help in the release of oxytocin which will enhance uterine contraction thereby reducing bleeding. This will help in the expulsion of clots by gravity, thereby facilitating uterine involution. Dry and clean pads will help to prevent infection as wet pads habour infections.

Check the uterus for contractility 4houry. Check for a full bladder 4houry. Check the sanitary pad for amount and consistency of lochia.

Encourage Mrs. RC to exclusively breastfeed her baby.

Encourage mobilization.

High risk for infection related to altered skin integrity (tear).

Mrs. RC will not develop infection throughout her period of hospitalization

Advise Mrs. RC to put on dry clean pads and to change at least 3times a day and whenever they are wet.

Check the odor of lochia and inspect the tear 12 hourly.

Encourage Mrs. C Dirty skin and on general body clothes hygiene. habour

infections Advise Mrs. RC This will to clean perineum prevent fecal from front to back matter from contaminating the sutured area. Altered comfort, pain related to uterine contractions and tear. Mrs. RC will verbalize reduced pain after 30 minutes of midwifery interventions. Promote bed rest and sleep, especially when the baby is asleep. Unnecessary movements exert pressure on the tear and would irritate nerve endings thereby causing pain. Observe pain cues.

Explain the source of pain to Mrs. RC.

This will help the client to avoid actions that will cause pain. This will distract the client from concentrating on pain. This will reduce pressure on the tear. Sits baths also have a soothing effect. This will

Provide diversion therapy, for example, chat with the Mrs.C.

Encourage client to do sitz baths 8hourly.

Administer

Paracetamol 1g every 8hours.

inhibit the production of prostaglandins that cause pain. This provides physical relaxation and rest This prevents anxiety, physical and psychological stress. This will prevent interruption as all interventions are done at once. This will enable her to have time to sleep and rest as it is difficult to sleep when the baby is awake. Observe for signs of fatigue.

Potential for rest and sleep disturbance related to perineal tear and new attained motherly role.

Mrs. RC will not experience sleep disturbance throughout the 48hours of hospitalization

Provide a comfortable bed for sleep. Nurse client in a quite and calm environment

Provide care in block

Advise the mother to take advantage of sleep when the baby is sleeping.

Advise the mother Adequately to breastfeed the breastfed baby exclusively. babies would not frequently cry, thereby providing the mother with time to rest. Advise the mother To avoid

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on bladder emptying before sleeping. Knowledge deficit on self and baby care related to inadequate information and experience. Mrs. RC will demonstrate understanding in postpartum self and baby care. Give thorough health education on the following; exclusive breastfeeding, hygiene, exercises, nutrition, rest and sleep, family planning, self and baby care, how to keep baby warm and how to maintain attachment and bonding.

waking up during the night. Knowledge on these areas will help to prevent postpartum complications and promote physiological, psychological, and emotional return to pre pregnant state. Mrs. RC will verbalize understanding of postpartum self and baby care.

MIDWIFERY CARE PLAN FOR THE BABY MIDWIFERY GOAL INTERVENTIONS DIAGNOSIS High risk for There will be Teach the mother hemorrhage no bleeding to observe and related to from the cord report any signs of exposed blood for the first 48 bleeding from the vessels. hours of cord. admission. Advise the mother to avoid touching the cord unnecessarily. High risk for The cord will Teach the mother

RATIONALE To detect signs of bleeding as soon as bleeding occurs. This can make the cord loose and induce bleeding. To prevent

EVALUATION Check the tightness of the cord twice a day.

Check for signs

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cord infection not develop related to open infection wound. during the period of hospitalization and after discharge

on how to do cord care using the five swab technique at least three times a day using spirit or salty water. Advice the mother to wrap the babys nappy below the umbilicus.

infection from the cord.

of infection for example redness, pus and fever.

To keep urine away from the cord To prevent hypothermia by not exposing the baby. This will enhance heat transfer from the mother to the baby thereby preventing hypothermia. Milk from the mother is warm and it will help to maintain heat. A soiled nappy makes the baby feel cold and this may induce hypothermia. Check temperature every 4hours for the first 48hours.

High risk for hypothermia, related to poor wrapping of the baby.

The baby will not develop hypothermia, the first 48hours.

Teach the mother how to wrap the baby.

Advise the mother to keep the baby close to her body.

Advise the mother on exclusive breastfeeding.

Advise the mother on frequent change of nappies whenever they are soiled.

MIDWIFERY CARE RECORDS 27/05/09 9:50 am

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Mother admitted from Labour ward. Bed was prepared for her and patient was orientated to the ward. Assisted the mother to a comfortable position. Vital signs: Respirations 22 breaths/minute, Pulse rate 100 beats/minute, Temperature 37.2 degrees Celsius, Blood pressure 110/60 mmHg. Uterus was firm, well contracted and in midline position. Lochia was red and moderate. Paracetamol 1g orally given. Mother explained the cause of pain. Mother advised to take some food and to continue breast feeding. Advised the mother to frequently empty the bladder and to report any heavy bleeding. Mother advised to rest. 1:30pm Mother reported that she was bleeding moderately and reduction in pain. Mother advised to change sanitary pads whenever they are wet to prevent infection. Advised the mother to do sitz bath 3 times a day. Mother educated on; exclusive breast feeding, positioning, Nutrition, perineal care, cord care. 4pm Observed the mother breastfeeding the baby. Vital signs; Temp 37 degrees Celsius, pulse rate 100 beats/minute, Respirations 24 breaths/minute, Blood pressure 110/60mmHg. Uterus was well contracted; Lochia was red (rubra) and moderate.

28/05/09 8:30am 13

S: Mrs. RC complained about general body pains, she has passed urine three times since yesterday, but has not yet passed stools since delivery. She report moderate flow of lochia, with no clots. She has changed pads which were half soaked two times since 6pm yesterday. She also reported that the baby has been crying at night and she dis not have adequate rest and sleep, baby is breastfeeding well, has passed stools twice and urine three times since yesterday from 6pm. O: Mother General condition: well kempt, happy looking face, well hydrated and well nourished. Vital signs: BP 110/60, T36.7 degrees Celsius, RR24breaths per minute, PR100beats per minute. Eyes: pink conjunctiva Mouth: pink mucus membranes Neck: no distended jugular veins Breast: symmetrical, soft, not tender, erect nipples, colostrums expressed. Abdomen: not distended, uterus, midline, well contracted, Fundal Height 14cm, bladder empty. Upper Extremities: no edema, adequate capillary refill. Lower extremities: warm, no edema, no cuff tenderness no varicosities. Genitalia: sutures intact, no redness, no pus. Lochia fresh red, mild flow, no odor and no clots. IMPRESSION 23 hours post SVD adapting well to prepregnant state. A: Altered comfort, pain related from uterine contractions and friction from the tear. High risk for hemorrhage related to raw placental site High risk for infection related to open wound Potential for rest and sleep disturbance related to pain from the perineal tear and new attained motherly role.

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P: refer to the care plan Subsequent Assessment of the Baby: T36.5 Degrees Celsius. General appearance Health looking, well flexed, pink, active. Head: fontanelles flat and no calput, no hematoma Eyes: pink and clear cornea, Nose: no congestion, no flaring. Chest: symmetrical, normal up and down movements with breathing, no chest in drawing, no stridor. Abdomen: soft and pink, not distended, cord not bleeding, clean, no signs of infection. Lower extremities: warm. IMPRESSION 23 hours old neonate, adapting well to extra uterine life A: High risk for hemorrhage related to open blood vessels High risk for infection related to open wound on the cord. High risk for hypothermia related to poor wrapping of the baby. P: refer to care plan 830am I:Sitz bath done Cord care done Health education on the following areas given; cord care, perineal care, frequent change of pads whenever they are soiled and keeping the perineum dry all the time.

1000am Polio 0 and BCG vaccines given to the baby.

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Educated mother on the immunization schedule and the importance of having all the immunizations given to the baby according to the schedule. Attachments observed and collection made on how well to position the baby. 1100am Chrolaphenicol eye ointment given to the baby. Encouraged mother to continue breastfeeding 8-12 or more times a day. Encouraged mother to rest whenever the baby is asleep Vital signs rechecked, BP110/60, RR23breaths per minute, PR 98beats per minute, T37.0degrees Celsius. Left mother and baby sleeping. 1230pm Observed mother taking nsima, eggs and vegetables. 200pm Sitz bath done. Cord care done. Observed mother breastfeeding the baby. 230pm Reminded mother to continue with cord care and perineal care after discharge, also reminded her to come for postnatal check up at 1 and 6weeks, to continue with exclusive breastfeeding, to take note of the danger signs whenever they occur. To note signs of infection on the cord and to always remember to eat a balanced diet. 300pm Left mother and baby to rest. 445pm E: Uterus checked and it was well contracted Bladder was empty No signs of infection observed on the cord and perineum Cord tight and clean.

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Vital signs checked BP110/60mmHg, T37.0degrees Celsius, RR24b/m, PR100b/m. Handover given to the night duty nurse on the condition of the client and the neonate. 29/05/09 8:00am S: there was no complaint raised, she said that she spent the night well except for the mild pain from the perineum, she has passed urine three times and stools once. She had nsima with beef and vegetables, this morning she had tea with bread, and baby is breastfeeding well, has passed urine three times and meconium once and that theres no bleeding from the cord. O: mother looks happy, well dehydrated, well nourished and well kempt. Vital signs: T 36.2 degrees Celsius, BP 120/60, RR23 breaths per minute, PR 92 beats per minute. Eyes: pink conjunctiva, clear , no jaundice. Mouth: no oral thrush, pink mucosa Neck: no distended jugular vein. Breast: soft, no sores, not tender, nipples erect, milk expressed. Upper Extremities: no edema, no pallor, capillary refill less than 2seconds. Abdomen: not distended, soft, not tender, uterus firm, midline position, well contracted, fundal height 13cm. Lower extremities: warm, no cuff tenderness, no edema, no varicosities. Genitalia: sutures intact, but some pus seen around the suture area, lochia rubra, mild flow, fresh, no odor. A: A prim Para 46hours post SVD adapting well to pre pregnant state. Infection related to altered skin integrity, (tear) as manifested by the presence of pus on the sutured area. Subsequent assessment of the baby T37.0 Degrees Celsius.

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General appearance Health looking, well flexed, pink and active. Head: fontanelles flat and pulsating Eyes: pink, clear conjunctiva, Nose: no congestion, no flaring. Chest: symmetrical, visible up and down movements with breathing, no chest indrawing, no stridor. Abdomen: soft and pink, not distended, cord not bleeding, clean, no signs of infection. Lower extremities: warm. A: 46 hours old neonate adapting well to extra uterine life. P: administer Erythromycin 500mg tds for 5days.or the plan of the baby. Refer to care plan f 9:00am I: observed mother doing sitz bath Mother educated on perineal care 3times a day. Advised mother to wipe perineum from front to back to prevent fecal matter from Contaminating the sutured area. Advised the mother on change of sanitary pads whenever they are wet and to put on dry sanitary towels. 10:30am Reminded mother on breast feeding, hygiene , nutrition, elimination, family planning, post natal check ups at one and six weeks, and about the danger signs that might occur to the baby and herself. E: mother was able to verbalize understanding of exclusive breast feeding, cord care, baby care, and the importance of eating a well balance diet and rest Mother was able to do a return demonstration of how to wrap the baby, cord care and breast examination.

CONSTRAINTS EXPERIENCED IN THE PROVISION OF CARE

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There was only one Blood Pressure machine, and one weighing scale, for labor ward and postnatal ward, this resulted in fragmented care. The hospital does not have warm water and it was difficult for the client do sitz bath and to bath the baby. It was also difficult to convince the client to stay in the hospital for 48hours because it is a routine that postnatal mothers are discharged after 24 hours. DISCHARGE CRITERIA Some of the counseling issues that we discussed with Mrs. RC in preparation for discharge are as follows: Advice on Perineal care and not to insert anything in the vagina rest and sleep importance of personal hygiene nutrition (six food groups) for the mother exclusive breast feeding family planning Immunizations and growth monitoring Umbilical care. Lactation was established, there was good attachment, and mother demonstrated knowledge on breastfeeding skills. The uterus was well contracted and involution had stated taking place. There was minimal lochia which was not offensive it was flowing mildly. DISCHARGE PLAN Discharge plan stated during the time of admission to the postnatal ward throughout hospitalization and during the time of discharge. This included the importance of exclusive breastfeeding, danger signs for the mother and the baby during peuperium, postnatal exercises like Kegel exercises to improve the muscle torn of the perineal muscles. The importance of rest and sleep, How to wrap the baby to avoid hypothermia, frequent change of pads and babys nappies whenever they are soiled, family planning counseling, the importance of immunization for both the mother and the baby, and postnatal check ups at 1week and at 6weeks. RECOMMENDATIONS

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There is need for adequate resources at the hospital, for example, BP machine, weighing scale and water heater. There is also need to intensify proper monitoring of women in labor and those who have just delivered. Women should also be told that the length of stay in the hospital depends on individual outcome of labor and delivery and its recommended that women in postpartum care may stay in the hospital for a minimum of 24 to 48 hours. SUMMARY OF THE CARE GIVEN Mrs. RC was cared for a period of 48hours using the midwifery care processes, health education was an ongoing activity. The care given was also cultural sensitive. By the time she was discharged she and the baby had met the criteria for discharge and she had gained knowledge on the care of the baby and herself.

REFERENCE

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Frazer, D.M.; Copper, M.A. & Nolte, A.G.W. (2006) Myles Textbook for Midwives 14th Ed. Churchill Livingstone. Philadelphia. Myles, M. (1989). Textbook for midwives: Longman, London. Obstetrics life skills training manual for Malawi (2000): Safe Motherhood-Helping to prevent maternal deaths; Ministry of health and population. Olds, S.B.; London, M.L.; Ladewig, P.A. & Davidson, S.V (2000). Obstetrics Nursing. Addison-Wesley Publishing Company. Menlo Park, California. Sellers, P.M. (2001) Midwifery. Cape Town; Juta & Co.

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