Matilda Durowaa Hinneh

CHAPTER ONE
1.0 INTRODUCTION
This chapter gives information about client and it includes personal and social history,
family history, medical history, surgical history, menstrual history, past obstetric history,
present obstetric history, and client life style or allow hobbies.
1.1 PERSONAL AND SOCIAL HISTORY

Madam Serwaa Boateng Josephine, gravida three [3] para two [2] alive, is a 28 years old
woman who hails from Ashanti Mampong –krobo in the Ashanti Region but resides at
Adukuma kurom, house number GCA0025 a suburb of Asutifi North in the Brong Ahafo
Region. She is dark in complexion, 5.3 feet tall and weighs 55kg.
she is an SHS graduate who completed Garden City Commercial at Kumasi. She added that
she couldn’t continue her education due to some financial problems faced by her parents.
Madam Josephine is married to Mr. Abudu Kadri Alhasan a 31 Years old man who is a moto
driver and a rice farmer as well which serve as a source of income to support home. Madam
Josephine speaks Asante Twi but her husband speaks Asante twi and Mamprusi.
They have two sons, namely, Magid Kadri and Saddick Kadri who are 6 years and 3 years old
respectively. Madam Josephine is a Christian and worship at Methodist Church of Ghana at
Owusu kurom which is about 60 Kilometers away from Adukuma kurom. Her next of kin is
her mother, Madam Charity Gyima Yeboah.
1.2 FAMILY HISTORY

Mr. Kwabena Dapaa and Mrs. Charity Gyima Yeboah are the parents of Madam
Josephine. She has one other sibling who is a female and alive.
Her parents are farmers and resides at Adukuma kurom which is a small village with
a single mud building where Madam Josephine with her mother, husband, children
and 4 other guys who are the laborers of her husband.
Madam Josephine said her family has a known diabetis medical history which even
killed her grandfather but she doesn’t know any other medical history like
hypertension, sickle cell disease, heart disease, epilepsy, mental illness ect. in the
family.
she also added that most of the deaths in her family are natural, meaning they grow
very old before death take them away. She also said multiples pregnancies run in the
family.
1
1.3 MEDICAL HISTORY
According to Madam Josephine, she has ever been admitted at the hospital with the
condition of anemia.
She also said she has a medical history of jaundice which she said has treated for many
years but is still not going. She said she has no history of heart disease, sickle cell,
hypertension and even diabetis that is running through her family.
According to her, she has ever experienced signs and symptoms of sexually
transmitted disease, that is gonorrhea. She said she was experiencing pruritus vulvae,
offensive whitish discharges from the vagina.
She is allergic to okro and peniclline. She also said she donated 4 pant of blood when
she was in senior high school.
1.4 SURGICAL HISTORY

Madam Josephine said she has never undergone any surgical operation like
salpingectomy, laparotomy ect since childhood and have not been involved in any
accident or injury to the head or pelvic bone.
She also added that she was transfused with blood when she was anemic and was
admitted at the hospital.
1.5 MENSTRAL HISTORY

According to Madam Josephine, she does not remember the age of her menarch but
she has 28days menstrual cycle with regular and moderate flow of blood for 6-7 days
without dysmenorrhea.
She added that she uses sanitary pad and change it when it is soaked and bath twice
daily. She also said she can’t remember her last menstrual period.
1.6 HABBIT OF DAILY LIVING

Client said she sleeps at 8pm and wakes up at 6am to do her household chores before
she lives the house to sell bread at the nearby village. She often empties her bowel
once daily and also bath twice daily and rest during her leisure time. She said she
usually goes to the farm for foodstuffs and fire wood. She does not drink or smoke.
2
1.7 PAST OBDSTERIC HISTORY
Madam Josephine, gravida 3 para 2, all alive. Fist born named Magid Kadri who is 6
years old and second born is Sadat Kadri who is 3 years old. Pregnancy reach 36 weeks and
40 weeks of gestation before labour was due. During pregnancy, client experienced some
minor disorders such as edematos feet and loss of appetite which was treated.
Client added that she attended Antenatal during all her pregnancies till labour was due. Client
had never received tetanus injections during her pregnancies.
Client said she has never suffered pregnancy induce hypertension and diabetes but anemia
during her first pregnancy. According to her, all her babies were delivered at the hospital with
no complication or retained placenta. Client said during her first pregnancy onset of labour
started at night but during her second pregnancy, labour started on Wednesday 6pm till
Friday 3:30pm.
Client also experienced minor disorders like waist pain and lower abdominal pain durin labor
in both pregnancies. Babies cry immediately they are born and there was moderate blood
loss. Weight of babies were 3.1kg and 3.9kg respectively. Client also said she exclusively
breastfed all her babies till for two years then supplementary feeds were introduced and stop
feeding.
Client added that her babies were immunized against childhood disease at Blessed Family
Maternity Home/Clinic. Madame never used any of the family planning method. Client went
through puerperium successfully without any complication with the support of her family.
1.8 PRESENT OBSTERIC HISTORY

Having glanced through her antenatal records book, client attended her first antenatal clinic
visit on the 13/01/2018 at Blessed Family Maternity Home/Clinic where she was 16 weeks of
gestation and felt fetal movement. Madam Josephine could not remember her last menstrual
period but the scan gave the expected date of delivery as 4/07/2018.
Client had no complains during the first Antenatal visit but complained of general body
weakness when she was 24 weeks of gestation. She weighed 68kg and her height was 162cm
at booking. Vital signs and laboratory investigations were conducted and recorded as follows;
Hemoglobin 14.1 gram per deciliter
Hepatitis B Negative
Blood Group O
Rhesus Factor Positive
3
VDRL Non
HIV Status Negative
G6PD Nonreactive
Urine for protein and sugar Negative
Sickling status Negative
Vital signs recorded as;
Temperature 36.6 degree celcious
Blood pressure 120/70mmHg.
Weight 68 kilograms
Height 162 centimeter
Symphysio fundal height 16 centimeters
Pulse
Respiration
Head to toe examination was done with no abnormality detected. She was 16week gestation,
fundal height was 16cm, fetal heart rate was present, there was no descent and no presenting
part by then. She had no complications. she has not taken any dose of Tetanus Dipheteria
[TD] but have taken all five doses of sulphadoxine pyrimethamin on 13/01/18, 13/02/18,
13/03/18, 13/04/18 and 12/05/18 respectively. She was counselled on malaria prevention,
hygiene, good nutritious food, exercise, rest and sleep. She was given treated mosquito net.
She was also given routine drugs as follows;
Tablet multivitamin 200mg Tid for 30 days

Tablet folic acid 5mg once daily for 30 days
Tablet ferrous
4
CHAPTER TWO
ANTENATAL CARE
2.0 INTRODUCTION
Antenatal care is the health care and education given to pregnant women from the time of
conception is confirmed until labour begins. This chapter gives information about the antenatal
visits of the client and the care that was rendered to the client from the first encounter with the
client and subsequent visits by the client to the clinic. It also talks about the number of visits
made by the student midwife to the client’s home till labour set in.
2.1 FIRST CONTACT WITH CLIENT
On Wednesday 27th June, 2018, Madam Josephine was encountered when she came to the
clinic for her antenatal care. She was experiencing frequency of micturition since she was in
her 36th week of gestation. She was worried because she had less knowledge about what was
happening to her so an opportunity was taken to educate her about the physiological changes
that occurs during pregnancy. A review was done in her antenatal care record and it was
realized that she sometimes complained of headache and tablet paracetamol was given as
treatment. Explanation on the procedures to be carried out was done to seek her consent of
which she accepted after attending to her, her weight and hemoglobin level was checked and
recorded as 58 kilograms and 11.5gram per deciliter respectively.
Her vital signs and other investigations were recorded as follows;
Temperature - 36.2 degree Celsius
5
Pulse - 78 beat per minute
Respiration - 20 cycles per minute
Blood pressure - 110/80 millimeter of mercury
After checking and recording of vital signs, head to toe examination was to be done so she was
kindly asked to empty her bladder and sample of her urine was taken and tested for sugar and
protein which tested negative. The amount of urine voided was also measured as 150 mls after
which she was helped to assume a lateral position on the examination bed. Hands were washed
and dried and all equipment needed for the examination were gathered.
She was asked to assume a supine position before the commencement of the examination. The
hair was first examined for softness, brittle and neatness, followed by the scalp to rule out any
dandruff. The eyes were examined for pallor, jaundice, Sclera for discoloration, the ears for
discharges, followed by the nose for discharges and congestions. The lips were examined for
cracks and the gums for bleeding. She was engaged in a conversation to rule out any halitosis,
dental caries and teeth distribution. The neck was examined for any distended neck veins,
enlarged lymph nodes and thyroid gland. The upper limbs were also examined for pallor and
the nail bed for neatness and to rule out any anemia followed by the axilla for any palpable
nodules. The breasts were to be examined but before that, she was asked to place her hand
under the head of the part of breast to be examined followed by the other. The breasts were
examined for equality, lumps and discharges and were also thought how to do self -breast
examination. The lower limbs were also examined for neatness, edema, varicose vein and the
nail bed for anemia. The back was examined for any spinal or vertebrae abnormalities, sacral
edema as well as the general wellbeing of client. After the examination, she was congratulated
6
and taught how to examine her breast and report to the Hospital if any lump or other
abnormality is seen.
ABDOMINAL EXAMININATION.
Hands were washed and dried; permission was sought from client. The abdominal examination
includes inspection, palpation and auscultation.
On Inspection;
On examination, the shape of the abdomen was ovoid and the size corresponds to her
gestational weeks. Linea nigra and striae gravidarum were present and fetal movement was
felt. No scars or rashes were seen on the abdomen. Hands were warmed by rubbing them
together to avoid inducing contractions. The abdomen was palpated for masses, tenderness as
well as enlarged spleen and liver but no abnormalities were detected.
Measuring of symphysiofundal height;

The abdomen was palpated with palms and fundus located. zero mark of the measuring tape
was placed on the fundus and extended along the contours of the abdomen along the midline
to the upper border of the symphysis pubis and it measured 38cm with 39 weeks of gestation.
Fundal palpation
Facing Madam Josephine, hands were rubbed together to warm the hands and the palms were
placed on either side of the fundus and fingers curved around the fundus, a soft mass was felt
indicating the buttocks.
7
Lateral palpation
The palms of the hands were placed on both sides of the uterus, midway between symphysis
pubis and fundus. The uterus was stabilized with one and examined with the other hand. The
entire area from the abdominal midline to the fundus was palpated in a rotatory manner. The
other hand was also used to stabilize the uterus and the procedure was repeated. The left lateral
palpation done at the left side of the mother felt rough which indicated the fetal limbs and the
right lateral palpation done at the right side of the mother, a smooth curve was felt which
indicated the back of the fetus. The position of the fetus therefore was right occipito anterior.
Pelvic palpation
Facing the feet of Madam Josephine, the palms were placed on either side of the uterus, with
the palms just below the level of the umbilicus and fingers directed towards the symphysis
pubis, thumbs almost meeting. A hard mass was felt indicating the fetal head. Therefore, from
the above, it was deduced that, lie was longitudinal and the presentation was cephalic.
Descent of fetal head
Location of the anterior shoulder was made using two fingers. The upper border of the
symphysis pubis was located. None of the fingers covered the head indicating no descent. Commented [M1]:
Auscultation
On auscultation, the fetoscope was warmed and placed at the area where the back was located,
the ear was placed against the fetoscope to listen to the fetal heartbeat. One hand was placed at
the maternal radius to differentiate between maternal and fetal pulse. The fetal heart rate was
checked for one minute and recorded as 140 beat per minute with good rhythm and volume.
8
Vulva examination
Permission was sought to inspect her vulva and perineum and she agreed, her underpants were
removed and was assisted to assume a lithotomy position and was draped. Soap and water were
used in washing hands and cleaned with a dry clean towel. A sterile glove was worn. The labia
were inspected, the skin was smooth, clean and pubic hair free of lice. The labia tissue was
soft, there were no swelling, redness or tenderness, rashes, sore, scars, warts, edema, varicose
veins, no discharges and no sign of fistula. Clitoris and perineum were inspected and no
abnormalities were found. There was no sign of female genital mutilation. The vagina was
swabbed using sterile cotton and savlon solution aseptically. The vagina was moist with no
offensive smell. Madam Josephine was congratulated for her co-operation. Gloved hands were
dipped in 0.5% chlorine solution and gloves were discarded. Hands were washed with soap and
water and dried with towel. Findings were communicated to her. Permission was then sought
from Madam Josephine for a home visit on Thursday 28th July, 2018 and she was happy and
gave the direction to her house as well as her mobile phone number. She was educated on
nutritious foods to help in the development of the fetus and regular mild exercise. The following
drugs were prescribed for her.
Tab folic acid 5mg daily for 10 days
Tab ferrous sulphate 200mg daily for 10 days
Tab Multivite 200mg daily for 10 days
She was scheduled for next antenatal visit and review date communicated to her or visit the
clinic any time she encounters any problem.
9
HOME VISITS
2.2 FIRST ANTENATAL HOME VISIT
On Thursday, 28th June, 2018, a visit was made to Madam Josephine’s house around 4:00pm
as scheduled. The aim of the visit was to observe her surrounding, prepare her towards delivery
and also to inspect her items for labour and find out how she was coping with pregnancy.
Madam Josephine lives in a mud building with six bed rooms and roofed with aluminum sheet
and there is a toilet, a bathroom and a kitchen. Client lives in the second room among the six
rooms in the house. Before entering the house, a stroll was taken around the house. The
surrounding of the house was clean and there is a farm behind it which makes the surrounding
bushy but no stagnant water was available. The house has four main entrances. There is no
electricity available and their source of water is a well which is a walking distance away from
their house. Client cooks in a mud kitchen structure. The kitchen was neat and the items were
nicely arranged to prevent accident. She had a small dustbin which was well covered for
keeping their rubbish and it was emptied whenever it was full. The refuse was emptied at the
refuse dump which is quite far from their house. She shares the same toilet and bathroom with
the other members of the house.
On arrival Madam Josephine was sitting outside with family members chatting. A seat was
offered in her room. The mission of the visit was asked as tradition demands and was stated
accordingly. The whereabouts of her husband and sons were inquired and she said her husband
had gone to work at his rice farm and her kids were outside playing. The room was divided
with curtains with one half of the room serving as a bedroom and the other half as a living
room. Client room was well ventilated with windows made up of wooden louvers. Her room
was neatly arranged and was congratulated on that. In order to know how prepared she was for
10
10
labour, she was kindly asked to bring her bag containing the items for labour and it was
encouraging because items like cot sheets, baby dresses, antiseptic disinfectant, parazone,
perinea pad, pampers and others were seen. Everything needed for labour were seen. She sleeps
under insecticide treated net every day. The entire house was neat and client had a cordial
relationship with the other family members.
Client complained of finding it difficult to sleep at night and also complained of anorexia. She
was advised to take a warm bath before going to bed and educated on the need to practice good
oral hygiene. She was also educated on birth preparedness such as getting her cloth, layette
NHI card, accompanied relative, a moto driver when her husband is not around, a blood donor
in case of emergency etc ready. Client was congratulated on how neat and clean she had kept
the house and was educated on regular exercise and was reminded on the intake of nutritious
diet. She was also educated to report to the clinic immediately when she experienced any of
the true labour signs like the presence of show and painful rhythmic uterine action. Madam
Josephine was thanked for her hospitality and permission was sought to leave. A day was
scheduled for the next visit to the clinic, thus 5th July, 2018.
2.3 SUBSEQUENT HOME VISIT
The next home visit was made on the 4th of July, 2018 at 3:00pm. The aim of this visit was to
know how the family was doing and also educate her on birth preparedness and complications
readiness, since she had not yet delivered. She was educated on the need to deliver at the health
facility to prevent complications like retained placenta, postpartum hemorrhage and importance
of breathing exercise during labour. She was also educated on complication readiness as to who
will donate blood in times of need, a relative to accompany her to the hospital during labour
and transportation to the clinic when in labour.
11
Education was made on intake of nutritious diet, fruit and vegetables and intake of more fluids
and also to continue taken her medications. Emphasis was laid on signs of true labour, thus
show and painful uterine contractions and was encouraged to report to the clinic if she
experiences these signs. She was also reminded to report to the clinic if she feels anything
unusual.
She was reminded on the next visit to the clinic and permission was sought to live.
2.4 SUBSEQUENCE VISIT TO THE CLINIC
on 5th July, 2018, was the day scheduled for Madam Josephine’s next visit to the clinic. She
arrived at 9:30am, she was offered a seat and welcome warmly. Her vital signs were checked
and recorded
Temperature 37.2 degree Celsius
Blood Pressure 110/80mmhg
Pulse 88bpm
Respiration 19cpm
She granted permission to perform head to toe examination after it was explained to her. The
purpose was to detect any abnormalities. She was asked to empty her bladder to promote
comfort during which midstream sample was collected and tested for sugar and protein and
results for both were negative. In the examination room, she was assisted to position herself in
a supine position on the examination bed. Hand washing with soap and water was done and
well dried with a clean towel, head to toe examination was done and no abnormality was
detected. On palpation, the gestation was 39 weeks, Symphysio-fundal height was 38cm, lie
longitudinal, and presentation cephalic, descent 4/5th, and fetal heart rate was 140bpm on
12
auscultation. Her hemoglobin level was checked and recorded as 12gramme per deciliter. She
was thanked and helped into a comfortable position on a chair, hand washing was done and
dried. Finding were communicated to her. She was encouraged to report to the clinic if there
are signs of true labour or if she encounters any problem. She was also encouraged to keep
taking the routine drugs that were given to her previously.
2.5 CARE PLAN DURING ANTENATAL
PROBLEMS IDENTIFIED
1. Frequency of micturition
2. Insomnia
3. Anorexia
4. Lower abdominal pain
5. Constipation
SHORT TERM OBJECTIVES
1. Client will be able to cope with frequency of micturition within 48 hours during pregnancy.
2. Madam Josephine will be able to sleep for at least four hours during the night and two hours
during the day within 48 hours.
3. Client will be able to regain her eating pattern within 48 hours.
4. Client will be able to cope with lower abdominal pains within 72 hours
5. Client’s will regain her normal bowel habit(1daily) within 48 hours.
13
LONG TERM OBJECTIVE
Madam Josephine will have a successful pregnancy, labour and puerperium outcome without any
complications to her and her baby.
DATE/ NURSING OBJECTIVE/OUTCOME NURSING NURSING DATE/ NURSING SIGN

TIME CRITERIA TIME
DIAGNOSIS ORDERS INTERVENTIONS EVALUATION
27/6/18 Frequency Client will be able to 1. Reassure 1. Client was 29/7/18 Goal fully
cope with frequency of client reassured
of met as client
9:30am micturition within 48 2. Explain the 2. The 9:30am
micturition verbalized
hours during pregnancy physiology of physiology of
related to as evidenced by; frequency of frequency of that she no
micturition to micturition was
descent of more urinates
a. Client verbalizing that her. explained to the
the frequently
increase in the 3. Encourage client.
presenting frequency of micturition client on the 3. Client was
has been reduced. need to keep encouraged on
part.
vulva clean the need to keep
b. Midwife witnessing
and wear vulva clean and
that client is no more cotton under wearing of
wears. cotton under
urinating frequently.
4. Encourage wears.
client to void 4. Client was
every 1 – 2 encouraged to
hours. void whenever
she feels the urge
5. Encourage to.
5. Client was
her to have a
encouraged to
pail close to
use a pail at night
her bedside
rather than
14
when walking a
sleeping. distance to
urinate

TIME CRITERIA TIME
27/6/18 Alteration in Client will be able to 1. Reassure 1. Client was 29/6/18 Goal fully
have at least six hours client. reassured.
9:30am sleeping 9:30am met as client
sleep during the night 2. Explain the 2. Physiology of
pattern reported that
and two hours during the physiology of micturition was
(insomnia) day within 48 hours frequency of explained to the she can now
during pregnancy as micturition to client.
related to have enough
evidenced by client the client.
frequency of sleep.
verbalizing that she now 3. Encourage 3. She was
micturition. has enough sleep. client to take encouraged to
a warm bath take a warm bath
before before sleeping.
sleeping.
4. Encourage
her on the 4. She was
need to encouraged to
ensure good ensure good
ventilation in ventilation in her
her room to room.
help her
sleep. 5. She was
encouraged to
5. Encourage
have some sleep
her to have at
during the day.
least 2 hours
15
rest and sleep
in the
afternoon.

TIME CRITERIA TIME
27/6/18 Altered Client will be able to 1. Reassure 1. Client was 29/6/18 Goal fully
the client reassured that she
nutritional regain her normal met as
9:30am that she will will regain her 9:30am
pattern eating pattern within 48 evidence by
regain her
16
(anorexia hours as evidence by normal normal eating client
eating pattern.
) related to client verbalizing that verbalizing
pattern.
hormonal she can eat half plate of that she can
2. Educate 2. Client was
changes food served. client to educated to now eat half
practice practice good oral
during plate of food
good oral hygiene.
pregnancy. served.
hygiene.
3. Encourage 3. Client was
client to eat encouraged to eat
food in bits food in bits but
but frequently.
frequently.
4. Encourage 4. Client was
client to eat a encouraged to eat
preferred a preferred food.
food. 5. Client was
5. Encourage
encouraged to
client to
remove all
remove all
nauseating
nauseating
articles around
articles
her when she is
around her
about to eat.
when she is
about to eat.

TIME CRITERIA TIME
17
5/7/18 Lower Client will be able to 1. Reassure 1. Client was 8/7/18 Goal partially
cope with lower client. reassured.
abdominal met as client
10:00am abdominal pains within 2. Explain the 2. The 10:00am
pain related verbalized
72 hours during physiology physiology of
to descent of pregnancy as evidenced associated with lower abdominal that pain was
by; lower pain was
the fetal a bit subside.
abdominal explained to
head.
a. Client verbalizing that pain at the client.
pain has been relieved. latter part of
pregnancy.
b. Midwife observing
3. Conversation
that client is comfortable. 3. Use and watching of
diversional television were
therapy to the therapies
divert client’s used to divert
mind from the client’s mind
pain. from the pain.
4. Client was
4. Encourage encouraged on
client on the enough rest and
need for rest sleep.
and sleep. 5.Tablet
5. Administer
paracetamol
prescribed
1gram
analgesics
administered.
18
TIME CRITERIA TIME
5/7/18 Altered Client will be able to 1 Reassure 1. Client was 7/7/18 Goal fully
client. reassured.
bowel empty her bowel once 2. The achieved as
10:00am 2. Explain the 10:am
physiology of
movement daily within 48 hours constipation was client said she
physiology of
explained to
(constipation) during pregnancy as constipation client. was able to
during
related to evidenced by client empty the
pregnancy to 3. Client was
hormonal verbalizing that she is encouraged on bowel once
the client.
effects of able to empty her bowel 3. Encourage the intake of daily.
client on fruits and
pregnancy once daily.
intake of vegetables to
fruits, prevent
roughages and constipation.
vegetables. 4. Client was
encouraged on
the need to
4. Encourage exercise.
client on mild
exercises like
walking.
5. Client was
5. Educate educated on the
client on the intake of more
intake of more fluids.
fluids
19
CHAPTER THREE
LABOUR
3.0 INTRODUCTION
This chapter talks about the care that was rendered from the time labour sets in till complete
expulsion of the fetus, placenta and its membranes, control of hemorrhage and proper
monitoring of mother and baby.
3.1 ADMISSION AND MANAGEMENT OF FIRST STAGE OF LABOUR
First stage of labour starts from the onset of labour till full dilatation of the cervix. Madam
Josephine came to Blessed Family Maternity Home/ Clinic accompanied by her husband and
mother. They were welcomed and offered a seat. Madam Josephine complained of lower
abdominal pains and painful uterine contractions. They arrived at the clinic at 12:15am but
according to the client, labour started on the 12th July, 2018 around 5pm.
Enquires made indicated that client had seen blood stained mucus(show). Client’s antenatal
book was glanced through for previous history and also to confirm expected date of delivery.
At the first stage room, client was offered a bed, Madam Josephine was reassured and
procedures to be done were explained to her and consent was sort. Client’s vital signs were
checked and recorded as follows;
Pulse 89 beats per minute
Respiration 20 cycles per minute
Blood pressure 110/86 mm/hg
20
Client was served with a bedpan to empty her bladder and specimen taken, which tested
negative for protein, and glucose. A total amount of 100mls of urine was emptied. Client was
then helped into a bed, hands were washed and dried with a clean towel, and she was examined
from head to toe and no abnormalities was detected. On abdominal examination, the shape was
ovoid with normal size and there was linea nigra and striae gravidarum presence. The
gestational age was 40weeks while the symphysiofundal height was 39cm.Upon palpation, the
lie was longitudinal, presentation was cephalic, descent was 4/5th, fetal heart rate on
auscultation was 140bpm. After palpation, hands were warmed by rubbing in order to check
for contractions. There were 2 contractions in 10 minutes lasting 25 seconds. Consent was
sought to perform vaginal examination to help know the dilatation of the cervix and she agreed.
A tray was set containing a sterile glove, a gallipot with sterile cotton wool swabs and another
gallipot with savlon, a sanitary pad and a receiver. Client was helped to assume a lithotomy
position and was draped. Hands were washed thoroughly with soap under running water, hands
were dried and sterile gloves were worn. The vulva was inspected and nothing abnormal was
detected. The vulva was then swabbed with five sterile cotton wool swabs soaked in savlon
solution.
The vulva was swabbed from labia majora to minora, and then the vestibule using a different
swab each time, the index and middle finger were then inserted gently into the vagina. The
condition of the vagina was warm, roomy and moist, cervix was soft and slippery with
dilatation of two (2) centimeters with membranes intact. Ischial spines were blunt with a well
curved sacrum, and a wide pubic arch. A fresh perennial pad was placed on the vulva and client
was asked to lie on side (lateral position) to prevent supine hypotension. Gloved hands were
dipped into 0.5% chlorine solution before removing. All findings and progress of labour was
21
communicated to the client and recorded on a monitoring sheet. She was cleaned nicely and a
sanitary pad was applied to the vulva. Client was thanked for her co-operation. On arrival it
was observed client was anxious and was going through pains. Madam Josephine was
approached and asked whether there were any other complaints which she complained of
fatigue, backache and lower abdominal pains. Client was reassured of normal labour with a
healthy baby without complications after delivery Client was encouraged to breathe through
her mouth when there was contraction and also avoid pushing during contraction since the
cervix was not fully dilated and to prevent edematous cervix. Bedpan was provided for her to
empty the bladder frequently to enhance effective contraction and descent of the fetal head
since full bladder could slow down progress of labour.
Client was educated on the importance of changing the pad when soiled and not to be touching
the perineal area.
Labour was monitored till 4:00am where vaginal examination was repeated. Cervical os was
4cm with membranes intact. Palm was warm by rubbing hands together, then placed on the
level of the fundus to time for contractions. Within 10 minute, contractions were 3 lasting 25,
30 and 34 seconds respectively. Fetal heart rate was 140bpm, maternal pulse was 89bpm, Blood
Pressure was 110/60mmHg, Temperature was 35.1Oc.
The fetal heart rate, contraction and maternal pulse were monitored every thirty (30) minutes
while temperature, blood pressure, dilation of the cervix and descent of the fetal head were
checked every four (4) hours and recorded on the partograph.
At 11:00am, membranes ruptured spontaneously, vagina examination was done to rule out cord
prolapse. On vaginal examination the vagina was warm and moist, the cervix was eight (8)
centimeters dilated and well applied to the presenting part, bones were separated and sutures
22
were easily felt, liquor was clear with descent 2/5and fetal heart rate was 142 beats per minutes,
Contractions were four (4) in ten (10) minutes lasting for fort five (45) seconds. Vital signs
were checked and recorded as below
Pulse 88 beat per minute
Blood Pressure 130/80 millimeter of mercury
The amount of urine emptied was hundred (100) milliliters. Client was made comfortable in
bed by cleaning all discharges and a new perineal pad applied. All findings were documented
on a partograph sheet.
At exactly 11:30am, client complained of bearing down sensation so another vaginal
examination was done and the cervix was fully dilated (ten centimeters) and there was no cord
prolapse, descent was 0/5, bonds were separated and sutures were easily felt, contractions were
five (5) in ten (10) minutes lasting fifty (50) seconds, fetal heart rate was 138 beats per minute
and urine output was 100 milliliters. Findings were recorded on the partograph sheet and client
was informed of the full dilatation of the cervix. Client was informed that the baby would be
delivered onto the abdomen to establish bonding. Delivery trolley was made ready with the top
shelf containing sterile delivery pack, sterile bulb syringe and 4 clean towels for draping the
client. The down shelf also contained a pair of sterile glove, a jug for measuring blood loss, a
receiver for placenta, fetal stethoscope, a
23
container with syringes and needles, oxytocin drug, extra perineal pad and antiseptic lotion.
3.2 PREPARATION FOR BIRTH.
The midwife in charge who would supervise labour and delivery was identified as a skilled
helper and she would also help in both care of the baby and mother. The unskilled helper that
was identified was Madam Charity, Madam Josephine’s mother who will assist in time of need.
A taxi was made available and the driver was informed that he would be called in case of
emergency. Contact number of referral point was reviewed.
The area was prepared for delivery. Madam Josephine was assisted to wash her hands, her
chest and abdomen and was then prepared for skin-to-skin care. Hands were washed with soap
under running water. A dry, flat and safe space was prepared for baby to receive ventilation if
needed. All equipment and supplies used for ventilation like the ventilation bag were tested if
they were functioning properly. All doors and windows were closed and a rechargeable lamp
on standby.
3.3 MANAGEMENT OF SECOND STAGE OF LABOUR
Second stage of labour is full dilatation of cervix to the birth of the baby.
Madam Josephine was assisted to assume the lithotomy position with her legs well supported
on the bed. Protective clothes were worn and hands were washed with soap and water then
dried with a clean towel. Sterile gloves were put on and delivery pack was opened. The vulva
was cleaned with savlon solution as well as the upper thighs. Clean towel was used to drape
the abdomen, thighs and buttocks. A sheet was placed on the abdomen and another was placed
under the buttocks. Fetal heart rate was also checked and recorded as 135beats per minutes.
She was encouraged to bear down in expulsive stage and rest in between contraction.
24
A fresh pad was applied to the perineum and the index and middle finger were placed on
advancing head to aid flexion. Flexion of the head was maintained to allow the smallest
diameter to distend the vulva. After the head crowned, she was asked to pant while the head
was delivered by extension as the sinciput, face and the chin swept the perineum. The eyes,
nose and mouth were cleaned and airway was cleared with a bulb syringe. The neck was felt
for cord around neck but there was none. Restitution and external rotation of the head took
place allowing the shoulder ready to be born. The head of the fetus was held in both palms on
each side of the bi-parietal bones and a downward traction was applied to allow the anterior
shoulder slipped under the pubic bone. The head was flexed towards the mother’s abdomen
and the posterior shoulder was delivered. The baby was delivered by lateral flexion onto the
mother’s abdomen as explained. Baby was dried, the wet cloth was removed from mother’s
abdomen, she was dried before baby was placed on mother’s bare abdomen in between the
breast and covered with dry warm cloths. This is to help in skin-to-skin contact as well as
providing warmth and bonding between the mother and the baby. A healthy baby girl was
delivered and sex confirmed by the mother. The breathing pattern of the baby was assessed
while drying her and the APGAR score within the first minute was 9/10, and the fifth minute
10/10. The woman was congratulated for her cooperation.
3.4 IMMEDIATE CARE OF THE BABY
Immediately the head was born, the baby's face was wiped with a sterile gauze swab and
eyes were cleaned with a sterile gauze from the inner canthus outwards. A piece of sterile gauze
was wrapped around the little finger and was used to clean the baby’s mouth to remove any
thick mucus. Cord around neck was felt and none was detected while waiting for restitution.
As soon as the rest of the body was delivered onto the mother’s abdomen, the liquor was wiped
off quickly from his body with a warm towel and place skin to skin with the mother to prevent
hypothermia. The baby cried shortly after birth. The cord was clamped with two artery forceps.
25
It was re-clamped with a plastic cord clamp 3cm away from the baby’s abdomen and 2cm from
the first clamp. The cord was cut in between the two cord clamp with a sterile scissors whiles
covering it with a sterile gauze to prevent the splashing of blood. The First and fifth minute
Apgar score was assessed and recorded as 9/10 and 10/10 respectively. Wet towels were
replaced with warm dry towels. An identification band with mother's name, baby’s sex, time
and date of delivery was tied on the baby’s wrist and he was put to breast.
3.5 MANAGEMENT OF THIRD STAGE OF LABOUR
Third stage of labour is the period from the delivery of the baby to the complete explosion of
the placenta, it membranes and control of bleeding
Madam Josephine was in the lithotomy position and a receiver placed near the vulva in
between the thighs. Procedure was explained to her. After the delivery of the baby, the uterus
was palpated to rule out the presence of an undiagnosed twin and ten (10) units of oxytocin
was injected intramuscularly on the mother’s thigh to aid in the contraction of the uterus and
separation of the placenta. Non dominant hand was placed on the fundus to feel for
contraction of the uterus. The cord was re-clamped nearer to the perineum with one artery
forceps. The cord and artery forceps was held with the dominant hand. As soon as the uterus
contracted, the non-dominant hand was removed and placed just above the symphysis pubis
with the palm facing the abdomen of the mother to provide counter traction to prevent uterine
inversion during removal of the placenta. At the same time, the dominant hand that held the
clamped cord was pulled gently in a downwards traction. With steady controlled cord
traction, the process was repeated until the placenta was visible at the vulva and cupped with
the two hands, and was rolled round to gently tease the membranes. The placenta was
completely delivered at 11:55am. A quick examination of the placenta was made where both
the maternal and fetal surfaces were intact. The placenta was placed in a receiver for
26
thorough examination later. The uterus was rubbed for a contraction and clots were expelled.
The client was taught how to massage the uterus. The vulva was cleaned with savlon, the
labia were patted and cleaned. Two sterile gauzes were wrapped on the middle and index
finger for inspection and there were no lacerations on the perineum. The vaginal walls and
cervix were inspected but there were no tears. The total blood loss was 200 milliliters. Client
was cleaned and a new perineal pad was applied to the vulva to absorb any lochia and client
was congratulated.
3.6 EXAMINATION OF THE PLACENTA AND MEMBRANES
In the sluice room, the placenta was immersed in 0.5% chlorine solution to make it safer for
examination. Firstly, the umbilical cord had two arteries and a vein with no knot, the umbilical
cord was situated at the center of the fetal surface and blood vessels were radiating outward.
The fetal surface was bluish grey in color. The umbilical cord was held upward to bring the
membranes down the placenta was placed on a flat surface for further examination. The amnion
was peeled from the chorion up to the umbilical cord and was fully viewed. The maternal
surface was examined by cupping the placenta in the hand, there was no infarct, the color was
reddish brown and the lobes were intact. Hand was spread inside the membranes to examine it
for completeness and it was intact. After the examination, hands were dipped in chlorine
solution before discarding the gloves. The instruments were also decontaminated in 0.5%
chlorine solution for 10 minutes. The instruments were removed, washed, rinsed, dried and
made ready for sterilization. She was encouraged to urinate frequently for the uterus to contract
and was told that if she should feel any changes, she should not hesitate to report. She was told
that she would be taken to the lying in and observed for the next six hours. All findings were
recorded on the partograph.
3.7 MANAGEMENT OF FOURTH STAGE OF LABOUR
27
During the fourth stage of labour, close observation of the mother and baby is made for about
six hours following the expulsion of the placenta, membranes and the subsequent arrest of
hemorrhage. The mother and baby were assessed every 15 minutes for two hours and 30
minutes for the next one hour. Vital signs for the baby was checked and recorded as follows;
Temperature - 36.1oC
Apex beat - 130bpm
Respiration - 34cpm
The mother's vital signs for every 15 minutes for the first 2 hours ranged from:
Temperature 35.6 - 36.30c
Pulse 79 – 94 beats per minute
Respiration 18 – 20 cycles per minute
Blood pressure 120/60 - 130/80 millimeter of mercury
The uterus was massaged to ensure that it was well contracted and client was encouraged to
massage her uterus. She was encouraged to report any unusual bleeding. Symphysio fundal
height was 19 centimeters. Client was given vitamin A 200,000IU capsule. The Lochia was
also checked, with its color being red (rubra) and not offensive. She was again encouraged to
empty her bladder frequently to prevent postpartum hemorrhage and also to change soiled pads
frequently to prevent infections. She was educated to wash her hands with soap and water after
changing her pad and also before and after attending to the baby. She was also educated on
how to fix baby to breast, the importance of exclusive breastfeeding for the first six months.
Madam Josephine and her baby were sent to the lying in after delivery for further monitoring
of both mother and baby.
28
Client husband was allowed to see her and she was served with warm porridge and bread to
restore energy. General condition of client and baby was satisfactory and all labour notes
were recorded on the partograph sheet.
3.8 PREVENTION OF INFECTION
Immediately the baby was born, the eyes were cleaned from inner cantus outwards. Hands
were washed and dried before handling the baby. Gentamycin eye drop was instilled on the eye
as prophylaxis against eye infection and was injected with 1.0mg of vitamin K intramuscularly
on the thigh to aid in clotting. Attention was paid to the cord by cleaning it with sterile cotton
soaked with methylated spirit and kept dry to prevent infections. She was reminded to wash
her hands under running water before and after handling the baby.
3.9 SUMMARY OF LABOUR
On 14thJuly 2018; at 11:49am, Madam Josephine had a spontaneous vaginal delivery to a live
female child. At 11:50am, injection oxytocin 10 units were given. Apgar score first minute was
9/10, fifth minute 10/10. At 11:55am the placenta and membranes were completely delivered.
Baby weighed 3.5kg. Perineum was intact, blood loss was 200 milliliters.
3.10 CONDITION OF MOTHER
Blood pressure 120/60millimetres per mercury
Fundal height 18centimetres
29
Uterus Contracted
Lochia Red(rubra)
Perineum Intact
Estimated blood loss 200mls
Condition Satisfactory
3.11 CONDITION OF BABY
Apgar score
First minute 9/10
Fifth minute 10/10
Sex Female
Birth weight 3.5kilograms
Apex heart beat 130 beats per minute
Length of the baby 53 centimeters
Head circumference 32centimeters
Meconium Passed
Urine Passed
Abnormalities No abnormalities detected
30
Condition Satisfactory
3.12 CARE PLAN DURING LABOUR
14th July, 2018
Madam Josephine complained of
1. Lower abdominal pain
2. Fatigue
3. Painful uterine contractions
4. Anxiety
5. Frequency micturition
1. Madam Josephine will cope with lower abdominal pains within 1 hour.
2. Client will be relieved of fatigue within 2 hours.
3. Client will cope with painful uterine contractions within 1 hour.
4. Client will be relived of anxiety within 30 minute.
5. Client will understand the physiology of frequency micturition and cope within 8
hours.
LONG TERM OBJECTIVES
Madam Josephine will go through all the stages of labour successfully without any form of
complications.
31
DATE/ NURSING OBJECTIVE/ NURSING NURSING DATE/
TIME OUTCOME TIME EVALUATION SIGN
DIAGNOSIS ORDERS INTERVENTION Commented [M2]:
CRITERIA
14/7/ Lower Client will 1. Reassure 1. Client was told 14/7/ Goal fully met as
18 abdominal cope with client that the her condition is 18 client reported
pain related to lower pain will be temporal and the pains has reduced
12:15 physiological abdominal 1:15a and midwife
reduced pains will reduce.
am process pains within m witnessing client
involving first an hour as was able to cope
stage of evidence by 2. Educate 2.Client was told with pain
labour. client client on the lower
verbalizing physiology abdominal pain
that she is of lower was as a result of
able to cope abdominal descent of the
with pain and
pain. presenting part
midwife
witnessing
client coping 3. Massage 3.Sacral region
with pain. the sacral was massaged
region during during contraction
contraction to reduce pain
4. Engage 4. Client was

client in engaged in
diversional conversation
therapy to during the whole
relieve the period of labour to
mind of pain. relieve her mind of
pain.
5.
Encourage 5.Client assumed
client to left lateral position
assume left during the first
lateral stage to help
position reduce pain and to
during first aid in descent of
stage of the presenting
labour.
32
DATE/ NURSING NURSING NURSING ORDERS NURSING DATE/ EVALUATION SIGN
TIME DIAGNOSIS OBJECTIVES/ INTERVENTION TIME
OUTCOME
CRITERIA
14/7/18 Fatigue Client will be 1. Encourage client to 1. Oral fluid (fruit 14/7/18 Goal fully met
take oral fluids to juice) was
12:15am related to relieved of hydrate her. given to the 2:15am as client said
client to client
increased fatigue within 2 that she was no
2. Encourage deep to hydrate her.
energy hours as breathing exercise 2. Deep breathing longer
when in pain. exercise was
requirements evidence by done during exhausted and
3. Encourage her to contractions
during labour client adopt a more midwife
comfortable position 3.Client was
verbalizing that observed no
that is harmless like encouraged to
she is no more left lateral position assumed the lateral signs of fatigue.
position during 1st
tired and the stage of labour
4. Encourage client to
midwife pant and relax in 4. She panted and
between relaxed in-
visualizing that
contractions. between
client is relaxed contractions.
Give emotional and
and not showing 5.Client was given
physical support
signs of fatigue. emotional and
throughout labour
physical support
throughout labour
33
Commented [M3]:
DATE/ NURSING NURSING NURSING NURSING DATE/ EVALUATION SIGN

TIME DIAGNOSIS OBJECTIVES/ ORDERS INTERVENTION TIME
OUTCOME
CRITERIA
14/7/18 Painful Client will cope 1.Reassure 1. Client was told 14/7/18 Goal fully met
client that that the pains will as client
12;15am uterine with painful the pain is help her baby to be 1:15am reported she
temporal delivered was coping and
contractions uterine 2. Encourage 2. She coped by midwife
her to cope carrying out all she observing the
related to contractions with the pain was told to do client
since it is 3. Client performed deep
physiological within 2hours as physiological performed deep breathing
3. Perform breathing exercise exercise during
involvement evidenced by deep during uterine contractions
breathing contractions
of labour client exercise with 4. Client walked
client
verbalizing she 4. Encourage around the ward
client to
is coping and ambulate
midwife
visualizing
client abiding
the education
given
34
DATE/ NURSING NURSING NURSING NURSING DATE/ EVALUATIO SIGN
TIME DIAGNOSIS OBJECTIVES/ ORDERS INTERVENTI TIME N
OUTCOME ON
CRITERIA
14/7/18 Anxiety Madam 1. Reassure 1.Client was told 14/7/18 Goal
related to Josephine will client about the of the caliber of achieved as
12:15a 12:45a
unknown be relieved of competency of the staff on duty midwife
m m
outcome of anxiety within the staff and the and they were reported that
labour 30minutes of outcome of introduced to her client was
labour as labour. relaxed in
evidence by 2.Before timing bed.
midwife 2. Explain every contractions or Client said
she was no
observing client procedure to be listening to fetal
more
with relaxed carried to her to heart rate, client anxious.
looks. allay her was told
Client anxiety and
verbalizing that fear. 3.Client was told
she is no more the finding of
anxious. 3. Educate her each
on the outcome examination
of labour to 4.Client
make her feel performed deep
less anxious. breathing
exercise during
4. Encourage uterine
deep breathing contractions
exercise to
make client feel 5.Client asked
comfortable and
questions on the
relieve her of
outcome of
anxiety.
contraction and
5.Encourage
client to ask
35
questions and answers was
answer them.
given tactfully
DATE/ NURSING NURSING NURSING NURSING DATE/ EVALUATION SIGN

TIME DIAGNOSIS OBJECTIVES/ ORDERS INTERVENTION TIME
OUTCOME
CRITERIA
14/7/18 Frequency of Client will 1. Reassure 1. Client was 14/7/18 Goals fully met
client that reassured that
12:15am micturition understand the 8:15am as evidence by
she is in the she was in the
related to the physiology of client
hands of hands of
descent of the frequent competent competent verbalizing that
midwives. midwives.
foetal head micturition and she now
exerting cope with it understands the

2. Explain 2. Physiology of
pressure on within 8 hours the frequent physiology of
physiology micturition was
the bladder. as evidence by frequent
of frequent explained to her.
client micturition and
micturition 3. Bedpan was
verbalizing that to her. served whenever is coping with
client needed it.
she understand it.
3. Serve
and is coping
bedpan 4. Client was
with the whenever encouraged to
client needs. urinate when she
situation.
has the urge.
4.Encourage
client to
36
urinate 5 Client was
when she
educated to change
has the
urge.
5 Educate
client to
change
37
CHAPTER FOUR
PUERPERIUM
4.0 INTRODUCTION
Puerperium is a period of six weeks following the complete expulsion of the placenta and
membranes from the uterus and control of hemorrhage.
This chapter describes the management of both mother and baby from day one to six weeks
postpartum. It is during this stage that the various organs with exception of the breast, return
to their non-pregnant stage.
4.1 DAY OF DELIVERY
On 14th July 2018 at 8:10am Madam Josephine and baby were sent to the lying-in-ward where
baby was wrapped nicely and put beside her. Client was educated on the need to ensure proper
personal hygiene and empty the bladder frequently so that the uterus could contract and prevent
bleeding. The need to change perineal pad when soiled and applying of new pad to prevent
perineal sepsis was also emphasized. The baby was then put to breast. A capsule of 200,000 I.
U vitamins ‘A’ was served and recorded. Client was educated to feed the baby frequently and
on demand, also, exclusive breastfeeding and fixing of the baby to breast were well explained
to mother. Emphasis was also made on hand washing after visiting the toilet, removing baby’s
soiled napkins to help prevent infection. Client vital signs were checked and recorded every 15
38
minutes for two hours, 30 minutes for one hour and hourly for the next three hours. The first
three hour vital signs that were the blood pressure and pulse were also recorded on the
partograph. The first reading was however recorded as below;
Blood pressure 130/80 millimeters of mercury
Symphysiofundal height 17 centimeters
Madam Josephine complained of lower abdominal pains, she was reassured that the pain would
resolved with time. She was however given analgesic (tab paracetamol 1g tid for 5days). Her
husband and mother were allowed to visit her and the baby of whom they were very happy.
Client was congratulated on her effort of delivery and was allowed to rest.
4.2 SUBSEQUENT CARE OF THE BABY
After six hours of birth, the baby was examined from head to toe with the consent of the mother
but no abnormality was detected. The baby was given first bath before the cord was cleaned
with sterile cotton wool swabs and methylated spirit. No bleeding was noticed. Baby passed
urine and meconium during the bath. Baby’s vital signs checked and recorded were as follows;
Apex beat 130 beats per minute
39
Weight 4.0kilogram
PROCEDURE FOR BABY BATH
The baby was bathed after the sixth hour observation. Head to toe examination was done and
no abnormality was detected. Madam Josephine was informed about the procedure to seek her
consent and she accepted. She was asked to observe closely how her baby was going to bathed
in order to practice it at home. Requirements needed for the procedure were gathered as
follows;
Soap, sponge, baby oil, powder, basin, towel, cot sheet, apron, sterile gloves, baby dress, cap
and socks, mackintosh, Jug containing hot and cold water each, two receptacles for used water
and dirty cot sheet, pair of scissors sterile cord clamp, brush, comb, methylated spirit, sterile
gallipot containing sterile water for the eye, sterile cotton wool swabs. Plastic apron was worn
after water was mixed and temperature checked with elbow. Hands were washed with soap
under running water. Gloves were worn. Baby was placed on a protected flat surface and
undressed after which he was wrapped with a cot sheet this was done to prevent heat loss. Eyes
were cleaned with wet towel from inner cantus to outer cantus. Baby’s face was also clean with
damp face towel and dried. The nape of the baby’s neck was supported with one hand and ears
were plugged with two fingers (the middle finger and thumb) of the hands supporting the
baby’s head. Head was washed with soapy sponged after which the baby was lifted off the flat
surface. Madam Josephine was educated that, the ears had to be covered with the fingers to
prevent water from entering. Still supporting the nape of the neck and the body resting on the
elbow to the edge of the bowl, hair was rinsed and dried. Baby was placed back on the protected
40
flat surface. His arms and front of trunk were washed paying attention to the skin folds. The
baby’s back was turned with the arm supporting the chest and with the hands holding the distal
arm. The back was washed down to the feet paying attention to the skin folds. Baby was
supported firmly and immersed in the bath of warm water with head above the water and rinsed
thoroughly. Baby was placed on a flat surface and covered with a clean sheet. Small towel was
used to dry the baby, paying attention to the skin folds. His cord was dressed. He was smeared
with baby oil. The baby was dressed in his welcome baby dress with socks and cap.
PROCEDURE FOR CORD DRESSING
This procedure was explained to the mother to gain her consent. Hands were washed
thoroughly with soap under running water and were dried with clean towel. Surgical gloves
were worn and the cord was inspected for bleeding but no bleeding was seen. All the
instruments necessary for the procedure were gathered on a tray. Six cotton wool swabs were
soaked in methylated spirit. One of the swabs was used to hold the cord clamp. The base of the
cord was cleaned with one cotton wool swab. The anterior, posterior and lateral portion of the
cord was cleaned starting with the base to the upper part using swabs of each stroke. The tip of
the cord was cleaned with a cotton wool swab. The swab that was used to hold the cord clamp
was then used to clean the whole of cord clamp. The cord was then left exposed. Both gloves
hands were immersed in a 0.5%chlorine solution. The baby was wrapped in a clean cot sheet
and was handed over to the mother to breastfeed. All findings were documented and
communicated to Madam Josephine.
The baby was examined from head to toe and no abnormality was detected.
41
EXAMINATION OF THE NEW BORN
After the fourth stage, every procedure carried on baby was explained to mother. Hands were
washed and dried with a clean towel. The baby was put on a clean warm and flat surface. Baby
was then exposed systematically as it was examined from head to toe. Baby’s color was pink
on observation; the head was examined for shape and size, widened sutures, bulging/depressed
fontanelles, any edematous swelling, caput succedaneum, microcephaly, anencephaly, and
hydrocephaly. A tape measure was used to encircle its head starting from the occipital
protuberance to the supraorbital ridges to measure the head circumference. The ears were
examined for size, shape, patency, softness of the cartilage, alignment and the eyeballs were
examined for its presence, color, pallor, jaundice and deformities. The nose was examined for
shape, size, patency, deviated septum and discharges. The buccal cavity was inspected for false
teeth, tongue tie, color of tongue and gum, cleft lip and palate by using the little finger to feel
for palate, sub mucous cleft. The neck was also palpated for nodules, rigidity and congenital
goiter. On the chest, respiratory movement was normal, nipples were in alignment, and breast
had no mass. The upper extremities were inspected for equality, number of palmer creases
clubbed fingers, extra/loss digits. Baby’s ability to perform moro and grasp reflexes were also
checked. The abdomen was examined for shape and size, with no bleeding from the umbilical
site and abnormalities such as omphalocele, gastrochiehis were absent. The extremities were
inspected for equality, clubbed feet, extra or loss digits. Congenital hip dislocation was also
checked. The back of the baby was examined for abnormalities like spinal bifida, meningocele,
all these were absent. The genitalia were developed with testis descended into the scrotum and
urethral and anal orifices were patent as it passed urine and meconium respectively. Gloves
were removed and disposed aseptically before washing and drying hands.
42
4.3 EDUCATION TO THE MOTHER ON BABY
Madam Josephine was educated to wash her hands before and after breastfeeding the baby.
She was educated on how to properly fix the baby to the breast to prevent breast engorgement,
cracked, sore nipple and also to promote and maintain adequate breast milk supply to the baby.
Madam Josephine was educated on the needs of exclusive breastfeeding for the first six months
and she was encouraged to practice it. She was educated and encouraged to allow the baby to
completely empty one breast before giving the other breast to the baby. She was educated to
avoid the use of herbs and other medications in dressing the cord to prevent infection. She was
told to use only the methylated spirit given to her to dress the cord. She was encouraged to
always keep the cord dry. Madam Josephine was told not to apply any hot water to the baby’s
fontanelles since they will close by themselves when the time is due. Mother was also educated
and encouraged to eat a well-balanced diet and also to take her routine medications given as
well, in order to help in lactation.
4.3 FIRST DAY POST DELIVERY
On 15th July 2018, was Madam Josephine’s first day post-delivery. Client woke up healthy
and cheerfully looking. All procedure to be carried out on both mother and baby were
explained. Perineal pad was inspected for the flow of lochia which was small and red
(rubra) in color with no odor. Mother then took a warm bath and was served with porridge
and bread. Permission was sought from client and head to toe examination was done with
no abnormalities detected. The uterus was well contracted and the symphysiofundal height
was 14 centimeters. Client vital signs were checked and recorded as,
Temperature 36.8 degree Celsius,
Respiration 24circles per minute
43
The baby was then wrapped in a clean and warm cot sheet and handed over to the mother for
breastfeeding with which Madam Josephine properly positioned and attached the baby to
breast. Mother was then served with her second dose of 200,000 I. U of vitamin A supplement.
Client was reminded on the intake of nutritious diet, fruit and frequent breastfeeding of the
baby. Education was given on the change of perineal pad when soiled and the need to wash
her hands after removal and before breastfeeding the baby to prevent infections. Client was
also educated on postnatal exercises such as Kegel, ambulation and family planning as well as
exclusive breastfeeding, change of napkins frequently, wash and dry them in sun and keeping
the baby warm always. The baby was given oral polio vaccine and Bacillus Chalmette Guerin
(BCG) vaccine intra-dermally at the right upper arm at the child welfare clinic. Madam
Josephine was educated not to apply anything on the injection site, she was also told that the
baby may have slight fever and swelling at the site of injection which would subside.
Madam Josephine was given the following drugs;
Tablet folic acid 5mg tablet daily for 10 days
Tablet ferrous sulphate 200mg tablet daily for 10days
Tablet multivitamin 200mg tablet daily for 10 days
Tablet paracetamol 1g tids for 5days
Client was discharged and was helped to pack belongings after serving medications. Her
hospital bills were settled by the National Health Insurance Scheme. Client was accompanied
home and a day was scheduled to visit them. Client was congratulated and bade farewell.
4.4 FIRST HOME VISIT EVENING OF DISCHARGE
On the 15th of July 2018, a visit was made in the evening to Madam Josephine’s house. They
were found in good health. All procedures to be carried out on both mother and baby were
explained. Perineal pad was inspected for the flow of lochia which was small and red (rubra)
44
in colour with no odour. Permission was sought from client and head to toe examination was
done with no abnormalities detected. The uterus was well contracted on palpation. Symphysio
fundal height was 13cm. Client’s vital signs was checked and recorded as follows;
Blood pressure 120/80 millimetres of mercury
The values recorded for the baby were;
Apex heart beat 130 beat per minute
Respiration 30 cycles per minutes
They were very happy after a little interaction where they were informed of the next visit and
thanked me for the visit as they escorted me outside the house.
4.5 SECOND POSTNATAL HOME VISIT
On the 16th July 2018 at 4:15pm, Madam Josephine and family were visited as promised. Client
was at home with husband and children on arrival. General health condition of mother and baby
was good. Client was examined from head to toe and nothing abnormal was detected. Breast
was lactating well; lochia was red and the flow was small with no offensive odor. On palpation,
the uterus was well contracted and the symphysiofundal height was 12 centimeters. Vital signs
checked and recorded were;
Temperature 36.8degree Celsius
45
The baby was toped and tailed the cord was dressed with cotton wool swab and methylated
spirit. Head to toe examination was performed with no abnormalities detected. The baby was
wrapped and breastfed. Client lower abdominal pain had subsided when enquired but
complained of fatigue and back ache. She was reassured and advised to have warm bath before
bed and rest in a noise free environment and also limit time spent with visitors during the day.
The baby’s vital signs were checked and recorded as,
Temperature 36.8degree Celsius
The mother was educated to avoid applying hot compresses on the fontanels with the intentions
of healing a wound. It was explained to her family that the fontanelles will naturally close.
Client was also advised to keep the baby warm always and not to expose the baby to cold
weather. The baby’s weight was checked and recorded as 3.6kg. The surrounding was neat and
she was congratulated and encouraged to keep it up. She was thanked for cooperation and
permission was sought to leave and return the following day.
4.6 THIRD DAY POST NATAL HOME VISIT
On 17th July 2018, the second visit was made to Madam Josephine’s house around 4:00pm in
the evening. Madam Josephine said her condition had improved, lower waits pain and fatigue
46
has subsided and baby was also breastfeeding well. Permission was sought to examine both
mother and baby. Head to toe examination was carried out on her and no abnormalities were
detected. The perineal pad was inspected and the flow of lochia was small and red in color
(rubra) which was not offensive. The symphysio fundal height was 10 centimeters. Her vital
signs were checked and recorded as follows;
Temperature 36.6 degrees Celsius
Blood pressure 110/70millimeters of mercury
The baby was examined from head to toe and there was no abnormality, the mother complained
of fullness of the breast and also inadequate sleep due to frequent breastfeeding in the night.
Mother was reassured and encouraged to sleep during the day time and also the need to take
nutritious diet. Mother was educated to continue breastfeeding. The cord was dressed with
cotton wool swab and spirit and the mother was educated not to apply any herbs on the cord.
The baby was examined again and cord dressed after bathing. The baby’s weight was checked
and recorded as 3.6kg, vital signs was recorded as:
Temperature 36.4 degrees Celsius
47
Permission was sought to leave and Client said she was very grateful and appreciated the care
that was given to them.
4.7 FOURTH DAY POSTNATAL HOME VISIT
Madam Josephine was visited at home on the 18th July 2018 to know how she is faring at
4:10pm. Greetings were exchanged and permission was sought to inspect client’s perineal pad
and it was pink, moderate in flow without any offensive smell. Her breasts were lactating well.
Symphisio Fundal height 8 centimeters. Her vital signs were checked and recorded as follows;
Temperature 36.2degrees Celsius
The baby was bathed and general examination was carried out and no abnormality was present.
The cord was neatly dressed with no abnormality detected. The baby also passed stool and
urine. Baby’s weight was checked and recorded as 3.8kg. Baby’s vital signs were taken and
recorded as follows;
Respiration 36cycles per minute
48
4.8 FIFTH DAY POSTNATAL HOME VISIT
On the 19th of July 2018, the next home visit was made to the client’s house. They were found
in good health and the family was congratulated for taking good care of the baby. Client said
fullness of breast was better and had no complaints. Client was encouraged to continue sleeping
during the day time and also the need to take in nutritious diet. Baby was given warm bath and
the cord however went off on this day. Vital signs recorded on this day were as follows;
Blood pressure 120/80 millimetres of mercury
Symphysio-fundal height 7centimeters
The values recorded for the baby were;
Weight 3.7 kilograms
They were very happy after a little interaction and thanked me for the visit as they escorted me
outside the house.
49
4.9 SIXTH DAY POSTNATAL VISITS
Madam Josephine and baby were visited again on the sixth day postnatal, 20th July, 2018. Their
general health was good, head to toe examination was done and there were no abnormalities
detected. Client lochia was pink in color (serosa) with moderate flow and not offensive. Client
was asked if she was able to sleep for six hours within the two days which madam Josephine
answered positively. The symphysio-fundal height was measured to be 5 centimeters and the
vital signs checked and recorded on the sixth day were as follows;
Pulse 89beat per minute
Blood pressure 120/80millimeter of mercury
The baby was also free from any abnormality and the cord stump when dressed was dry and
clean. The baby's vital signs were checked and recorded
Weight 3.8 kilogram
Client said the fullness of breast had relieved. she was encouraged to continue applying cold
compresses on the breast and put on a well-fitting brazier. She was again encouraged to breast
feed the baby frequently. Madam Josephine was thanked and told of the last home visit.
4.10 SEVENTH DAY HOME VISIT
The seventh day postnatal home visit was done on 21st July 2018 at 4:30pm. Greetings were
exchanged with client and her family and a seat was offered in client’s room. Mother and baby
were both in a healthy condition. On head to toe examination, no abnormalities were detected.
50
Her breast was lactating well. The Fundal was not palpable. Inspection of the lochia was done
and the color was pink (serosa) without any bad odor. The baby was examined after bathing
and dressing of the umbilical stump was done. The wound had healed.
Client’s vital signs were checked and recorded as follow
Pulse 88beats per minute
Baby’s vital signs were taken and recorded as follows:
Apex heart beat 134 beats per minute
Weight 3.8 kilogram
The baby was dressed and handed over to the mother for breastfeeding. Emphasis was made
on her perineal care and the intake of nutritious diets as well as avoiding the use of hot
application on the fontanelles. Client was encouraged to continue exclusive breastfeeding for
6 months. It was further explained that the exclusive breastfeeding could serve as a family
planning method. Mother was reminded of the 1st postnatal visit to the clinic and its
importance and also the need to immunize the baby at the child welfare clinic against the
childhood preventable disease. Client was told to report to the hospital when there was any
problem as soon as possible and also made her aware that, the day was my last visit to her
51
house, Madam Josephine was thanked with the entire family for their cooperation and I
departed.
4.11 FIRST DAY POST NATAL VISIT TO THE CLINIC
On the 22nd July 2018, Madam Josephine came to the clinic for the first postnatal visit. Both
mother and baby were fine and neatly dressed. Every procedure to be carried on client was
explained to her; vital signs were checked and recorded as follows;
Blood pressure 120/80 millimeters mercury
Weight 60kg
The client was given a specimen bottle to collect midstream urine to test for protein and glucose
and they tested negative. Client was asked to lie on a bed for head to toe examination. On the
head, the hair was neatly dressed. The eyes were free from discharges and the conjunctiva was
not pale and no jaundice noted. The ears were also free from discharges.
The breast was examined and there was no mass, engorgement or sore nipple. There was no
tenderness, enlarged liver or spleen when the abdomen was palpated and the uterus was no
more palpable. The extremities were inspected and no abnormalities were detected. The vulva
was examined for infections, scars and lochia but none was present. The baby was taken from
the mother with permission and examined from head to toe and nothing abnormal was detected.
The baby's vital signs were taken and recorded as follows;
52
Weight 4.0 kilogram
After the examination, client was educated on the need to wash hands before attending to the
baby and was also reminded on various types of family planning methods and emphasized on
the need to feed the baby exclusively. They were reminded on the second postnatal visit to the
clinic on the 6th week or 40 days post-delivery. Madam Josephine was also encouraged to
register the baby at the birth and deaths registry. Client and her baby were handed over to the
midwife in -charge for continuity of care and was thanked for her co-operation throughout the
care.
4.12 SIXTH WEEK POSTNATAL VISIT TO THE CLINIC
According to the midwife in charge on the 25thof August 2018, Madam Josephine came to the
clinic for sixth week postnatal visit. She was warmly welcomed. Both mother and baby were
all looking very healthy. General examination was conducted from head to toe on both mother
and baby. Their vital signs were checked and recorded as follows:
Blood pressure 100/70 millimeters mercury
Weight 60kg
The client was given a specimen bottle to collect midstream urine to test for protein and glucose
and they tested negative. Client hemoglobin level was 11.5gram per deciliter. Client was asked
to lie on the couch for head to toe examination. On the head, the hair was neatly dressed. The
eyes were free from discharges and the conjunctiva was not pale and no jaundice noted. The
ears were also free from discharges. The breast was examined and there was no mass,
53
engorgement or sore nipple. There was no tenderness, enlarged liver or spleen when the
abdomen was palpated and the uterus was no more palpable. The extremities were inspected
and no abnormalities were detected. The vulva was examined for infections, scars and lochia
but none was present. The baby was taken from the mother with permission and examined from
head to toe and nothing abnormal was detected. The baby's vital signs were taken and recorded
as follows;
Weight 4.7 kilogram
After the examination, client was thanked for her co-operation throughout the care and also
educated on the need to bring the baby to clinic for immunization on the appointed date.
4.2 CARE PLAN DURING POST PARTUM PERIOD
PROBLEM IDENTIFIED
1. Client complained of after pains
2. Client complained of fatigue
3. Client complained of back ache.
4. Client complained of fullness of breast (Potential for breast engorgement)
5. Client complained of inadequate sleep
54
1. After pains will be reduced within 72hours
2. Client will be relieved of fatigue within 48 hours.
3. Client’s back ache will be reduced within 48 hours.
4. Client will empty the breast completely at each feed within 48hours
5. Client will sleep at least 1 hours in the day and 6hours in the night within 72 hours.
LONG TERM OBJECTIVE
Client will go through puerperium successfully without any complication to both mother
and baby.
DATE/ NURSING NURSING NURSING NURSING DATE/ EVALUATI SIGN

TIME DIAGNOSIS OBJECTIVE/ ORDERS INTERVENTION TIME ON
OUTCOME
CRITERIA
14/07/18 Altered body After pains 1. Reassure 1. Client was 17/07/18 Goal fully
4:00pm comfort (after will be client the reassured by 4:00pm met as client
pains) related reduced within pain she explaining the said that the
to uterine 72 hours as temporal. Physiology of after pain has
involution evidenced by 2. Encourage pains. reduced and
client client to void 2. Client voided midwife
verbalizing frequently. frequently to witnessing
that the pain 3 Encourage prevent the growth client with
has subsided client to of microorganisms relaxed facial
and midwife breastfeed and the spread of expression
witnessing that frequently infection.
client is and on 3. Client breastfed
feeling demand. frequently and on
comfortable. demand and
4. Encourage completely
client to emptied one breast
55
gently before giving the
massage the other.
lower 4. Client gently
abdomen. massaged the
5.Encourage lower abdomen
client to lie during pain.
with her face 5.Client slept with
down and her face down with
with pillow pillow under her
under her abdomen to
abdomen minimize pain
6. Give 6. Client took

client paracetamol 1g
paracetamol before
1g 30 breastfeeding
minutes
before
breastfeeding
to reduce
pain.
56
DATE/ NURSING OBJECTIVE/ NURSING NURSING DATE/ EVALUA SIGN
TIME OUTCOME ORDERS INTERVENTION TIME TION
DIAG CRITERIA
NOSIS
16/7/18 Backache Client 1.Reassure 1.Client was 18/7/18 Goals

related to backache will client she reassured she will 4:15pm fully met
4:15pm
poor posture reduce within will be be relieved of as
during 48 hours as relieve of backache evidence
breastfeeding. evidence by backache by client
client 2.Client was verbalizin
verbalizing 2.Encourage encouraged to g that
that her client to assume good backache
backache has assume posture when has
subsided good breastfeeding subsided
posture
when 3. Client was
breastfeedin encouraged to
g apply cold pack at
the area
3.Encouage
client to 4.Client was
apply cold encouraged to
pack at the massage the area
area gently
57
4.Encourage 5.Client was
client to encouraged to
gently place pillow at the
massage the back when sleeping
area
5.Encourage
client to
place pillow
at the back
when
sleeping
58
DATE/ NURSING NURSING NURSING NURSING DATE/ EVALU SIG
TIME DIAGNOSIS OBJECTIVE/ ORDERS INTERVENTION TIME ATION N
OUTCOME
CRITERIA
16/07/18 Fatigue Client’s fatigue 1. Reassure 1. Client was told to 18/07/18 Goal
4:15pm related to will be resolved client about rest when baby is 4:15pm fully met
stresses of within 48 hours recovery of asleep. as client
labour. as evidenced by her condition. 2. The client rested verbalize
the client 2. Explain the during the day in d she was
verbalizing that, need to have between activities relieved
she is relieved of enough rest. 3. She rested of stress
body discomfort 3. Encourage whenever baby was and
and midwife client to rest asleep. midwife
witnessing client when her witnessin
has no signs of baby is 4. Client slept in a g client
fatigue. asleep. noise free showed
4. Encourage environment and no signs
client to visitors were of
ensure noise restricted tiredness
free
environment 5.Madam Josephine
had a warm bath
5.Educate the before resting since
client to have it will induce sleep
a warm bath and make her feel
before resting comfortable
6.Support person
6.Encourage did most of the
client support house hold chores
person to help to enable client
with the house have enough rest
hold chores
59
DATE/ NURSING NURSING NURSING NURSING DATE/ EVALUA SIGN
TIME DIAGNOSIS OBJECTIVES/ ORDERS INTERVENTION TIME TION
OUTCOME
CRITERIA
17/7/18 Breast Client will empty 1.Reassure 1.Client was told 19/7/18 Goal fully
4:00pm engorgement the client that her condition is 4:00pm met as
related to breast she will be temporal client
inability to completely at relieved of verbalized
empty breast each feed within her 2. Client ensured the breast
completely. 48hours as condition the baby emptied was
evidenced by one breast before completely
1. Client 2.Educate breastfeeding with emptied
verbalizing client to the other breast. and
that she feels ensure the midwife
comfortable baby 3.Client positioned witnessing
in her breast complete baby well when the client
and emptying breastfeeding showed no
2. Midwife one breast signs and
visualizing that 4.Client had good symptoms
client has no 3.Educate brassier on to of
signs and client on support the breast engorged
symptoms of how to breast
breast position 5. Client expressed
engorgement. baby well the breast milk after
when feeding when breast
breastfeedi was not emptied.
ng
4.Encourag
e the client
to support
the breast
with good
brazier or
60
breast
binder
5.
Encourage
client to do
gentle
manual
expression
of the
breast if
breast is not
emptied
after
feeding.
61
DATE/ NURSING OBJECTIVE/ NURSING NURSING DATE/ EVALUATION SIGN
TIME DIAGNOSI OUTCOME ORDERS INTERVENTIO TIME
S CRITERIA N
22/7/18 Sleeping Client sleeping 1. Encourage 1.Client was 24/7/18 Goal fully met
client to have
patterns pattern will be encouraged to as client
8:00am enough rest 8:00am
disturbances restored during the have enough rest verbalizes that
day when the
(inadequate (8hours) within during the day she is able to
baby is
sleep) related 48 hours as asleep. when baby is sleep.
to night evidenced by asleep.
2. Educate
breastfeeding client client to 2.Client was
breastfeed
verbalizing educated to
baby to her
that she is able satisfaction. breastfeed baby to
to sleep. her satisfactory.
3. Encourage
her relatives 3.Client relatives
to help her
were encouraged
with the
house hold to help her in the
chores.
house chores
4. Encourage 4.Client was
the client to
encouraged to
have warm
bath in the have a warm bath
evening
in the evening
before going
to bed. before going to
bed.
5. Serve
prescribed 5.Prescribed
medication.
medication was
served.
62
SUMMARY AND CONCLUSION
This family and client centered maternity care study was conducted on Madam Serwaa Boateng
Josephine, a 28 years old woman, who is gravida 3 para 2 all alive. She was met at Blessed Family
Maternity Home/Clinic, Twabidi no1 in the Brong Ahafo Region. The client was 39week gestation
when she was met on 27th June 2018. Client hails from Ashanti-Mampong, krobo, in the Ashante
Region but resides at Adukuma kurom.
Various observations and examination including laboratory investigations were carried out to aid
in the progress of normal pregnancy, labour and puerperium. She went through some minor
disorders during pregnancy which were managed successfully. Madam Josephine’s labour and
delivery were carefully managed without any complications and she delivered an alive female
child on the 14th of July 2018 at Blessed Family Maternity Home/Clinic, Twabidi no1.
After delivery, she experienced backache, fullness of breast and after pain among others as some
disorders associated with puerperium. She was managed accordingly and they resolved within the
shortest possible time. Our interaction at the postnatal clinic ended on the 22nd of July, 2018 and
She was handed over to the midwife in charge of the facility.
All postnatal visits to the house and subsequent visit to the clinic by the client were done and all
examinations were conducted on both mother and baby. Client, her baby and the entire family
were handed over to the public health nurse in her community for continuity of care.
This client /family centered maternity care given has enabled me gain much experience about the
importance of proper client management during pregnancy, labour and puerperium.
63
It has also helped me to improve my skills as a student midwife in planning, interviewing,
implementing, setting objectives and evaluating them to solve client’s problems identified.
I end it all by saying that, the care study is an important and managerial tool in which theoretical
knowledge could be put into practice and deal with maternity problem as midwifery professionals.
BIBLIOGRAPHY
Antenatal Records Book
Dutta, D.C. (2011). Textbooks for obstetric (7th ed). London: New central Books Agency
Limited.
Myles, M. (2016). Textbook for midwives. london: elsevier limited.
Ghana Health Service (2008). National Safe Motherhood Service Protocol. Accra: Ministry of
health.
Henderson, C.& Macdonald, S. (2011). Mayes Midwifery a textbook for midwives.
London: Elservier limited.
Marshall, J. & Raynor, M. (2014). Myles textbook for midwives. london: elsevier limited
Ojo, O.A (1982). Textbook for midwives in the tropics. New Delhi: Hodder Arnold Medical
Publishers limited
64
Tiran, D. (2008). Baillieres Midwives Dictionary (11thed, pg 183) London: International Book
Manufacturing limited.
Verrals, S. (2008). Anatomy and physiology applied to obstetric (3rd ed). Pitman publishing
limited.
APPENDIX I
COMPLETE DIAGNOSTIC INVESTIGATION
DATE SPECIMEN INVESTIGATION NORMAL VALUE FINDING REMARKS
13/1/18 Urine Sugar Negative Negative Normal

protein Negative Negative Normal
Blood Hemoglobin level 11-16g/dl 14.1g/dl Normal
Sickling Negative Negative Normal
Grouping A, B, AB, O O Normal
Rhesus factor Positive/negative Positive Normal
HIV/AIDS Negative Negative Normal
Hepatitis Negative Negative Normal
Syphilis(VDRL) Negative Negative Normal
G6PD Normal Normal Normal

Blood Hemoglobin level 11-16g/dl 13.3g/dl

12 /4/18 Urine Sugar Negative Negative Normal

Blood Hemoglobin level 11-16g/dl 13.3g/dl normal
65

protein Negative Trace Normal

Blood
Hemoglobin level 11-16g/dl 13.2 Normal

Blood Hemoglobin level 11-16g/dl
13.3g/dl Normal
66
APPENDIX II
PHARMACOLOGICAL DRUGS FOR MOTHER
NAME OF CLASSIFICATION ROUTE DOSAGE ACTUAL SIDE SIDE EFFECT

DRUG EFFECT EFFECT EXPERIENCED
Tablet folic acid Vitamin preparation Oral 5mg daily Maturation of Nausea None
for 30days red blood and
cells vomiting
Tablet Vitamin preparation Oral 200mg Increased Gastroint None
Multivitamin daily for appetite estinal
30days irritation
Tablet ferrous Iron preparation Oral 200mg Formation of Abdomin None
sulphate daily for red blood al
30days cells discomfo
rt,
diarrhea
dark stool
Tablet Anti-malaria and Orally 3 tablet stat Prevent Itching, None
Sulphadoxine prophylaxis from 16 malaria in vomiting,
pyrimethamine weeks pregnancy nausea
intervals/qui
ckening and
the 2nd and
3rd doses in
4 weeks
interval but
not after 36
weeks
Tetanus toxoid Anti-tetanus Subcutan 0.5miligram Prevention of Slight None
injection eous tetanus fever and
chills
Oxytocin Oxytocic drug Intramusc 10units Increase Hypotens None
ular contractions ion and
hyper
stimulati
on
Vitamin A Group A vitamin Oral 200000unit Growth Vomiting None
supplement once daily development,
prevent
infection and
blindness
67
Tablet Analgesic Oral 500mg Relieve pain Liver None
paracetamol damage
with
prolong
use
APPENDIX III
PHARMACOLOGICAL DRUGS FOR BABY
NAME OF CLASSIFICATION DOSAGE ROUTE ACTUAL SIDE SIDE EFFECT
DRUG EFFECT EFFECT EXPERIENCED
Vitamin K Group K vitamins 1milliliter Intramuscular Production Hypersensiti None
of ve reaction
prothrombin
that aids in
clotting
Gentamycin Antibiotics 2 drops Instillation To prevent None None
eye drop eye infection
Oral Antigen vaccine 2 drops Orally Gives Diarrhea, None
Poliomyelitis immunity fever
against
poliomyelitis
Injection Antigen vaccine 0.5 ml Intradermal Production Blister Blister was
Bacillus of antibodies formation formed
Chalmette and and slight
Guerin prevention fever
of
tuberculosis
68
NAME OF CLASSIFI- DOSAGE ROUTE ACTION/ ACTUAL SIDE SIDE
DRUG CATION USES EFFECT EFFECT EFFECT
EXPERIENC
ED
Pneumo Antigen 0.5 Intramuscularly Vaccinates Pneumonia Redness None

coccal neonates prevention at the observed
milligram against side of
pneumonia injection
and fever
5 in 1 Antigen 0.5 Intramuscula- Vaccinates Prevention Low None
vaccine milligram rly neonates of grade observed
(Pentavalent) against childhood fever
diphtheria, preventable
pertussis diseases
(whooping
cough),
tetanus,
hepatitis B,
heamophilu
s influenza
type B
Rota virus Antigen 1.5 Orally Prevention Gastroenter None None
millligra of itis observed
ms gastroenterit prevention
(2 drops) is
69
APPENDIX IV
ANTENATAL CHART
Date Weigh Blood Urine Gestat Fundal Presentation Descent Fetal Complains Treatment Name
t pressure Protein ional height heart rate and
(kg) (mmHg) Sugar age (cm) signature
13/1/ 68 120/70 Negative/ 16 16 - 5/5 Mild No Tablet
18 Negative movement complain (Multivit, folic
acid, ferrous
sulphate
13/2/ 69.5 100/60 Negative/ 20 20 - 5/5 positive No Tablet
18 Negative complain (Multivit, folic
acid, ferrous
sulphate,
Sulphadoxine
Pyrimethamine)
13/3/ 71 110/60 Negative 24 25 cephalic 5/5 positive General Tablet
18 /negative body (Multivite, folic
weakness acid, ferrous
sulphate,
Sulphadoxine
Pyrimethamine)
12/4/ 69 110/60 Negative/ 28 28 Cephalic 5/5 146beat General Tablet
18 negative per minute body (Multivite, folic
weakness acid, ferrous
sulphate,
Sulphadoxine
Pyrimethamine)
12/5/ 69 120/60 Trace 32 31 Cephalic 5/5 138 Nil Tablet
18 /Negative (Multivite, folic
acid, ferrous
sulphate,
Sulphadoxine
Pyrimethamine)
12/6/ 73 110/60 Negative 36 34 Cephalic 5/5 132 Nill Tablet(Multivit,
18 folic acid,
ferrous
sulphate,
Sulphadoxine
Pyrimethamine)
70
27/6/ 75 120/60 Negative 38 37 Cephalic 4/5 140 Insomnia ,
18 anorexia, Tablet(Multivit
frequency e, folic acid
of ferrous
micturition sulphate,)
5/7/1 77 110/80 Negative/ 39 38 Cephalic 4/5 142 Lower Tablet
8 negative abdominal (Multivit, folic
pains , acid, ferrous
constipatio sulphate
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85

Matilda Durowaa Hinneh

Hochgeladen von

Dokumentinformationen

Originaltitel

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Matilda Durowaa Hinneh

Hochgeladen von

Copyright:

Verfügbare Formate

CHAPTER ONE

1.1 PERSONAL AND SOCIAL HISTORY

1.2 FAMILY HISTORY

1.4 SURGICAL HISTORY

1.5 MENSTRAL HISTORY

1.6 HABBIT OF DAILY LIVING

1.8 PRESENT OBSTERIC HISTORY

Tablet multivitamin 200mg Tid for 30 days

2.1 FIRST CONTACT WITH CLIENT

recorded as 58 kilograms and 11.5gram per deciliter respectively.

Her vital signs and other investigations were recorded as follows;

Temperature - 36.2 degree Celsius

Respiration - 20 cycles per minute

Blood pressure - 110/80 millimeter of mercury

includes inspection, palpation and auscultation.

well as enlarged spleen and liver but no abnormalities were detected.

Measuring of symphysiofundal height;

indicating the buttocks.

Descent of fetal head

drugs were prescribed for her.

Tab folic acid 5mg daily for 10 days

Tab ferrous sulphate 200mg daily for 10 days

Tab Multivite 200mg daily for 10 days

clinic any time she encounters any problem.

2.2 FIRST ANTENATAL HOME VISIT

the other members of the house.

relationship with the other family members.

2.3 SUBSEQUENT HOME VISIT

and transportation to the clinic when in labour.

2.4 SUBSEQUENCE VISIT TO THE CLINIC

Temperature 37.2 degree Celsius

Blood Pressure 110/80mmhg

taking the routine drugs that were given to her previously.

2.5 CARE PLAN DURING ANTENATAL

4. Lower abdominal pain

SHORT TERM OBJECTIVES

during the day within 48 hours.

3. Client will be able to regain her eating pattern within 48 hours.

5. Client’s will regain her normal bowel habit(1daily) within 48 hours.

complications to her and her baby.

DATE/ NURSING OBJECTIVE/OUTCOME NURSING NURSING DATE/ NURSING SIGN

DATE/ NURSING OBJECTIVE/OUTCOME NURSING NURSING DATE/ NURSING SIGN

DATE/ NURSING OBJECTIVE/OUTCOME NURSING NURSING DATE/ NURSING SIGN

DATE/ NURSING OBJECTIVE/OUTCOME NURSING NURSING DATE/ NURSING SIGN

client on the intake of more

intake of more fluids.

monitoring of mother and baby.

3.1 ADMISSION AND MANAGEMENT OF FIRST STAGE OF LABOUR

checked and recorded as follows;

Temperature 36.2 degree Celsius

Pulse 89 beats per minute

Respiration 20 cycles per minute

Blood pressure 110/86 mm/hg

since full bladder could slow down progress of labour.

the perineal area.

Pressure was 110/60mmHg, Temperature was 35.1Oc.

checked every four (4) hours and recorded on the partograph.

were checked and recorded as below

Temperature 35.9 degree Celsius

Pulse 88 beat per minute

Respiration 22 cycles per minute

Blood Pressure 130/80 millimeter of mercury

At exactly 11:30am, client complained of bearing down sensation so another vaginal