OBSTETRIC CASE STUDY ON MULTIPLE PREGNANCY

CHAPTER ONE

INTRODUCTION

A case study is defined as a detailed analysis of a group, person or situation, especially as a model of medical phenomenon, over a period of time, with a view to develop the person, group or situation under study. In the case of gynaecology and obstetrics, it is a study of obstetric and/or gynaecological or medical conditions that can endanger the life of the mother, baby or both, and it is done over a specified period of time. It is an in-depth analysis and systematic description of one patient or group of similar patients to promote understanding of nursing interventions (BT Basavanthappa, 2014)

A case study has the following significances to the study of Midwifery:

Ø The student midwife and/or midwife develops confidence to face challenges related to problem solving.

Ø Case studies enhance critical thinking towards problem-solving strategies. Meaning, the student/midwife will better up their skills to analyze and decide on action, and evaluation of actions undertaken.

Ø Case studies facilitate for an improved clinical judgment of situations, and making quick adjustments to interventions regarding the situations under study.

Twin pregnancies are the result of a complex interaction of genetic and environmental determinants. Their frequency is now increasing, after a decreasing trend lasting 30–40 years. To explain these trends, maternal age, parity, race, nutrition, fecundity and, for the increasing trend particularly the use of fertility drugs, have all been associated with the risk of pregnancy. The role of these factors, however, may differ for dizygotic (DZ) and monozygotic (MZ) pregnancies, and in different populations.

Available epidemiological evidence on risk factors for multiple births is scanty and partially controversial (Landy and Keith, 1998).

Over the past two decades, an epidemic of multiple pregnancies has taken place in the developed world due to the widespread use of assisted reproductive technology. The general public has come to accept the phenomenon of higher order multiple as being a normal occurrence, expecting a good outcome for both the foetuses and the mother. However, physicians caring for these patients appreciate that these pregnancies have an increased number of complications both for the mother and foetus. The mother suffers substantial morbidity not just due to the risk and interventions of prematurity but also the increased incidence in medical complications. The foetuses are at jeopardy not just due to premature delivery, but also the increased rates of anomalies in multiples, and those complications uniquely associated with multiples, such as twin to twin transfusion syndrome.

The incidence of twin pregnancy varies from country to country, the highest rates being reported in Nigeria, and the lowest in Japan (Golding, 1990).

It is needful to incorporate case studies to midwifery training for the following reasons:

Ø The student midwife and/or midwife develop confidence to face challenges related to problem solving.

Ø Case studies enhance critical thinking and problem solving strategies.

Ø It helps student midwives to better up skills to analyse and decide on actions, and evaluation of actions taken.

Ø Case studying helps to improve on clinical judgment of situations and making quick adjustments to interventions regarding the situation(s) under study.

CASE OVERVIEW

Multiple pregnancies are a type of pregnancy in which a woman has two or more foetuses developing in utero at the same time. It occurs by simultaneous release and fertilization of two or more ova, by one or more spermatozoa, or by early division of a single fertilized ovum. Foetuses that come from the same ovum are referred to as identical. This happens when one egg is fertilized by the same sperm.

There are different types of multiple pregnancies:

Ø Twin – two (2) foetuses are developing, has the most common incidence (98%).

Ø Triplets – three (3) foetuses are developing.

Ø Quadruplets – four (4) foetuses.

Ø Quintuplets – five (5) foetuses.

Ø Sextuplets – six (6) foetuses.

Ø Septuplets –seven (7) foetuses.

Ø Octuplets – eight (8) foetuses.

Multiple pregnancies have a tendency to run in families, and especially, in women with a history of infertility treatment, which causes a stimulation of ovary production.

GENERAL OBJECTIVE

At the end of the case study I should be able to acquire knowledge and understanding on the management of multiple pregnancy.

SPECIFIC OBJECTIVES

1. Define multiple pregnancy

2. Outline the professional information and support to the women and her family from the time diagnosis is made until the babies are 6 weeks old.

3. Explain the prevention of complications that may arise during pregnancy.

4. Ensure that the client has a safe delivery to live mature infants without complications.

5. Explain the individualized nursing care that will be given to the client with special consideration of her physical, psychological, economical and social support.

6. Outline an ideal relationship within the family which would foster participation by all family members in the care of the client and the babies.

7. Outline the follow up care antenatally and postnatally which will be provided.

HOW I MET MY CLIENT

I met my client on the 3rd of April 2018, during her admission to the hospital – Maternity B ward. I was allocated to the same ward.

She is Gravida 3 and Para 2. She is aged 27 years old. I have been following up case during her hospital stay, and happen to have loved it.

She was admitted to the hospital as a case of Malaria in Pregnancy. She was as well not a booked case for antenatal and so I was assigned to book her and prepare for her an antenatal card. It was during booking that I learnt that she was a suitable client for a case study, to follow up her case of malaria.

Mrs. E. N. B was then booked for obstetric ultra sound scan to confirm the gestational age by the Doctor. On 4th April 2018, I took her for scan, for which results turned out to be a multiple pregnancy with two live foetuses developing in utero. Consequently, my case changed from Malaria in pregnancy to multiple (twin) pregnancy.

CLIENT PROFILE

This case study is about Mrs. E. N. B. who is in 2nd trimester of pregnancy. She is Gravida 3 Para 2, and was diagnosed with multiple pregnancies (twin pregnancy).

SOCIAL HISTORY

NAME	E.N.B
AGE	F/27 Years old
ADDRESS	house number 1866, Toka Road, Kabushi
MARITAL STATUS	Married
EDUCATIONAL LEVEL	Grade 9
OCCUPATION	Business lady (Salaula)
EDUCATION LEVEL (SPOUSE)	Grade 12
OCCUPATION SPOUSE	Business man owns a bar
RELIGION	Christian (Seventh - day Adventist)
TRIBE CULTURAL TABOOS	Nothing that she knows.
SOCIAL HABITS	She does not take alcohol or smoke.
NEXT OF KIN	Mr. B. A – Husband

There is nothing significant to the condition under study from the above information. However, it helps in client identification, as well as establish basis for Information, Education and Communication (IEC). We could communicate in English and Bemba with the client.

ENVIRONMENTAL HISTORY

ACCOMODATION

Mrs. E.N.B. and family stay in a three roomed house which is divided as a bedroom, kitchen and seating room. The rooms have medium-sized windows. The occupants are six (6) in total; two (2) children, two (2) dependants and the couple. The house is lit by Zambia Electricity Supply Company (ZESCO). The client is not at risk of Respiratory Tract Infections which can be due to poor ventilation, or overcrowding in the house.

WATER SUPPLY/SANITATION

My client has a tap within the yard, with running water supplied by Kafubu Water and Sewerage Company. She boils her drinking water and sometimes chlorinates it. She has well prepared and kept buckets which are used for the purpose of storing their drinking water.

She uses a pit latrine, which is constructed at a good distance from the main house westwards. The toilet is kept clean and covered. The bath shelter is constructed alongside the Pit latrine. She does not have any risk of diarrhoeal diseases.

REFUSE DISPOSAL

Mrs. E. N. B. has a rubbish pit dug away from the house westward, opposite the toilet/bath shelter. She burns the combustible waste in the rubbish pit. And if the pit gets full, she buries the pit and has another one dug. My client therefore is not at risk of diarrhoeal diseases arising from flies that would be flying from poorly managed domestic waste.

SURROUNDING

Her surroundings are well kept clean by sweeping. She stays on well-sized plot. She has two trees: Mango and Lemon within the plot. She has adequate space for a backyard garden, which would facilitate for growing of vegetables, thus reducing costs of buying vegetables from the market almost on a daily basis. No risk of environmental factor that contribute to disease transmission (diarrhoeal).

FAMILY MEDICAL HISTORY

Her family medical history is free from ailments such as Diabetes Mellitus, Asthma, Hypertension, Mental illness, Sickle Cell Disease (SCD), Epilepsy. She also denied any exposure or contact with a person and/or family member that has had suffered from Tuberculosis (TB).

However, she a positive history of her elder brother having had twins, which history was directly linked to twin pregnancies in the family affecting the females.

No predisposition to the above ailments (but for the twins by her brother) that tend to affect pregnancy and pregnancy outcomes, and unborn baby.

PERSONAL MEDICAL HISTORY

My client has no history of any childhood illnesses and/or hospital admissions. She has never suffered from Hypertension, Diabetes Mellitus, Epilepsy, Psychosis, Sickle Cell Disease, Urinary Tract Infections (UTIs), chronic coughs or repeated attacks of Malaria (where the current attack was the first one during pregnancy). She has never suffered from Sexually Transmitted Infections (STIs). No actual risks of suffering from the above ailments during this pregnancy. Potentially, she may be at risk of, e.g. UTIs, because every pregnancy is unique.

SURGICAL HISTORY

Mrs. E. N. B. Has never had any trauma to warrant surgery to the spine, pelvic bones, or lower limbs, or even the abdomen. Trauma to structures such as the pelvis may alter with the pelvic diameters, which situation would lead to difficult or obstructed labour.

She has no history of Blood Transfusion, which treatment may be a predisposition to ailments such as Hepatitis B, HIV infections in the event of improperly screened blood, and Rhesus ISO- immunization if she a blood group variable that is negative.

MENSTRUAL HISTORY

My client attained menarche at the age of 13years. Her cycle regular takes 28days. The flow is normal and takes five/5 days from start to end of menses. She does not bleed between menses. She is not at risk of anaemia resultant from heavy and/or prolonged menses. Her fertility period was also determined.

CONTRACEPTIVE HISTORY

She expressed excellent knowledge on contraceptive methods. She used to use Depo- provera injectable. She just decided to stop and opted for implants, Jadelle in particular, since 2015. In 2017, September, she decided to have it removed because she intended to conceive.

PAST OBSTETRIC HISTORY

My client is Gravida 3, Para 2. The table below summarizes the past obstetric history

Year

Sex

Duration

Of pregnancy

Health during

Pregnancy

Mode of delivery

Birth

Weight

Health

Baby

Health

Puerperium

Mode of feeding

Duration of feeding

2008

Term

GOOD

SVD

3.1Kg

Alive

Good

EBF

5Months

2012

Term

GOOD

SVD

3.4kg

Alive

Good

EBF

4months

PRESENT OBSTETRIC HISTORY

Her last menstrual period was on 10th October 2017. There is no vaginal bleeding or draining in this pregnancy. The expected date of delivery is 17th July 2018, calculated as follows;

10 10 2017

+7 +9

17 19

-12

17 07 2018

The gestational age by dates will be calculated as follows:

Months	Weeks	Days
October	3	0
November	4	2
December	4	3
January	4	3
February	4	0
March	4	3
April	0	3
	23	14
*Gestational Age*	25	0

This history helps the provider to prepare adequately for management of the current pregnancy.

QUICKENING

My client first felt her fetal movements at 16 weeks. This is to help in the event that the client does not know or remember her Last Menstrual Period (LMP).

HEALTH DURING CURRENT PREGNANCY

My client’s health during this pregnancy has been good, except for the Malaria attack, which lead to her admission. She has had experience of danger signs in this pregnancy, such as draining of liquor, severe frontal headache, or vaginal bleeding.

There was no risk of complications during this pregnancy, but for the malaria and appropriate IEC was given.

HIV/AIDS KNOWLEDGE AND TESTING

She expressed adequate knowledge and understanding of what HIV/AIDS is, and asked to be tested during this pregnancy. She consented to counselling and testing and it was done instantly. The results came out negative. She was very happy. The testing was done on 3rd April 2018. There was no risk of HIV/AIDS in this pregnancy.

DIATARTY/NUTRITION STATUS

Mrs. E. N. B’s diet and/or nutrition this pregnancy is very simple. She eats usual food that everyone at home eats. She has preference, however, to vegetables such as Cassava leaves (Katapa), Kalembula, and Bondwe to be included always in her diet, for the benefit of iron found in these vegetables. She loves Nshima, too. She does not have craving for non-food substances such as soil. She does not have any dietary insufficiencies indicated.

MEDICATIONS

My client is currently on Anti-malarial treatment for the attack which led to her hospital stay; Artesunate 120mg intravenously at O (stat), 12hours, and 24hours -12hourly interval, the first day. Then to switch to Coartem on the subsequent days (3), given as 4tablets 12hourly. She was also started on Folic Acid 5mg once daily, Ferrous Sulphate 200mg once daily, Panadol 1000mg three/3 times daily for three days.

Malaria Parasite Slide (MPS) and Rapid Diagnostic Testing (RDT) were being done daily to check for clearance of Malaria Parasites. She was put back on Artesunate on the 4th day of her stay on the ward because the Parasites had not cleared. The mentioned doses were repeated, and the 5th day MPS results came out negative, and the drug was discontinued.

She was not on any other medication like Anti-hypertensive drugs. She does not use herbs for treatment of diseases. There was no risk of taratogenisity in this pregnancy.

TETANUS TOXOID IMMUNNIZATION

My client has not received all the five/5 required doses, but only three/3 doses as follows:

Dose	Year given
1^st dose	2005
2^nd dose	2008
3^rd dose	2012

She was given IEC on the importance of having to receive all the five/required doses. She was further encouraged to receive another dose during this pregnancy.

BIRTH PLAN

Before the diagnosis changed, she planned to deliver from Lubuto Clinic. But with the outcome of the Ultra sound scan, ordered on 3rd April 2018 and done on 4th April 2018, that she was carrying twins, a hospital delivery was indicated. Her Antenatal visits will also be done from the hospital.

She has a support person, being her elder sister. The children at home would remain with her young brother who is 21years old. She has been keeping some funds for emergency, and has been buying things in preparing for the birth of the baby. She has kept phone numbers for taxi drivers that she would call in case of emergency. The husband supports her financially. She is well prepared for the birth of her babies. And she has excellent knowledge on the danger signs of pregnancy.

PHYSICAL EXAMINATION

OBSERVATIONS URINALYSIS

Temperature : 36.90C Colour : Coca-cola

Pulse : 98bpm Smell : Aromatic

Respirations : 22bpm Amount : 50mls

Blood Pressure : 107/69mmHg Blood : Trace

Height : 167.2cm Leucocytes : 2+

Shoe Size : 7 Nitrates : Nil

Weight : 71.5Kgs Acetone : Nil

Albumin : Nil

My client’s urinalysis results are suggestive of a urinary tract infection, whereas the coca-cola colour is indicative of haemolysis of the red blood cells, secondary to the malaria infection which she had.

HEAD – TO – TOE EXAMINATION

Her general condition was excellent. She looked tidy and organized.

HEAD

The hair was well combed and of a good, and healthy texture. There was no malnutrition.

EYES

There was no Jaundice, pallor, oedema, abnormal discharges. There was no risk of eye infections and/or evidence of anaemia noted.

NOSE

No nasal bleeding, abnormal discharge, or nasal polyps.

MOUTH

On inspection, no cracked lips were noted, no dehydration. There was normal colour of the lips. No oral thrush, sores or dental caries was noted. She had very good oral hygiene.

EARS

My client was inspected for abnormal discharges and patency of the auricular meatus, there were no abnormalities were detected. On palpation for enlargement of the peri- auricular lymph nodes, nothing abnormal was noted. My client had no signs of infection on the head.

NECK

The neck was palpated for the enlargement of the cervical lymph nodes, submandibular lymph nodes or enlargement of the thyroid gland, there were no abnormalities detected. My client had no chronic infections in the upper chest. There was no goitre.

UPPER LIMBS

The upper limbs were both symmetrical and no obvious deformities were observed. On inspection of the palms, there were no signs of pallor, jaundice seen. On compression of the nail beds, there was good capillary refill, suggestive that there was no pallor. My client had no anaemia.

AXILLA

On inspection, there was very good personal hygiene and no signs of infection. On palpation, there was no enlargement of the axillary lymph nodes. My client was free from chronic chest or upper limb infections.

THE BREAST

The breasts were both symmetrical on inspection. There was obvious formation secondary areola tissue (skin pigmentation) around the nipples, which were also of good size and not retracted. There were obvious signs of pregnancy.

On examination, the both breasts were not tender. There were no abnormal breast lumps palpated in the quadrants and centres of both breasts. The nipples were centrally placed, no cracks and no abnormal discharges. There was no risk of breast cancer.

ABDOMINAL EXAMINATION

On inspection, the shape of the abdomen was globular. The size corresponded with the calculated gestational age. No abnormalities were seen. Presumptive signs of pregnancy were obvious – the linea nigra, stretch marks, fetal movements.

On palpation, the following summary was the findings:

Height of Fundus (HOF)	30/40 weeks.
Lie	Longitudinal.
Presentation	Cephalic.
Position	Right Occipital Anterior (ROA).
Descent	5/5 palpable above the symphysis pubis.
Fetal Heart Sounds	148^R; where R stands for Regular.
NB: Fundal palpations	Fundus was well rounded and soft.
Lateral palpations	Right– Felt continuous and smooth suggestive of the back of the foetus.
	Left – Felt irregular and fetal kicks were felt; suggestive of fetal limbs, hence my position finding as ROA.
Syphysiofundal height	28cms
Pelvic palpations	Fetal head was not engaged. Pelvis felt adequate.

Therefore, there was no risk of cepahalopelvic disproportion (CPD).

LOWER LIMBS

The lower limbs were symmetrical, capillary refill was very good, and no pallor in the sores of the feet, on inspection. On examination, there was no peddle, ankle and tibia oedema elicited. I palpated for calf tenderness while observing the client’s facial expression, varicose veins, nothing abnormal was detected. There was no swelling of either of the limbs, thus no deep vein Thrombosis.

VULVA

Inspecting the vulva, there were no vaginal warts, oedema, or sores and/or scars seen, no skin rashes observed. There was very good personal hygiene. There was no abnormal discharge, no cystocele or varicose veins, no chanchroid observed.

On palpation, from the femoral down to the inguinal region, there were no abnormalities detected. The supra pubic region was not tender to palpate. The bladder was well and freely emptied. There was no risk of Sexually Transmitted Infections (STIs), Pelvic Inflammatory Disease (PID) or Urinary Tract Infections (UTI).

ANAL REGION

There were no abnormalities detected both on inspection and palpation, such as anal fissures, haemorrhoids, fistulae. The anal region appeared clean.

THE BACK

There were no abnormalities noted on inspection and palpation such as spinal deformities (Scoliosis, Kyphosis), and sacral oedema.

PROBLEMS IDENTIED

1. Malaria in pregnancy which was the cause of her admission.

2. Risk of anaemia due to haemolysis of red blood cells which is as a result of malaria infection.

3. Risk of urinary tract infection as shown by the results of urinalysis (on Admission and booking for antenatal).

4. Late antenatal booking.

NURSING DIAGNOSIS

Multigravida in 3rd trimester antenatal booking, with malaria in pregnancy, with Urinary Tract Infection (UTI).

PLAN OF ACTION

AIMS

ü To do investigations

ü To give medication

ü To monitor maternal fetal well being

ü To give Information Education and Communication (IEC).

INVESTIGATIONS

On admission, the following were the investigations ordered for:

ü Blood: Full blood Count (FBC) and Differential count (DC), Erythrocyte segmentation Rate (ESR), Cross Match, to have the blood picture of the disease process (Results shown below in the table).

ü Rapid Diagnostic Test (RDT), to quickly check for Malaria parasites, which came out positive.

ü Blood slide for Malaria parasites, which were seen.

ü Urine for urinalysis – the above urinalysis showed leucocytes 2+ and traces of blood, which was suggestive of a Urinary Tract Infection.

Blood results are summarized below in table form.

Full Blood Count		Values	Flags	Ref. Intervals
White blood cell count		5.28×10^ʌ9/L		4.00 – 10.00
Red Cell count		3.76×10^ʌ12/L		3.73 – 4.89
Haemoglobin		11.6 g/dL	L	12.1 – 16.3
HCT		32.7%	L	35.0 - 47.0
MCV		87.0 fl		79.1 – 98.9
MCH		30.9 pg		27.0 – 32.0
MCHC		35.5 g/Dl		32.0 – 36.0
Platelets		86×10^ʌ9/L	L	178 – 400
Mean platelets volume		13.8 fl	H	7.0 – 11.4
Platelet distribution width		13.8%		14.0 – 17.0

Differential Count		Values	Flags	Ref, Intervals
Neutrophils		54.4% 2.87×10^ʌ9/L		0.96 – 6.40
Lymphocytes		24.6% 1.30×10^ʌ9/L		0.84 – 3.26
Monocytes		19.7% 1.04×10^ʌ9/L	H	0.08 – 0.61
Eosinophils		0.4% 0.02×10^ʌ9/L		0.00 – 0.28
Basophils		0.9% 0.05×10^ʌ9/L		0.00 – 0.05

Malaria Test	Malaria Parasites Seen

On the 3rd of April 2018, of her hospital stay, the Doctors after review ordered for the obstetric abdominal ultra sound scan to ascertain gestational age. She was booked to do the scan the next day at 14:00hrs.

MEDICATIONS

On 2nd April 2018, injection Artesunate 120mg intravenously, was ordered to be given as follows: 0, 12, 24 hours (12hourly interval). Subsequent doses were to be given once daily for two/2 days then revert to Coartem 4tablets, orally twice daily for three days. This was the treatment plan for Malaria. RDT and MPS were done after Artesunate injections were finished, but the parasites were not cleared. She was therefore, put back on Artesunate 120mg intravenously once daily until RDT and MPS tests were negative, to stop the treatment once RDT and MPS recheck results were negative. This was after RDT recheck showed a positive result, on 4th April 2018, when the ward Doctors reviewed her.

She was also being given Paracetamol 1g three times daily at an interval of 8hours for pain relief; folic acid 5mg once daily; ferrous sulphate 200mg once daily as haematinics and prevention of neurotubal deformities spine bifida in the foetus.

She also received Amoxicillin 500mg 8houly for five (5) days as treatment cover for urinary tract infection.

INFORMATION, EDUCATION AND COMMUNICATION

PREVENTION OF MALARIA

I advised my client on the preventive measures of malaria as follows:

Ø Sleeping under an insecticide treated net (ITNs). She needed to be sleeping under a treated net so as to kill out the mosquitoes as they rest on the net before biting her. Pregnant women are at a high risk of suffering from malaria attacks, as their immunity generally is compromised due to physiological changes and/or demands of pregnancy.

Ø Indoor Residual Spraying as yet another measure to prevent Malaria infections. The internal walls of the house are sprayed with an insecticide that kills off mosquitoes, as they fly into the house. Before they start to bite, they rest on wall of the house while waiting for time to start biting.

Ø I also mentioned about the importance of keeping the surroundings clean; cut down tall grass and/or lawn, burying all ditches or depression around the yard that keeps water stagnant, to stop the mosquitoes from breeding, wearing long clothes to keep the body well covered thereby preventing mosquito bites; early closing of windows and keeping doors closed towards the evening.

PREVENTION OF URINARY TRACT INFECTION

We discussed the preventive measures of UTIs also. I encouraged her to be using cotton underpants, because cotton sucks the excessive sweat which comes from around the genital region as compared to nylon pants. Sweat is a good media for bacterial or fungal infections.

I further alluded to the point of avoiding to clean the vagina with soap as this disturbs the original and/or ideal environment, thereby predisposing her to infections; she should, as much as possible, avoid the use of public toilets, because these facilities are very compromised in terms of hygiene.

IMPORTANCE OF EARLY ANTENATAL BOOKING

We finally discussed the importance of antenatal booking early: as soon as one learns that they have conceived or at least at 12 weeks gestation. Antenatal booking and contacts (visits) help monitor progress of pregnancy as they facilitate for checking fetal growth, as well as the well being of the mother. It also prepares the woman for delivery.

During antenatal, actual and potential problems are detected early enough and treatment of such problems is faster and effective.

Antenatal also helps identify potential and actual complications early so as to have them attended to on time.

REVIEW DATES

She was advised to come to Gynae clinic seven (7) days from the discharge date (9the April 2018), which falls on the 16th of April 2018. She was therefore advised to come on 19th April 2018 when the antenatal clinic is being conducted

Mrs. E.N.B was advised further to be attending antenatal clinic every two weeks as her pregnancy was peculiar and need hospital monitoring until delivery.

CHAPTER TWO

INTRODUCTION

This chapter looks at the incidence of multiple pregnancies, causes, types and respective management. It is vital for me as a midwife to have knowledge on this condition as it is not a normal pregnancy.

DEFINITION OF MULTIPLE PREGNANCIES

It is a term used to describe the development of more than one foetus in utero at the same time. (Fraser & Cooper, 2003)

TYPES OF MULTIPLE PREGNANCIES

1. Uniovular/monozygotic/Identical Twins

These kinds of twins are also called Identical Twins. They develop from one ovum and one spermatozoon. After fertilization, the ovum divides at different stages of development into similar masses. The reason for this separation is not clearly understood.

Monozygotic (‘identical’, MZ, monozygous, uniovular) twins arise when a fertilized egg (zygote) divides into two identical halves during the first 14 days after fertilization. They will have the same genetic make-up and will therefore be of the same sex, apart from the rare case of an XO/XY chromosomal anomaly (Perlman et al 1990). XO/XY is a rare disorder of sex development in humans associated with sex chromosome aneuploidy and mosaicism of the Y chromosome.

Characteristics of monozygotic twins

Ø The babies are very similar in appearance, colour and finger prints.

Ø They are always of the same sex.

Ø They are often alike in their physical and mental characteristics.

Ø The electro-encephalography patterns are similar.

Ø Mostly, they share the same placenta and chorionic sac (monochorionicity), but each with its own amniotic cavity (diamonioticity).

Ø The blood groups are the same.

Ø Their genetic make-up in their chromosomes is identical.

Ø Anomalies are common resulting in high abortion rate and if separation of the zygote is not complete, conjoined twins can result.

Ø The twins are usually of similar mass unless there is an anastamosis of blood circulation when one could be much bigger and heavier than the other.

Ø The blood circulation of the foetuses may anastomose to a greater or lesser degree and this can be seen on the foetal surface of the placenta after delivery.

2. Dizygotic/fraternal/binovular or non-identical Twins

These are also called fraternal twins or non-identical twins. These kinds of twins develop from two or more ova which are fertilized by separate spermatozoa. Each foetus is a separate individual.

Characteristics of dizygotic twins

Ø The babies maybe of the same sex, but are usually of different sexes.

Ø If they are of different sexes, they are immediately diagnosed as dizygotic twins.

Ø The similarities between the babies may be like that which occurs in any sibling of the same family.

Ø They have a separate placenta, Chorion and amnion. The placenta may fuse and appear as though only one is present to the naked eye.

Ø The fetal circulations do not mix.

INCIDENCE

There are geographical variations in the incidence of multiple pregnancies, with more common occurrences among African than European women.

Race also has a bearing on the incidence of multiple pregnancies; three major racial groups in the world show vastly different rates as follows:-

1. The Negroids (Africans) show an incidence rate of 1: 50 viable pregnancies.

2. The Caucasians (Europeans) show an incidence rate of 1:85 – 100 viable pregnancies.

3. The Mongoloids (Asians) show an incidence rate of 1:150 viable pregnancies.

Since the 1980s, the incidence of multiple pregnancies has been increasing. The reason for this corresponds to two related and overlapping trends: first, delay in childbearing results in increased age at conception. Second, the increased use of infertility treatments, such as ovulation induction and in-vitro fertilization, often by order women, contributes further (Ten Teachers, 2006).

In women with history of twins in the family especially on the mother’s, side the incidence is also higher.

In Zamia, showing cases of twin pregnancy attending the University Teaching Hospital (UTH), Lusaka, are analyzed. The incidence was one case per 62.8 deliveries. The main problem encountered was low birth weight, which was present in 63% of cases. 58% of the infants were breech deliveries.

Medical staff was involved in only 37% of the total twin deliveries. The perinatal mortality was high at 63 per 1000 live and still births. (PMID: 7052993 [Indexed for MEDLINE]).

At Ndola Teaching Hospital (a picture of Ndola on twin pregnancies), the following are the statistics on twin pregnancies from January to June 2017 and 2018 the same period.

Table 1 showing incidences for the period January to June 2017

JANUARY TO JUNE 2017 CASES
NONTH	NUMBER OF CASES	NUMBER OF BABIES
JANUARY	13	26
FEBRUARY	12	24
MARCH	09	18
APRIL	12+1(triplets)	25
MAY	13	26
JUNE	11	22
TOTAL	70	141

Table 2 showing incidences for the period January to June 2018

JANUARY TO JUNE 2018 CASES
MONTH	NUMBER OF CASES	NUMBER OF BABIES
JANUARY	15	30
FEBRUARY	10	20
MARCH	14	28
APRIL	08	16
MAY	10	20
JUNE	09	18
TOTAL	66	132

The above information was sourced from the registry office in the department of Gynae and Obstetrics.

The incidence of twin Pregnancies in Ndola is quite high but comparing the year 2017 and 2018, there has been a reduction in the incidence of twin pregnancies.

PHYSIOLOGY OF TWIN PREGNANCY

Multiple pregnancies are a type of pregnancy with two or more foetuses. When the ovum is fertilized by the same sperm, the resultant zygote then divides into two or more similar separate zygotes. The foetuses which develop from these zygotes become very similar in appearance and colour with similar or even identical finger prints, and are of the same sex. In most cases they share the same placenta and Chorion but each with its own amnion. It is less common that they share the placenta and the Chorion. But it is less common that they share all the three. This is the case of twins known as uniovular or monozygotic.

In binovular or dizygotic twins there are two or more ova which are released spontaneously at ovulation, and fertilization is by two separate spermatozoa. The resultant foetuses maybe or may not be of the sex. Although they have two functionally separate placentae (dichorionic), the placentae can become anatomically fused and appear to the naked eye as a single placental mass. They always have separate amniotic cavities (diamniotic) and the two cavities are separated by a thick three-layer membrane (fused amnion in the middle with Chorion on either side). The similarly between the twins is such as may arise with any other sibling of the family.

AETIOLOGY

The reason for spontaneous release of two or more ova or division of the fertilized ovum into two is not known. Naturally, however, there are occurring factors that predispose to multiple pregnancies; including the following:-

Ø Hereditary – A family history of multiple pregnancy increases the chances of twins.

Ø Order age – Women over 30 years have a greater chance of twin conception.

Ø Having one or more previous pregnancies, especially a multiple pregnancy increases the choices of having multiples.

Ø Race – African American women are more likely to have twins than any other race.

Other factors include the following:-

Ø Drugs that stimulate ovulation such as clomiphane and follicle stimulating hormone (FSH), help produce many eggs which if fertilized can result in the multiple babies.

Ø Assisted reproductive technologies such in vitro fertilization (IVF) and other technologies help couples conceive. These technologies often use ovulation stimulating medication to produce many eggs which are then fertilized and returned to the uterus to develop.

Ø Social class: It is also common among the lowest income.

Ø Maternal height and weight (obesity): predisposes to twin pregnancies, especially dizygotic twinning.

THE OUTCOME OF TWIN PREGNANCY

1. CONJOINED TWINS OR SIAMESE TWINS

Arise from the separation in uniovular twins which is not complete during development. The degree of union can vary from the joining of the skin to the sharing of the thoracic cage and even internal visceral. This may be separated but success depends on the degree of union and expertise.

2. TWIN-TO-TRANSFUSION SYNDROME(TTTS)

Common in uniovular twins and it is due to anastamosis of the foetal circulations when the placenta is shared. One of the twins derives most of the blood and the nutrients, whereas the other is deprived of the same. It can be acute or chronic and occurs in approximately 15% of monochorionic diamniotic twin pregnancies (Fisk 1995). It arises because of unequal blood flow through placental anastomoses from one foetus to the other. The donor twin transfuses blood via arterio-venous anastomoses of the placenta to the recipient twin. This then results in growth restriction, oligohydramnios and anaemia in the donor twin (‘stuck twin’) and polycythaemia with circulatory overload in the recipient twin (hydrops). The fetal and neonatal mortality is high; early intervention with serial amnioreduction, laser coagulation of connecting placental vessels or amniotic septostomy may prolong the pregnancy until the foetus is viable. There is a great difference in mass and both foetuses are at risk of cardiac failure. Usually the donor twin appears smaller than the recipient twin, and the bigger twin is usually at risk of complications.

3. FOETUS PAPYRACEOUS

A foetus dies in utero as a result of twin transfusion syndrome or because the heart and circulation have not developed normally. The foetus shrinks, becomes flattened, compressed, pale and paper like. This is usually expelled with the placenta at delivery.

4. ANTEPARTUM HAEMORRHAGE

It is significantly increased (MacGillivray & Campbell 1988). Placenta praevia is also more common, because of the large placental site encroaching on the lower uterine segment, and placental abruption may occur following rupture of the membranes and subsequent diminution in uterine size, or be associated with pregnancy-induced hypertension.

5. PRETERM LABOUR

This is a major risk of twin pregnancy.

EFFECTS OF MULTIPLE PREGNANCIES ON PREGNANCY

Ø Increased incidence of pre-eclampsia and eclampsia due to a large placental site.

Ø Anaemia due to increased foetal demands for iron and haemoglobin is usually below 10gdl.

Ø There is an exaggeration of minor disorders or pregnancy such as backache, vomiting, heart burn etc.

Ø There is an increased rate of abortion.

Ø Polyhydramnious both acute and chronic.

Ø Pressure symptoms are increased in the 3rd trimester such as varicose veins, haemorrhoids, oedema etc.

Ø Placenta praevia incidences increases because of large placenta and this can lead to ante partum haemorrhage.

Ø Because of over distension of uterus preterm labour occurs.

Ø Intra uterine growth restriction due to the sharing of nutrients between the two foetuses.

Ø There is a high incidence of foetal abnormalities.

EFFECTS OF MULTIPLE PREGNANCIES ON LABOUR

Ø Preterm labour due to over distension of the uterus.

Ø High incidence of caesarean section due to complications of twin pregnancy.

Ø Increased still births and neonatal morbidity and mortality rate especially of twin two.

Ø Ante partum haemorrhage from placenta praevia and abruption.

Ø Uterus inertia after the first twin due to the distended uterine muscles.

Ø Increased incidence of obstructed labour due to malpresentation especially transverse lie or conjoined or locked twin.

Ø Intrapartum haemorrhage from early separation of the placenta after the birth of the 1st twin and before the birth of the 2nd twin.

Ø Post partum haemorrhage due to uterine atony, anaemia, previous APH and or large placental surface.

Ø Formation of the uterine constriction ring after the birth of the 1st twin and causing retention of the 2nd twin.

EFFECTS OF MULTIPLE PREGNANCIES ON THE BABY

Ø High perinatal morbidity rate due to increased number of vaginal examinations that are done to ascertain descent of the second twin. This increases the chances of infection on the baby.

Ø Twin transfusion syndrome as one twin would be deriving nutrients and blood from the other. The recipient twin appears bigger than the donor twin.

Ø Asphyxia neonatorum especially of the second twin which may delay due to descent, delayed uterine contractions, breech presentation.

Ø Preterm babies and its accompanying complications. Prematurity is common in twin pregnancy because of reduced uterine space and delivery would be before term or the babies may be small for their gestational age.

Ø Small for gestation age babies due to the above stated reason

Ø Birth injuries usually occur with manipulative procedure in breech presentation (with extended head and hands), transverse lie.

Ø Foetal malformation conjoined or locked twins which situation would arise due to incomplete division of cells in early pregnancy (during cell division).

DIAGNOSIS OF MULTIPLE PREGNANCIES

1. HISTORY TAKING

ü Race group and home territory. Twin pregnancies are most common among African- Americans, Asians and Negroids.

ü History of twins in the family on the mother’s side specially increases the risk of multiple gestations.

ü History of previous multiple pregnancy also increases the chance of twin pregnancy in subsequent pregnancies.

ü In the present pregnancy if there any complaints of increased minor disorders of pregnancy such as backache or vomiting.

ü The fundus may appear larger than expected or more than the gestational age.

ü History of excessive pressure symptoms such as oedema.

2. ABDOMINAL EXAMINATION

ü Inspection: The uterus will be broad and round rather than oval. The abdomen will be larger compared to the gestational age, especially after the 20th week. Foetal movements will be more than usual, they will be exaggerated. There may also be excess striae graviderum.

ü Palpation: The height of fundus will be more than the expected gestational age especially in the 2nd trimester when growth of the foetuses is rapid. Two heads may be felt at any place within the uterus. The size of the foetal head will be felt to be small in comparison with the size of the enlarged uterus. There will be unusual number of limbs felt. On lateral palpation, two foetal backs may be felt or limbs on both sides of the abdomen. Palpating three foetal poles is diagnostic of at least two foetal poles.

ü Auscultation: Two foetal heart sounds may be heard but there should be a difference of at least 10 beats within a silent area between.

3. ULTRASOUND: Where ultrasound scan facilities are available, and the woman consents, multiple pregnancies can be diagnosed as early as 6weeks. Because of the increased maternal and foetal risks with monochorionicity, determination of chorionicity is critical and is most reliably determined by ultrasound in the late first trimester. In dichorionic twins, there is a V-shaped extension of the placental tissue into the base of the inter-twin membrane, referred to as the ‘lambda’ or ‘twin-peak’ sign. In monochorionic twins, this sign is absent and the inter-twin membrane joins the uterine wall in a T-shape.

Assessment of chorionicity later in pregnancy is less reliable and is based on the assessment of foetal gender, number of placentae and characteristics of the membrane between the two amniotic sacs. The lambda sign becomes less accurate and membrane thickness must be utilized. Different-sex twins must be dizygotic and, therefore dichorionic. In same-sex twins, two separate placentae means dichorionic, although the babies may still be monozygotic. However, monozygotic dizygotic twins do not carry the additional risks of vascular anastamosis. It is recommended that all women should at least have one ultra sound scan done in the first trimester in order to detect any possible abnormalities.

4. X-RAY: This will show 2 foetal skeletons and is indicative of multiple gestations

COMPLICATONS OF MULTIPLE PREGNANCIES

Ø Locked twins are rare but serious complications which can either be the head to breech or breech to head. This is dangerous to both the mother and foetuses; hence the best method of delivery is caesarean section.

Ø Conjoined twins: Commonly found in uniovular twins.

Ø Cord prolapsed: Particularly of the 2nd twin.

Ø Transverse lie of the second twin which can lead to obstruction or retained 2nd twin.

Ø Intra partum haemorrhage: Bleeding before the delivery of the 2nd twin.

Ø Undiagnosed twin: This is suspected if the abdomen is larger than the expected gestational age and after delivery of the baby.

Ø Prolonged labour due to hypotonic uterine action which is associated with malpresentation.

Ø Increased incidence of caesarean sections due to Siamese twin, retained twin, antepartum haemorrhage and malpresentation.

Ø Post partum haemorrhage (PPH) due to a large placental site and hypotonic uterus caused by over distension.

Ø Retained 2nd twin: ideally the 2nd twin should be born within 15 – 20 minutes.

Ø Premature rupture of membranes due to mal presentation and Polyhydramnious.

Ø Foetal abnormalities especially in monozygotic.

Ø Abortions: Due to abnormalities and in some cases over distension of the uterus can lead to later abortions.

Ø Polyhydramnious: Acute which occur at around 26 – 30 weeks and maybe associated with foetal abnormalities.

MANAGEMENT

ANTENATALLY

AIMS

1. To manage the pregnancy as close as possible to term.

2. To prevent complications such as anaemia to the mother.

3. To monitor the pregnancy closely.

4. To give appropriate psychological care.

MANAGEMENT

Ø Screening of all clients at risk and referral to the nearest hospital.

Ø Watch for anaemia, pregnancy induced hypertension and hydramnious if present, admit to the hospital and manage accordingly.

Ø Encourage plenty of rest and discourage strenuous work, travelling and carrying heavy loads.

Ø Encourage the mother to take supplements of iron every day.

Ø Encourage prevention of malaria by provision of treated mosquito nets, intermittent presumptive treatment of malaria and healthy education about not keeping long grass around the house, closing windows early and burying of water that is stagnant.

Ø If the woman has no serious complications and able to follow advise she can be managed at home

VISITS/CONTACTS

Ø From the time the diagnosis is made until 24 weeks the woman is seen in the clinic every 4 weeks.

Ø From 24 weeks until 32 weeks she is seen every 2 weeks.

Ø From 32 weeks until 38 weeks she is seen every week.

Ø At 38 weeks the woman must be admitted to hospital.

PSYCHOLOGICAL CARE

I explained to Mrs. E. N. B what is required of her during this pregnancy such as antenatal visits, drug compliance, enough rest and adequate nutrition. I also stressed the importance of seeking medical attention if any problems arise such as vaginal bleeding, severe headache or swelling of the feet. I encouraged her to include the support person(s) in her care; explain the need for adequate preparation to them – the husband and the sister in -law. Further she was advised on the benefits of hospital delivery. She was also prepared her for delivery and the possible outcomes of the pregnancy and labour.

INTRAPARTUM

Ø It is ideal for labour to take place in the hospital environment where resuscitative equipment and emergency care is available.

Ø Blood samples for haemoglobin estimation and grouping and cross matching must be collected and taken to the Laboratory in case of severe bleeding.

Ø Intravenous access to administer fluids and drugs if need arises.

Ø Explain to the woman everything that is being done to gain co-operation.

Ø Physical examination of the woman and abdominal palpation.

FIRST STAGE OF LABOUR

Ø The woman must be monitored like any other woman in labour by use of a partograph. This tool is only opened when cervical dilation is 4cm. It is a tool that covers the parameters itemized below and the timings.

Ø All the observations must be done accordingly and within the stipulated time interval.

Ø Foetal well being by checking the foetal hearts sounds every ½ hourly while moulding and the liquor are monitored every 4 hours.

Ø Vaginal examination must be done on admission to labour ward to ascertain if the woman is truly in labour, but after that must be done every 4 hours to assess the descent and cervical dilatation.

Ø Contractions must be monitored every ½ hourly and if any abnormalities arise must be noted and reported. These monitor progress of labour by monitoring descent and cervical dilatation.

Ø The woman must also be monitored by use of observations of vital signs, pulse every ½ hourly, blood pressure 4 hourly, temperature 2 hourly. Also to monitor and examine the urine whenever necessary.

Ø To ensure that oral fluids are given to provide energy but in case an operation is anticipated, administer intravenous fluids.

Ø Preparation for second stage by ensuring the rescusitaire, oxygen and suction machine are in good working order.

Ø The mode of delivery is dependent on the presentation of the foetus.

SECOND STAGE

Ø Must be confirmed by vaginal examination.

Ø When the foetuses are in normal vertex presentation management is like any other normal delivery. However there are considerations if the presentation is otherwise the vertex.

DELIVERY OF THE FIRST TWIN

Ø Continue with foetal heart sounds monitoring until delivery.

Ø Ensure the woman is in lithotomy position.

Ø When the 1st twin is born, time is noted, cord clumped and cut depending on the APGAR SCORE, either short or long. Airway cleared, baby wiped and scored at 1 minute and 5 minutes. Sex identified by the mother, baby weighed and identity band is put indicating twin 1. Baby is wrapped in warm clothes after a quick physical assessment.

DELIVERY OF THE SECOND TWIN

Ø After the 1st twin has been delivered and labelled twin 1, a quick palpation of the abdomen to get the lie of the second foetus, the descent and position.

Ø Continued monitoring of foetal heart sounds, contractions and observation of vital signs.

Ø A vaginal examination is done to check the presenting part, rule out cord prolapse and closure of the cervical os.

Ø If baby is in an abnormal lie the doctor must be informed.

Ø The contractions recommence usually about 5-7 minutes after twin 1 is born.

Ø If contractions do not start, 20 IU of oxytocin in 500mls 5% dextrose is started. This is to ensure recommencement of uterine contractions.

Ø After the 2nd twin is born note the time, APGAR SCORE , clamp and cut and secure the cord, show the sex to the mother, put identity band as twin 2, weigh the baby, wrap in warm clothes and put to the side of the mother if the condition allows.

MANAGEMENT OF THIRD STAGE OF LABOUR

Ø Active management of 3rdstage of labour must be undertaken since post partum haemorrhage is a real danger in multiple pregnancies.

Ø Mother must continue to be monitored in the first 6 hours up to 24 hours in case of severe bleeding also observations of vital signs must continue in case of shock so that it is detected early.

Ø Placenta and membranes must be examined to detect any abnormalities and to determine whether the twins are uniovular or binovular

MANAGEMENT OF BABIES AFTER A TWIN DELIVERY

Ø Nurse babies in special care baby unit until the condition is satisfactory since they are usually preterm or small for gestational age.

Ø Babies must be examined to exclude complications such as birth injuries or congenital abnormalities.

Ø If the babies are preterm, at birth the management is as for preterm babies.

CHAPTER THREE

INTRODUCTION

This chapter deals with the details of how my client was actually managed throughout the pregnancy until the time of delivery and postnatal. My client had unique twins, which were mono chorionic and monoamniotic. Monochorionic monoamniotic pregnancies are associated with greater complexity and risks to the mother and the babies. It is therefore recommended that a woman with this type twin pregnancy should be referred to a tertiary hospital for specialized care.

ACTUAL MANAGEMENT

AIMS

1. To educate Mrs. E. N. B on her condition and gain co-operation in the management.

2. To prepare Mrs. E.N. B. for the care of two children at the same time.

3. To ensure a safe delivery for both mother and her babies.

4. To monitor the pregnancy from the time of diagnosis to term.

5. To monitor labour from admission to delivery.

6. To prevent complications during pregnancy, labour and puerperium.

INVESTIGATIONS

1. Blood slide for malaria done with a positive result.

2. Urine for urinalysis – No abnormalities detected.

3. Blood for HIV test – Negative.

4. Blood for haemoglobin estimation – 14g/dl. This estimation signified that my client was not anaemic, thus not at risk of any blood transfusion.

5. Ultra sound scan; which confirmed pregnancy and viability of two foetuses.

MEDICATION

1. Folic acid 5mg once daily throughout pregnancy to prevent anaemia.

2. Fansida 3 tablets start for three times during the pregnancy to prevent malaria.

3. Ferrous sulphate 200mg once daily to prevent anaemia.

4. Mebendazole 500ml start to prevent and treat worm infection.

5. Tetanus toxoid 0.5mls to prevent neonatal tetanus, the fifth dose.

ANTENATAL

PSYCHOLOGICAL CARE

I explained to Mrs. E. N. B about her condition, that she is carrying two foetuses in the uterus. I reassured her of support from the medical personnel especially me. I encouraged her to be strong to allay anxiety. I advised her on seeking medical attention early in case of need and benefits of hospital delivery; the importance of which, her pregnancy was a high-risk pregnancy and so everything was to be followed up and done under specialized care, to prevent complications.

ENVIRONMENT

I discussed with Mrs. E. N. B that throughout pregnancy the environment should be free of infections to prevent any diseases such as malaria by burying ditches or points where water collects and does not move (mosquitoes breed well in stagnant water) and cutting long grass around the house. She was also reminded to continue sleeping under an insecticide treated net even after delivery. I also advised her to keep the environment clean and close windows earlier in the day to prevent mosquitoes from entering the house.

REST AND EXERCISE

I stressed the importance of rest and that she should avoid strenuous work as this may cause premature labour; duties such as lifting heavy things was to be avoided. However, walking would be a good exercise to promote blood circulation and descent towards term or during labour. After the walking exercises, she should be doing limb elevation to promote venous return thus preventing oedema of the lower limbs.

POSTION

I advised Mrs. E. N. B. to be taking positions that do not compromise her breathing or comfort, hence I advised her to be sleeping in the lateral position to prevent supine hypotensive syndrome.

HYGIENE

I advised her on personal hygiene to prevent infectious diseases. I encouraged her on hand washing after using the toilet, before eating any food and when preparing meals, to keep her finger nails short always. Daily baths and frequent changing of pants for comfort and also prevention of urinary tract infections.

NUTRITION

A balanced or mixed diet is what I encouraged her to take inclusive of proteins for buildup of body tissues on the foetuses, Carbohydrates such as Nshima for energy both to the mother and the foetuses. She also needed Vitamins for buildup of immunity and iron to boost haemoglobin levels for the growth of the foetuses. Examples of various simple foods that would contain the food values mentioned were given, such as Kapenta, Katapa, Bondwe, Oranges, Masuku, Vegetables like Chinese Cabbage, Spinach contain some calcium.

OBSERVATIONS

Throughout pregnancy maternal well being was monitored by taking and recording of vital signs at each visit so as to detect any deviation from the normal. Parameters such as Blood Pressure, Weight (nutritional status), and Height at first contact, Temperature, Pulse and Respirations, and haemoglobin levels were being checked constantly. Foetal well being was monitored by checking the increase in height of fundus at each visit and listening to the foetal heart sounds noting the difference between the two foetuses.

SUMMARY OF ANTENATAL VISITS

DATE

G/A

HOF

POS.

PRES.

LIE

FHR

OEDEMA

PALLOR

PROTEIN

GLUCOSE

(kg)

TCB

03/04/18

25wks

28/40

Weeks

ROA

Ceph.

Long.

FHR

107/69

Nil

Neg.

19/04/18

19/04/18

27wks2/7

30/40

Weeks

ROA

Ceph.

Long.

FHR

104/63

Nil

Neg.

17/04/18

17/05/18

31wks2/7

34/40

Weeks

ROA

Ceph.

Long.

FHR

101/63

Nil

Neg.

24/05/18

24/05/18

32wks2/7

34/40

Weeks

ROA

Ceph.

Long.

FHR

119/67

Nil

Neg.

21/06/18

21/06/18

36wks2/7

36/40

Weeks

ROA

Ceph.

Long.

FHR

113/72

Nil

Neg.

05/07/18

INTRAPARTUM MANAGEMENT

AIMS

Ø To conduct a clean and safe delivery.

Ø To monitor maternal - foetal well being.

Ø To monitor the progress of labour.

Ø To prevent complications from arising.

ADMISSION

Mrs. E. N. B. was admitted to Ndola Teaching Hospital on 30/06/18. She reported to Labour ward from home with complaints of lower abdominal pains and some per vaginal bleeding since 22:00 hours of 30/06/18. She denied intake of herbal medication to accelerate labour. She gave history of having eaten at 19:00 hours (30/06/18). She was escorted by the Elder sister and the husband.

Her Elimination of Mother to Child Transmission (EMTCT) was Non- Reactive (NR).

GENERAL EXAMINATION

Height	160cm
Weight	75kgs
Shoe size	6
The above are significant because they give an indication of the adequacy of the pelvis, which if the height, for example was 145cm, a smaller pelvis would be anticipated. Thus for the above readings, no cephalo-pelvic disproportion would be foreseen.
URINALYSIS
Amount	150mls
Colour	Reddish
Smell	Aromatic
Protein	Negative
Acetone	Negative
Glucose	Negative
Normal urine analysis. No urinary tract infection and baseline data established.
VITAL SIGNS/OBSERVATIONS
Temperature	35.8°C
Pulse	78 beats per minute
Respirations	22 breaths per minute
Blood pressure	110/70mmHg
Vital signs were normal, except the temperature was on slightly on the lower side. Baseline information was established, with which a comparison in the subsequent observations will be made.

PHYSCIAL EXAMINATION (HEAD TO TOE)

General condition	She was calm and stable
Head	Hair was clean and well plaited. No signs of chronic illness like tuberculosis or HIV/AIDS or malnutrition. It had good texture
Eyes	No discharge, no jaundice and no conjunctiva pallor.
Nose	No polyps and she had no running nose
Ears	No polyps, no discharge or enlarged lymph nodes.
Mouth	No pallor on mucus membrane or tongue, no sores, oral thrush, dental carries or dentures.
Neck	No enlarged lymph nodes, thyroid gland normal. No goiter. No pain when swallowing.
Arms	Symmetrical, nails short and clean. No pallor or knuckle oedema.
Axillar	Clean and well shaved no enlarged axillary lymph nodes.
Breasts	On inspection secondary areola present and dark nipples prominent and suitable for lactation. On palpation no lumps felt and client did not complain of any pain on both breasts.
ABDOMINAL EXAMINATION
ON INSPECTION
Shape	Globular
Size	Enlarged though not corresponding with gestational age.
Foetal movements	Seen during inspection
Skin	No abdominal scar seen, linear nigra present and striae graviderum were very visible
ON PALPATION
Height of fundus	41cm by tape
Lie	Longitudinal
Presentation	1st twin – Cephalic
	2nd twin – Breech
Position	1st twin – Right Occipital Anterior (ROA)
	2nd twin – Left Sacral Anterior (LSA)
Descent	5/5
Contractions	Moderate
Foetal heart sounds	Twin 1 – 146 beats per minute.
	Twin 2 – 136 beats per minute
VAGINAL EXAMINATION
Vulva	Good personal hygiene, no warts, scars, oedema, sores or varicose veins.
Vagina	Warm, moist and distensible
Membranes	Intact and bulging
Cervix	Thin and well applied to the presenting part
Os	5 cm dilated
Presentation	Vertex
Station	-5 above ischial spines
Position	Right occipital anterior
Caput	No caput felt
Moulding	No moulding
Sacro- promontory	Not reached
Hollow of sacrum	Well curved
Ischial spines	Round smooth and not prominent
Pubic arch	Admitting 2 fingers
Inter tuberous space	Accommodating 4 knuckles
Show	Present
Therefore, the pelvis was adequate for vaginal delivery.

NURSING CARE IN THE FIRST STAGE OF LABOUR

ENVIRONMENT

Mrs. E, N. B. was admitted to labour ward that is well ventilated, clean and dump dusted with chlorine 0.3%. In the unit, there were resuscitative equipment that included the suction machine that was working well, oxygen machine in good working condition, vital signs tray, drip stand, intravenous infusion tray, delivery pack and a working rescusitaire.

PSYCHOLOGICAL CARE

I assured Mrs. E. N. B. that the medical team was available to help her deliver her babies well, to allay anxiety. I explained to her that she was in established labour and she needed to be admitted and monitored to gain her co-operation. I explained all the procedures before I performed them to gain her co-operation. I helped her sign a consent form in case of any surgery.

POSITION

Due to the risk of supine hypotension, I advised Mr. E, N. B. to take the lateral positions so as not to deprive the foetuses of oxygen.

OBSERVATIONS

During this stage of labour, Mrs. E. N. B was monitored by use of a partograph. In three phases as follows:-

1. Maternal well being

I checked her:

ü Pulse half hourly, to exclude tachycardia or bradycardia,

ü Temperature 2 hourly to rule out fever due to infection.

ü Blood pressure 4 hourly to exclude hypertension and pre-eclampsia.

I advised her to be voiding to prevent full bladder which may obstruct the presenting part from descending. No drug was given for pain relief instead back rubs where employed.

2. Foetal well being

I monitored the foetal heart sound half hourly on both fetuses for 1 full minute to detect any distress if above or below normal levels (100 – 180 beats per minute).

The membranes were still intact and there was no moulding and these were assessed 4 hourly and findings plotted and recorded on the partograph.

3. Progress of labour

I monitored contractions half hourly noting the frequency, duration and intensity to know how labour was progressing.

Vaginal examinations were done 4 hourly for the same reason. The other vaginal examination was done when membranes ruptured to exclude cord prolapsed; at this point, the cervix was 10cm dilated with clear liquor. All the findings were recorded.

HYGIENE

I changed linen when it was soiled to promote comfort. Every time I did a vaginal examination, I cleaned the vulva to prevent ascending infections.

ELIMINATION

I advised Mrs. E. N. B to void; urine was then measured and documented.

REST AND ACTIVITY

I advised Mrs. E. N. B to be ambulant before the rupture of membranes to help with the descent of the presenting part. And allowed her to rest between contractions.

ADVICE

Ø I advised Mrs. E. N. B. to be strong as labour is bearable.

Ø I advised her to void frequently to prevent obstruction.

Ø I encouraged her to breathe through the mouth during a contraction to promote oxygen supply to the foetus.

Ø I encouraged her to take fluids like tea for energy in the 2nd stage.

Ø I advised her on how and when to bear down as labour progressed.

PREPARATION FOR SECOND STAGE OF LABOUR

I prepared for second stage of labour by use of a trolley that included a delivery pack on the top shelf with Oxytocin 10 IU and a cord clump. Resuscitative equipment like oxygen machine, resuscitative suction machine, emergency tray were checked and baby layette, a cleaned scale and a wall clock were put in place.

MANAGEMENT OF SECOND STAGE OF LABOUR

At 06:10 hours on 1st July 2018 membranes ruptured and a vaginal examination was done to exclude cord prolapse. It was during this time that she became fully dilated and I advised her to start bearing down with every contraction.

DELIVERY

FIRST TWIN

On 1st July 2018 at 06:30 hours labour progressed as breech delivery that was assisted to a live mature female infant with APGAR SCORE 8/10 at 1 minute and 9/10 at 5 minutes after suctioning. Baby was delivered onto the mother’s abdomen. Head, mouth and face wiped dry to prevent hypothermia and clear airway, cord clamped, secured with a cord clamp and cut short. Baby was shown to the mother for sex identification. Birth weight was 2.8kgs and length 48cm. The identity band was prepared and placed on the baby’s hand. The baby was then dressed and wrapped warm.

SECOND TWIN

At 06:42 hours twin 2 was also delivered as spontaneous vertex delivery to a live mature female infant APGAR SCORE 9/10 at 1 minute. Baby delivered onto the mother’s abdomen, head, face and mouth wiped dry to prevent hypothermia and to clear the airway. The cord was clamped, secured with a cord clamp and cut short. The baby was shown to the mother for sex identification. Birth weight was 2.9kgs, length – 48cm. The identity band was prepared and placed on the baby’s hand. The baby was dressed and wrapped warm. They were both put in lateral position with the heads tilted on the side to aid in drainage of secretions.

THIRD STAGE OF LABOUR

Following the birth of the 2nd twin, the mother’s abdomen was palpated to rule out a third baby, oxytocin 10IU was given intramuscularly start with good effect, as active management of third stage of labour. During the next contraction, the placenta with the membranes was delivered by controlled cord traction method at 06:50 hours. The placenta was delivered by Schultz method and on examination it appeared healthy and complete. The uterus was massaged and felt well contracted. Bladder was emptied by catheter. Blood loss was approximately 180mls. Perineum sustained a 1st degree tear. I then cleaned up Mrs. E. N. B after examination and ensured she was comfortable. I then put the instruments I used in chlorine 0.5% for 10 minutes then washed then in soapy water and rinsed them under running water. Dried them and packed them for autoclaving.

FOURTH STAGE OF LABOUR

Mrs. E. N. B. was monitored for the next 2 hours with the babies by taking the vital signs and recording so as to monitor how both babies are coping with extra uterine life. Lactation was initiated in the first hour of life.

POST DELIVERY READINGS

MOTHER

Temperature : 36.7°C

Respirations : 24 breaths per minute

Pulse : 90 beats per minute

Blood pressure : 130/80mmHg

General condition : GOOD

TWIN 1

Temperature : 35.8^oC

Apex Beat : 138beats per minute

Respirations : Spontaneous

Cord : Not bleeding

Meconium : Passed

Urine : Passed

Reflexes : All present (suckling, rooting, moro, grasping, primitive walk)

General condition : GOOD

TWIN 2

Temperature : 36.^oC

Apex Beat : 136beats per minute

Respirations : Spontaneous

Cord : Not bleeding

Meconium : Passed

Urine : Passed

Reflexes : All present (suckling, rooting, moro, grasping, primitive walk)

General condition : GOOD

EXAMINATION OF THE BABIES AFTER SIX HOURS

FEATURE	TWIN 1	TWIN 2
Temperature	36°C	36.2°C
Respirations	38 breaths per minute	40 breaths per minute
Apical beat	138 beats per minute	137beats per minute
Head circumference	33cm	34cm

PHYSICAL EXAMINATION

FEATURE	TWIN 1	TWIN 2
Eyes	Present, no discharge, no pallor, no jaundice or haemorrhage	Present, no discharge, no pallor, no jaundice or haemorrhage
Ears	In line with eyes. No discharge or webbing.	In line with eyes. No discharge or webbing.
Mouth	Clean, moist, pink, no false teeth, tongue tie, cleft lip or palate	Clean, moist, pink, no false teeth, tongue tie, cleft lip or palate
Neck	No webbing, no enlarged lymph nodes	No webbing, no enlarged lymph nodes
Hands	Symmetrical, palmer creases present and well formed. No webbing or extra digits	Symmetrical, palmer creases present and well formed. No webbing or extra digits
Chest	Circumference 33cm. Breast tissues present, no abnormalities detected	Circumference 34cm. Breast tissues present, no abnormalities detected
Abdomen	No distension, exomphalos, bleeding from the cord, or hernia	No distension, exomphalos, bleeding from the cord, or hernia
Genitalia	SEX – Female ü Genital organs well formed. ü Clitoris well enclosed by the labia majora ü Passed urine and meconium.	SEX – Female ü Genital organs well formed. ü Clitoris well enclosed by the labia majora Passed urine and meconium
Legs	Symmetrical, no talipes, extra digits or webbing. Planter creases present	Symmetrical, no talipes, extra digits or webbing. Planter creases present
Back	Well curved no spinal bifida	Well curved no spinal bifida
Length	48cm	48cm
Reflexes	All present. Otolan’s test negative	All present. Otolan’s test negative
Weight	2800 grams	2900 grams

PLAN FOR DISCHARGE

After observing the mother and the twins for 6 hours, and examining them, no abnormality was detected and the babies were active and adapting well to the environment. The mother was also coping well with puerperium. Therefore, I discussed with Mrs. E. N. B about being discharged which she received with gratitude. Birth records and discharge slips were written and given to her. The mother was also given vitamin A 200,000IU start. The mother and her two babies were discharged on 2nd July 2018 and advised her to come for six days postnatal review on 9th July 2018.

Note that her actual sixth day fell on a Saturday; hence she was advised to go on Monday, a clinic day at the hospital MCH clinic.

INFORMATION, EDUCATION AND COMMUNICATION

1. Good personal hygiene – I encouraged Mrs. E. N. B to change the sanitary pads and pants wherever soiled to prevent ascending infections. I advised her to be wiping the anal area from front to back after opening bowels to prevent misplacement of normal flora that may cause infection. I also emphasized washing of hands after changing the pad and the babies’ nappies.

Further, because she had a perineal tear (1st degree), I advised her to do sitz baths at least twice daily and immediately after bathing. She would be sitting in pre-boiled and cooled water for at least 10 minutes. While seated in the water, I encouraged her to be doing Kegel exercises to promote return of good perineal muscle tone, after the over stretching during the birth process.

2. Ambulation and rest – I advised Mrs. E. N. B to be ambulant to promote blood circulation and to ensure that she gets adequate rest to promote healing and quick recovery.

3. Danger signs in puerperium – I advised her to be watchful of the danger signs such as excessive per vaginal bleeding, severe headache or fever, foul smelling vaginal discharge, signs of infection on the wound such as pus, excessive pain and heat; to quickly seek medical attention if any one or two occur.

4. Good nutrition – I encouraged her to be taking a balanced (mixed) diet inclusive of proteins like beans and groundnuts for tissue repair, Nshima for energy and vitamins to boost the immune system. I also encouraged her to be taking a lot of starchy fluids such as Munkoyo, Chibwantu for the promotion of good lactation.

5. Post natal dates – I advised her to come for review in MCH/gynae clinic at the hospital so that she can be re-examined to see how she was coping with puerperium at 6 days and 6 weeks, also for the benefit of the babies that they be examined.

6. I advised Mrs. E. N. B not to insert any herbs in the vagina as this irritates the mucosa and may predispose to cancer of the cervix. I encouraged her to do sitz baths with pre-boiled cooled water, at least two to three times daily and allow the perineum to be dry.

ADVICE ON THE CARE OF THE TWINS

1. Warmth – I advised Mrs. E. N. B to ensure that at all times the babies are well covered in warm clothes to prevent hypothermia. Also to ensure that they are not over exposed to the environment as this would cause chilling, there by predisposing them to Pneumonia.

2. Breastfeeding – I encouraged her to be breastfeeding the babies 2hourly and on demand, ensuring that they are not over fed or under fed, as this may cause distension of the abdomen. I emphasized that she should always wash hands and the nipples before breastfeeding the babies to prevent infections like diarrhoea. I encouraged her to pat the babies after breastfeeding them to help them belch as this prevents aspiration of gastric contents in case of regulations. I also advised her to ensure that she exclusively breastfeed the babies for 6 months. Positions and techniques of breastfeeding were discussed.

3. Prevention of infection – I advised Mrs. E. N. B to ensure that the babies sleep under a treated mosquito net to prevent malaria. I cautioned her on the cleanliness of the room where the babies will be kept to prevent respiratory tract infections. Also not to allow a lot of people to visit the babies and most especially those with infections like rhinitis. I advised her to clean the cords of the babies with cooled boiled water and not to put anything to prevent infections like septicaemia.

4. Change of nappies – I encouraged her to change the nappies of the babies whenever soiled to prevent nappy rash on the buttocks of the baby.

5. I encouraged her to attend Children’s (under5) clinics so that the babies can be receiving vaccines and their growth monitored by weighing them.

6. Danger signs in a neonate – I advised Mrs. E. N. B to be watchful at the danger signs in a neonate such as convulsions, fever, bulging fontanelles, refusing to breastfeed, high pitched cry; to seek medical attention in case they occur as quickly as possible.

Finally I helped her pack all her things and walked her up to the station where she was to board a taxi to her place. I thanked her for the co-operation and encouraged her to consult in case of need.

CHAPTER FOUR

INTRODUCTION

In this chapter there are details of follow up care which was done to monitor the progress of the pregnancy and puerperium, identify problems and give appropriate health education. Some visits were done antenatally while others were done during puerperium. Here is described too, the continuation of care was given to Mrs. E. N. B at home, in her own environment.

ANTENATAL VISIT ON 6TH MAY 2018

OBJECTIVES

1. To locate Mrs. E. N. B’s residence.

2. To meet Mrs. E. N. B and family.

3. To assess the general condition of Mrs. E. N. B

4. To give appropriate health education according to the problems identified.

On the stated date I went to visit Mrs. E. N. B for the first time with the escort of my female colleagues. I was given directions that were correct and so it was easy to locate the house. On arrival, she recognized me and was warmly welcomed. She introduced me to the children who were around. She then introduced the children to me and my friends who escorted me. We began our discussion. I explained to her that I was there to firstly know her residence and to assess her and the fetuses. We had a discussion for a while where she was concerned about her babies and how she was to care for them it was first time to experience twins, and that twins are not easy to handle. I reassured her and asked for permission to examine her so as to assess her and the fetuses well being.

EXAMINATION

VITAL SIGNS

Temperature : 36.4°C

Pulse : 80 beats per minute

Respirations : 18 breaths per minute

Blood pressure : 100/78mmHg

PHYSICAL EXAMINATION (HEAD TO TOE)

Head	Hair was clean and well plaited with no signs of malnutrition or infection
Eyes	Clear, no pallor or jaundice
Nose	No nasal polyps or discharge.
Ears	No polyps, no discharge or enlarged lymph nodes.
Mouth	No pallor, thrush or dental carries.
Neck	No goitre or enlarged lymph nodes, swallowed without pain.
Axilla	There was some hair, though looked clean, no enlarged lymph nodes.
Hands	Symmetrical, no pallor or oedema with good venous returns .
Breasts	Symmetrical, medium sized, prominent nipples, secondary areola tissue present. No abnormal lumps were felt.
ABDOMINAL INSPECTION	The abdomen was, globular, no scars, linea nigra and strae graviderum present. Fetal movements were noted. The abdomen looked bigger for the gestational age. The gestational age as of 6th May 2018 was 29 weeks 5days. Her abdomen by inspection looked 32weeks.
ABDOMINAL PALPATION
Height of fundus	32/40
Lie	Longitudinal both fetuses
Presentation	Twin 1 Cephalic
	Twin 2 Breech
Position	Twin 1 Right occipital anterior
	Twin 2 Left Sacral anterior
Descent	5/5 palpable
Foetal heart sounds	Twin 1 136^R beats per minute
	Twin 2 146 beats per minute regular
Lower limbs	Symmetrical no oedema, pallor, varicose veins or calf muscle tenderness.
Vulva	Good personal hygiene, no warts, sores, scars, varicose veins or abnormal discharge observed.
Back	Well curved spine.
Sacrum	No oedema.
Anal area	No haemorrhoids.

The physical examination done did not indicate any abnormalities and the fetuses were in good condition.

INFORMATION, EDUCATION AND COMMUNICATION

Ø I advised Mrs. E. N. B to be having adequate rest and to avoid lifting of heavy things as this can cause premature labour.

Ø We discussed the importance of good nutrition in pregnancy for the good development and nourishment of the fetuses.

Ø I advised her on the benefits of good personal hygiene as prevention of infection especially that her immune system was low due to pregnancy and for the sake of her comfort.

Ø I encouraged her to seek medical attention in case of any danger sign such as bleeding vaginally, severe headache, no foetal movements so that appropriate help is given.

Ø We also discussed that this pregnancy would have pressure because she was carrying two fetuses and so she should be expectant.

POST NATAL VISIT AT 6 DAYS

OBJECTIVES

1. To find out how Mrs. E. N. B was managing with the twins at home.

2. To check how the twins were adapting to extra uterine life.

3. To continue with health education as any issues pertaining to both the mother and babies.

As Mrs. E. N. B was being discharged from the hospital after delivery, I made an appointment to visit her in the next 6 days and on 9th July 2018. She was going to call me as soon as she reached the hospital. During the visit, I asked that i would be accompanied by two of my female classmates. We met at Ndola Teaching Hospital at 09:00 hours at the MCH clinic. The sisters in the clinic welcomed us. The recognized her from antenatal contacts. I explained to the sister the reason for our accompanying her to the clinic for the visit, and the sister gave us a go ahead with proceedings.

After a discussion I did physical examination on both the mother and the twins and I explained my findings to Mrs. E. N. B and to the sister in-charge. Thereafter, health education was given. The examinations done were as follows:-

EXAMINATION OF THE MOTHER POSTNATALLY

VITAL SIGNS- MOTHER

Temperature	36.4°C
Pulse	88 beats per minute
Respirations	22 breaths per minute
Blood pressure	128/78mmHg
PHYSCIAL EXAMINATION
General condition	Good and healthy though weak
Head	Hair well combed, clean and nourished
Eyes	No pallor, discharge or jaundice
Ears	No discharge, polyps or enlarged lymph nodes.
Nose	No polyps or bleeding observed.
Mouth	Moist, no pallor, cracks or dental carries.
Neck	No swelling, thyroid gland normal and no pain on swallowing.
Hands	Nails clean, no oedema, good venous return.
Axillae	Very good personal hygiene, no enlarged lymph nodes.
Breasts	Full soft and tender to touch, nipples prominent and suitable for breastfeeding, lactating well and no lumps palpated.
Abdomen	Uterus contracted, no distension the fundal height was 8cm above the symphysis pubis.
Vulva	Clean well shaved, no sores, scars, warts or varicose veins.
Lochia	Alba minimal flow not offensive
Legs	No pallor, no oedema, good capillary refill, no varicose veins or calf muscle tenderness.
Sacrum	No sacral oedema.

EXAMINATION OF THE BABIES AT 6 DAYS

FEATURE	TWIN 1	TWIN 2
Temperature	36.1°C	36.4°C
Respirations	36 breaths per minute	38 breaths per minute
Apical beat	134 beats per minute	148 beats per minute
Head circumference	36cm	36.3cm
Eyes	No discharge, pallor or jaundice	No discharge, pallor or jaundice
Ears	No discharge or polyps	No discharge or polyps
Mouth	Clean, pink and moist no thrush, no false teeth.	Clean, pink and moist no thrush, no false teeth.
Neck	No enlarged lymph nodes, no rash, no webbing.	No enlarged lymph nodes or rashes, no webbing.
Hands	Symmetrical, palmer creases present, no pallor	Symmetrical, palmer creases present, no pallor
Chest	Circumference Chest movements normal	Circumference Chest movements normal
Abdomen	No discharge from the cord stump. Cord stump dried and healing. No distension	No discharge from the cord stump. Cord stump dried and healing. No distension.
Genitalia	Normal and passing urine well	Normal and passing urine well
Anus	Patent, baby passing normal stool well	Patent, baby passing normal stool well
Legs	No talipes, symmetrical creases present	No talipes, symmetrical creases present
Reflexes	All present	All present
Feeding method	Breast feeding well	Breast feeding well
Weight	3.2kg	3.2kg

PROBLEMS IDENTIFIED

1. Poor breast attachment.

2. Poor hygiene on the cords of both babies.

INFORMATION, EDUCATION AND COMMUNICATION

Ø I encouraged her to continue with the care of the babies at home by keeping them warm to prevent hypothermia, prevention of infection by keeping the cord stamps especially clean, and breastfeeding 2hourly and on demand.

Ø I advised Mrs. E. N. B on cord care and emphasized that she should not at any point put anything such as powder after cleaning or bathing the babies, as this may predispose to neonatal tetanus. Further showed her to best clean the cord; using cooled pre-boiled water, a clean clothe for each twin, which should be washed after the procedure and ironed before use again.

Ø I advised Mrs. E. N. B to change the nappies of the babies as soon as they are soiled to prevent nappy rash, to be checking the nappies continuously as the baby would often a time signal by crying if the nappy is soiled and needs changing. Further shown to her was how to dress the baby with a nappy by not touching the cord stamp to prevent friction onto the area.

Ø I educated Mrs. E. N. B on the breastfeeding positions as she breastfeeds and proper breast attachment; leaning against a chair, babies must face the mother’s abdomen, the babies must not make any sound when sucking as this is done by ensuring that all the nipple and areola are in the baby’s mouth to create a vacuum.

Ø I also emphasized that in case of any danger signs in the babies (neonates) as discussed on discharge, she must immediately seek medical attention.

Ø She was advised on considering starting family planning at or after 6 weeks, which service she would be given as she comes for her postnatal visit.

NOTE: She made a request to the sister in-charge of the clinic to allow her to attend the next meeting from her local area clinic (Kabushi Clinic) because of transport constraints. The sister agreed to the request, but emphasized that she should make sure she attended the clinic, and if any danger signs in the neonates and her were noted, she should not hesitate to come to the hospital without delay.

3RD VISIT AT 6 WEEKS POST NATAL – 15th August 2018.

OBJECTIVES

1. To check on how Mrs. E.N. B is coping with the babies.

2. To encourage her to take the babies for their first vaccines and register at under five clinic.

3. To examine the mother and the babies physically to note if there are any problems.

4. To arrange the date to close the case

On the stated date above, I visited Mrs. E. N. B at her home in the company of two of my fellow students. When we reached, she offered us seats and we began discussing how she was doing with the babies and how she was coping so far. We reviewed the previous visit and the lessons we had discussed. I then explained the purpose of our visit and the activities we would carry out to which she consented.

PHYSICAL EXAMINATION OF THE MOTHER

VITAL SIGNS

Temperature : 36.2°C

Pulse : 80 beats per minute

Respirations : 20 breaths per minute

Blood pressure : 110/78mmHg

General condition : Composed, clean, calm and happy

PHYSCIAL EXAMINATION

MOTHER

Head	Clean, well combed, no signs of malnutrition or chronic illness.
Eyes	No pallor, discharge or jaundice.
Ears	No discharge, polyps or enlarged lymph nodes.
Nose	No polyps, discharge or bleeding
Mouth	Pink, moist, no oral thrush or dental carries
Neck	No enlarged lymph nodes, thyroid gland normal.
Hands	No pallor and nails were clean and short, no oedema
Axillae	Excellent personal hygiene, clean and no enlarged lymph nodes.
Breasts	Nipples prominent and lactating well, no sores, no lumps felt.
Abdomen	Soft, no tenderness, uterus not palpable.
Vulva	Well shaved, clean, no sores, scar, warts, no foul smelling discharge
Legs	No pallor, oedema, varicose veins or calf muscle tenderness.

This physical examination was to exclude any puerperal complications and to ascertain return of the Mrs. E. N. B to her pre-gravid state. All the findings were communicated to her during the examination and were documented on the antenatal card as record.

EXAMINATION OF THE BABIES AT 6 WEEKS

FEATURE	TWIN 1	TWIN 2
Temperature	36.4°C	36.8°C
Apical beat	130 beats per minute	126 beats per minute
Respirations	32 breaths per minute	34 breaths per minute
Weight	3.5kg	3.8kg
Head circumference	38cm	37cm
Length	51cm	52cm
Head	Posterior fontanelle closed. Anterior fontanelle normal sutures ossified.	Posterior fontanelle closed. Anterior fontanelle normal sutures ossified.
Eyes	Symmetrical, no pallor, jaundice or discharge.	No discharge, pallor or jaundice.
Ears	No polyps or discharge.	No polyps or discharge.
Nose	No discharge, no nasal polyps	No discharge, no nasal polyps
Mouth	Moist pink, no sores or oral thrush.	Moist pink, no sores or oral thrush.
Neck	No rash, thyroid gland normal.	No rash, thyroid gland normal.
Hands	Symmetrical, no pallor creases present.	Symmetrical, no pallor creases present.
Abdomen	Soft, no distension, cord healed.	Soft, no distension, cord healed.
Legs	Symmetrical, planter creases present.	Symmetrical, planter creases present.
Genitalia	Well formed.	Well formed.
Back	Well curved.	Well curved.

The examination was done to exclude any abnormalities and how the babies were coping and developing.

INFORMATION, EDUCATION AND COMMUNICATION

Ø I communicated the findings of the physical examination both for the mother and the babies, to keep the mother aware of her babies’ development as well as her well being.

Ø Emphasis was placed on the importance of breastfeeding on demand and that babies must be exclusively breastfed to avoid diarrhoeal diseases caused by mixed feeding.

Ø She was also encouraged to take the babies for under five children’s clinic on the dates given to monitor their growth and prevention of diseases by immunization.

Ø She was further advised to consider starting family planning at this point because her reproductive organs have now completely returned to their pregravid state. She would conceive at this point in the event of conjugal duties with her husband.

Ø I encouraged her to continue sleeping under a treated mosquito net to prevent malaria attacks to both the babies and her.

I finally, thanked Mrs. E. N. B for her co-operation and hospitality. She was at this stage told that the day to close the case will be communicated to her in due course because it requires me to come with my supervisor.

CHAPTER FIVE

TERMINATION OF THE CASE STUDY

AIMS

1. To introduce my Supervisor to the client and her family.

2. To terminate the case.

3. To attend to any arising need(s).

4. To thank my client and her family for according me the chance to do a case study in their family.

On 17^th October, 2018, we went with Mr. Muzyamba for closure of the case study. We arrived in Kabushi at her home around 13:45hours. We found her home waiting for us with the children. They welcomed us warmly and gave us seats into the house. I immediately introduced my Supervisor to my client and I also introduced my client Mrs. E. N. B to my Supervisor. I thanked Mrs. E. N. B for allowing me to do a case study on her and the relationship which was between me and her family. She was also very thankful for the care and the lessons shown to her from the first contact in the hospital through to delivery up to the time of case closure of the case: the twins were 13 weeks old.

My Supervisor encouraged Mrs. E. N. B on the lesson she learnt during our interaction, he stressed the importance of children’s clinic and seeking medical attention when need arises. She (my Supervisor) acknowledged that it is through such interactions that relationships of medical staff and the community are built.

Lastly, I thanked Mrs. E. N. B for her time and allowing us to visit her and the family, all these times and for being such a hospitable home. The case study was closed.

SUMMARY

This case study was based on Mrs. E. N. B with multiple pregnancy. She was married with a multiparty of now 4children (set of twins plus two others) and staying with her children.

I met her on 3^rd April, 2018. She delivered spontaneously to female mature infants Apgar score 9/10 and 8/10 at 1 minute respectively. The first twin weighed 2800g and 2nd twin 2900g. The babies had no abnormalities. And the mother’s condition post delivery and during the first 6hours of postnatal was satisfactory. She was discharged on 2nd July 2018. I continued monitoring both the babies and the mother postnatally at 6 days, 6 weeks up to the closure of the case study when the babies were 13 weeks old.

CONCLUSION

Having undertaken this case study on multiple pregnancies, it is an achievement to me. During the study, I learnt that with good antenatal, Intrapartum and postnatal management and good health education to the mother, multiple pregnancy and birth can be complication-free, irrespective of the many risks involved. Gratitude goes to members of staff at Ndola Teaching Hospital, especially the midwives who were involved in the management of Mrs. E. N. B.

RECOMMENDATIONS

HOSPITAL

1. I recommend that the special attention that is given to High Risk pregnancies such as Twin Pregnancies at Ndola Teaching Hospital be continued and intensified.

2. Intensify exclusive antenatal, Intrapartum and postnatal care and/or management in its verity, and intensive health education (in groups and individualized) to mothers with such cases, so as to reduce on complications and Caesarean sections, it is workable as evidenced in my case study, for such high risk pregnancies. This not only gains the co-operation from the mothers involved, it also gives them the confidence to face the ‘burden’ of having to bear twins with great courage and responsibility.

SCHOOL

This requirement of having a case study in the midwifery course as one of the attainments should continue as it gives the student midwives an opportunity;

1. To learn more on how to handle obstetrics and non obstetric cases faced during training, thereby preparing a well equipped midwife for service post training.

2. Enhances the acquisition of the skills of counselling and teaching as the student interacts with the mothers and the community on one-to-one basis.

3. The student midwives gain the knowledge and skill to make enriched judgment and decision about certain critical situations. This builds on the capacity of critical thinking in the student, as I have learnt through this study.

REFERENCES

1. Basavanthappa BT (2006), A Textbook for Midwifery and Reproductive Health Nursing, 1st Edition, Jayppe Brothers Publishers, New Delhi, India.

2. Fraser D.M Cooper M.A and Nolte A.G.W (2006) Myles Textbook for Midwives, African Edition. Churchill Livingstone, UK.

3. Sellers PM (2008), Midwifery a textbook and reference book for midwives in Southern Africa. Volume 2, Juta and Co. Ltd.

4. www.indiaparenting.com/preconception/108-43-13/multiple-pregnancies.html-95kSinnler pages

5. www.medilexicon.com/medical dictionary.php? t=96202.

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