M.

S RAMAIAH INSISTUTE OF NURSING EDUCATION AND RESEARCH

CASE PRESENTATION ON preparation for labour

SUBMITTED TO MRS.DIVYA RAGHAVAN LECTURER, DEPT OF OBG NURSING, M.S.R.I.N.E.R SUBMITTED BY MRS.LIMA MATHEWS 1ST YR MSC NURSING M.S.R.I.N.E.R

SUBMITTED ON :19/02/2011
INTRODUCTION As a part of my speciality clinical posting, at M.S.Ramaiah Hospital ,I Mrs.Lima Mathews ,Iyr M.Sc Nursing student has selected Mrs.Namitha for my antenatal case study,whose P ! is "# w$s .She is a primigra%idae mother !& Po Lo Ao BASELINE DATA Name Age Marital status )ard Nationality Religion *ducation ccupation Address ' Mrs. Namitha. ' (" yrs

' Married ' Semi special ward ' Indian ' Hindu ' SSL+ ' Home ma$er ,A$e$atta,Na%eli post +N Halli -um$ur

Admission date 1stetrical score LMP *.2.+ !estational age

' ./#/(0&0 ' !& Po Lo Ao ' &/&(/(00# ' 4/#/(0&0 ' "5 wee$s +onsulted 1y ' 2r. 3ma de%i

2ate of care started ' ./#/(0&0 2ate of care ended ' &&/#/(0&0

2iagnosis

' "5 wee$s with cephalic presentation ,primigra%idae

CHIEF COMPLAINT Mrs.Namitha came to the hospital for safe confinement with the complaint of 1ac$ pain and a1dominal pain OBSTETRICAL HISTORY PAST OBSTETRICAL HISTORY PRIMI!RA6I2A PRESENT OBSTETRICAL HISTORY 1s T!"#$s $! Patient concei%ed spontaneously after & year of married life. Pregnancy was confirmed after urine pregnancy test after &/( month of amenorrhea. Regular antenatal chec$up was done. 7lood and urine in%estigations were done. Her H1 was &(.4 gm8. 3rine e9aminations are normal. 3ltrasound scan was done, normal findings. No history of %omiting or 1leeding per %agina.7p,&( /40 mmof Hg, wt,: ;$g 2%& T!"#$s $! <uic$ening felt at ; month. ( doses of -- in=ections ta$en. Iron and calcium ta1lets were ta$en. No a1normal findings .Regular antenatal chec$ up done . '!& T!"#$s $! >etal mo%ements well appreciated. Iron and calcium supplements were continued. Scan a1domen was done. It showed normal findings. 7lood in%estigations done. All reports were normal. 7lood group 7 ?%e. No swelling at lower lim1s . She has undergone regular antenatal chec$up.Now she got admitted for the safe confinement with the complaints of 1ac$pain

MEDICAL HISTORY PAST MEDICAL HISTORY Mrs.Namitha is not ha%ing any history of medical illness li$e hypertension, dia1etes, tu1erculosis, epilepsy, thyroid disorders etc PRESENT MEDICAL HISTORY Mrs. Namitha is ha%ing history of amenorrhea .No other medical illness li$e hypertension ,dia1tes ,epilepsy is present .Not suffering from anyother communica1le and non,communica1le disease. SURGICAL HISTORY PRESENT AND PAST SURGICAL HISTORY She has not undergone any surgeries FAMILY HISTORY Mrs. Namitha 1elongs to a nuclear family. No history of dia1etes mellitus, hypertension, epilepsy, 1lood disorders and any other communica1le diseases. No history of congenital anomaly and twinning in the family.

FAMILY GENOGRAM

.0 @RS

5: @RS

:4 @RS

:;

(EY

>emale

Male

patient

PERSONAL HISTORY Mrs. Namitha 1elongs to a middle class family. Her hus1and is the 1read winner of the family. -hey li%e in their own house. -heir house got all facilities li$e water supply, electricity, drainage system etc 2ietary pattern, appetite is good -a$ing mi9ed diet *limination pattern, 1owel and 1ladder ha1its are regular Rest and sleep, regular *9ercise, no specific e9ercise pattern Personal hygiene, maintains good personal hygiene +ultural history, doesnAt ha%e any cultural 1elief that would affect her health ccupational history, house wife MENSTRUAL HISTORY, Age of menarchy, &;yrs Regular (4 days cycle with ;,: days of 1leeding No dysmenorrhea MARITAL HISTORY

married life ( yrs Arranged marriage Ha%ing good relationship with hus1and Non, consanguineous marriage Ha%e not used any contracepti%e methods PARTNER)S HISTORY Name, Mr.Suresh Age, (4 yrs *ducation, P3+ ccupation B *lectrician !enetic disorder, no history of genetic disorders Health pro1lem, no significant health pro1lem Ha1its, no 1ad ha1its 7lood group, ?%e

Attitude, positi%e attitude towards pregnancy

PHYSICAL E*AMINATION . .GENERAL APPEARANCE Height )eight 7ody 1uilt rientation Sensorium ' &54cm ' 50 $g ' moderate ' oriented to time, place and person. ' conscious.

Le%el of acti%ity ' Restricted VITAL SIGNS -emperature Pulse Respiration 7lood pressure ' #4.5C> ' 4;1t/mt ' (;1reath/mt ' &(0/40 mm of Hg

HEAD TO FOOT ASSESSMENT S(IN +olour -e9ture ' >air ' Smooth

-emperature Lesions >oul dour *dema HAIR +olour -e9ture 2istri1ution Infection NAIL Shape +olor Infection

' )arm And 2ry ' A1sent ' A1sent ' A1sent

' 7lac$ ' Smooth ' *Dually 2istri1uted ' A1sent

' Normal ' Pale ' A1sent

HEAD AND FACE SiEe Shape ' Normal ' Normal

>acial Appearance' Normal Sinuses EYES *ye1rows *yelashes ' *Dually distri1uted ' Normal ' Normal.

*yelids Sclera Pupil 6ision +on=uncti%a E+! Alignment

' 7ilaterally Symmetrical ' +lear And )hite ' Pupils eDual and reacting to light ' Normal ' Pale

' Normal

+ondition f S$in ' Normal +olor *9ternal Pinna 2ischarge Hearing )e1er test Rinne test NOSE SiEe Shape Symmetry Nasal Septum Nostrils 2ischarge ' Normal ' Normal ' Symmetric ' No 2e%iated Nasal Septum ' No +rust, Infection, ' A1sent ' Normal ' No Lesion, And Infection ' No 2ischarge ' Normal ' Air conduction is more than 1one conduction.FnormalG ' Air conduction is more than 1one conductionFnormalG

MOUTH , THROAT +olour Lesion Symmetry Lips -eeth ' pin$ ' a1sent ' eDual ' dry, pin$ in colour ' 1rown, no loosening, and decayed teeth

Mucus mem1ranes' normal and dry -ongue dour 3%ula ' not coated and dry ' a1sent ' midline position

ral mucosa and gums' normal Hard and soft palate NEC( -onsils -hyroid gland Range of motion CHEST Inspection ' no lesion, discoloration, 1ilateral chest e9pansion Palpation ' no mass, no tenderness, ' Normal ' Normal ' Normal ' normal and pin$

Percussion ' resonance sound heard, eDual air entry Auscultation ' S& HS(, sounds heard

A9illa and cla%icular nodes' not enlarged BREAST I%s-$. "/% SiEe ' 7oth are symmetrical

Primary aerola ' Present Monotogomery tu1ercle ' present Nipple ' erect No pain ,redness ,tenderness Palpation Palpation done 1y circular method )arm to touch No lymphnode enlargement No pain, redness, tenderness ABDOMEN Inspection ' Shape is %oid

+ontour is con%e9 3m1ilicus is flat >lan$s are full 7ladder is emptied Striae gra%ida and Linea nigra present Palpation ' >etal mass present

Auscultation BAC( 7ody cur%e Lesions GENITALIA 2ischarges 7owel Pattern 7ladder Pattern E0 !$#" "$s

' >etal Heart sound present

' normal ' a1sent

' A1sent ' Reduced ' Normal

No edema or 26OBSTETRICAL E*AMINATION I%s-$. "/%1 SiEe Shape +ontour 3m1licus >lan$s >oetal mo%ement +ondition of 1ladder S$in changes P+2-+ "/% ' ' ' ' ' ' Appro9imate to the period of gestation o%oid +on%e9, s$in elastic >lat >ull %isi1le fetal mo%ement present

' *mptied ' Linea Nigra and striae gra%idarium present

A1dominal girth,#0 cm >undal height,"4 in cm "( in wee$s >undal palpation, Soft irregular mass suggesti%e of fetal 1uttoc$s Lateral palpation Right side Left side Pel%ic palpation At Pel%is ' Hard glo1ular non 1allota11le mass suggesti%e of fetal head, +on%erging hand indicate head is not engaged ccipital pole Syncipital pole ' palpa1le ' not palpa1le ' Small irregular $no1 li$e structure suggesti%e of fetal lim1 ' +ontinuous smooth well cur%ed structure suggesti%e of spine

+on%erging/ di%erging ' con%erging 2escend of the head ' :/:th *ngaged Pel%ic grip SiEe >le9ion +om1ine grip At fundus At pel%is ' 7road soft irregular mass suggesti%e of fetal 1uttoc$s ' Hard glo1ular non 1allota1le mass suggesti%e of fetal head ' ' normal >le9ed ' not *ngaged

A3s.32 + "/% >etal heart sound Rhythm F"%&"%4s !estational age Lie Presentation Position Attitude 2escend *ngaged >HS ' ' ' ' "5 wee$s Longitudinal +ephalic presentation L A ' &;; 1/mt ' Regular

' >le9ion ' :/: th ' not *ngaged ' &;; 1/mt Regular R L

INVESTIGATION SL %/ I%5$s "4+ "/% P+ "$% )s 5+23$ N/!#+2 5+23$ I#-!$ss"/%

1. a 1 c

U!"%$ !/3 "%$ $s +olour Appearance pH specific gra%ity

@ellow +lear 5.: &.0&.

@ellow +lear, haEy ;.5 B 4 &.0&5 B &.0((

Normal Normal Normal Normal

2. a 1 c d e f g h ' a

C6$#".+2 $0+#"%+ "/% /7 3!"%$ Protein !lucose Ietone 7ile salt 7ile pigment 3ro1ilinogen 7lood Nitrates

Negati%e ?? Negati%e Negati%e Negati%e Negati%e 0 .( Negati%e Negati%e Negati%e Negati%e Negati%e Negati%e 0." , & Negati%e trace Negati%e

P!/ $"%3!"+ Normal Normal Normal Normal Normal Normal Normal

M".!/s./-". $0+#"%+ "/% *pithelial cells

& B (/hpf

ccasionally few/hpf 0 B ;/hpf

Normal

Pus cells

& B (/hpf

Normal

R7+s

Nil

d e f 8 a 1 c d 9 a 1 c : a 1 c d e f g h i

Mucous strands +rystals +asts

A1sent Nil Nil

Male, o B "/hpf >emale, 0, :/hpf A1sent A1sent A1sent

Normal

Normal Normal Normal

Serum glucose Random 1lood sugar 3rine sugar +reatinine 3ric acid

4; mg/dl &5 mg/dl 0.4"mg/dl ".5 mg/dl

.0 B &;0 mg/dl &: B ;: mg/dl 0.55 B &.0# mg/dl (.: B 5 mg/dl

Normal Normal Normal Normal

Serum electrolytes Serum sodium Serum potassium Serum chloride

&". mmol/L (.# mmol/L #. mmol/L

&": B &;: mmol/L ;." mmol/L #4 B &0.mmol/L &&.: B &;.:gm/dl ".4 B ;.4 millions/cumm "0 B ;58 40 B &00 fl (. B "5 pg "( B ":gm/ dl ;B &&thousand/cmm ;0 B .:8 (0 B ;:8

Normal Normal Normal

Haematology Haemoglo1in R7+ count Pac$ed cell %olume M+6 M+H M+H+ )7+ count Poly morph Lymphocyte

&(."gm/dl ;."million/cmm "48 ##fl "0 pg "5gm/dl 4.#thousand/cmm 4.8 "08

Normal Normal Normal Normal Normal Normal Normal Infection Normal

= $ l . a 1 c

*osinophil 7asophil Platelet

;8 08 "(.thousand/cumm

0 B 58 0 B &8 &:0 B ;:0thousand/cm m Normal Normal Normal

Normal Normal Normal

C2/ "%4 -!/7"2$ 7leeding time +lotting time Acti%ated partial throm1o plastine

".( minutes 5 minutes "(.0# sec

(,5minutes 4,&: minutes "o,;0 sec

ULTRA SOUND Single intrauterine li%e foetus with cephalic presentation of ": wee$s of gestation. >oetal growth is normal

PREPARATION OF WOMEN FOR A!OUR

INTRODUCTION +hild1irth is one of the most mar%ellous and memora1le segment in a womanAs life. It does not really matter if the child is the first, second or the third one. *ach e9perience is uniDue and calls for a cele1ration. ne of the most 1eautiful time period during a womenAs life is the pregnancy period. 7ecause her life will 1e satisfied 1y gi%ing 1irth to her 1a1y. >or that she will 1e ready to suffer all the pains with full happiness. LABOUR Series of e%ents that ta$e place in the genital organs in an effort to e9pel the %ia1le products of conceptions out of the wom1 through the %agina into the outer world is called la1our . Normally it occurs 1etween "4 wee$s ;( wee$s .if it is occurring 1efore "., it is called as preterm and if it is occurring after ;( it is called post term. Parturient is a patient in la1our .Parturition is the process of gi%ing 1irth. CHANGES OCURRING IN THE BODY DURING CHILD BIRTH C6+%4$s "% +%+ /#".+2 s !3. 3!$

-he 1ones and muscles of the -$25"s pro%ide support for the growing uterus and 1a1y, and pro%ide a passage through which your 1a1y emerges during 1irth. -he 3 $!3s surrounds the 1a1y, growing as the 1a1y grows. -he .$!5"0 is actually a part of the uterus, 1ut made up of different tissue. 2uring pregnancy, the cer%i9 is thic$ and closed. As you approach the time of 1irth, your contractions draw the cer%i9 up into the 1ody of the uterus, and it 1ecomes thinner Fcalled effacementG and opens Fcalled dilationG. )hen the cer%i9 is fully dilated Fa1out ten centimetersG, contractions help the 1a1y 1egin to mo%e from the uterus into the %agina.

-he 5+4"%+ leads from the cer%i9 to the outside of your 1ody. -he inside of your %agina has many folds, called rugae, which unfold as the 1a1y passes through

WHAT HAPPENS IN BODY BEFORE LABOUR BEGINS 7ody prepares for child1irth throughout your pregnancy, 1ut in the last few wee$s, it does some final preparation.

H/!#/%$s ;/!< / s/7 $% 6$ 2"4+#$% s =$ ;$$% 6$ =/%$s "% -$25"s, which gi%es your pel%is additional room for 1irth. 2uring this time, mother might feel a shift in her sense of 1alance, =oints might feel looser, and might feel sore and achy.

O 6$! 6/!#/%$s =$4"% / s/7 $% .$!5"0, which is the nec$ of the uterus. -hroughout most of pregnancy, motherAs cer%i9 is closed, holding the 1a1y inside motherAs uterus. Much of the wor$ of la1or is in opening the cer%i9 to the passage of motherAs 1a1y. Howe%er, motherAs cer%i9 may 1egin to soften, thin, and open e%en 1efore la1or 1egins. -his %aries from woman to woman, and from pregnancy to pregnancy. Some women may ha%e closed cer%i9es until la1or starts. thers may ha%e pre,la1or contractions that dilate their cer%i9 to three or four centimetersG 1efore la1or 1egins.

E%4+4$#$% . 2escending of the fetus towards the lower a1domen .>or first time mothers, this may ta$e place up to a few wee$s 1efore the 1irth. >or some second, or su1seDuent,time mothers, engagement may not occur until after la1or 1egins.

M/ 6$! #+> $0-$!"$%.$ 6$ -+ss+4$ /7 s !"%4>, -$!6+-s =2//&1 "%4$& #3./3s. -his Jmucous plugJ has 1een in place inside the cer%i9 during pregnancy, and as the cer%i9 1egins to soften and open, this mucous loosens and may 1egin to pass from the %agina. Some women may notice this increased mucous passage for a few days For e%en wee$sG 1efore la1or 1egins, others may not notice it at all.

T6$ =!$+<"%4 /7 6$ =+4 /7 ;+ $!s ?!3- 3!$& #$#=!+%$s@ may also occur 1efore la1or 1egins. >or most women, contractions will follow within a day.

STAGES OF LABOUR *%ents of la1our can 1e di%ide into ; stages First stage Bstarts form the onset of true pain till the full dilatation of the cer%i9 .duration is &( hours in primi and 5 hours in multi

Second stage Bstarts from the full dilatation till the e9pulsion of the foetus.It has got two phases. 2uration is ( hours in primi and "0 min in multi. aGpropulsi%e phase,starts from full dilatation to the descent of the presenting part to the pel%ic floor . 1Ge9pulsi%e phase Bfrom the maternal 1earing down effort till the deli%ery of the foetus Third stage Bfrom the e9pulsion of the fetus till the e9pulsion of the placenta .duration is &: min in 1oth multi and primi FACTORS INFLUENCING THE PROGRESSION OF LABOUR +hild1irth professionals often refer to the following factors influencing la1or progression as the J>our PsJ of la1or'

P+ss$%4$! F 1a1yG P+ss+4$ Fthe pel%ic 1ones, cer%i9 and %agina, and the muscles in pel%isG P/;$! F contractionsG Ps>.6$ F emotionsG

FACTORS THAT EASE LABOUR La1our is a gradual phase that gains momentum with each contraction. A %ariety of factors could trigger la1our , and e%ery womanKs e9perience is uniDue. Since a normal, hassle,free deli%ery is what any woman would preferL here are a few factors that would facilitate a safe and easy la1our. B!$+ 6"%4 R"46 7reathing techniDues play an important role in la1our and child1irth. Most antenatal and la1our preparation classes train e9pectant mothers in the right form of 1reathing, which encourages focus and concentration during la1our. -hough there are many types of 1reathing e9ercises, 1ut there are no

particular rules a1out how you ought to 1reathe. Most women find that adopting a particular 1reathing pattern helps them control la1our pain during deli%ery. -he emphasis is on lengthening the out,1reath, following it till the %ery end. S +>"%4 A. "5$ It has 1een pro%en that women who are fit ha%e safer and more positi%e 1irth outcomes. Acti%ity encourages circulation and the production of natural hormones. It also enhances energy le%els and strengthens muscle tone in preparation for child1irth. *9ercising regularly is more 1eneficial than e9ercising randomly as it 1uilds strength and stamina and reduces the possi1ility of in=ury. P"2+ $s Pilates is a 1ody conditioning discipline that focuses on the 1reath to achie%e impro%ed fle9i1ility and strength for the whole 1ody. Pilates help impro%e posture and aid 1ody control and stress management. It strengthens the pel%ic floor muscles in preparation for child1irth and also focuses on the a1dominals, 1ac$ and 1uttoc$s. Pilates can 1e practised from the 1eginning of the second trimester. And 1ecause it is a non,aero1ic, no,impact system, the 1asic e9ercises are ideal during pregnancy and child1irth as they are gentle and slow. Y/4+ @oga is a safe, effecti%e and rela9ing form of e9ercise during pregnancy. It relie%es stress and an9iety, encourages hormonal 1alance, increases stamina and calms the mind. Many women consider yoga a most empowering way to prepare for la1our and child1irth. @oga also helps lower 1lood pressure, aids effecti%e digestion, strengthens the pel%ic floor muscles and reduces constipation. A2 $!%+ $ T6$!+-> In recent times, there is an emphasis on %arious alternate therapies that could ease the pain and trauma of la1our. Refle9ology, massages, meditation, aromatherapy, acupressure, acupuncture or shiatsu, which in%ol%e stimulation of pressure points along the 1ody , are popular among e9pectant mothers. It is 1elie%ed that water therapy helps the uterus to contract more effecti%ely, while Masmine in aromatherapy is noted for preparing the uterine muscles for la1our. Refle9ology , the techniDue of massaging pressure points on the feet , has 1een pro%en to help induce la1our and num1 pain.

G$ "%4 P6>s".+2 -uning in to 1ody is %ital during the final stages of your pregnancy, as gi%ing 1irth is a natural physical tas$. Studies ha%e found that se9ual intercourse during the last few wee$s of pregnancy can help soften the cer%i9 in preparation for la1our. -he prostaglandins found in semen, helps soften the connecti%e tissue of the cer%i9 and increase o9ytocin production in the muscle cells of the wom1 in preparation for la1our. As synthetic prostaglandin gel is often used to soften the cer%i9 and wom1 to induce la1our, medical professionals nowadays recommend se9 during the last few wee$s of pregnancy. P$!"%$+2 #+ss+4$ 1 massaging the area of tissue 1etween the anus and the %agina during the last few months of pregnancy, is considered to 1e helpful in minimising possi1le tearing or the need for an episotomy. 7reast and nipple stimulation ha%e 1een pro%en to induce strong uterine contractions. Nipple stimulation has 1een 1eneficial

PREPARATION +@ W6+ "s / =$ -+.<$& A Pac$ing your hospital 1ag is an e9citing way to prepare for the 1ig day and itAs 1est to do it a1out si9 wee$s 1efore your due date. Many maternity 1rands sell special hospital 1ags, which include anything from sections to $eep your clothes separate from your 1a1yAs, to 1ottle holders and laundry 1ags. 7ut a wee$end 1ag is fine, too. It needs to 1e 1ig enough to carry all the essentials B 1ut remem1er these are what you need for a hospital stay, not a fi%e,star wee$end away.Some women prefer to pac$ two 1ags B one with items to use during la1our and one for staying in hospital afterwards.

G/"%416/#$ /3 7" -here will 1e need clothes to go home in, so mother has to pic$ a comforta1le outfit that wonAt crease easily and will allow you to 1reastfeed. A fa%ourite maternity dress with a front opening would 1e great. N$;=/!% Ess$% "+2s Pac$ a few new1orn sleep suits mitts, 1ootees, 1i1s, a 1lan$et, new1orn nappies and cotton wool for those first changes.

N3!s"%4 %"46 ;$+! -his is a must. >eeding tops ha%e a crosso%er front, detacha1le strap or front opening so mother can comforta1ly and discreetly 1reastfeed your 1a1y. C+#$!+ Howe%er e9hausted and sweaty you feel, you will 1e glowing after gi%ing 1irth. -he first time mother holds your child is an e%ent to capture for $eeps, so ma$e sure the 1attery is fully charged. D!$ss"%4 4/;%/.+!&"4+% 3seful co%er,up for early la1our. T6$ 2+ $s "ss3$ /7 P3=2".+ "/%s Inorder to fill the days of pregnancy H$+&=+%& Ieep your hair 1ac$ during la1our. D"s-/s+=2$ <%".<$!s +%& B!$+s -+&s Pac$ se%eral pairs of paper $nic$ers or old pants to wear in early la1our and afterwards..

M+ $!%" > -+&s -he hospital will pro%ide with some, 1ut mother has to get ready with necessary one

B"! 6 -2+% Should ta$e a copy of 1irth plan B itAll help to get the 1irth they want. TENS #+.6"%$ In foreign countries we are ha%ing this as a complementary therapy .+an ease early la1our pains 1y sending an electric charge through pads on the s$in.

S2"--$!s +%& s/.<s )arm cold feet in la1our and wear if mother stay in hospital afterwards. "P/& helps to ha%e peaceful and happy in mind S%+.<s Pac$ chocolate, 1ananas, energy 1ars, high,energy drin$s li$e +o$e and LucoEade, and straws for easy drin$ing. T/"2$ !"$s )ash 1ag, tra%el tooth1rush, toothpaste, mini hair1rush, lip 1alm, face cream, anti1acterial hand gel, and liDuid facial soap. BIRTH OPTIONS It is the right of the women and family mem1ers to choose the type of 1irth she wanted 7H/#$ ="! 6

It is gaining more importance as the women will 1e getting free from all types of tensions and worries along with the 1elo%ed mem1ers W+ $! B"! 6 Mother canAt insist on gi%ing 1irth in water 1ecause we need a midwife e9perienced in water .In foreign hospitals we can use this option successfully I%&3. "/% According to NI+* guidelines, if your pregnancy goes 1eyond ;& wee$s you mother isa offered induction . If mothers 1eing pressured into induction, which in%ol%es 1eing gi%en drugs to trigger la1our,mother has to as$ these Duestions B B what are the 7enefits of doing thisN R B )hat would 1e the Ris$s if we do thisN A B )hat are the Alternati%es we could try firstN F)hether a mother can go home and try ta$ing a long wal$G I B )hat is my Instinct telling meN F2o I really want this 1a1y out now or am I ner%ous a1out induction and would I prefer to let it happen naturallyNG N B )hat if we do Nothing for the ne9t day/wee$N +an I come in daily for monitoring to $eep a chec$ on the 1a1yN E2$. "5$ C+$s+!$+% Research has found that many of the women who as$ for a caesarean do so 1ecause of fears a1out la1our or 1ecause theyA%e had a traumatic la1our pre%iously. Howe%er, all women should 1e offered counselling and support 1y a midwife to help o%ercome her fears, 1ut if it canAt 1e o%ercome, a report from a psychologist or counsellor may help when the o1stetrician is ma$ing the decision. D!"-

OIf mother is offered a drip, as$ if she can go for a wal$ or change your position to try and get things going naturally first. A drip wonAt necessarily mean a Duic$er and easier la1our, as it can ma$e contractions much more painful %ery Duic$ly, E-"&3!+2 Omother can reDuest an epidural, 1ut donAt e9pect it to happen immediately. If thereAs an emergency in another part of the hospital, the anaesthetist might not 1e a%aila1le for a while. And if mother is at the end of the first stage of la1our, an epidural may not 1e appropriate, as it can affect a1ility to push, so she All 1e offered alternati%e pain relief instead,A

N/!#+2 B"! 6 A7 $! A C+$s+!$+%A Mother should 1e told a1out the slight ris$ of scar rupturing 1y your consultant and if she want a home 1irth we can e9pect some opposition, though itAs not impossi1le. She All 1e offered electronic fetal heart monitoring more freDuently during la1our Fthough you donAt ha%e to accept thisG and will 1e encouraged to gi%e 1irth in hospital, rather than a 1irthing unit, so that a caesarean can 1e done Duic$ly if necessary. T+2<"%4 / $+# B+&5".$ P +ommunication is the most important thing 1etween you and your midwife P -ry to disregard any comments which may seem dismissi%e, li$e OyouAre only three centimetres dilatedA after hours of contractions. Remem1er that the first stage is usually the longest and the ne9t will go much faster P 7e asserti%e 1ut calm in as$ing for what you want. And if you donAt get what you want right away, $eep on as$ing calmly and donAt 1e fo11ed off P Ma$e sure 1irth partner $nows all her wishes inside out so they can 1e asserti%e for her if she is not in a position to do it yourself

WRITING A BIRTH PLAN

-he most important thing to remem1er a1out a 1irthing plan is that these are preferences. mom and if that means ma$ing some tough choices, then so 1e it. No regrets Here is an e9ample for 7irth plan

ne must

remain open and fle9i1le if e%ents stray from chosen path. 3ltimately, you want a healthy 1a1y and

SETTINGS FOR BIRTH As hospital deli%ery may not 1e your only option. Many women now deli%er at a 1irthing center, 1ut worldwide, the most widely used setting is a home1irth. PATIENT PREPARATION P6>s".+2 -!$-+!+ "/% ,Sha%ing or clipping of the %ul%a is done. ,-he %ul%a and perineum are washed with soap and water ,-he women should ta$e shower ,+ontinous encouragement and emotional support N3 !" "/%+2 -!$-+!+ "/% ,Patient is maintained in N.P. and ice pieces can 1e gi%en if necessary B/;$2 -!$-+!+ "/% ,*nema has to 1e gi%en on the early morning of the deli%ery

POSITIONS USED IN ACTIVE LABOUR

S +%&"%4 /! 2$+%"%4 7/!;+!& ;6"2$ s3--/! $& => >/3! -+! %$! /! + -"$.$ /7 73!%" 3!$ -his position pro%ides support 1ut it also allows to ta$e ad%antage of gra%ity. Lean 1ody weight into each contraction. -his position may relie%e 1ac$ache. It also allows partner to gi%e you a massage.

(%$$2"%4 ;" 6 >/3! 3--$! =/&> !$s "%4 +4+"%s + .6+"! /! >/3! -+! %$!Cs 2+-his position ta$es the weight off spine and is a good position for pel%ic tilts, which can relie%e 1ac$aches. Many women also find it is a restful position.

O% D+22 7/3!sD -his also ta$es the weight off spine and allows you to tilt your pel%is to relie%e 1ac$aches. It

can help encourage the 1a1y to rotate from a posterior position. )aggling your hips may help the 1a1y mo%e.

S" "%4 +s !"&$ + .6+"! 7+."%4 6$ =+.< Straddling the chair widens the pel%is and may ma$e more comforta1le. 3se a pillow on the 1ac$ of the chair to protect 1elly and put arms o%er the 1ac$ of the chair. -his position ta$es the pressure off 1ac$ and allows partner to gi%e you a massage. If necessary, a fetal monitor can also 1e used in this position.

S" "%4 /% + /"2$ 2$+%"%4 7/!;+!& "% / >/3! -+! %$! -his position may 1e restful simply 1ecause it allows to rela9 pel%ic floor muscles without fear of an Kaccident.K

P!/--$& 3- "% =$& -his may wor$ simply 1ecause many of us associate 1eing in 1ed with rest and rela9ation. It also wor$s well when e9ams need to 1e done or if a fetal heart monitor is 1eing used.

L>"%4 /% >/3! s"&$ -his is a restful and rela9ing position that ta$es the pressure off your 1ac$ For your hemorrhoids if you ha%e anyG, and it allows your partner to gi%e you a massage. @our nurse or midwife will encourage the use of this position if your 1lood pressure is ele%ated. It is also a practical position if you are ha%ing an epidural.

A ="! 6"%4 =+22 or 1irthing stool can 1e used to support different positions, to help $eep a woman upright, and to speed the 1irth along. A 1irthing stool can also 1e used in the later stages.

Late in acti%e la1our and during transitioning, changing your position can enhance the 1a1yKs passage downward through the 1irth canal. @ou may want to try these positions'

SE3+ "%4 -his position widens pel%is to the ma9imum and ta$es ad%antage of gra%ity, to mo%e the 1a1y through the 1irth canal. Pushing in this position is easier for some women, 1ut others find it tiring and uncomforta1le. It is not recommended if the 1a1y is coming Duic$ly.

S$#"1s" "%4 ;" 6 >/3! +"21=/%$ 72+ +4+"%s 6$ =$& -his is a restful position that allows you to lay 1ac$ 1etween contractions. It ma$es %aginal e9aminations or the use of a fetal monitor easy.

L>"%4 /% >/3! s"&$ -his is a restful position that lets you rela9 1etween pushes. It ta$es the pressure off 1ac$ and allows an epidural to 1e used. -his position can slow down a rapid 1irth.

COMMON INTERVENTIONS DONE DURING LABOUR -hese are the most common inter%entions used during la1our to help you deli%er your 1a1y. Episiotomy An episiotomy is a cut made in the perineum Fthe s$in and muscle 1etween the %agina and anusG. It is used to enlarge the %aginal opening and ma$e the 1irth of the 1a1y easier if the perineum is not stretching. Local anesthetic can 1e used and the cut will 1e stitched up after the 1irth. It should heal within se%en to &0 days.*pisiotomies used to 1e performed routinelyL howe%er, se%eral studies showed that with normal 1irths, women who did not ha%e episiotomies generally fared 1etter than women who had one. -he procedure ma$es it more li$ely that a woman will ha%e a larger tear that e9tends into the rectum, that her tear will ta$e longer to heal, and that she will ha%e pain in the wee$s and months following the 1irth. -here are times when an episiotomy is needed B for e9ample, if the 1a1y is in distress B 1ut there is no e%idence to show that routine episiotomies 1enefit women or their 1a1ies. Most doctors no longer perform episiotomies routinely 1ut a few still do. Midwi%es can perform episiotomies 1ut are far less li$ely to do so than doctors. Electronic Fetal Monitoring -his is a machine used to record the 1a1yKs heart1eat and the freDuency of the motherKs contractions during la1our. *lectrodes that record the 1a1yKs heart1eat can 1e put on the motherKs 1elly with a 1elt Fe9ternal monitoringG or can 1e placed onto the 1a1yKs scalp, through the motherKs %agina Finternal monitoringG.

*lectronic fetal monitoring is not used routinely 1ut it may 1e used to chec$ the 1a1yKs health during the 1irth. )hen internal monitoring is done, your water must 1e 1ro$en if this has not already occurred naturally. -he monitor will 1e attached to your 1a1yKs head with a scalp clip. Support people may need to ma$e an e9tra effort to focus on the mother rather than the machine. Some women feel that electronic fetal monitoring interferes with the natural 1irthing process, while others, especially women who may ha%e had complications with pre%ious 1irths, find it reassuring to $now that the 1a1yAs heart1eat is 1eing monitored. 2iscuss the pros and cons with your care pro%ider. Forceps and Vacuum E traction -hese instruments are designed to guide the 1a1y out of the %agina, when the woman canKt push her 1a1y out completely. -hese methods may 1e used if'

you are e9hausted the position or siEe of the 1a1y ma$es the 1irth difficult there is fetal distress you are ha%ing difficulty pushing due to medication

If forceps or a %acuum e9tractor is used, mother will 1e gi%en a local anesthetic and an episiotomy will often 1e done.7oth procedures can cause temporary changes in 1a1yKs appearance 1ut these will disappear with time. >orceps may lea%e mar$s on the side of the 1a1yKs face and a %acuum e9tractor may cause temporary swelling on the top of the 1a1yKs head. !nduction"Augmentation -hese inter%entions may or may not use drugs to start FinduceG or speed up FaugmentG la1our. -hey are used when a more rapid child1irth is needed to protect the health of the mother or the 1a1y, or when mother had significantly past your due date. A fetal heart monitor is often used during an induced la1our to ensure that all is well. -he most common ways of inducing la1our are'

artificial rupture of mem1ranes FARMG prostaglandin gel

o9ytocin

A! "7"."+2 !3- 3!$ /7 #$#=!+%$s In the hopes of starting la1our, caregi%er may 1rea$ the 1ag of amniotic fluid surrounding the 1a1y. -his may 1e done with a long thin plastic hoo$ called an amniohoo$. -his procedure can increase the ris$ of infection of the fetal mem1ranes and amniotic fluid. P!/s +42+%&"% 4$2 /! /0> /."% 7oth prostaglandin and o9ytocin are hormones. Prostaglandin gel can 1e used when the cer%i9 is less than three centimeters dilated. It is applied to the 1ac$ of the %agina where it softens and JripensJ the cer%i9, to help it dilate. It is a milder way to induce la1our and may 1e done on an outpatient 1asis, depending on the hospital. 9ytocin may cause intense contractions and usually ma$es the 1irth proceed rapidly. It is gi%en through an intra%enous line after the woman is in the 1irth room. #esarean Section A cesarean section is a surgical procedure used to deli%er a 1a1y. A cesarean section For +,sectionG is a surgical operation where the 1a1y or 1a1ies are 1orn through an incision in the uterus. -oday one out of e%ery four or fi%e women in +anada gi%es 1irth 1y +,section. +anadaAs +,section rate has increased dramatically o%er the past four decades. -he most common reasons for a cesarean are'

dystocia Fa slow or difficult la1ourG 1reech 1irth Fwhen the 1a1y has not turned into a head,down position 1ut is in a position to 1e 1orn 1ottom first or feet firstG multiple pregnancy Fparticularly if there are more than twins, although many women do deli%er multiples %aginallyG placenta pre%ia B a pregnancy complication that can cause 1leeding 1efore or during deli%ery

PSYCHOLOGICAL PREPARATION FOR LABOUR 7irth partner, or partners can pro%ide support in the following ways'

Physical support , they can help $eep you comforta1le, 1ring your drin$s and snac$s, and help you to mo%e around. *motional support , simply ha%ing someone there for you is really important. Reassurance and words of encouragement will also help.

Ad%ocacy , you may not feel li$e answering Duestions so ha%ing someone there to e9plain your %iews can 1e really helpful.

MEDICATION >or some women, these techniDues are enoughL other women choose to com1ine them with medications to reduce the amount of drug they use. If choose to a%oid or delay medication, it is wise to in%estigate the medications you might choose -here are two main drug options for pain relief'

narcotic drugs, such as morphine, gi%en early in la1our an epidural

Narcotics 2rugs, such as meperidine F2emerolQG or morphine, can 1e gi%en during early la1our, if the 1irth is not e9pected within four hours. -hese drugs relie%e pain, although pain relief may 1e less complete than the relief achie%ed with an epidu Epidural An epidural uses local anesthetic Fa medication that num1s the area and causes loss of feelingG. -his medication is in=ected into the lower 1ac$, to num1 the ner%es to the uterus and 1irth canal. A small dose of a morphine,li$e drug is often included to reduce the amount of freeEing reDuired.

COMPLICATIONS OF DRUGS USED IN LABOUR -here are also a num1er of possi1le complications to 1e aware of' 1Low 1lood pressure ,Shi%ering ,7ladder control ,7ac$ pain ,Ner%e damage ,headache ,Se%ere in=ury ACTIVITIES TO TRY -hat depends on what interests you and what your doctor ad%ises. Many women en=oy dancing, swimming, water aero1ics, yoga, Pilates, 1i$ing, or wal$ing. Swimming is especially appealing, as it gi%es you welcome 1uoyancy Ffloata1ility or the feeling of weightlessnessG. -ry for a com1ination of cardio Faero1icG, strength, and fle9i1ility e9ercises, and a%oid 1ouncing. Appropriate exercise can ,relie%e 1ac$aches and impro%e your posture 1y strengthening and toning muscles in your 1ac$, 1utt, and thighs

,reduce constipation 1y accelerating mo%ement in your intestine

,pre%ent wear and tear on your =oints Fwhich 1ecome loosened during pregnancy due to normal hormonal changesG 1y acti%ating the lu1ricating fluid in your =oints ,help you sleep 1etter 1y relie%ing the stress and an9iety that might ma$e you restless at night ,loo$ 1etter. ,*9ercise increases the 1lood flow to your s$in, gi%ing you a healthy glow.

COMPARISON OF BOO( PICTURE WITHPATIENT PICTURE

BOO( PICTURE PREPARATION PAC(I NG TO HOSPITAL ,!oing,home outfit ,New1orn *ssentials ,Nursing nightwear ,+amera ,2ressing gown ,-he latest issue of Pu1lications ,2isposa1le $nic$ers and 7reast pads ,Head1and

PATIENT PICTURE

She was prepared with the cloths needed for the hospital stay New1orn dresses and clothes were also ta$en

She had ta$en certain health magaEines to occupy her leisure

,Maternity pads ,7irth plan ,-*NS machine ,Slippers and soc$s ,IPod ,Snac$s ,-oiletries

Maternity pads were carried to the hospitals

Slippers and soc$s were carried to the hospitals Snac$s was ta$en

Soap and other necessary toiletries was ta$en BIRTH OPTIONS ,Home 1irth ,)ater 7irth ,Induction ,*lecti%e +aesarean ,2rip ,*pidural ,+aesareanN PHYSICAL PREPARATION Sha%ing or clipping of the %ul%a is done. +lient got prepared physically for the la1our . She got admitted for the institutional deli%ery

Her %ul%al hairs were sha%ed ,-he %ul%a and perineum are washed with soap and water She too$ the showwer

,-he women should ta$e shower ,+ontinous encouragement and emotional support NUTRITIONAL PREPARATION ,Patient is maintained in N.P. pieces can 1e gi%en if necessary BOWEL PREPARATION ,*nema has to 1e gi%en on the early morning of the deli%ery POSITIONS LABOUR USED IN ACTIVE She had ta$en a lithotomy position for the la1our and ice *nema was administered in the early morning

She was under N.P. 1efore deli%ery

,Standing or leaning forward while supported 1y your partner or a piece of furniture ,Ineeling with your upper 1ody resting against a chair or your partnerKs lap , n Jall foursJ ,Sitting astride a chair facing the 1ac$ ,Sitting on a toilet leaning forward into your partner 1P!/--$& 3- "% =$& ,Lying on your side ,SDuatting ,Semi,sitting with your tail,1one flat against the 1ed ,Lying on your side COMMON INTERVENTIONS DONE DURING LABOUR She had undergone a right mediolateral

,*pisiotomy ,*lectronic >etal Monitoring ,>orceps and 6acuum *9traction ,Induction/Augmentation ,A! "7"."+2 !3- 3!$ /7 #$#=!+%$s ,P!/s +42+%&"% 4$2 /! /0> /."%

episiotomy Assessment of the uterine contractions were monitored .>etal heart rate was monitored using electronic fetal monitoring ARM was done 9ytocin drip was started

PSYCHOLOGICAL PREPARATION FOR LABOUR

She was psychologically prepared for the la1our

APPLICATION OF THEORY1PEPLAUS INTERPERSONAL THEORY Hildegard peplau 1egan her nursing career in &#"& .He first pu1lished the model in &#:( in interpersonal relations in nursing .He 1ased her model on psycho dynamic nursing .In his model the phases of interpersonal relationship reflects occurrence in personal interaction .-he four phases are orientation,identification ,e9ploitation and resolution. 2uring this phases the nurse assumes so many roles such as teacher, resource counseller,leader,e9pert and surrogate. > 3R PHAS*S B-H*@ AR* R rientation RIdentification R*9ploration RResolution

ORIENTATION Mrs. Namitha is a antenatal women and she became oriented the situation and hospital seting and the services provide in the hospital

IDENTIFICATION Mrs.Namitha , a client I found during my posting ,an antenatal mother E"P OITATIONI gave health education about the breast feeding and the excercises and she is willing to accept me as a health worker

NURSING DIAGNOSIS

RESO UTION Mrs.Namitha is willing to go for follow up and continue a healthy life and happily we ended up our therapeutic IPR.

Impaired tissue perfusion related to preclampsia secondary to arteriolar %asospasm as e%idenced 1y edema on legs

Ris$ for in=ury related to signs of pre eclampsia

>ear and an9iety related to Pre eclampsia and its effect on the fetus

2i%ersional acti%ity deficit related to imposed 1ed rest as e%idenced 1y %er1al response

PROGRESS NOTE F/9/2010 Mrs.Namitha admitted in ward 1y the complaint of a1dominal pain. 6ital signs chec$ed and recorded. Health education gi%en a1out salt restricted diet. 7lood sample for restriction G/9/2010 6ital signs and >HS chec$ed and recorded. Her wt is :4 $g .*9plained the patient a1out importance of ta$ing diet. Ad%ice the patient to ta$e plenty of fluids to a%oid constipation 9/9/2010 6ital signs chec$ed and recorded. Health education gi%en a1out personal hygiene and and how to co operate during La1our. Medicines gi%en. Ad%ised the patient to a%oid tension and engaged in acti%ities that gi%e more mental pleasure 10/9/2010 6ital signs chec$ed.7p is &(0/40mmof Hg and P,45 1/min .)t chec$ed :4$g.Patient loo$s happy and %ery acti%e.Ad%iced her to lie in left lateral position and also ad%ice her regarding the diet .

HEALTH EDUCATION

DIET: Ad%ised the mother to ta$e nutritious and easily digesta1le food li$e green leafy %egeta1les ,fruits etc. Ad%ised her to ta$e iron rich,protein rich food Ad%ised the mother to ta$e plenty of fluidF&0,&: glsses of waterG

E*ERCISE Ad%ised the patient to do mild e9ercise and acti%ities *9plained a1out acti%e and passi%e e9ercise Ad%ised mother a1out antenatal e9ercise li$e pel%ic floor and a1dominal e9ercise -aught a1out the 1reathing e9ercise to 1e practised throygh the intranatal period Ad%ise to a%oid the strenuous acti%ities li$e lifting hea%y o1=ects

PERSONAL HYGIENE Ad%ised the importance of oral hygiene Ad%ised the patient a1out oral hygiene and also a1out to ta$e regular 7ath

*ducate a1out perineal hygiene -aughtr a1out the 1reast care needed

MEDICATION Ad%ised client to ta$e medication at correct time ,dose and route as prescri1ed 1y doctor

CARE OF BREAST Ad%ised to $eep the 1reast clean, taught a1out 1reast self e9amination 7reast should 1e cleaned with lu$e warm water and dry it properly

FOLLOW UP I ad%ised the patient to ta$e medication regularly as per physician order and as$ed the patient to come for follow up.

FETAL MOVEMENT COUNT )omen is ad%ised to and taught to monitor fetal mo%ements and fetal heart sounds Ad%ised to chec$ the mo%ements at least " times a dayFmorning ,noon,and e%eningG.

RECTAL MOVEMENT CARE *ncouraged to include plenty of fruits and green leafy %egeta1les in the diet -aught the importance of roughage rich diet A%ised ti increase the fluid inta$e

CONCLUSION Mrs.Namitha (" yr old lady admitted on./#/(0&0 with the complaint of mild pedal edema and headache. !eneral condition of the patient is good. I pro%ided all care to the patient .Now her condition is impro%ed to some e9tent. 2uring these days she was %ery cooperati%e and followed my instruction regarding diet and e9ercise

BIBLIOGRAPHY Adele pilliteri O Maternal And +hild Health NursingA. :th edition. 3nited States Lippincott )illiams and )il$ins ' (00.. 5&#,5"0. 7o1a$ B Mensen. O *ssentials f Paternity NursingA. "rd edition. Mos1yAs pu1lications. 3nited f America '

States f America' &##&. :;.,:50. 2utta. 2.+. O -e9t 7oo$ &;:,&:" Mos1yAs S2rug +onsult for NursesT. "rd edition. *%ol%e pu1lications. (005. ".#, ;5& Myles. O-e9t1oo$ for Midwi%esA. &:th edition. London' +hurchill Li%ingstone *lse%ier' (004. 5:;, 55&. f 1stetricsA. 5th edition. +alcutta' New +entral 7oo$ Agency' (00;.

)illiamAs O-e9t1oo$ of .&0.

1stetricsA. ((nd edition. 3SA. Medical pu1lishing di%ision' (00: . 5#5,