ACKNOLEDGEMENTS This case study should not have been a success if it were not for the generous contributions

and assistance of some individuals worthy mentioning. Firstly I would like to express my heart felt appreciation to Maria Sadi for consenting to be the subject of this study. The difficulty of conducting this study was largely eased by her understanding and cooperation. I would like to extend my appreciation to Mrs. Galilea and Mrs. Msusa; the acting Chief Nursing Officer and labor ward in charge respectively at Zomba Central Hospital for supervision, guidance and contributions that enabled me to smoothly carry out this study. I would also like to acknowledge the contribution of Mrs. Kamanga my clinical supervisor without whose guidance this study should not have been the way it is. Lastly but by no means the least I thank God for the gift of life.

INTRODUCTION This paper presents a case study done on Maria Sadi (in this paper referred to as X) aged 22 years, gravida 3 para 2, who underwent vacuum extraction delivery on December 17, 2008. Vacuum delivery was indicated because she had a previous caesarian section scar. This paper presents care rendered to her during labor, delivery and post-natal periods. It therefore includes subjective data, objective data, care plan, implementation health education, challenges and lessons learnt.

SUBJECTIVE DATA PERSONAL HISTORY X was 22 years old gravida 3, para 2. She hails from Matiya village T/A Chikowi in Zomba district. She is Manganja by tribe. She was residing at Mpunga location in Zomba city. She was married to her first husband and she was the only wife. She was a house wife and her highest level of education was standard 8. She was a Christian of Seventh day Adventist. Her next of kin was her mother Stella Phiri. CHIEF COMPLAINT X complained of lower abdominal pain and backache.

MEDICAL HISTORY X said that she had never suffered from any of the following disease: tuberculosis, asthma, diabetes mellitus, epilepsy, hypertension, renal diseases, heart disease, epilepsy or mental illness. SURGICAL HISTORY X underwent caesarian section with her second pregnancy which resulted in a live full term female infant. FAMILY HISTORY She stated that there are no disease conditions that run in the family neither from the paternal nor maternal side and there is no history of multiple gestation. NUTRITIONAL HISTORY X takes a balanced diet evidenced by her 24 hour dietary recall which was comprised of all the six food groups i.e. porridge, groundnuts, Nsima, fish, vegetables, mangoes, and beans. She takes three main meals a day i.e. breakfast, lunch, and supper and snacks in-between meals. She did not experience any pica or excessive salivation during her entire period of her pregnancy. She never had problems like vomiting and diarrhoea. There are no food restrictions during pregnancy in her culture. SOCIAL HISTORY She had been married to Mr. Sadi for six years. It was a monogamous family. Her husband did his education up to form 4 and is a Clerk at government print. The husband earns enough money to afford basic household needs. She reported that she had been receiving enough social and financial support from

her husband and significant others during her pregnancy. She is in good relationship with her husband and significant others. PSYCHOLOGICAL HISTORY X stated that the pregnancy was unplanned but they had both accepted it. They had planned to be on family planning method after the birth of their child. GYNAECOLOGICAL X attained menarche at the age of 13. She experiences regular menstrual cycle. She menstruates for about 4 days and her menstrual flow is always mild. She experiences dysmenorrheal which gets relieved after taking brufen. FAMILY PLANNING HISTORY X uses has been using depo provera since the birth of her first child. She stopped using the method in January 2008 because she had stopped menstruating and thought she would not get pregnant. She plans to continue with depo provera after delivery SEXUAL HISTORY She reported that she stopped having coitus when she was seven months pregnant. Her culture advocates that a couple should stop having coitus when the woman is 8 months pregnant for fear of causing trauma to the fetus. After delivery they are supposed to resume coitus after 4 months. She stated that she did not experience dyspareunia or any sexual discomfort since she fell pregnant. PREVIOUS OBSTETRIC HISTORY Her first delivery (2004) was SVD of a live full term female infant who weighed 2700 grams and cried at birth, her second delivery (2006) was through caesarian section due to cephalo-pelvic disproportion. The baby weighed 3800kg and cried after birth. The surgical wound healed without any complications. Currently both children are in good health. REST AND SLEEP X said that she did not sleep and hardly rested since labor commenced due to lower abdominal and labor pains. PRESENT OBSTETRICAL HISTORY Her Last Normal Menstrual Period (LNMP) was in October 2007 (she could not remember the exact dates). She realized that she was pregnant in May 2008 when she went to a family planning clinic and was told so by the nurse who was attending to her. She never drained liquor nor experience any vaginal bleeding during pregnancy. She had been taking Iron tablets daily since the day she started attending antenatal clinic at Zomba Central Hospital. In additional to Iron tablets she took two doses of Fansidar twice during her entire period of her

pregnancy; on the initial visit and a month later. She also finished her dose of Tetanus Toxoid Vaccine. She was never experiencing any disorders with this pregnancy. She started experiencing the labour pains around 9pm on 17/12/08/ and she reported at Zomba Central Hospital at around 11pm on 18/12/08 where she was admitted to await delivery. OBJECTIVE DATA PHYSICAL EXAMINATION GENERAL APPEARANCE Healthy looking lady, well kempt in body and clothes, well nourished and hydrated but with a strained facial expression which was an indication of pain. VITAL SIGNS Temperature-36.4 degrees Celsius Pulse rate- 63 beats per minute Respirations-18 breaths per minute Blood pressure-110/80 mm/Hg Body weight-66 kg Height-164 cm HEAD TO TOE ASSESSMENT HEAD Proportional to body size. Clean and treated hair. No dandruff, no scars, no sores nor lacerations.

NOSE Symmetrical, in midline position, wide and patent nostrils, no growths, nor discharges. EARS Symmetrical, no foreign bodies, no growths, nor discharge. Non-palpable preauricular lymphnodes. EYES Symmetrical in size and shape, pink conjunctiva, no discharges, no opacities and clear cornea.

MOUTH Lips were of normal size and shape, pink in colour, no cracks nor sores, pink gums, no gingivitis. White and clean teeth, no dental caries. Pink and moist oral mucosa membranes. Pink and symmetrical tongue. No bad odour nor oral thrush. NECK Symmetrical in shape. No distended nor visible jugular veins. Non-palpable lymphnodes, no swelling nor masses. Normal thyroid gland. Able to turn head to both sides and allowing some flexion and extension. CHEST Symmetrical and barrel shaped. Symmetrical respiratory movements. No crackles and no creptations. BREASTS Symmetrical, no visible masses seen, clean nipples, no sores nor cracks on the nipple. Prominent and erectile nipple. No palpable masses on the breasts. Colostrum expressed. UPPER EXTREMITIES Symmetrical, no tattoos, capillary refill time within 2 seconds, no palmar pallor, non-oedematous arms. LOWER EXTREMITIES Symmetrical, no scars, no varicose veins and no oedema. No swelling and no tenderness on palpation of calf muscles. ABDOMEN Symmetrical, caesarian scar present. Linea nigra and striae gravidarum present. No organomegaly. Fundal height was 40 weeks gestation with 4 fingers below xiphisternum, longitudinal lie, cephalic presentation and Right Occipital Anterior position. Urinary bladder was empty and the fetal heart rate was 140 beats per minute.

GENETALIA Vaginal Inspection Clean, no sores, no lacerations, no warts, non-oedematous, no varicose veins, no bleeding, no show seen and no abnormal vaginal discharge.

Vaginal Examination Warm and moist vagina, thin cervix, 90% cervical effacement and cervix was 4 cm dilated. The presentation was cephalic and the presenting part was well applied to the cervix. Membranes were intact and cord was not felt. The sutures and fontanelles could not be defined, the head was above ischial spines and there was no moulding and no caput. Pelvic Assessment Shape of brim could not be followed, sacrum was curved, sacro promontory was not tipped, sacrospinous ligaments were flexible and ischial spines were not prominent. Sub-pubic arch was more than 90 degrees and intertuberous diameter could admit 4 knuckles. PROBLEMS IDENTIFIED Altered comfort pain related to uterine contractions manifested by strained facial expressions and verbalization. High risk for haemorrhage related to maternal soft tissue injury secondary to invasive procedure. High risk for altered fluid and nutrition related to slowed digestive functioning and emptying time of stomach/ reduced food intake. High risk for infection related to invasive procedure during labour and ruptured membranes. High risk for bladder injury related to compression of the descending fetal head. High risk for hypoxia related to compression of the placenta during uterine contractions. High risk for trauma to the fetal head related to invasive procedure High risk for infant hypoglyceamia related to infrequent feeding secondary to fetal-maternal separation. Ineffective individual coping, anxiety related to labouring in an unfamiliar environment, knowledge deficit on labour and delivery process, outcome and expectation of the midwife.

ANALYSIS OF ANTENATAL CARE X made four visits to the antenatal clinic. She first went to the antenatal clinic at 18 weeks gestation. X received 2 doses of sulfadoxine pyrimethamine to prevent her from catching malaria. She received her first dose of SP on her first visit and second dose on her second visit. X also received ferrous sulphate at each visit. She however did

not get albendazole throughout her antenatal period because it was not available at the clinic. Blood test for hemoglobin level was done only once on her first visit and the results was 12.5g/dl. Xs blood was also tested for HIV and VDRL and the results came out negative. Urine was tested for albumin and the results were negative. Xs blood pressure was checked on each visit and the results were as follows: 120/80mmHg, 110/80mmHg, 110/70mmHg and 110/70mmHg respectively. She was also gaining weight throughout antenatal period from 60kg during the first visit then 61kg, 63kg and 66kg respectively. Her height was 158cm. X received her two last doses of tetanus toxoid vaccine. PROGRESS NOTES 17/12/08 S: X complained of lower abdominal pain and backache. O: refer to physical examination. A: Altered comfort pain related to uterine contractions manifested by strained facial expressions and verbalization. High risk for haemorrhage related to maternal soft tissue injury secondary to invasive procedure. High risk for altered fluid and nutrition related to slowed digestive functioning and emptying time of stomach/ reduced food intake. High risk for infection related to invasive procedure during labour and ruptured membranes. High risk for bladder injury related to compression of the descending fetal head. High risk for hypoxia related to compression of the placenta during uterine contractions. High risk for trauma to the fetal head related to invasive procedure

P: As per care plan.

INTERVENTIONS 4Pm 17/12/08 welcomed X to labour ward. Oriented her to the ward. (To the toilet, bathroom and nurses station). Explained to her about her condition and the process of labour that contractions will be increasing in intensity. She was also told that she would have an assisted delivery of vacuum extraction. She was also assured of my being there for her throughout labour, delivery and post-natal periods and was encouraged to verbalise concerns, worries and to ask questions. X was encouraged to ambulating within the labour ward to facilitate descent of the presenting part. An intravenous infusion of 5% dextrose as commenced to provide her with energy. A urinary catheter was inserted to keep her bladder empty and hence promote progress of labour. She was also told to avoid pushing until she was told to do so when her cervix is fully dilated. 5:30 pm Fetal heart rate was checked and it was 136 beats per minute. She was assured the fetus was well. 6 pm X complained of pain. She was massaged on her lumbar sacral region and she expressed that it was comforting. She was encouraged to be changing positions and was advised to be lying on her side more to avoid supine hypotension which would result if she slept on her back for long which would limit oxygen perfusion to the fetus and cause fetal distress. Vital signs were checked and were as follows: Pulse rate: 90 beats per minute, Blood pressure: 110/62mm hg. Fetal hear rate was 136 beats per minute. She was having 3 moderate contractions in ten minutes. I drained 200ml of urine. Xs mother was asked to prepare porridge for X to take.

6:30pm Fetal heart rate was 135 beats per minute. X started crying on top of her voice. She was thus advised to avoid crying but rather to be panting when there is a contraction to avoid burning off her energy which she would need when time comes for to start bearing down. Pethidine 100mg was administered intramuscularly. 7pm Vital signs were as follows: Pulse rate was 88 beats per minute, Blood pressure was 108/62 mmHg. Fetal heart rate was 136 beats per minute.

She was having 4 moderate contractions in 10 minutes. She was told that so far labour was progressing well and that the fetus was well. X was told on what to do when she is in second stage of labour like bearing down only when there is a contraction. 7:30 pm Fetal heart rate was at 130 beats per minute. Her mother brought porridge which she took. 8pm X was sweating and expressed an urge to defeacate. Contractions were 3 strong in 10 minutes. Her vital signs were as follows: Pulse rate was 80 beats per minute, Blood pressure was 100/70mmHg, fetal heart rate was 130 beats per minute. Vaginal examination was done and the results were as follows; cervix was thin and 10 cm dilated, Fetus was presenting with head in right occipital anterior position. There was no caput and no moulding of fetal head. Liquor was clear. She was told that she was in second stage of labor. Vacuum extractor was collected. A delivery trolley with delivery pack and equipment for episiotomy were also collected. Resuscitare on radiant warmer was also prepared in case the baby got asphyxiated. X was told what will be expected of her during the procedure. She was assisted to be in lithotomy position with her buttocks on the edge of the bed, her legs flexed and thighs abducted. She was reminded to be pushing only when told to do so and when there is a contraction. She was further reminded that when a contraction is gone she needs to breathe deeply using her mouth in order to take in air. Vaginal examination was repeated to confirm position of sutures and fontanelle. Presentation was still cephalic with right occipital anterior position and there was no caput and no moulding of the fetal skull. Fetal head was at 0/5 station and the cervix was thin and 10cm dilated. An assistant was called to help with the procedure. Vacuum cup was inserted sideways and was attached on anterior part of the fetal skull approximately 6cm away from the anterior fontanelle and 3cm away from the posterior fontanelle. The sagital suture was in midline of the cup. Time was noted. With an index finger I assessed around the rim for maternal tissues and they were not there. Fetal heart rate was checked and was at 130 beats per minute. An assistant was instructed to create pressure up to 0.2kg/cm 2 by pumping. Rim of the cup was reassessed for maternal tissues which were excluded. Fetal heart rate was reassessed and was at 126 beats per minute. After 2 minutes the assistant was instructed to increase pressure to 0.4kg/cm 2. Fetal heart rate was reassessed and was at 124 beats per minute. It was still within normal range. After another 2 minutes pressure was increased to 0.6kg/cm2. Fetal heart was reassessed and was at 126 beats per minute. Maternal tissues were excluded. After another 2 minutes pressure was

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increased to 0.8kg/cm2. Fetal heart rate was reassessed and was at 124 beats per minute. Maternal tissues were excluded. An index finger was placed on fetal head to check for descent and thumb was placed on anterior rim of cup to prevent it from coming off. Traction was applied downwards following curvature of the birth canal to allow head to descend and flex allowing occipital bregmatic diameter of 9.5cm to distend the perineum. Mother was instructed to bear down with a contraction while traction was being applied. As the head advanced the perineum position of the thumb was changed to posterior rim of the cup and index finger was maintained on the fetal head. Perineum was observed to be tight. It as then infiltrated with lignocane and an episiotomy was made medial laterally as the head distended the perineum. The head was pulled outwards for crowning to take place. The head was delivered at 8:12 am and immediately pressure was released and the cup was removed from the fetal skull. The rest of the body was delivered by lateral flexion and baby was placed on mothers chest where she was dried thoroughly and covered. Baby cried at birth and had an apgar score of 9/10 at one minute athen 10/10 at 5 minutes. The umbilical cord was clumped and cut soon after delivery. Pitocin 10 units was administered intramuscularly to mother to promote uterine contraction and facilitate delivery of the placenta and membranes. At 8:17 am placenta and membranes were delivered by controlled cord traction. Vaginal examination was done to assess for tears and lacerations and there were none. Vital signs were checked and were as follows; pulse rate was 78 beats per minute, blood pressure was 100/70 mm hg. Babys temperature was 36.7degrees Celsius, heart rate was 130 beats per minute and respirations were 32 breaths per minute. Her umbilical cord was still well secured and was not bleeding. Her skin was also pink. Mothers uterus was firm and well contracted and it was below the umbilical cord. Placenta and membranes were assessed and were complete. It was a healthy placenta and it weighed 300grammes.Cord was centrally inserted with three blood vessels and was 48cm long. Blood loss was estimated at160ml. Baby was labeled and placed on the radiant warmer as suturing equipment was being prepared. An explanation for the need of suturing was given to the mother. Mother was cleaned and the bed was also cleaned. The episiotomy was then sutured. X was advised to be doing sitz baths to promote healing of the episiotomy. She was further advised on perineal hygiene. At 8:32pm vital signs were checked and the results were as follows: Xs pulse rate was 74 beats per minute, blood pressure was 100/64mmHg, and temperature was 36.6 degrees Celsius. Her uterus was firm and well contracted. Catheter was still in situ and was draining. Lochia was flowing mildly. Baby was brought back to the mother and was put to the breast. Baby was able to suckle breast milk. Skin was pink, baby was active. Vital signs for the baby were as follows: Temperature was 36.4 degrees Celsius; heart rate was 130

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beats per minute and respirations were36 breaths per minute. Cord was still well secured and not bleeding. At 8:47pm mothers vital signs were as follows; temperature was 36.5 degrees Celsius, pulse rate was 70 beats per minute , Blood pressure was 100/60mm Hg. Bladder was empty and uterus was well contracted. There was mild flow of lochia. Baby was suckling well. Babys vital signs were as follows; temperature was 36.7degrees Celsius, heart rate was 130 beats per minute and respiration was 34 breaths per minute. Skin was pink and baby was active. At 9 pm X was reassessed she was stable and her vital signs were as follows: temperature 37degrees Celsius, pulse rate 70 beats per minute and blood pressure 108/62mmHg. Her uterus was firm and well contracted on midline of the abdomen and between the lower level of the umbilicus and upper level of the sphysis pubis. There was mild flow of lochia. Bladder was empty and catheter was removed. 500ml of urine was drained from the catheter. Baby was asleep and her vital signs were as follows: temperature was 36.7degrees Celsius, heart rate was 130 beats per minute and respirations were 32 breaths per minute. Her umbilical cord was still well secured and was not bleeding. Her skin was also pink. At 9:10 pm consent was obtained from mother to conduct an initial assessment of her baby. INITIAL ASSESSMENT OF THE BABY Vital signs were as follows: Temperature: 36.3degrees celcius, Heart rate: 126beats per minute, Respirations: 36 breaths per minute. Height of the baby: 51cm. Body weight: 2800g General condition Pink skin, active and suckling well. Healthy and mature baby with no breathing problems. Head to toe examination Head Well distributed hair with fine texture. Anterior and posterior fontanelles were pulsating and were neither bulging nor sunken. Chignon was approximately 6cm away from the anterior fontanelle and 3cm away from the posterior fontanelle. And was on the mid line of sagital suture. There was no moulding of the fetal

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skull. There was also no bleeding and no scratches on the scalp. Head circumference 32cm. Eyes Eyes were symmetrical. Conjuctiva was pink. There was no bleeding from the sclera and no scratches on the sclera. Nose There was no bleeding from the nose and no nasal flaring. Nostrils were well patent. Mouth Gums tongue and lips were pink. There were no false teeth, no cleft palate or lip. No oral thrush. Rooting, suckling and swallowing reflexes were present. Ears Both ears were symmetrical. Upper part of the ear is on the same level with the outer canthus of the eyes. There was no bleeding from the ears and no any sores. Neck There are no wrinkles or webs around the neck. Passive range of movement was positive. The neck could be abducted, turned to the right and left without problems. Chest There was normal chest movement. The chest was moving together with the abdomen. Chest was clear on auscultation with no crackles and wheezes. Breast was well developed with nipples. Upper extremities Had 5 digits on both hand. Palmar creases present on both palms. Calpilaly refill was normal at 6 seconds. Grasping and moral reflexes were present. The babys elbow joint could be abducted. Abdomen Umbilical cord was well secured and not bleeding. There were three vessels on the cord i.e. one vein and two small arteries. The abdomen was not distended. There was no organomegally. Lower extremities Baby had 5 digits on both feet. Grasping and walking reflexes were present. Genitalia Babys labia majora and labia minor were well developed. Clitoris was present. Urine and meconeum was passed indicating patent urethra and anus.

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An explanation of findings was made to the mother. X was then instructed to take a bath and was advised to empty her bladder frequently. Baby was put under radiant warmer in supine position with head turned to the side to promote drainage of secretions. 9:45 pm After mother was back from the bathroom an explanation was given to her about the need for the baby to be taken to nursery ward for observation. The baby was taken to nursery ward in company of the mother. Mother was oriented to nursery ward and its protocols and was shown where baby would sleep. X was taught on possible complications of vacuum extraction such as nose bleeding, crying too much and convulsions. She was advised to watch out for these signs and report to nurses on duty immediately for assistance. Baby was handed over to night duty nurses at nursery ward. X was escorted to high risk postnatal ward for observation. She was given a bed and was encouraged to breast feed the baby frequently to promote growth and development. She was also handed over to night duty staff.

DAY ONE POST-NATALLY 8 am 18/12/08 S: X said she spent the night well but complained of still having lower abdominal and perineal pain from the episiotomy wound. O: X was kempt in both body and clothes, had good gait but made facial expression of pain. Vital signs: Temperature 36.2degreees Celsius, pulse rate 70 beats per minute respirations 20 breaths per minute and blood pressure 110/70mmhg. Her conjuctiva was pink. Had pink mucous membranes. Colostrum could be expressed, no cracks on nipples. No masses felt in breast. No palmer pallor and capillary refill time was 3 seconds. Bladder was empty. Fundus was at 13cm between lower boarder of umbilical cord and upper boarder of the symphsis pubis. Her uterus was well contracted and centrally positioned on the lower abdomen. No varicose veins on lower extremities. No oedema of the tibia, ankle and pedal. Lochia was lubra and was flowing mildly. The sutured episiotomy was intact and not gaping. 8:30am Baby in nursery

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Vital signs: temperature was 36.4degrees celcius, Heart rate was 120 beats per minute and respiration 40 breaths per minute. General condition: Baby had regular breathing pattern, Her body was pink with smooth skin. She was able to breastfeed. Head to toe Exam Head: no caput, no cephalohematoma, no scratches, no bulging fontanel and no sunken fontanelle. Eyes: Had pink conjuctiva.There was no eye discharge and no jaundice. Nose: No bleeding nor discharge from the nose. Mouth: pink mucosa membranes, no oral thrush nor sores. Ears: No any discharges. Chest: Normal, regular and symmetrical chest movement. Upper extremities: No palmer pallor. Capillary refill time was 3 seconds. Abdomen: Not distended and nun tender. Umbilical cord was dry and was not bleeding. Baby had passed meconeum and had urinated. A: - Altered comfort pain related to uterine involution and episiotomy. -High risk for bleeding related to episiotomy and non detached umbilical stump. -High risk for infection related to episiotomy and exposed cord. -Ineffective coping mechanism (anxiety) related to mother baby separation. P: As per care plan. 8:35am Babys bed was cleaned, wet linen was removed and baby was cleaned. Baby was put in supine position with head slightly extended and turned to one side. Room temperature was maintained at 30degrees Celsius. X was advised to change any wet linen or cloth from the baby and replace them with dry ones to prevent hypothermia. She was also advised to always fully cover the baby leaving only the face to prevent hypothermia. Mother was also taught on exclusive breast feeding and its importance and babys proper attachment to the breast. She was further advised to postpone bathing until 24hours after delivery. X was also taught on danger signs in baby an advised to seek health care providers advice immediately they occur. X was advised to be on high protein to promote wound healing. X was also taught on pereneal care and sitz bath. 2pm Mothers vital signs were as follows Temperature: 36.5degrees Celsius. Blood pressure: 100/60mmHg. Pulse rate: 66 beats per minute.

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Respirations: 20 breaths per minute. Babys vital signs were as follows Temperature: 36.4degrees Celsius. Heart rate: 124 beats per minute. Respirations: 38 breaths per minute. Baby was pink and had regular breathing pattern. X was told of the findings. A demonstration of cord care was given to X and she was advised to be cleaning the cord clump at least three times a day. X was also taught on how to rub up a contraction and expel clots if the uterus is relaxed and there is bleeding through vagina. She was also taught to be on high fiber diet to avoid constipation which can strain and disturb episiotomy suture line. She was further taught on six food groups and mixed diet and examples of locally found nutritious food was given. 5pm X and her baby were handed over to night duty staff. 8am 19/12/08 S: said that she spent the night well with mild pain from the episiotomy wound. She also said that the baby was well and was being breastfed frequently. O: MOTHER X was kempt in both body and clothes and was bright. The baby was alert, pink and active. Mothers vital signs were as follows: Temperature: 36.7degrees Celsius. Pulse rate: 68 beats per minute. Blood pressure: 110/60mmhg. Respirations: 20 breaths per minute. Eyes: Pink conjuctiva. Breast: Clean, colostrums expressed no cracks on nipples and no masses in the breast. Upper extremities: No palmar pallor, no oedema. Abdomen: Fundus centrally located between lower boarder of umbilical cord and upper boarder of sphysis pubis with fundal height of 12 cm. urinary bladder was empty. Lower extremities: No oedema and no cuff tenderness. Genitalia: there was mild flow of lochia, sutured episiotomy was clean non oedematous and sutures were in plain.

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BABY Babys vital signs were as follows Temperature: 36.5degrees Celsius. Heart rate: 124 beats per minute. Respirations: 42 breaths per minute. body weight: 2750grams General condition Baby had pink skin was active with normal breathing pattern. Eyes: No jaundice, no discharge and no bleeding. Nose: No nasal flaring, no nasal stuffiness and no discharge from the nose. Chest: No chest in drawing, clear air entry, symmetrical respiratory movement. Abdomen: Umbilical cord was dry and was shrinking off. Genitalia: passing urine and stools. A; High risk for infection related to episiotomy wound and umbilical cord. P: As per care plan. I: 9:00am Babys bed was cleaned wet linen was removed and replaced with dry one. Baby was discharged from nursery ward and was with the mother in post-natal ward. X was taught on immunization and its importance. She was further taught on immunization schedule. Baby was given BCG vaccine and polio o with consent from her mother. 2pm Mothers vital signs were as follows: temperature: 36.7degrees Celsius, pulse rate was 70 beats per minute, blood pressure was 100/68 mmHg and respirations were18 breaths per minute. Babys vital signs were as follows; temperature 36.5degrees Celsius, heart rate 130 beats per minute and respirations were 40 breaths per minute. Baby was breastfeeding well, had pink skin and was active. X was taught on post-natal exercises like kegels exercises. Mother was informed that if she met discharge criteria she would be discharged the following day. 5pm X and her baby were handed over to night duty staff. 20/12/2008 8am

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S: mother said she was well and spent the night well. She also said that baby was well. O: MOTHER X looked well and was kempt in body and clothes. Mothers vital signs were as follows: Temperature: 36.9degrees celcius. Pulse rate; 70 beats per minute. Blood pressure: 110/64mmhg. Respirations: 20 breaths per minute. Eyes: Pink conjuctiva. Breast: Clean, colostrums expressed no cracks on nipples and no masses in the breast. Upper extremities: No palmer pallor, no oedema. Abdomen: Fundus was centrally located between lower boarder of umbilical cord and upper boarder of sphysis pubis with a fundal height of 11 cm. her urinary bladder was empty. Lower extremities: No oedema, no cuff tenderness. Genitalia: Lochia was flowing mildly. Episiotomy suture line was in place, clean and non oedematous. Babys vital signs were as follows Temperature: 36.5degrees Celsius. Heart rate: 122beats per minute. Respirations: 40 breaths per minute. Body weight: 2800grams General condition Pink skin, active with normal breathing pattern. Eyes: No jaundice, no discharge and no bleeding. Nose: No nasal flaring, no nasal stuffiness and no discharge from the nose. Chest: No chest in drawing, clear air entry, symmetrical respiratory movement. Abdomen: Umbilical cord was dry and shrinking, there was no discharge, no redness, no pus or pustules at the root of the umbilicus. Genitalia: baby had passed urine and stools. A. Mother was adapting well post-natally and baby was well. P: Discharge mother and baby. Counsel X on sexuality and family planning. I: X was counseled on sexuality and family planning. 10:00am X was discharged and was told to report back for review on 26/12/08.

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DISCHARGE PLAN Before discharge X will be taught on the following topics: Immunization for baby and mother. Perenieal care. Post-natal exercises. Sleep and rest. Bladder care. Sexuality. Family planning. Nutrition. Cord care Danger signs for infant and post-natal mother.

DISCHARGE CRITERIA MOTHER Her vital signs should be within normal ranges of Temperature: 36-37.4 degrees celcius, Blood pressure: 100/60 to 120/80 millimeter per mercury, Respiration: 16-20 breaths per minute, Pulse rate: 60-100 beats per minute. Her uterus must be firm, well contracted, centrally located thus between sphysis pubis and umbilicus. It should also be non tender. The mother must be able to position and attach baby well to the breast and must demonstrate understanding on the significance of exclusive breastfeeding. The mother should demonstrate understanding on the importance of immunizations and the schedule. The mother should be able to urinate and defecate. The mother must not show any signs of infection, anemia and jaundice. The mother must be physically and psychologically healthy and stable. The mother must understand the importance of keeping the baby warm. The mother must demonstrate knowledge of the danger signs. BABY The baby must have stable vital signs. Temperature 36.5 to 37.4 degrees Celcius, Heart rate of 120 to 160 beats per minute and respirations of 30 to 60 breaths per minute. The baby must be able to pass urine and meconeum. 19

The baby must show no signs of infection like having fever, bulging fontanelle, septic spots, eye discharge or pus on meconeum. The baby must be able to suckle the breast. The babys reflexes must be tested i.e. moral, rooting, suckling, swallowing, grasping and walking. The baby should not have jaundice and oral thrush. The baby must be active and alert with pink body.

CHALLENGES AND LIMITATIONS Limitation of resources e.g. sterile packs for cleaning cord, basins to demonstrate bathing of the baby. There was no auditory privacy because a number of clients were being examined in the same room at the same time with only covering of screens. Husband was always at work hence X was counseled alone on relevant issues to husband like family planning. LESSONS LEARNT Multiparas women should not be taken for granted that they know a lot about child care. They need to be taught everything. Psychological preparation of the mother is very important as it is the basis for cooperation.

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REFERNCE Bennet, V.R and Brown, L.K (1999) Myles textbook for midwives. (13th Edition) Edinburgh, Churchill Livingstone Ministry of Health, (2000) Obstetric Life skill Training Manual for Malawi-Safe Motherhood program. Ministry of Health, (2000) Concepts of Antenatal Care and Focused Antenatal Care Olds,S.B., London, M.L., & Ladewig, P.A. (1999) Maternal newborn nursing: A family and community based approach. (6th edition) London, Pretince Hall. Sellers P.M, (2001) Midwifery, (volume 2) Cape Town, Juta and Company. Sweet, B.R. (1999) Mayes Midwifery(12th edition) London, Bailliere Tinall.

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