INTRODUCTION This paper presents a case study done on Mrs.

Rhoda Chatha (in this paper referred to as Rhoda), aged 26, Para 2. She was admitted in the a!our ward at "om!a Centra #ospita from home on 2$%&2%'( at $)''pm with comp aints of ower a!domina pain and !ac*ache. +ssessment re,ea ed that the foetus was presenting with !reech and she was in acti,e stage of a!our. +n informed consent was o!tained for case study. She was monitored throughout a!our. +t (pm a !reech de i,ery of a i,e fu term ma e infant was conducted. -a!y and mother were ta*en to post.nata ward where they were cared for, for $ days. /n 26%&2%'( mother and !a!y were discharged after meeting the discharge criteria.

SUBJECTIVE DATA PERSONAL PARTICULARS 0ame. Rhoda Chatha +ge. 26years #ome address. Chid1aro ,i age, T%+ Chi*owi, "om!a. /ccupation. #ousewife Re igion. C.C.+.P. Tri!e. 2omwe Marita status. Married 3ducationa e,e . Standard ( 0e4t of *in. Ma ita -andawe (mother) CHIEF COMPLAINT Rhoda reported in the a!our ward from the high ris* antenata ward with comp aints of a!our pains. She was e4periencing ower a!domina pain and !ac*ache. She reported that she had !een in pain for 6 hours. MEDICAL HISTORY Rhoda stated that she had ne,er suffered from any of the fo owing disease) Tu!ercu osis, asthma, dia!etes me itus, epi epsy, hypertension, rena diseases, heart disease or menta i ness. SURGICAL HISTORY Rhoda had ne,er !een operated on, had ne,er !een in,o ,ed in any serious accident and had ne,er recei,ed any ! ood transfusion !efore. FAMILY HISTORY She stated that there are no disease conditions that run in her fami y and there is no fami y history of mu tip e gestation. NUTRITIONAL HISTORY Rhoda ta*es a we !a anced diet. #er 25 hour dietary reca was composed of a the si4 food groups. She eats three main mea s a day i.e. !rea*fast, unch, and supper. She a so snac*s in !etween mea s. She ta*es appro4imate y 2 iters of f uids in a day. She did not e4perience any pica nor e4cessi,e sa i,ation during her entire period of her pregnancy. She e4perienced nausea and ,omiting for the first three months of her pregnancy. 6n her cu ture there are no food restrictions for pregnant women. SOCIAL HISTORY She was the first wife to her first hus!and Mr. Chatha whom she was married to for 7years. 6t is monogamous fami y. She did her education up to form 2 whi e her hus!and did his education up to form 5. The hus!and wor*s as a sa es man at a !a*ery. She is a house wife. The hus!and earns enough money to afford !asic needs at home. She reported that she had !een recei,ing enough socia and

financia support from her hus!and and significant others during her pregnancy. She is in good re ationship with her hus!and and significant others. PSYCHOLOGICAL HISTORY Rhoda stated that the pregnancy was p anned and they had !oth accepted it. They p anned to !e on fami y p anning method after de i,ery so that they can pre,ent unp anned pregnancy. They a so p anned to ha,e one more chi d. GYNAECOLOGICAL HISTORY She attained menarche at the age of &6. She e4periences regu ar menstrua cyc e. She menstruates for $ days. She has had no a!ortions !efore. She had !een using depo pro,era since the !irth of her first chi d unti 0o,em!er, 2''8. She has !een on this method for 2 years. SEXUAL HISTORY She reported that she did not e4perience any se4ua discomfort i*e dyspareunia during pregnancy. They stopped coitus at ( months gestation !ecause in their cu ture it is !e ie,ed that coitus after ( months causes wide fontane s. They are a so e4pected to resume coitus si4 months after de i,ery. PREVIOUS OBSTETRIC HISTORY Rhoda was gra,ida 2 para&. #er first !orn is a gir whose de i,ery was spontaneous ,erte4. She was !orn in 2''7 at "om!a Centra #ospita and had weighed 26''g at !irth. #er daughter was reported to !e in good hea th. 9uring her antenata period for her first pregnancy she did not e4perience any pro! ems. 0either did she e4perience any comp ications after de i,ery. PRESENT OBSTETRICAL HISTORY #er 2ast 0orma Menstrua Period (20MP) was &$%'$%'( and her 3stimated 9ate of 9e i,ery (399) was 2'%&2%'(. #er gestation !y dates was 5' wee*s. Since !eing pregnant she had not drained i:uor nor e4perience any ,agina ! eeding. She had !een ta*ing 6ron ta! ets dai y since the day she started attending antenata c inic. She a so too* two doses of ;ansidar. She a so recei,ed two doses of Tetanus To4oid <accine. She had !een attending antenata c inic at "om!a Centra #ospita . She had !een fee ing feta mo,ements throughout pregnancy. She e4perienced nausea and ,omiting during the first three months of pregnancy. She started e4periencing a!our pains in the morning of 2$%&2%'( and was ta*en to the hospita !y her mother and hus!and.

LABORATORY INVESTIGATIONS #6< test resu ts came out negati,e during antenata period. The test was repeated in a!our ward and came out negati,e. #er haemog o!in test resu t was &&.(gm%d antenata y. <enerea disease research a!oratory came out negati,e. =rina ysis re,ea ed negati,e presence of a !umin.

PHYSICAL EXAMINATION GENERAL APPEARANCE #ea thy oo*ing ady, of medium si1ed height with no o!,ious deformity of the pe ,ic area. She had poor gait pro!a! y due to a!our pains. She was we *empt in !ody and c othes and was we nourished and hydrated. VITAL SIGNS Temperature.$8 degrees Ce sius Pu se rate. 6( !eats per minute Respirations.&6 !reaths per minute - ood pressure.&2'%(' mm%#g -ody weight.65 *g #eight.&7( cm HEAD TO TOE ASSESSMENT HEAD Proportiona to !ody si1e. C ean and we p aited hair. 0o dandruff, no scars, no sores nor acerations. NOSE Symmetrica , in mid ine position, wide and patent nostri s. 0o puru ent nor ! oody discharge. EARS Symmetrica with no growths, nor discharge. Pre.auricu ar ymphnodes were non.pa pa! e. EYES Symmetrica in si1e and shape with pin* con>uncti,a no discharges, no opacities, c ear cornea and no esions. MOUTH

2ips were of norma si1e and shape with pin* co our and no crac*s nor sores. #ad pin* gums, no gingi,itis, no denta caries. Pin* and moist ora mucosa mem!ranes. Pin* and symmetrica tongue. 0o ora thrush. NECK Symmetrica in shape. 0o distended nor ,isi! e >ugu ar ,eins. 0on.pa pa! e ymph nodes, no swe ing nor masses. 0orma thyroid g and. +! e to turn head !oth sides. CHEST Symmetrica and !arre shaped. Symmetrica respiratory mo,ements. 0o a!norma !reath sounds i*e crac* es and creptations. BREASTS Symmetrica , no ,isi! e masses, no sores nor crac*s on the nipp e. Prominent and erecti e nipp e. 0o pa pa! e masses on the !reasts. Co ostrum e4pressed. UPPER EXTREMITIES Symmetrica , capi ary refi time was ess than 2 seconds, no pa mar pa or, non. oedema of arms. LOWER EXTREMITIES Symmetrica with no ,aricose ,eins nor oedema. 0o swe ing nor tenderness of ca f musc es. ABDOMEN Symmetrica and o,a shaped. #ad inea nigra and striae gra,idarum. 0o hepato. sp enomega y. ;unda height was $$ cm which indicates $( wee*s gestation. The fundus was 2 fingers !e ow 4iphisternum. #ad ongitudina ie, !reech presentation and Right Sacro.anterior position. ?as e4periencing $ moderate contractions in &' minutes. #er urinary ! adder was empty and her feta heart rate was &5' !eats per minute. GENETALIA Vaginal Inspec i!n C ean with no sores, no acerations nor warts. 6t was non.oedematous, had no ,aricose ,eins, no ! eeding, no show and no a!norma ,agina discharge. Vaginal E"a#ina i!n ?arm and moist ,agina, thin cer,i4, &''@ cer,ica effacement and cer,i4 was 5 cm di ated. The presentation was !reech and the presenting part was not we app ied to the cer,i4. Mem!ranes were intact and cord was not fe t. Pel$ic Assess#en

Shape of !rim cou d not !e fo owed, sacrum was cur,ed, sacro promontory was not tipped, sacrospinous igaments were f e4i! e and ischia spines were not prominent. Su!.pu!ic arc was more than A' degrees and intertu!erous diameter cou d admit 5 *nuc* es. IMPRESSION + high ris* mu ti.gra,ida with !reech presentation in acti,e stage of a!our NURSING DIAGNOSES #igh ris* for haemorrhage re ated to materna soft tissue in>ury secondary to de i,ery manou,res. + tered comfort pain re ated to uterine contractions manifested !y patientBs own ,er!a isation and strained facia e4pressions. #igh ris* for trauma to the fetus re ated to de i,ery manou,res. #igh ris* for a tered f uid and nutrition re ated to s owed digesti,e functioning and emptying time of stomach and reduced food inta*e. #igh ris* for infection re ated to in,asi,e procedure during a!our and ruptured mem!ranes. #igh ris* for hypo4ia re ated to compression of the p acenta during uterine contractions. 6neffecti,e indi,idua coping, an4iety re ated to a!ouring in an unfami iar en,ironment, *now edge deficit on a!our and de i,ery process, outcome and e4pectation of the midwife.

PROGRESS NOTES %&'(%')* &&am <ita signs) Temperature. $6.5 degrees Ce sius, Pu se rate. 66 !eats%minute, -%P.&2'%8' mm#g, Respirations. &6 !reaths%minute Abdominal assessment ;undus C $( wee*s Presentation . !reech Position . RS+ 2ie . ongitudina Contractions C $ moderate in &' minutes ;eta #eart Rate C &$( !eats per minute =rinary ! adder C empty Vaginal inspection C ean and dry 0o warts, no sores, no acerations 0o ! oody discharge Show not seen Vaginal examination ?arm and moist tissues Thin cer,i4 &''@ effaced and 5cm di ated Presenting part not we app ied to the cer,i4 6ntact mem!ranes Cord not fe t &&)&' am Rhoda was gi,en an orientation of her immediate surroundings. She was a so reassured that she wi not !e eft a one throughout a the stages of a!our She was a so taught re a4ation techni:ues to ma*e her re a4 and maintain ade:uate supp y of o4ygen to the fetus She was ad,ised to a ways ie in atera position un ess ad,ised otherwise to pre,ent compression of inferior ,ena ca,a and aorta which can compromise supp y of o4ygen to the fetus. +n intra,enous infusion of 7 @ de4trose was commenced to at &7 drops per minute in order to promote ade:uate hydration status. &&)$' am ;eta #eart Rate was &$' !eats per minute Rhoda was taught re a4ation techni:uesD deep !reathing techni:ues

&2 noon +ssessments Temperature) $8 degrees Ce sius. Pu se) 68 !eats per minute Respirations) &A -eats per minute -%P)&2'%(' mm#g ;eta #eart Rate&2( !eats per minute. $ moderate contractions in &' minutes. =rinary ! adder was empty &2)&7 pm Rhoda comp ained of se,ere ower a!domina pain and se,ere !ac*ache. Rhoda was o!ser,ed !earing premature y. She was discouraged from !earing down. Pethidine &''mg was administered after assessment of ,ita signs which were sta! e and were as fo ows) Temperature) $8 degrees Ce sius Pu se) 68 !eats per minute Respirations) &( -eats per minute -%P)&2'%(' mm#g ;eta heart rate was chec*ed as we and was &$' !eats per minute Pethidine &''mg was gi,en intramuscu ar y

&2)$' pm ;eta heart rate was &$7 !eats per minute &pm +ssessments Rhoda reported reduction in pain. Pu se rate) 8' !eats per minute -%P) &2'%(' mm#g ;eta heart rate) &$( !eats %minute $ moderate contractions in &' minutes Rhoda was encouraged to as* :uestions and air out concerns. #er ips were moistened with <ase ine to pre,ent e4cessi,e drying. -ac* ru!s pro,ided to reduce pain.

&)&7 pm Rhoda went to the toi et to urinate and she reported to ha,e managed to urinate. =pon return from the toi et she was taught and ad,ised to do pe ,ic roc*ing e4ercises to promote descent of the presenting part.

&)$' pm ;eta heart rate was &$' !eats per minute Mother too* porridge. 2 pm Assessments Temperature) $8 degrees ce cius, Pu se rate) 66 !eats%minute Respirations) &( !reaths%minute -%P) &&'%('mm#g ;eta heart rate)&5' !eats per minute Contractions) 5 moderate in &' minutes - adder) empty Vaginal examination ?arm and moist ,agina Thin cer,i4, &''@ effaced and 8 cm di ated Presenting part poor y app ied to the cer,i4 Mem!ranes intact and cord not fe t. Show was seen which was not ! ood stained. The findings were communicated to the c ient. Rhoda was ad,ised to change positions fre:uent y to re ease tension. 2)&7 pm Rhoda was ad,ised to get off the !ed and perform pe ,ic roc*ing e4ercises. 2)$' pm ;eta heart rate was &$6 !eats%minute She was encouraged to fre:uent y am!u ate and empty her ! adder. $ pm ;eta heart rate was &$( !eats per minute. Pu se rate) 65 !eats per minute Respirations) &( !reaths%minute -%P)&&'%(' mm%#g She was e4periencing $ strong contractions in &' minutes ;indings were communicated to the c ient.

$)$' pm ;eta heart rate was &2( !eats per minute #er mother !rought porridge which the patient too*. She was gi,en a !edpan to urinate in. she urinated a!out &''m s. She was ad,ised not to !ear down un ess ad,ised to do so when cer,i4 is &'cm di ated. 5 pm Assessment Pu se) 66 !eats%minute Respirations)2' !reaths%minute -%P)&&'%('mm#g ;eta heart rate) &26 !eats per minute Contractions) $ strong in &' minutes #er urinary ! adder was empty. 5)$' pm ;eta heart rate was &$5 !eats per minute -ac* ru!s were pro,ided to minimi1e pain. 7 pm Mem!ranes ruptured spontaneous y. 2i:uor was meconium stained. + ,agina e4amination was done. The cer,i4 was A cm di ated. Cord was not fe t and the presenting part was not we app ied to the cer,i4. 6t was a comp ete !reech. ;eta heart rate was &$$ !eats % minute. Temperature)$8 degrees Ce sius Pu se rate) 68 !eats per minute Respirations)2' !reaths per minute -%P.&2'%(' mm#g She was to d of the findings. 7)2' pm. + de i,ery tro ey was prepared with the fo owing e:uipments) de i,ery pac*, suturing pac*, ignocane. Resuscitaire was a so prepared in readiness for an asphy4iated !a!y 7)$' pm ;eta heart rate was &5' !eats per minute + urinary catheter was inserted and &''m of urine was drained to ensure that the ! adder was empty.

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6 pm Assessment ;eta heart rate) &5' !eats % minute. Pu se rate) 8$ !eats per minute Respirations) 2' !reaths per minute -%P) &2'%(' mm%#g Contractions) $ strong in ten minutes. ;indings were communicated to the mother. VAGINAL EXAMINATION ?arm and moist ,agina tissues Cer,i4 thin, &''@ effaced and &' cm di ated ;our fingers inserted into the ,agina to confirm cer,ica di atation. Cord was not fe t and the presenting part was not we app ied to the cer,i4. Presenting part was !e ow the ischia spines 2i:uor was meconium stained. Rhoda was informed that she was in second stage of a!our !ut was ad,ised not to start !earing down un ess ad,ised to do so i.e. when the presenting part !ecomes ,isi! e at the ,u ,a. Mother was instructed to continue deep !reathing. ?hen the presenting part !ecame ,isi! e on the ,u ,a she was assisted to assume supine position with her !uttoc*s on the edge of the !ed, egs f e4ed and *nees a!ducted. She was instructed to !ear down on y with a contraction ;eta heart rate was chec*ed and there was no sign of feta distress. -uttoc*s and genita ia together with the two feet appeared on the ,u ,a. Rhoda was encouraged to continue pushing. -uttoc*s and the egs were !orn. +t 6)27pm when um!i icus appeared on the ,u ,a Rhoda was instructed to stop !earing down. The oop of the cord was gent y pu ed down to oosen it. Pu sations on the cord were fe t to !e regu ar and strong at &$5 !eats per minute. Two fingers were inserted in the ,agina. 3 !ows were not present on the !a!yBs chest !ut the a4i a was fe t. The arms were e4tended. The !a!y was co,ered with a warm c oth. -oth thum!s were p aced on the sacrum whi e the fingers were p aced in front of i eac crest. The woman was instructed to push with a contraction. ?ith a contraction and the woman !earing down the !ody was rotated at an ang e of &(' degrees *eeping the !ac* upper most in order to !ring the shou der which was more posterior to !ecome more anterior and it was ying under the symphysis pu!is. The inde4 and third fingers were p aced o,er the shou der, the upper arm was sp inted, f e4ed and then !rought down across the !a!yBs face and chest. Then the !a!yBs !ody was rotated !ac* &(' degreesD *eeping the !ac* upper most in order to !ring the shou der that was more posterior to !ecome more anterior unti the shou der was ying under the symphysis pu!is. The inde4 and third fingers of the hand facing the !a!yBs !ac* were p aced o,er the shou der. Then the upper arm was sp inted and f e4ed and !rought down across the !a!yBs face and chest.

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6)2( pm The !ody of the !a!y was eft to hang downwards with the head inside the pe ,is. Then the nape of the nec* appeared under the pu!ic arc. #ands were *ept near the !a!yBs pe ,is to pre,ent the !a!y from fa ing down. The !a!yBs feet were firm y grasped with the right hand, e4erting firm downward, then outward and upward traction. ?hen the mouth and the nose were free from the perineum the airway was gent y c eared of secretions. The woman was instructed to continue !reathing deep y unti the ,au t of head was de i,ered s ow y and the !ody was drawn upward o,er the materna pe ,is with the eft hand guarding the perineum to pre,ent the head from emerging too :uic* y. The head was de i,ered at 6)$' pm. The !a!y was :uic* y ta*en to the resuscitaire where it was suctioned and !agging was done. The !a!y cried strong y 57 seconds after !irth. THIRD STAGE O+ LABOUR &' units of pitocin was administered intramuscu ar y to promote uterine contractions and the p acenta was de i,ered 6 minutes ater at 6)$6pm !y contro ed cord traction. C ots were e4pe ed. =pon e4amination of the perineum the cer,i4 was intact !ut she sustained a first degree perineum tear. The mother was c eaned up and wet inen was rep aced with dry inen in readiness for suturing. - ood pressure immediate y after de i,ery was &&'%('mm#g and pu se rate was 68 !eats per minute. P acenta and mem!ranes were comp ete, weighed 77'g and it was a hea thy p acenta. The cord was 7'cm ong and had $ ! ood ,esse s. - ood oss was a!out &(' m . + tampon was inserted into the ,agina to a!sor! ! ood. Perinea tear was c eaned with ch orhe4idine prior to in>ection of &'m of &@ ignocaine on !oth edges of the tear. Then the tear was sutured with chromic 2.' in two ayers and ch orhe4idine was a so used to c ean the sutured tear to pre,ent infection. +OURTH STAGE O+ LABOUR 8)$' pm - ood pressure was &&'%('mm#g, pu se rate was 66 !eats per minute, Temperature was $6.6 degrees Ce sius, uterus was in mid ine position, firm and we contracted and there was moderate f ow of ochia. 6ntra,enous infusion was stopped and drip was remo,ed. Rhoda was then instructed to ta*e a !ath and wash her c oths. IMPRESSION + ow ris* mother one hour post de i,ery adapting we to non.gra,id state. MIDWIFERY DIAGNOSIS #igh ris* for haemorrhage re ated to e4posed ! ood ,esse s at p acenta site. #igh ris* for infection re ated to e4posed tissues on the sutured perinea area.

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PLAN OF CARE 3ncourage Rhoda to !reastfeed e,ery 2 hours to stimu ate o4ytocin production which promotes uterine contractions 3ncourage the c ient to urinate fre:uent y !ecause a fu ! adder interferes with uterine contractions. +d,ise the c ient to ie in supine position with egs crossed. This position promotes uterine contractions. +d,ise the c ient to report e4cessi,e f ow of ochia !ecause this can !e a sign of acti,e ! eeding Chec* ! ood pressure and pu se rate e,ery 5 hours !ecause increased pu se rate and decreased ! ood pressure is suggesti,e of ! eeding. +d,ise the c ient to do sit1 !ath at east three times a day. +d,ise the c ient to change perinea pads fre:uent y !ecause a moist pad is a conduci,e en,ironment for micro!ia growth. 7:35 pm ASSESSMENT OF THE BABY Temperature) $6.( degrees Ce sius Gene al appea ance +cti,e, a ert and norma musc e tone, pin* s*in co our, no apparent in>ury nor a!norma ity. 0o cyanosis, no pa mar pa or , no >aundice, no meconium stained s*in. S ight ,erni4 caseosa and anugo on the face. !ead 3,en, !ones s ight y mo,a! e at sutures, open, f at and soft fontane es. 0o mou ding nor caput. 6ntact sca p and good sca p growth, no !ruising, no a!rasions, no cuts, no acerations. #ead circumference was $5cm. E"es Symmetrica , norma si1e and shape, correct p acement, no su!.con>uncti,a hemorrhage seen. 0o discharge, nor cornea u ceration, !right and shinny cornea, white sc era. Nose 6n mid ine position, f attish, wide and patent. 0o ! oody nor puru ent discharge, no nasa f aring. Mo#t$ Symmetrica and pin* ips of norma si1e and shape, pin* tongue and gums. 0o gingi,itis, no c eft pa ate, no fa se teeth. Pin*, moist and shinny mucus mem!rane. Ea s

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Symmetrica , no e4tra auric es, we formed ears, upper ear in ine with outer corner of the eye. 0o foreign !ody or discharge. ?e formed auric es. Nec% Short, symmetrica , with s*in fo ds, no we!!ing. #ead in mid ine position, no masses present, some head contro of side to side mo,ement seen p us e4tension and f e4ion. 0either swe ing nor creptus sound found on e4amination. &$est -arre shaped chest, prominent end of 4iphisternum, symmetrica respiratory chest mo,ement, no chest in.drawings, no ri! recession, no in,o ,ement of a!domina musc es during !reathing. 0o a!norma !reath sounds on auscu tation. 58 !reaths per minute, regu ar heart !eat. Pa pa! e !reast nodu es. Abdomen Symmetrica , no organomega y, no tenderness, non.distended a!domen, !owe sounds present. C ean and moist um!i icus. 2i,er and sp een non.pa pa! e. Two arteries and one ,ein present on the um!i ica cord, no ! eeding on the um!i icus. 'ppe ext emities Symmetrica , fu range of motion e4ercises, we formed hands, no e4tra digits, no we!!ed fingers, we formed pa mar creases, no fracture of ong !ones. Lo(e ext emities Symmetrica , semi.f e4ed hips and egs. ;u range of motion e4ercises inc uding a!duction. 0orma si1e of ong !ones. ;emora pu se fe t. ?e de,e oped p antar creases. 0o e4tra digits, no we!!ed feet, no c u!!ed feet no ta ipes. /rto anBs test was negati,e ie no congenita hip dis ocation. Genetalia ?e de,e oped testes pa pa! e in a sac. Patent urethra opening at center of g ans penis correct y positioned. The !a!y had passed meconium a ready. )ac% and spine Straight, easi y f e4ed, no spina !ifida nor meningoce e nor sacra dimp e sinus. Ne# ological assessment Moro ref e4 present. ga,e a start ed response !y f inging out arms Rooting and suc* ing ref e4 was present) when infantBs chee* corner of the mouth was touched, infant turned head towards stimu us and opened the mouth. Swa owing ref e4 was present) suc*ing was coordinated with swa owing with no gagging, coughing or ,omiting. Erasp ref e4 was present) !a!y firm y grasped tip of the finger P antar. toes cur ed downwards when finger was p aced at the !ase of the toes. ?a *ing ref e4 was present . infant stimu ated wa *ing !y ifting and p acing one foot in front of the other.

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The !a!y weighed $&''g. IMPRESSION + ow ris* infant one hour post de i,ery adapting we to e4tra.uterine ife. NURSING DIAGNOSIS #igh ris* for hypothermia re ated to e4posure to co d en,ironments #igh ris* for hypog ycemia re ated to inade:uate inta*e #igh ris* a teration in !onding re ated to fatigue

PLAN OF CARE Feep the !a!y thorough y dried and co,ered with a warm dry c oth Pre,ent the !a!y from !eing in contact with co d surfaces Post.pone !athing for the first 5(hours. 3ncourage the mother to !reastfeed the !a!y e,ery 2 hours. +d,ise the mother to watch the !a!yBs um!i icus for ! eeding. Monitor !ody weight dai y. Co,er the !a!yBs head with a hat. 3ncourage the mother to cudd e the !a!y whi e !reastfeeding to promote !onding through touch. 3ncourage mother to maintain eye contact whi e !reastfeeding. 3ncourage the mother to ta * to the !a!y whi e !reastfeeding to promote !onding. ( pm Rhoda and her !a!y were ta*en to postnata ward where she was gi,en a !ed. -a!y was wrapped in a c ean and dry c oth and the mother was ad,ised to *eep the !a!y a ways warm and to immediate y change soi ed inen. -a!yBs head was co,ered with a hat. Mother was ad,ised to !reastfeed the !a!y e,ery 2 hours. Mother was ad,ised to maintain eye contact and ta * to the !a!y when !reastfeeding to promote !onding. Mother ad,ised to empty the ! adder fre:uent y to promote uterine contractions Mother ad,ised to ie in supine position with egs crossed to promote uterine contractions. She was ad,ised to report e4cessi,e f ow of ochia She was ad,ised to c ean the sutured area with warm sa ty water to pre,ent infection. She was ad,ised to change perinea pads fre:uent y. She was a so encouraged to as* :uestions and e4press her concerns. ()$' pm Rhoda and her !a!y were handed o,er to night duty staff.

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DAY 2

24/12/08

Mo !"#$% &%%"%%'"( S,-.ec i$e /a a Rhoda reported that she had spent the night we . She said that she was sti ha,ing some mi d a!domina pain especia y when !reastfeeding. She reported that she had !een !reastfeeding throughout the night e,ery 2 hours and the !a!y is suc*ing we . She had ta*en porridge and tea and was not ha,ing any pro! ems with eating. She reported that she had a ready ta*en a !ath in the morning and had changed the perinea pad. She reported that she was not ha,ing hea,y ochia. She reported that she had passed stoo s and urine in the morning She a so reported that she was e4periencing mi d pain in the genita ia due to the sutured tear !ut the wound was not ! eeding. She a so reported that the !a!y had passed stoo s ear y in the morning.

O-.ec i$e /a a ?e *empt in !ody and c othes. <ita signs) Temperature)$8.2 degrees Ce sius, pu se rate) 8& !eats per minute, respirations)&( !reaths per minute, -%P)&&'%8'mm%#g Pin* con>uncti,a 0on.oedematous upper e4tremities, capi ary refi time within 2 seconds 0on.engorged !reasts, co ostrum e4pressed. =terus was &6 cm from the symphysis pu!is. 6t was in mid ine position, firm and we contracted. =rinary ! adder was empty. 0on.oedematous ower e4tremities, non tender ca f musc es, no ,aricose ,eins, no deep ,ein throm!osis. The genita ia was c ean, perinea pad s ight y soa*ed, no ! ood c ots, no offensi,e sme , no ! ood nor pus on the sutured tear, no oedema and norma wound hea ing process. I#p0essi!n + ow ris* mother 25 hours post de i,ery adapting we post.nata y. Assess#en #igh ris* for haemorrhage re ated to raw p acenta site + tered comfort pain re ated to uterine contractions (after pains), presence of sutured tear as e,idenced !y ,er!a i1ation. #igh ris* for infection re ated to presence of tear in the perineum.

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Plan 3ncourage mother to empty ! adder fre:uent y to promote uterine contractions. 3ncourage mother to continue !reastfeeding e,ery two hours to promote production of o4ytocin that promotes uterine in,o ution. Chec* the perinea pad e,ery 5 hours to assess amount of ochia. Chec* ! ood pressure and pu se rate e,ery 5 hours. Reassure mother that a!domina pain during !reastfeeding is due to uterine contractions secondary to o4ytocin production and that pain wi su!side with time. +dminister Pa acetamo &g e,ery ( hours ora y to reduce pain 3ncourage deep !reathing and re a4ation techni:ues +d,ise the mother !e on high fi!er diet to promote digestion and minimi1e straining during defecation that aggra,ates pain. +d,ise the woman to a so !e on high protein diet to promote wound hea ing +d,ise the woman to change perinea pads fre:uent y !ecause moist perinea pad is a conduci,e en,ironment for micro!ia infection 3ncourage the woman to am!u ate in order to promote drainage of ochia thus reducing the ris* of infection. +d,ise the woman to ha,e sit1 !ath in sa ty water to pre,ent infection. Teach the c ient to c ean the perineum from front to !ac* to a,oid introducing micro!es on the perineum which can cause infection. 3ncourage the mother to fo ow hand washing techni:ue and o!ser,e a infection pre,ention measures. BABY$S ASSESSMENT Temperature) $6.8 degrees Ce sius Gene al appea ance +cti,e, a ert and norma musc e tone, pin* s*in co our. 0o cyanosis, pa mar pa or, nor >aundice. !ead 0o sun*en nor !u ging fontane es. 0o !ruising, no a!rasions, no cuts, no acerations. Nose 0o nasa f aring, patent nostri s with no secretions. Mo#t$ Pin* ips with no sores and no crac*s, pin* and moist ora mucosa, no ora thrush nor gingi,itis. &$est Symmetrica respiratory chest mo,ement, no chest in.drawings, $5 !reaths per minute and heart !eat was &2$ !eats per minute.

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Abdomen Symmetrica , no um!i ica hernia, no organomega y, dry um!i icus. Ne# ological assessment 0o con,u sions, no a!norma cry, no signs of cere!ra irritation. -a!yBs !ody weight was 2A7'g I')#"%%*o( + ow ris* !a!y 25 hours post.de i,ery adapting we to e4tra.uterine ife IMPLEMENTATION A)'' am +dministered &g of ora pa acetamo to mother. Mother taught on importance of emptying the urinary ! adder. Mother taught on importance of !reastfeeding fre:uent y for the first $ days !ecause co ostrum contains anti!odies that protect the !a!y from infections. Mother reassured that a!domina pains wi go with time and she shou d continue !reastfeeding despite a!domina pains. &')'' am Mother was taught on proper positioning and proper !reast attachment during !reastfeeding Mother was reminded to *eep the !a!y warm and change the nappies whene,er they get wet. Mother encouraged to cudd e the !a!y, and to maintain eye contact during !reastfeeding in order to promote !onding. -a!yBs um!i icus was c eaned with surgica spirit and the mother was taught on how to c ean !a!yBs um!i icus. Mother was ad,ised to watch the um!i icus for ! eeding or any signs of infection and report immediate y. -a!yBs head was co,ered with a hat. &')$' am -a!y was gi,en -CE ,accine and Po io ' ,accine to protect the !a!y from Tu!ercu osis and po iomye itis respecti,e y. The mother was ad,ised not to ru! the in>ection site on the right hand to pre,ent reducing the potency of the ,accine. She was a so ad,ised to wait for $' minutes !efore !reastfeeding the !a!y to pre,ent ,omiting !ecause Po io ' ,accine causes nausea. &&am <ita signs for the mother were as fo ows) Temperature)$6.( degrees Ce sius, pu serate)6( !eats per minute, respirations)&( !reaths per minute, -%P)&&'%8' mm#g

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<ita signs for the !a!y were as fo ows) Temperature) $6.( degrees Ce sius, respirations) 5' !reaths per minute, heart !eat) &'' !eats per minute Mother was ad,ised to a ways c ean perineum from front to !ac*. Mother was ad,ised to !e ta*ing at east $ iters of ora f uids in 25 hours. Mother was encouraged to ta*e foods high in fi!er content to pre,ent constipation which can aggra,ate pain due to straining when defecating. & pm Mother o!ser,ed changing the nappies. She was taught to pre,ent um!i ica cord from coming in contact with urine and stoo s to pre,ent introducing infection on the um!i icus. Mother was encouraged to am!u ate to promote drainage of ochia &)$' pm Mother was gi,en hea th education on fami y p anning. 9ifferent methods of fami y p anning their ad,antages and side effects were discussed. She was ad,ised to start fami y p anning 6 wee*s after de i,ery. She was ad,ised not to fa pregnant in a period of ess than 2 years so that she can ha,e enough time to ta*e care of the !a!y and a so a ow the !ody to fu y return to pre.pregnancy form. She was a so taught that coitus can resume 6months after de i,ery. 2)$' pm Mother was taught on si4 food groups. #ea th education on the importance of e4c usi,e !reastfeeding was gi,en Mother was a so educated importance ade:uate rest. $)'' pm MotherBs ,ita signs were as fo ows) Temperature)$8.& degrees Ce sius, pu se rate)82 !eats per minute, respirations)2' !reaths per minute, -%P)&&'%8'mm%#g. -a!yBs ,ita signs were as fo ows) Temperature) $8 degrees Ce sius, respirations) $( !reaths per minute, #eart !eat)&'' !eats per minute. $)$' pm Mother and !a!y were o!ser,ed s eeping. 5)$' pm Perinea pad was chec*ed and was s ight y soa*ed. Mother was o!ser,ed !reastfeeding. The !a!y was we positioned and we attached to !reast and was suc* ing we . 7)'' pm

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Mother and !a!y were handed o,er to night duty staff.

DAY + (+M

2,/12/08

S,-.ec i$e /a a Rhoda stated that she and the !a!y spent the night we . The !a!y had !een suc*ing we during the night. She reported that she had a ready ta*en a !ath and had c eaned the sutured perinea tear with warm sa ty water and she was e4periencing mi d f ow of ochia. She was a! e to pass urine and stoo s and she was no onger e4periencing a!domina pain nor pain on the sutured tear. She a so reported that the !a!y had passed stoo s as we O-.ec i$e /a a Mot$e ?e *empt in !ody and c othes. <ita signs) Temperature)$8.2 degrees Ce sius, pu se rate) 82 !eats per minute, respirations)&A !reaths per minute, -%P.&&'%8'mm#g Pin* con>uncti,a 0on.oedematous upper e4tremities, capi ary refi time within 2 seconds 0o !reast engorgement, no masses fe t, co ostrum e4pressed. =terus in mid ine position, &7 cm from the symphysis pu!is, firm and we contracted uterus. =rinary ! adder was empty. 0on.oedematous ower e4tremities, non.tender ca f musc es, no ,aricose ,eins, no deep ,ein throm!osis. C ean geneta ia, perinea pad mi d y soa*ed, no ! ood c ots, no offensi,e sme , non.oedematous perineum, norma hea ing process of the sutured perinea tear. I#p0essi!n + ow ris* mother 5( hours post de i,ery adapting we to non.gra,id state )ab" Eenera appearance Pin* s*in, a ert and acti,e. <ita signs) Temperature)$6.2 degrees Ce sius, respirations)$2 !reaths per minute, #eart rate)&2' !eats per minute, !ody weight)$'''g

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#ead Symmetrica , no sun*en nor !u ging fontane es. 6ntact sca p and good sca p growth, no !ruising, no a!rasions, no cuts, no acerations. #ead circumference was $7cm. 0ose 0o nasa f aring, patent nostri s with no secretions. Mouth Pin* ips with no sores nor crac*s. Pin* and moist ora mucosa with no ora thrush nor gingi,itis. Chest Symmetrica respiratory chest mo,ement, no chest in.drawings, $5 !reaths per minute and heart !eat was &25 !eats per minute. +!domen Symmetrica , no um!i ica hernia, no organomega y, dry um!i icus and no ompha itis. 0o a!domina distension. 0euro ogica assessment 0o con,u sions, no a!norma cry, no signs of cere!ra irritation. I#p0essi!n + ow ris* !a!y 5( hours post.de i,ery ad>usting we to e4tra.uterine ife. P-&( +s per care p an. ()$' am The um!i ica stump was c eaned with surgica spirit and the mother was as*ed to do a return demonstration. She c eaned the um!i icus correct y. She was reminded to pre,ent the um!i ica area from coming in contact with urine and stoo s. She was a so warned on the dangers of adding anything on the um!i icus. She was further reminded on the importance of *eeping the !a!y warm. A)$' am Mother was ad,ised to continue c eaning the sutured tear with warm sa ty water after !eing discharged home ti the wound hea s. She was counse ed on the dangers of inserting traditiona her!s into the ,agina The mother was reminded on the importance of ade:uate rest. The mother was taught on the importance of eating the si4 food groups and she was taught on the importance of !reastfeeding the !a!y e4c usi,e y

21

&')'' am Rhoda was reminded a!out e4c usi,e !reast feeding. She was a so reminded to a ow the !a!y to suc* e empty the !reast !efore gi,en the other !reast to pre,ent !reast engorgement. She was a so ad,ised to *eep her !reasts c ean a the time. &')2'am Mother was ad,ised to report to the hospita immediate y if she e4periences any of the fo owing danger signs) se,ere headache not re ie,ed with ana gesics, hea,y ochia f ow, fou sme ing ,agina discharge, ! urred ,ision, con,u sions, fe,er, pus or ! oody discharge on the sutured perinea tear. She was a so ad,ised to report to the hospita immediate y if the !a!y e4periences any of the fo owing danger signs) fe,er, a!oured !reathing, refusing to !reastfeed, distended a!domen and ina!i ity to pass stoo s, con,u sions and puru ent or ! oody discharge on the um!i icus. &')7' am She was ad,ised to report !ac* at the hospita after one wee* for chec*.up. She was further ad,ised to report again at the hospita after si4 wee*s for post. nata chec* up, fami y p anning and for !a!yBs immuni1ation. &&)''am Rhoda was discharged after hea th education as per home. #ea th education as per discharge p an.

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DISCHARGE CRITERIA MOTHER 0orma ,ita signs. Mi d ochia f ow with non offensi,e sme . 0o pus, no ! oody discharge from the sutured perinea tear. 0o !reast engorgement, easi y e4pressed co ostrum. ;irm and we contracted uterus, in mid ine position. Proper positioning and good attachment to the !reast +!i ity to descri!e the si4 food groups +!i ity to e4p ain the danger signs for the mother and the !a!y. +!i ity to mention the ne4t appointment date. BABY 0orma ,ita signs. -ody temperature of ess than $8.2 degrees Ce sius 0o a!ored !reathing, a!sence of chest in.drawings, respiratory rate of ess than 6' !reaths per minute. 0o con,u sions, no a!norma cry, nor any signs of cere!ra irritation. 0o pus or ! oody discharge on the um!i icus +! i ity to suc* e without any pro! ems

DISCHARGE PLAN Ei,e hea th education on the fo owing topics) Si4 food groups. ;ami y p anning. 34c usi,e !reastfeeding. Persona !ody hygiene. 6mportance of ade:uate rest.. 9anger signs in post.nata mother and !a!y. Perinea care. #ea thy se4ua practices 9iscourage harmfu traditiona practices and encourage !eneficia ones.

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ANALYSIS OF CASE STUDY -ased on data co ected and care rendered to Rhoda, the fo owing are the pertinent issues. She is 2A years o d meaning that she is in the chi d !earing age and this does not put her at ris* as far as age in concerned. The ,ery young (!e ow &( years) woman runs an increased ris* of de,e oping comp ications during pregnancy. ?omen aged !etween 2'.$' years of age ha,e the owest o!stetric ris*s, !ut a!o,e the age of $7 there is a so an increased ris* which is a so com!ined with the ris* of high parity that may resu t in pro onged a!our and haemorrhage (Safe Motherhood 2'''). #er height of &7( cm does not put her at ris* !ecause ris* of cepha o.pe ,ic disproportion due to contracted pe ,is is common in women !e ow &7' cm. /n socia history she ac*now edged that she is recei,ing ade:uate socia and psycho ogica support from her hus!and and significant others. The fami y is a! e to purchase essentia !asic through the money they get from farming and running a sma sca e !usiness. This is good !ecause it ensures a,ai a!i ity of !asic needs i*e food and c othes thus fostering motherBs hea th and proper de,e opment of the fetus. -oth do not smo*e and drin*. This is good as we for the we !eing of !oth the mother and the fetus. 0icotine su!stance in to!acco causes interference with o4ygen e4change in ung a ,eo i. The end resu t wi !e reduction of o4ygen in circu ating ! ood. + coho reduces appetite thus eading to ma nutrition in the mother which in turn may a so ead to feta intrauterine growth retardation. Progress of feta growth was norma according to the weight gain of the mother. /n initia ,isit she weighed 65 *g and on second ,isit she weighed 66 *g D a weight gain of 2 *g which is norma in the second trimester. 9uring the third ,isit she weighed 6( *g and on the fourth ,isit she weighed 8' *g. +ccording to Se ers (2''&), in norma pregnancy, 2 *g is supposed to !e gained in the first trimester whi e in the second trimester she is supposed to gain at east '.7*g e,ery wee*. The summary of the weight gains and other findings ha,e !een attached to the case note. She had a haemog o!in e,e of &&g%d . This is a good haemog o!in e,e in pregnancy !ecause there is an increased demand of o4ygen for the growing fetus and the mother as we . 6t is a so essentia for transportation of nutrients for feta growth and we !eing of the mother. This indicates that the woman was not anaemic !ecause in Ma awian setting anaemia is defined as a haemog o!in e,e of ess than &'g%d which is a resu t of deficiency in the :ua ity and :uantity of red ! ood ce s (Safe Motherhood, 2''').

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/n urina ysis, urine a !umin was negati,e thus ru ing out hypertensi,e disorders and possi!i ity of de,e oping pregnancy induced hypertension. Proteinuria in the a!sence of urinary tract infections is indicati,e of g omeru ar endothe iosis whi e a significant increase in proteinuria coup ed with diminished urinary output indicates rena impairment <enerea 9isease Research 2a!oratory (<9R2) was not done. 6t is important to do this test !ecause it is good for the fetus and the mother as we since presence of syphi is in pregnancy may ead to a!ortions, preterm a!our and sti !irths if not treated. This is so !ecause syphi is impairs the integrity of the p acenta. She was gi,en ;ansidar $ ta! ets as a prophy a4is for ma aria in the second and third trimester to pre,ent the mother and the fetus from ma aria. Ma aria resistance is reduced during pregnancy (My es, 2''$). 0eonates !orn with congenita ma aria are we at !irth !ut de,e op fe,er, >aundice and sp enomega y within &'.2' days of !irth (Mayes, 2''5). 6ron ta! ets 2''mg ora y once a day for one month throughout the antenata period was gi,en to impro,e haemog o!in e,e so as to pre,ent anaemia. /ften times supp y of fo ic acid from diet is destroyed through ong coo*ing period of green eafy ,egeta! es (Safe Motherhood). Tetanus To4oid ,accine was gi,en on initia antenata ,isit and one month ater in order to pre,ent the mother and the fetus from tetanus. =pon admission and assessment it was confirmed that it was a !reech presentation. There are no *nown causes of !reech presentation according to (Se ers 2''&). -ut some of the predisposing factors are as fo ows) preterm !a!ies, sp inting of the fetus due to e4tended egs and mu tip e pregnancy, a ,ery mo!i e fetus common in po yhydramnios and in grande mu tiparous woman. -reech presentation is a so common when the feta head can easi y !e accommodated in the uterine fundusD in conditions i*e contracted pe ,is, p acenta prae,ia, fi!roids in the ower uterine segment, utrine a!norma ities such as !icornuate uterus, hydrocepha us and anencepha y. #er su!>ecti,e data does not predispose her to !reech presentation. /!>ecti,e y, = tra Sound Scanning (=SS) was not done so it is difficu t to ru e out the other causes. +fter esta! ishing that the woman was in a!our she was commenced on intra,enous f uids of 7 @ de4trose to maintain ade:uate hydration status and pro,ide energy. There were no signs of materna distress !ecause the ,ita signs were within the norma ranges. There was norma progress of a!our in the sense that the contractions were progressing we from mi d to strong contractions. The feta heart rate a so remained within the norma ranges. The i:uor stained meconium is norma in !reech presentation and is an indication of feta compromise. +s the !reech descends into the pe ,is, meconium is forced out of the co on and anus and fresh meconium with a deep y engaged presenting part is indicati,e of !reech presentation. This is the on y indication in which meconium is not necessari y a sign of feta compromise.(Se ers, 2''&)

25

+t $)'' pm there was spontaneous rupture of mem!ranes. The i:uor was meconium stained. + ,agina e4amination was done. The cer,i4 was A cm di ated. Cord was not fe t and the presenting part was not we app ied to the cer,i4. 6t was a comp ete !reech. ;eta heart rate was &$' !eats % minute. She was e4periencing $ strong contractions in &' minutes. She de i,ered an hour ater meaning that she did not need any anti!iotics !ecause anti!iotics are administered when &2 hours ha,e gone after rupture of mem!ranes. (My es, 2''$) The !uttoc*s and the egs were !orn at 5)2' pm. ?hen the oop of the cord appeared at 5)22 pm, she was discouraged from pushing and it was gent y pu ed down and oosened and strong pu sations were present. 2oosening of the cord is important !ecause it pre,ents tension on the cord that can ! oc* ! ood supp y to the fetus. 6t was a so important to note the time when the oop of the cord appeared !ecause there is on y 8 to &' minutes a,ai a! e soon after the cord has appeared ti de i,ery if the !a!y is to sur,i,e !ecause once the feta head enters the materna pe ,is ! ood supp y is cut from the fetus (Se ers 2''$). 6n this case the oop of the cord appeared at 5)22 pm and de i,ery was comp eted at 5)$' pmD which means it too* &' minutes and the !a!y sur,i,ed with an +pgar score of 8%&', &'%&'. The e4tended arms were de i,ered using 2o,setBs manou,re. This manou,re is important in the de i,ery of e4tended arms !ecause it pre,ents se,ere perinea tears and trauma to the fetus. The head was de i,ered using -urnBs Marsha Manou,re !ecause it was f e4ed. +fter de i,ery the mother was e4amined for any tears. She sustained first degree perinea tear which was sutured using chromic 2.' suture with prior administration of &@ ignocaine as a oca anaesthesia. +fter suturing the mother was ad,ised to !e c eaning the area with sa ty water to pre,ent infection. The !a!y was a so e4amined for trauma. There was no apparent in>ury. 25.5( hours post.de i,ery the !a!y had !een ha,ing a norma cry, no con,u sions and did not de,e op >aundice. This was an indication that the !a!y did not sustain any in>ury. The !a!y and the mother were gi,en nursing care in the postnata ward for $ days. The mother did not de,e op any comp ications post.nata y.The !a!y had !een suc* ing we and has had no pro! ems with e imination. #is !irth weight was $'''g and was discharged on day $ with a !ody weight of 287'g. The weight oss was norma !ecause a !a!y is e4pected to ose a most &'@ of the !ody weight for the first $ days and regain it for the ne4t &' days. The weight oss is due to inade:uate co ostrum for the ear y days, passing out of meconium, and insensi! e water oss. The weight is regained ater !ecause after $ days of de i,ery !reast mi * production !ecomes we esta! ished.

26

-efore discharge the !a!y was gi,en -CE and po io ' ,accines. The topics that were co,ered !efore discharge inc uded the fo owing) fami y p anning, e4c usi,e !reastfeeding, si4 food groups, !ody hygiene, importance of ade:uate rest, importance of honouring appointment dates, danger signs for the mother and the !a!y to !e reported immediate y once o!ser,ed or e4perienced. C/0C2=S6/0 #er a!our asted for &6 hours. This was not pro onged a!our !ecause pro onged a!our is when it e4ceeds 25 hours. The fetus did not e4perience feta distress as indicated !y a norma feta heart rate. The contractions were progressing :uite we . The ,ita signs for the mother were a so within the norma ranges throughout a!our. The !reech de i,ery was conducted within the recommended time and the appropriate manou,res were used to de i,er the !a!y and that is why the !a!y did not sustain any in>ury or disp ay any signs of cere!ra irritation. The mother ad>usted we to the non. gra,id state and the !a!y a so ad>usted we to the e4tra.uterine ife.

P3RS/0+2 6MPR3SS6/0 The c ient did not e4perience any significant pro! ems antenata y. =pon admission into the a!our ward a good rapport was esta! ished and that is why she co.operated ,ery we throughout the a!our process. The materna and feta condition was monitored thorough y throughout a!our and there was no de,iation from the norma ranges. The !reech was successfu with good outcome for the mother and the !a!y as we . The mother and the !a!y did not de,e op any comp ication after de i,ery. -ut on a!oratory in,estigations <9R2 was not done antenata y !ecause she was attending antenata care at a #ea th center. This is one of the important in,estigations that are supposed to !e conducted on each and e,ery antenata woman. So 6 fee there is need to put in mechanisms that wi ensure that <9R2 is done on each and e,ery antenata mother !e it at a hea th centre or at a 9istrict hospita . 6 a so fee that =tra Sound Scanning (=SS) was ,ery necessary antenata y to ru e out predisposing factor i*e hydrocepha us, anencepha y, p acenta prae,ia, uterine fi!roids in the ower segment and po yhydromnios. 2uc*y enough a these conditions were not present. -ut a in a 6 sti fee the mother recei,ed the appropriate physica and psycho ogica care upon admission, during a!our and de i,ery and fina y postnata y. R3C/MM309+T6/0S <9R2 shou d !e done on each and e,ery antenata woman to protect the mother and the un!orn !a!y from syphi isD !e it at a hea th centre or a district hospita .

27

6t shou d !e a must to do = tra Sound Scanning (=SS) on any antenata woman whose presentation of the fetus is not cepha ic in order to ru e out feta a!norma ities. 6f resources permitting, = tra Sound Scanning (=SS) shou d !e done on each and e,ery antenata woman in order to ru e out feta a!norma ities and to determine the si1e of the !a!y in re ation to the materna pe ,is so as to predict the appropriate mood of de i,ery.

REFERENCES -ennet, <.R and -rown, 2.F (&AAA) M.-"% "/ 0oo1 2o# '*34*5"%. (&$th 3dition) 3din!urgh, Churchi 2i,ingstone -urroughs + (&AA8), M& "#(* . (6#%*(78 A( *( #o369 o#. "/ : (8th edition), Phi ade phia, ?- Saunders company. ;raser 9M, Cooper M.+. (2''5) M.-"% T"/ 0oo1 2o# M*34*5"%, (&5th 3dition) , 3din!urgh, Churchi 2i,ingstone. Ministry of #ea th, (2''') O0% " #*9 L*2" %1*-- T#&*(*(7 M&(6&- 2o# M&-&4*;S&2" Mo !"#!oo3 )#o7#&'< Ministry of #ea th, (2''') Co(9") % o2 A( "(& &- C&#" &(3 Fo96%"3 A( "(& &C&#" / ds,S.-., 2ondon, M.2., G 2adewig, P.+. (&AAA) M& "#(&- ("40o#( (6#%*(78 A 2&'*-. &(3 9o''6(* . 0&%"3 &))#o&9!< (6th edition) 2ondon, Pretince #a . Se ers P.M, (2''&) M*34*2"#., (,o ume 2) Cape Town, Huta and Company.

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Sweet, -.R. (&AAA) M&."%$ M*34*2"#. (&2th edition) 2ondon, -ai iere Tina .

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