OBSTETRICS CASE STUDY- HYPERTENSION

CHAPTER ONE

DEFINITION OF CASE STUDY

Case study is the study of a person, a small group, a single situation, or a specific case. It involves extensive research, including documents evidence of a particular issue or situation, symptoms, reactions, effects of certain stimuli and the conclusion reached following the study. (Swanbora)

INTRODUCTION

Nursing case study is a holistic approach that gives a chance to a student midwife to identify a client with an obstetrical problem which can put the mother or baby’s life into danger leading to complications. It also enables the student midwife to offer adequate support and assistance to the client as well as the family. It does not only focus on medical treatment alone but also covers physical, psychological and spiritual support. My case study involved management of a pregnant woman who was in her 2^nd trimester with hypertension. I will refer to my client as Mrs. N.K. the case student involved care during antenatal, intrapartum and postnatal periods at home and in hospital. It also included the disease process of hypertension, effects of hypertension in pregnancy, labour and the baby in comparison with the disease process which occurred in the client. The family members especially the husband was involved in her case which built up a good interpersonal relationship.

OBJECTIVES

1. To enable me acquire knowledge on hypertension on my client, management and the complications that may arise.

SPECIFIC OBJECTIVES

1. To study hypertension and its management.

2. To study the complications that may arise on my client and the fetus if not well managed and help mothers with hypertension.

3. To have more knowledge on how to diagnose, manage and help mothers with hypertension.

4. To have live health baby.

5. To educated and offer psychological care to the client and the family so that they understand the condition.

HOW I MET MY CLIENT

I met my client in MCH where I was working as she came for her antenatal revisit. As I was doing the observations, I came across her having a raised Blood pressure and protein in urine. I told the sister I was working with Mrs. Chilembo that am suppose to do a case study, told her about the client I have found and gave me permission to go ahead. I greeted my client and introduced myself to her. I went through her antenatal card and found that the last visit the blood pressure was okey. I explained my intentions to the client and what was involved in the case study. She asked why I had chosen her condition. In response to her question I told her that it’s a challenging condition and I would like to learn more about it.

I also explained that it would also be beneficial to her as I would be monitoring her condition antenatally, intrapartum and postnatally. She willingly agreed, hence my case study on pre-eclampsia.

CLIENT’S PROFILE

HISTORY TAKING

The aim of history taking is to help me identify my client, know how to relate and communicate with her it will also help me to record facts and assess needs of my client, her family and the baby and to bring to her attention any problem that could affect her during pregnancy, labour and puerperium.

SOCIAL HISTORY

Date: 15/01/15

Antenatal card number 712/14

Name : Mrs. N.K. for identification

Age : 28 years – she is within the child bearing age

Address : MpandaFishala – where to follow her up during visits

Religion : Christian (Pentecostal Church) – There is no restriction on

medical treatment in her church

Marital status : Married – To know who is supporting her

Education level : Grade 11 – To know her level of understanding

Occupation : House wife – To know what type of job she does if

strenuous or not

‘2Tribe : Tumbuka

Tabbos : None – To know if she believes in any Traditional beliefs

like taking of herbs after delivery

Hobbies : Mrs. N.K. enjoys singing (Gospel songs)

Social habits : She does not smoke cigarettes or drink beer

Next of kin : Mr. M.K. (Husband)

Occupation : Teacher – To know if he will afford to support her

financially

Social habits of next of kin : Mr. N.K. does not smoke cigarettes but drink beer

HOW SHE WAS FEELING

Mrs. N.K. was fine. She did not complain of any danger signs of pregnancy such as severe headache, shortness of breath, severe lower abdominal pains, blurred vision, per viginal bleeding, severe frontal headache and draining liquor. These symptoms would have required Mrs. N.K. to go for immediate medical attention. Although she complained of body weakness and heart palpations at that time it was not presey.

ENVIRONMENTAL FACTORS

Accommodation

Mrs. N.K. lives in a 3 roomed house, 1 bedroom, sitting room and a kitchen. The house is iron roofed, cement blocks and has 3 windows. There are occupants in the house, Mrs. N.K., her husband, her 2 sisters and their 2 children. The house has cement floor and is electrified. This information is important to rule out risk of Mrs. N.K. having respiratory infections due to congestion in the house and poor ventilation which is not the case.

Surrounding

The surrounding is kept clean and have no backyard garden. The grass is kept short to prevent diseases like malaria. Mrs. N.K. is not at risk.

Refuse disposal

They use a pit dug outside the house within the yard but not near the house. It is about 15m away from the house. When it is full the waste is burnt and another one is dug.

Toilet facilities

They use a pit latrine toilet which is dug 20 metres away from the house. They keep it clean by using chlorine and cover the hole to keep the flies away.

Water supply

They draw water from a communal tap within their surroundings. She adds chlorine to drinking water or sometimes she boils to keep it safe and store in containers with a lid on for safety.

This history was taken to ascertain factors that may contribute to diarrhoeal diseases due to poor sanitation. My client is not at risk of these diarrhoeal diseases like dysentery and cholera.

FAMILY MEDICAL HISTORY

There is no history of Diabetes mellitus, Asthma, Epilepsy, cardiac diseases, sickle cell anaemia, psychosis, hypertension and twins. This was important to know because these conditions tend to run in families and she is not predisposed.

PERSONAL MEDICAL HISTORY

She has never suffered from Diabetes mellitus, sickle cell anaemia, epilepsy, psychosis and mental illness. Mrs. N.K. has suffered from Asthma when she was a young girl, and she is hypertensive but not on treatment as at now she is also on HAART. There is no history of Tuberculosis. She has never had repeated attack of malaria or chronic cough. This history is obtained to identify which conditions Mrs. N.K. has suffered from which are likely to re-occur in pregnancy and cause complications.

PERSONAL SURGICAL HISTORY

There is no history of pelvic injury which could alter the diameters. No surgery on uterus which could lead to uterine rupture. No history of blood transfusion which could put her at risk of iso immunization if Rhesus Negative.

CONTRACEPTIVE HISTORY

She was receiving contraceptives of Depo-provera. She stopped receiving Depo-provera in 2014 February because she wanted to have another child. This information was important because I had to know if the pregnancy was planned and for my client the pregnancy was peanned.

MENSTRUAL HISTORY

She attained mernach at 15 years. She has been having regular cycles of 28 days and her bleeding takes 4 days and is of normal flow. This history is important as it helped me to determine her fertility and to rule out anaemia which can result from heavy bleeding for which she had a normal pattern.

PAST OBSTETRIC HISTORY

No.	Year	Duration of pregnancy	Health during pregnancy	Mode of delivery	Birth weight	Alive dead or still birth	Puerperium
1.	2009	39 weeks	Good	SVD	3.5kg	Alive	Normal
2.	2012	39 weeks	Good	SVD	4.0kg	Alive	Normal

PRESENT OBSTETRIC HISTORY

Her last normal menstrual period was 11/06/14 and her EDD 18/03/15.

CALCULATED GESTATIONAL AGE

MONTH	NUMBER OF DAYS	WEEKS	DAYS
June	19	2	5
July	31	4	3
August	31	4	3
September	30	4	2
October	31	4	3
November	30	4	2
December	31	4	3
January	15	2	1
		28 + 3	22/7

Calculated gestational age – 31 weeks 1 day

HIV STATUS

She knew her HIV status when she came for antenatal booking on 21/10/14 which was reactive. She came with her partner who tested positive as well. This was important to establish prevention of mother to child transmission of HIV infection.

GENERAL HEALTH

Mrs. N.K. has been in good health during pregnancy. She has not experienced any danger signs like vaginal bleeding, vaginal discharge, urinary tract infection, severe headache and lower abdominal pain. This information was important for early intervention in case of any infection or danger signs.

MEDICATION

She is not taking any medication at the moment or any drugs that could cause harm to the baby.

TETANUS TOXOID

Mrs. N.K. has received 3 doses of tetanus toxoid. This is given to protect her against tetanus injection to the mother and the unborn baby. She is not yet protected against tetanus. Next dose will be in 2015 December.

DIETARY INTAKE

Her diet had been good. She does not select foods to eat and she manages to eat atleast 3 -4 times per day. She eats any food which is available and has no pica for soil which can predispose her to worm infestation which causes Anaemia.

SOCIAL SUPPORT

Her main support is from the husband and is the one giving her financial and emotional support. He is the one who will be available when she goes in labour.

BIRTH PREPAREDNESS

My client 2 days ago she has already started buying baby layette. So far she has bought 2 dresses, 5 napkins, baby towel, baby shawl and other useful things she is going to use in labour and after delivery.

COMPLICATION PREPAREDNESS

She is aware of obstetric complications that may arise. She knows about the dangers such as severe headache, vaginal discharge, vaginal bleeding and many others. She has saved some money of about K300.00 for emergency.

ANTENTATAL RECORD

DATE

BY DATES

FUNDUS

LIE

PRESENTATION

ENGAGED

FETAL HEART

BLOOD PRESSURE

OEDEMA

ALB

GLU

AGE

REVIEW REMARKS

21/10/14

19 wks

20cm

Undefined

¹¹²/66

mmHg

Nil

Neg

27/11/14

24²/7

21cm

Undefined

¹⁰⁰/59

mmHg

Nil

Neg

15/01/15

31¹/7

29cm

Undefined

Longitudinal

Not/

engaged

138b/m^R

¹⁶⁸/98

mmHg

Nil

Neg

19/02/15

PHYSICAL EXAMINATION

This is done to detect any abnormalities. Mrs. N.K’s general condition and nutrition status was good. She was walking upright and not limping. She appeared clean and happy.

Observations

Gait - Not limping

Stature - Medium height and has a good posture

Height - 160cm

Weight - 68kg

Shoe size - 6

Temperature - 36.8°C

Pulse - 84 beats/minute

Respirations - 20 breaths/minute

Blood pressure - ¹⁶⁸/98mmHg. This was raised the normal is between 100/60mmHg

- ¹³⁰/80mmHg

Urinalysis

Amount - 50mls

Colour - Amber

Smell - Aromatic

Glucose - Nil

Proteins - +

Acetone - Nil

This is to rule out abnormalities which could signify conditions like pre-eclampsia, renal disease, diabetes mellitus and general starvation. So pre-eclampsia is being ruled out.

HEAD TO TOE EXAMINATION

The head to toe examination was done and the findings were as follows:-

Head - Mrs. NK’s hair was clean and looked healthy, the texture was good which

is a sign of good nutritional status is a sign of good nutritional status.

Eyes - She has no pallor or jaundice on the conjunctiva and sclera respectively.

There was no abnormal eye discharge or periorbital oedema.

Ears - She had no ear discharge. No periauricularlymphnodes enlarged on

palpation which showed that there was no injection.

Nose - No polyps, no abnormal discharge and nostrils were clean. This showed

that there was no nasal obstruction.

Mouth - The lips appeared pink and no cracks were noted. The tongue and mucus

membranes were pink and moist which is a sign of good blood supply, no oral thrush, sores or dental carries were observed and no sign of anaemia was detected. Sublingual and submandibular lymphnodes were not enlarged hence no systemic injections.

Neck - There was no enlarged cervical lymphnodes palpated. This was done to

rule out any chronic disease like tuberculosis. When palpated for thyroid enlargement no mass was present on the anterior neck. This was done to rule out goiter.

Arms - They were symmetrical, no deformities noted which could effect on the

baby during baby handling and care during breast feeding. Her palms were pink the nail beds had a good venous return on pressure. This was indicating that she had a good blood flow and anaemia was ruled out. There was no knuckle oedema noted when she made a first.

Arm pits - Both axillae were well shaved and clean. This is a sign of good hygiene.

No lymphnode enlargement felt a palpation which showed that there was no injection present.

Breast - Both breasts were hemispherical, there was formation of the secondary

areolar, montogomerytubercule were present indicating presumptive signs of pregnancy. The nipple was prominent which is good for breast feeding. No sores, cracks or skin rashes were present.

On palpation - There were no lumps felt and no tenderness felt. Mrs. N.K was shown

how to breast examination at home to aid in early detection of breast abnormality at home.

ABDOMINAL EXAMINATION

On inspection - The abdomen appeared oval longitudinal. The lineanigra was

more darker. There was no scar on abdomen. This is to rule out any previous caesarian section or laparotomy done.

On palpation - The height of fundus was estimated at 31 weeks from the upper

boarder of the umbilicus

Fundal palpation - 29cm by tape measure

Lateral palpation - Right occipital anterior

Pelvic palpation - It was ⁵/5 descent

Auscultation - The fetal heart was heard and it was 138b/m^R

SUMMARY OF ABDOMINAL EXAMINATION

Height of fundus - 29cm

Presentation - Cephalic

Lie - Longitudinal

Position - Right occipital anterior

Fetal heart - 138 beats/minute regular

Contractions - There were no contraction on examination.

Vulva - It was well shaved and looked clean on inspection. No sores, warts,

or vaginal discharge was seen. On palpation on the supra pubic area no tenderness or inginallymphnodes palpated. This was done to rule out any sexually transmitted infections

Sacrum and back - The spine was well curved, there was no sacral oedema on pressure

and there was no rash on the back

Anus - There were no growth, no varicose veins and no haemorrhoids

noted

Legs - Both legs were symmetrical, no signs of anaemia on the sores of

feet. There was no pedal, ankle and tibialoedema. On palpation on the calf there was no calf tenderness and varicose veins on inspection.

INVESTIGATIONS

The aim of the investigations was to detect any abnormalities and treat accordingly.

DATE INVESTIGATIONS RESULT

15/1/15 Rapid plasma reagen Non – reactive

15/1/15 HIV Reactive

15/1/15 Haemoglobin Not ready

PROBLEMS/NEED IDENTIFIED

· Need for prophylactic drugs

· Need for Information Education and Communication

DIAGNOSIS

Pre-eclampsia in 2^nd trimester of pregnancy with HIV.

PLAN OF ACTION

· To do investigations

· To give prophylactic drugs like fansida, tetanus toxoid, folic acid, ferrous sulphate and mebendazole

· To give information education and communication

· Hospital delivery

MEDICATION

Mrs. NK received the following:-

· Mebendazole 500mg start for prevention of worms.

· Folic acid 5mg start for prevention of anaemia.

· Ferrous sulphate 200mg once daily for prevention of anaemia.

· Fansider 3 tablets stat as a 3^rd dose to prevent malaria.

INFORMATION, EDUCATION AND COMMUNICATION

· The importance of taking the ARVs on time and regularly to reduce the viral load.

· Danger signs of pregnancy especially that she had a raised blood pressure and these signs are: severe frontal headache, blurred version, epigastric pain, flash of lights, vaginal discharge, vaginal bleeding and lower abdominal pains so that once she experienced these signs, should come to hospital without delay.

· Complication preparedness.

· Hospital delivery.

· Regular check up of blood pressure.

· Importance of having a mixed diet so as for her to remain healthy and to have energy when she goes into labour and have a live and healthy baby.

· Low salt intake to reduce the blood pressure.

CHAPTER TWO

DISEASE PROCESS

INTRODUCTION

Hypertensive disorders of pregnancy represent a group of conditions associated with high blood pressure, protein with or without oedema and in some cases convulsions during pregnancy. However the most serious consequences for the mother and baby results from pre-eclampsia and eclampsia due to the presence of vaso spasms, patharogical vascular lessions in most organ system, increased platelet activation and activation if the coagulation in the micro vasculature system.

DEFINITION

Pre-eclampsia is a condition which occurs in pregnancy after 20^th week of gestation and is characterized by raised blood pressure of diastoric more than 90mmHg, during labour and or with in 48 hours of delivery, proteinuria with or without oedema. (Pauline Mc Call Sellers volume 2).

INCIDENCE

This condition is more common in multi gravida. It is more privilege in women over 35 years and frequency in all advancing age. It usually occurs in recurrent pregnancies. The severity of the condition is greatly lowered by good ante-natal care. Statistics available indicate that the incidence of eclampsia is estimated at 14% of all maternal deaths and it is assumed that pre-eclampsia account for 50% of all hypertensive disorders (www.tommy’s funding research.com, Mayes’ Midwifery 11^th edition).

CAUSES

The cause of pre-eclampsia are not known but there are some predisposing factors and these are as follows:

1. Prim-gravida (above 35 years or teenage below 16 years.

2. Lower income group are at risk of raised blood pressure because usually have inadequate ante-natal care.

3. Polyhydramious

4. Chronic nephitis are prone to hypertension

5. Abdominal pregnancy where the placenta has been attached to structures outside the uterus and has succeeded in maintaining foetus into the third trimester.

6. Rhesus iso immunization

7. Obese patients

8. Hydatidiform male

9. Essential hypertension

10. History of PIH and proteinuria in the previous pregnancy in the family

11. Multiple pregnancy due to greater placental tissue.

CLASSIFICATION

It is divided in three grades according to severity.

1. Mild pre-eclampsia

With the blood pressure of¹⁴⁰/90mmHg or more without proteinuria of proteinuria + 1, with oedema + 1 of the lower limbs.

2. Moderate pre-eclampsia

When there are two readings of 90 – 110 mmHg diastolic, blood pressure 4 hours apart after 20 weeks of gestation, proteinuria up to ++ with oedema ++ of the lower limbs to the knees.

3. Severe pre-eclampsia

This is when there is a diastolic blood pressure of more than 110mmHg, proteinuria 3+ or more and other signs and symptoms present which are:-

i. Epigastric pain

ii. Frontal headache

iii. Version changes e.g. blumed version

iv. Hyper eflexia i.e. increased in reflexion

v. Pulmonary oedema

vi. Origuria

vii. Vomiting

viii. Tenderness

PATHOPHYSIOLOGY

There are numerous abnormal alterations in the physiological in the mechanisms in patients with pre-eclampsia but there are etiological factors. Whilst cardiac out-put turns to reduce as pre-eclampsia worsens, generalized vassal spasms and vassal-constrictions appear which affects much of physiological activities in the body. Vassal spasms cause hypertension and ischaemia of the organs. This leads to renal damage and proteinuria. Together with renal damage there is increase capillary permeability and retension of salts resulting in extra vasicular collection of fluids. The presence of excess fluids with in the cells impeds oxygenation and tissues hypoxia occurs which may cause tissue necrosis of the vital organs e.g. the kidneys, uterus, liver, brain and the lungs.

PREVENTION

Each health and welfare organization should strive for the following conditions:-

i. Proper staffed ante natal clinics are made available to all patients in areas convenient to their homes.

ii. All pregnant women are encouraged to attend the clinics regularly from early pregnancy.

iii. The first signs of pre-eclampsia are sought, recognized and treated early and adequately.

iv. Sufficient prenatal beds are available so that treatment can be instituted.

EFFECTS OF PRE-ECLAMPSIA ON THE MOTHER

1. Condition may worsen and eclampsia may re-occur.

2. Placenta abruptio.

3. Haemotological disturbances may re-occur and kidneys, lungs, heart, uterus and liver may be seriously damaged.

4. Capillaries within fundus of the eye may be damaged and blindness may occur.

EFFECTS OF PRE-ECLAMPSIA ON THE BABY

1. Decrease in placental function may cause low birth weight. This is further worsened if mother smokes.

2. High incidence of hypoxia both in ANC and in intra-natal.

3. Placental abruptio – if minor will contribute to fetal hypoxia and if major can result in intra uterine foetal death (IUFD).

4. Early delivery if disease worsen or if placenta abruptio occurs will result in a premature baby.

5. Raised per-natal mortality and morbidity rates.

COMPLICATIONS OF PRE-ECLAMPSIA TO THE MOTHER

1. Eclampsia due to cerebral oedema and micro-haemorrhage causing cerebral hypoxia.

2. Placenta abruptio due to placenta tissue ischaemia thrombosis of the chronic infaration.

3. Subcapsular hepatic haemotoma due to hepatic failure and necrosis of the liver.

4. Cerebral Vascular Accident (CVA) due to cerebral oedema and thrombosis.

5. Disseminated Intravascular Coagulation (DIC) due to increased platelet consumption producing thrombocytopenia.

6. Renal failure due to glomenular or tabular necrosis.

7. Blindness due to hypertensive retinopathy.

8. Postpartum haemorrhage due to disseminated intravascular coagulation.

9. HELLP Sydrome (Haemolysis, Elevated, Liver enzymes and Low Platelets) can develop before or after delivery.

10. Pulmonary oedema due to increased extra – vascular fluids.

11. Severe vaso spasms high levels of blood pressure endrapture of blood vessels in various organs of the body and sub-sequent ischaemia giving rise to the following:-

- Severe frontal headache

- Visual disturbances

- Occular frontal changes may be seen

- Epigastric pain

- Twitching hyper- reflexia

COMPLICATIONS TO THE BABY

1. Intra-uterine growth retardation due to diminished placenta perfusion leading to decreased nutritive function of the placenta.

2. Intra- uterine fetal death due to anoxia following acute placenta abruptio.

3. Pre-maturity due to premature labour.

4. Fetal distress due to poor oxygen perfusion to the vital organs of the fetus.

5. Brain damage which can lead to handicap and mental retardation.

6. Raised perinatal mortality.

MANAGEMENT

AIMS

1. To provide a restful and tranquil environment.

2. To monitor the condition and prevent it from detoriating.

3. To control blood pressure and bring it as much to normal as possible.

4. To prevent complications during antenatal, labour delivery and post natal.

5. To ensure normal labour and puerperium.

INVESTIGATION

1. Urinalysis for proteinuria – Proteinuria greater or equal to 5g in 24 hours.

2. Full blood count – Haemoglobin, haematocrit, platelets findings: Haemoglobin 12.3g/dl, Haematocrit – 30.8%, platelets 162.

3. Renal function – Creativine, urea and uric acid.

The following alterations in the haemotological and bio chemical parameter indicative of pre-eclampsia.

- Increase haemoglobin and haemotocrit levels

- Thrombocytopenia

- Prolonged clotting time

- Raised serum creativine and urea levels

- Abnormal liver function test particulary raised transaminare

4. Ultra sound scan – for the bio-physical profile of the fetus and fetal movement, breathing and liquor volume,

5. Fetal maturity test – Pulmonary sulfactant lecithin sphingomyelin ratio normal is 2:1 for lung maturity.

- Urinalysis and blood tests may be ordered weekly.

MEDICAL TREATMENT

The following medication may be ordered depending on the Doctor’s orders.

a) ANTI HYPERTENSIVE

1. METHYLDOPA (ALDOMET) – 250mg – 500mg 8 hourly

A long term treatment until the fetus is more mature (35 – 36 weeks)

Action – It is a vasodilator

Side effects – sudden drop in blood pressure

Nursing intervention – Blood pressure to be rechecked 4 hourly

2. NIFEDIPINE (ANDALAT/RETARD)

10 – 20 mg orally twice daily

Sublingualysis useful acute lowering of blood pressure

Action – It is a calcium blocker

Side effects – Headache, dizziness, lethargy, tachycardia, nausea, increased

frequency of mucturation and eye pain

Nursing intervention – To be taken with or after food. Closely observe for above side

effects.

- Observations of vital signs to be done 4 hourly.

3. HYDRALLAZINE (APRESOLINE)

25mg tablet 8 or 12 hourly or 5mg bolus intravenously initially followed by 5mg every 20 – 30 minutes if the diastolic remains above 90mmHg until you give a maximum dose of 20mg.

Action – It is peripheral vasoconstrictor. Therefore its effect is noticed immediately.

Side effects – Postural hypotension and tachcardia

Nursing intervention – Blood pressure and pulse rate to be rechecked every 5 minutes until diastolic pressure reaches a sufficiently low and safe level.

- Observe for headache, vomiting and tremours.

- Observe that fetal heart is monitored. This is to detect whether the lowered maternal

blood pressure affects the fetal well being.

4. ANTERNOL

50 – 100mg daily orally

Action – It is a beta blocker, it reduces the blood pressure by slowing the heart rate.

Side effects – Brady cardia, heart failure, convulsive disorders and peripheral vaso

constriction

Nursing intervention – 2 hourly rechecking of blood pressure and pulse rate.

b) ANTICONVULSANTS

1. MAGNESIUM SULPHATE

4g (8ml solution) Diluted in 10mls of solution is injected slowly over 10 minutes, followed by 10g of 50% solution mixed with 1ml of 1% lignocaine in syringe is give to each gluteal region by deep intravenous infection. Then maintenance dose is 5mg of 50% solution with 1ml lignocaine every 4 hours in altenate buttocks.

Action – Prevents and treats convulsions.

Side effects – Reduced urine out-put, hyperflexia, restlessness, heart palpations and

cardiac failure

Antidote – Calcium gluconate

Nursing intervention

- Prior to injection, ensure urine out put is more than 30mls per hour.

- Knee reflexes should be present.

- Respirations should be above 16 breaths/minute.

2. PHENOBARBITONE (Given in small doses for mild pre-eclampsia when patient is not likely to go into labour)

30 – 60mg daily or twice daily

Orally or 200mg intramuscularly

Action – It is an anticonculsant

Side effects – It has depressing effects on both maternal and fetal respiratory centre

Nursing intervention – Observe for restlessness

c) SEDATIVES

1. DIAZEPAM (Vallium)

5 – 10mg once or twice daily or a loading dose of 10mg

Intravenously over 2 minutes

Action – It depresses the central nervous system, suppresses spread of seizures

Side effects

- Drowsiness

- Lethargy

- Depression effects on the fetal respiratory centre and maternal respiratory centre

- Slurred speech

OBSTETRICAL MANANGEMENT

1. The Doctor decides on the optimal time of delivery. This depends on the maternal and fetal well being and not the period of gestation.

2. In mild pre-eclampsia, if the patient and the fetus responds too well to treatment the pregnancy is usually allowed to continue in most cases. However labour is induced before term to reduce the effects placental insufficiency.

3. If the condition is severe and does not respond to treatment, an induction of labour is usually commenced after 24 hours.

4. Indication for induction are:-

- Fetal intra uterine growth retardation

- Uncontrolled rising blood pressure

- Poor renal function

5. Labour is induced by intravenous oxytocin being administered together with the rupture of membranes.

6. Episiotomy and forcep delivery or vaccum extraction is frequently carried out to prevent exertion on the client, as this may lead to eclampsia.

7. Caesarean section may be performed when labour is thought to be detrimental to the maternal and or fetal well being.

8. Epidural analgesics is now frequently used in labour and for caesarean section.

9. A pediatrician should be present at the time of delivery to attend to the high risk baby.

NURSING CARE

ANTENATAL CARE

Care and management of pre-eclampsia will vary depending on the degree of the condition.

AIMS OF CARE (NURSING)

1. To monitor the disease and prevent it from worsening.

2. To provide enough rest and a tranquil environment.

3. To prolong the pregnancy until the baby is sufficiently mature to survive extra uterine life while safe guarding the mother’s life.

4. To provide psychological care to the woman and the family support person.

ENVIRONMENT

The environment should be quiet, calm, clean and well ventilated to promote rest and prevent infections.

REST

The woman is advised to rest as much as possible to minimize stimulation of the central nervous system. This should be facilitated by the midwife and details of the importance of rest explained to the patient. The woman should rest atleast 12 hours at night and 3 hours during the day. This will promote improved blood flow to the heart and therefore to the placenta. The doctor may order a mild sedative to ensure rest and sleep like phenobarbitone 10 – 30mg, when the patient is not likely to go into labour.

DIET

Diet should be high in protein, high vitamin and high fibre, the low carbohydrate and no extra salt. Proteins and vitamins are important for nourishment of the growing fetus and prepare the baby for lactation, fibre to prevent constipation which can cause strain on the head, low carbohydrate and low salt to prevent weight gain and high blood, vitamin C and E supplement are effective in decreasing oxidative stress and improve vascular endotherial function.

OBSERVATIONS

Blood pressure is monitored 4 hourly in the ward to monitor if the hypertension is being controlled or is worsening urinalysis should be done daily to monitor the level of proteins, if increase may indicate disease progression.

- Abdominal examination is done daily and any tenderness or discomfort should be noted and

reported immediately to the doctor as it may be a sign of placenta abruption.

- The Midwife should observe and advise the patient to report any of the following signs and

symptoms.

i. Epigastric pain

ii. Visual disturbances

iii. Diminished urine out put

iv. Vomiting

v. Drowsiness

- Fetal assessment should be done daily to determine fetal well being by using a kick chart,

where the mother is asked to count how many times the baby is kicking in 12 hours (normal 10

– 12 times). Cardio tenograph monitoring, ultra sound scan to check fetal growth. Checking

of fetal heart is done 4 hourly and should be well documented.

PSYCHOLOGICAL CARE

Maternal and fetal condition together with the plan of care should be discussed with the woman and her family or support person particularly the prognosis of the pregnancy for them to co-operate and allay anxiety. Establish a good midwife/patient relationship.

Allow significant other to visit her but restrict others to promote rest and sleep.

WEIGHT GAIN

Daily weight should be done to rule out excessive weight, which can worsen the condition. A woman should not gain more than 12kg above her normal weight in pregnancy.

HYGIENE

Daily bath should be done to promote comfort and rest, also to promote blood circulation. Oral care should be done whenever necessary to promote appetite and good smell.

Bed linen should be changed whenever dirty to promote rest and comfort.

ELIMINATION

Bowel care

Patient should be advised on taking a lot of fibre and roughage to prevent constipation which can cause strain on the heart and worsen the condition. Mild laxatives may be given to prevent constipation.

Bladder care

Fluid intake and out put should be recorded and fluid balance monitored carefully. It there is severe damage to the kidney (obiguria) fluids may be restricted by the doctor to prevent fluid over load.

Exercises

Gentle exercises should be advised to prevent deep vein thrombosis and maintain optimal weight to prevent the condition from getting worse. Deep breathing exercises can be done to prevent hypostatic pneumonia. Monitor regular and gentle exercises especially when the blood pressure has been controlled.

Position

Patient should sleep either in the left or right lateral position to preventsupine hypotension. Patient’s advised to change positions to promote comfort and prevent bedsores.

INFORMATION, EDUCATION AND COMMUNICATION

Information will be given to the patient on the importance of rest to promote blood flow to the heart and reduce strain on the heart.

Importance of mild exercises will be experienced to the mother to prevent deep vein thrombosis and hypostatic pneumonia.

Importance of a high fibre diet and roughage, high protein and low salt will be explained to prevent strain on the heart with constipation and promote healing.

CHAPTER THREE

ADMISSION IN THE LABOUR WARD

It was on Wednesday on the 25^th March 2015 around 02:30 hours when I was called by Mrs. NK on phone that she was admitted in hospital. She came with complaints of abdominal pain and backache since 24/03/15 around 21:00 hours.

I immediately rushed to the ward where I found Mrs. NK and the staff admitting her and I finished with the rest of the work.

OBSERVATION ON ADMISSION

Vital signs

Temperature : 36°C

Pulse : 88 beats per minute

Respirations : 22 breaths per minute

Blood pressure : ¹¹⁰/60mmHg

GESTATIONAL AGE

MONTHS	DAYS	WEEKS	DAYS
June	19	2	5
July	31	4	3
August	31	4	3
September	30	4	2
October	31	4	3
November	30	4	2
December	31	4	3
January	31	4	3
February	28	4	-
March	25	3	4
		37 + 4	²⁸/7 41 WEEKS

PHYSICAL EXAMINATION

Head : Hair clean

Eyes : No pallor or jaundice

Nose : No nasal polyps

Mouth : No dental carries

Neck : No goiter or enlarged lymphnodes

Arms : No pallor, nails short, no knuckle oedema

Armpits : No enlarged lymphnodes, well shaved

Breasts

On inspection

Both breasts were hemispherical, there was darkening of primary areolar and formation of secondary areolar. The nipples were prominent which is good for breastfeeding. No sores, cracks or skin rashes were present.

On palpation

On palpation there were no lumps felt and no tenderness felt.

Legs : Nails short, no pedal, fibula oedema but slight ankle oedema. There was

no calf tenderness and varicose veins

On inspection

Vulva : Normal, clean and well shaved, no sores, no warts, show present

Anus : No hemorrhoids

Back : No deformities, no sacral oedema

ABDOMINAL EXAMINATION

Inspection

The abdomen appeared oval longitudinal. There was no scars on the abdomen. Linea nigra and striae gravidarum present.

Palpation

Height of fundus : 39cm by tape

Lie : Longitudinal

Presentation : Cephalic

Position : Left occipital anterior

Descent

Contractions

Contraction observed within 10 minutes lasting for 35 seconds.

Auscultation

Fetal heart rate was checked. It was 138 beats per minute using a fetal scope.

VAGINAL EXAMINATION

The procedure was explained to the client to know what is going on as well as to gain her cooperation.

Vulva : No warts or sores were seen

Vagina : Warm and moist

Cervix : Effaced and thin

Os : 5cm

Cord : Not felt

Station : 4 above ischial spines

Sacral promontory : Not reached

Sacrum : Well curved

Ischial spines : Round and smooth, not prominent

Pubic arch : Admitting 2 fingers

Intertuberous space : Accommodating 4 knuckles

The pelvis was adequate for vaginal delivery.

URINALYSIS

Amount : 150mls

Colour : Amber

Smell : Aromatic

Ketones : Not present

Proteins : Not present

Glucose : Not present

DIAGNOSIS – LABOUR IN ACTIVE FIRST STAGE

FIRST STAGE MANAGEMENT

Mrs. NK was admitted in labour ward.

POSITION

Mrs. NK was told to sleep in any position which was comfortable for her apart from supine position to avoid hypotension.

PSYCHOLOGICAL CARE

I explained to Mrs. NK that staff and I will be there for her throughout labour and try everything possible to help her. I told her that even herself should help us by obeying simple instructions like not to rush until told to do so. I informed her to tell me all she wanted to do so that she was helped. I encouraged her to ask questions where she did not understand. I also explained to her mother that all was to be fine and that they were to be informed from time to time. I told them to be checking on her so that she felt care for.

DIET

Tea was made for her around 05:00 hours with buns in order to give her energy when time for pushing come.

ELIMINATION

I encouraged her to be opening bowels and bladder so as to aid in the descent of the fetus. It is helpful to reduce extra pain which is felt when bladder and rectum is full.

PARTOGRAPH

I opened the partograph since Mrs. NK was in established labour in order to monitor maternal and fetal well being as well as the progress of labour.

FETAL WELL BEING

- Fetal heart rate was done ½ hourly ranging from 100 to 160 beats per minute.

- Moulding and liquor amni was observed to rule out any deviation from normal and it was clear in colour indicating no fetal distress. The time of rupture as noted and amount too.

PROGRESS IN LABOUR

- Contractions were observed ½ hourly ranging from 3:10:30 to 4:10:40 seconds

(moderate).

- Vaginal examination was done 4 hourly and the patient was progressing well. Documentation of everything was done and observed on Mrs. NK and recorded on partograph.

MATERNAL WELL BEING

- Temperature was done 2 hourly ranging from 30 – 36.7°C.

- Pulse rate was done ½ hourly ranging from 80 – 90 beats per minute.

- Respirations were done ½ hourly ranging from 18 – 24 breaths per minute.

- Blood pressure were done 4 hourly ranging from ¹¹⁰/60mmHg to ¹⁵⁰/90. Blood pressure was well maintained.

The client was encouraged to pass urine frequently to aid in the quick progress of labour. Urinalysis was done and there were no proteins present, glucose negative and ketones negative.

SECOND VAGINAL EXAMINATION

In confirming 2^nd stage of labour, the 2^nd vaginal examination was done at 07:00 hours. The client was 9cm dilated and membranes still intact.

At 09:20 hours, membranes ruptured and liquor was clear in colour. 3^rd vaginal examination was done to rule out cord prolapse. This time the Os was 10cm dilated.

ROOM

The labour room was prepared in advance with all equipments ready. A delivery pack was put on a trolley episiotomy scissors, cord clump, suturing material were in place. Suction machine was in good condition in case of asphyxia. Baby layette to wrap the baby was prepared.

Oxygen drugs were put in place to be given during the 3^rd stage of labour. I informed the staff on duty that Mrs. NK was in 2^nd stage of labour and she came to assist to deliver the baby.

POSITION

Mrs. NK was positioned in dorsal position. At 10:40 hours labour progressed well as spontaneous vertex delivery to a live mature female infant Apgar score 9/10 at 1 minute, 9/10 at 5 minutes. Cord clumped and cut short. Baby wiped and shown to mother for sex identification, weighed 3.6kg and length 48cm. Baby was wrapped in clean linen for warmth.

THIRD STAGE OF LABOUR

Mother’s abdomen was palpated to rule out 2^nd baby oxytocin 10 international units. Intramuscular was given. Placenta and membranes delivered by controlled cord traction. Placenta appeared complete and healthy on examination. It was dark red in colour and with all the lobes intact. Fundal massage was done to expel clots of blood. Approximately blood was 100mls. Perineum examined which was intact. Bladder emptied 100mls by passing a catheter to aid in the uterine contraction hence preventing post partum haemorrhage. Mrs. NK was cleaned and perineum padded. She was allowed to rest, made comfortable in clean linen. The baby was given to her for breast feed and to promote bonding.

POST DELIVERY READINGS

Temperature : 36°C

Pulse rate : 72 beats per minute

Respirations : 22 breaths per minute

Blood pressure : ¹¹⁰/70mmHg

General condition : She looked clean

Clinically : No pallor

Abdomen : Uterus well contracted, 10cm above the symphysis pubis

Lochia : Rubra, minimal flow

Bladder : Empty, I encouraged the mother to be passing urine frequently to

help in the contraction of uterus

General condition : Good

OBSERVATIONS FOR BABY

Observation and examinations were done to rule out any abnormalities on the baby.

Temperature : 36.2°C

Apex beat : 124 beats per minute

Respirations : 40 breaths per minute

Skin : Pink and intact

Head : Circumference 35cm, fontanelles and sutures present. No injuries on the

head of the baby

Eyes : No discharge, symmetrical with the ears, no pallor, no jaundice

Ears : No discharge and well formed

Nose : No polyps, no discharge, breathing well

Mouth : No pallor, no cleft palate or lip, no false teeth or tongue tie, baby sucking

well

Neck : No webbing of the neck, no congenital goitre

Hands : Symmetrical, palmer creases present, no extra digits no webbing

Chest : Breasts well formed, 34cm circumference

Abdomen : No exomphalus, umbilical cord not bleeding

Legs : Symmetrical, no extra digits, no tallipes, foot creases present, no webbing

Genitalia : Well formed, passed urine

Back : No spinal bifida

Anus : Patent, meconium passed

INFORMATION, EDUCATION AND COMMUNICATION

- Mrs. NK was encouraged on the importance of exclusive breast feeding to aid in good health of the baby and for her help in quick involution.

- Good hygiene was encouraged to prevent diseases such as puerperal sepsis to the mother and infection to the baby.

- Mrs. NK learnt the importance of good nutrition to help in the production of milk and also for good health status.

- Keeping the baby warm to prevent hypothermia which can lead to diseases such as pneumonia.

- Mrs. NK was advised on the neonatal danger signs like fever, pus around the cord stump and bleeding from the umbilical stump.

- Advise was given on the importance of cord care to prevent infection.

- Importance of taking the birth record to the civic centre so that baby can be counted.

CHAPTER FOUR

In midwifery practice, it is important to make visits to a woman during pregnancy and during puerperium (antenatal and post natal) to monitor the well being of both the mother and baby.

AIMS OF THE VISITS

1. To locate and assess the environment in which Mrs. NK lives.

2. To assess the general condition of Mrs. NK.

3. To ensure continued monitoring of Mrs. NK.

4. To ensure successfully initiation of breast feeding and proper maintenance of baby’s breast feeding period.

5. To ensure that both the mother and baby are coping up well with each other, are in good condition and to detect any problems or complications.

6. To give information, education and communication.

FOLLOW UP VISITS

FIRST ANTENATAL HOME VISIT – 08.02.15

Objectives

1. To locate the house.

2. To introduce myself to the rest of the family.

3. To check on the environment.

4. To monitor progress of pregnancy.

We started off with my fellow student from the hostels to MpandaFishala around 10:00 hours. We reached MpandaFishala around 10:20 hours. The land mark is the poster written MpandaFishala and we managed to locate the house without difficulties. We found her seated outside the house with her sister, husband and her two sons. She was really happy to see us come. She asked us to go inside the house which was well swept and clean. I asked her how she was feeling and she told me about headache and sometimes blurred vision. I asked her if at all the fetus was kicking and she said the fetus was kicking well and was able to feel the movements.

On examination, the general condition was stable and was taking the drugs given Niverapine and Aldomet on time. I asked her where we can do the examination from. We went into one of the bedrooms.

PHYSICAL EXAMINATION

General condition - She looked clean and happy.

VITAL SIGNS

Temperature : 36.5°C

Pulse : 82 breaths per minute

Blood pressure : ¹⁴⁰/90 mmHg

Respirations : 20 beats per minute

She did not have any serious complaints that needed immediate attention and all the readings were in the normal range except the blood pressure and I advised her to take her mid day drugs which was Aldomet 500mg.

HEAD TO TOE EXAMINATION

Head : Her hair looked clean and well plaited. No signs of malnutrition or

chronic illness

Eyes : There was no discharge, no pallor and no jaundice

Nose : There was no nasal polyps which could interfere with effective breathing

Mouth : There was no pallor of the lips, mucous membranes tongue and no

offensive breath

Ears : No discharge, no enlarged periauricular nodes which could suggest

systemic infections

Neck : No goiter and no enlarged cervical lymphnodes which could suggest

systemic infections

Upper limbs : Symetrical, no palmer pallor, slight knuckle oedema and there was good

venous return on the nail beds

Axilla : Clear, well shaved with no enlarged axillary lymphnodes

Breasts

On inspection : No sores or rashes, signs of pregnancy seen like the darkening of the

secondary areolar

On palpation : No abnormal lumps palpated

Abdomen

On inspection : longitudinally avoid in shape, size corresponding to the gestation age

which was 33cm by tape

Lie - Longitudinal

Presentation - Cephalic

Position - Left occipital anterior

Descent - 5/5

Auscultation - 138 beats per minute regular

Lower limbs : Symetrical with pedal, tibial and ankle oedema no planter pallor

and no calf tenderness

Vulva : No warts, no varicose veins, slight oedema, no sores, no abnormal

discharge and no enlarged inguinal lymphnodes

Sacrum : There was slight sacral oedema

These observations were made in order to monitor progress of pregnancy, monitor maternal and fetal well being. I explained all the findings to Mrs. NK and all the observations I made on her.

PROBLEMS IDENTIFIED

1. Headache

2. Oedema

3. Slight rise in blood pressure

INFORMATION, EDUCATION AND COMMUNICATION

It was given as follows:

- Headache – She was advised to have enough rest even during the day to reduce workload on

the heart muscles. She was also advised to be taking Panadol 500mg if the headache is too

much.

- Oedema - She as advised be elevating her lower limbs when in a sitting position or when

sleeping to increase venous return.

- Slight rise in blood pressure - To be taking her anti-hypertensive drugs at the right time and I also emphasized on the importance of having enough rest at home as this reduces workload on the heart muscle hence helps in stabilizing blood pressure.

SECOND ANTENATAL HOME VISIT – 21.03.15

On 21^st March 2015, I made an antenatal revisit to my client in MpandaFishala. I was accompanied by my fellow student.

PURPOSE OF VISIT

1. To assess her general condition.

2. To check her blood pressure.

3. To monitor progress of pregnancy both a mother and fetal well being.

We arrived at Mrs. NK’s house and we were welcomed by her and invited us in the house.

HOW SHE WAS FEELING

When I asked how she was feeling, she told me she was much better and only complaining of tiredness.

VITAL SIGNS

Temperature : 37.1°C

Pulse : 102 breaths per minute

Blood pressure : ¹⁵⁰/100 mmHg

Respirations : 18 beats per minute

General condition : She looked calm and did not give any complaints but looked

worried

HEAD TO TOE EXAMINATION

Head : The hair was well plaited

Eyes : No pallor, no jaundice or discharge

Nose : No obstruction was breathing well

Mouth : No cracks, lips pink no pallor, no oral thrush

Ears : No discharge, no palpation no pericuricularlymphnodopathy or

tenderness

Neck : No enlarged cervical lymphnodes

Upper limbs : Nails were cut short with good venous return. On the nail beds, no pallor

observed and there was no knuckle oedema

Breasts : No sores, rashes, on palpation no breast lumps palpated

Axilla : Clean and well shaved

Abdomen

On inspection : Shape was longitudinally avoid, fetal movements were observed

On palpation : Height of fundus 41cm by tape

Lie - Longitudinal

Presentation - Cephalic

Position - Left occipital anterior

Descent - 5/5

Contractions - Nil

On auscultation : Fetal heart rate 140 beats per minute and regular

Lower limbs : No calf tenderness, no varicose veins. There was oedema ++ of

the ankles, tibial and peddles

Vulva : Clean, no sores, no warts no varicose veins

Sacrum : There was slight oedema of the sacrum

PROBLEMS IDENTIFIED

1. High blood pressure

2. Oedema of the ankles, tibial and peddle which was increasing.

INFORMATION, EDUCATION AND COMMUNICATION

· She was advised on the importance of continuing on the antihypertensive drugs, taking them at the right time to bring the blood pressure as near to normal as possible.

· I advised her on the importance of going for her weekly check up of blood pressure and urinalysis so that the medical personel at the hospital check whether the condition is getting worse or not.

· I advised her on the importance of getting enough rest even during the day to reduce work load on the heart.

· I advised on elevating of the food when sitting or sleeping to improve venous return.

· After the information, education and communication, I inquired why she was looking worried and she explained that it was because the blood pressure was not coming down despite taking the hypertensive drugs consistently. I explained the disease process and that she will be only be okey after she delivers.

· I encouraged her to continue going to the hospital for blood pressure check ups, maternal and fetal well being to ensure a normal baby after delivery.

FIRST POSTNATAL VISIT – 01/04/15

POSTNATAL EXAMINATION AT 6 DAYS

On 01/04/15, I went to visit Mrs. NK at Mpanda Foshala the first week after she had delivered.

PURPOSE OF THE VISIT

- To monitor mother’s health postanatally.

- To monitor the blood pressure.

- To observe how both the mother and baby were coping.

- To observe for any maternal and neonatal danger signs.

- To ensure successful breast feeding for the first 6 months of life, which is exclusive.

MOTHER

EXAMINATION

Temperature : 37°C

Pulse : 84 beats per minute

Respirations : 18breaths per minute

Blood pressure : ¹⁴⁰/80mmHg

URINALYSIS

Amount : No measured

Colour : Deep amber

Smell : Aromatic

Proteins : Tract

Glucose : Negative

Acetone : Negative

PHYSICAL EXAMINATION

General condition: She was clean, calm and generally excited

Head : Her hair was clean and well plaited with no signs of malnutrition or

chronic illness

Eyes : No jaundice, pallor or discharge

Nose : No polyps which could obstruct the airway

Mouth : Lips were not cracked, the mucosa was pink with no signs of pallor, no

oral thrush and no dental carries

Ears : No discharge and there was no periacuricular tenderness and no enlarged

lymphnodes

Neck : No cervical lymph adenopathy and there was no enlarged thyroid gland

Hands : Symetrical with no palmer pallor. No knuckle oedema observed. Venous

return on the nail bed was good

Axillae : It was clean and well shaved with no enlarged lymphnodes

Breasts

On inspection

There were no sores seen, no cracks noted.

On palpation

There was no breast engorgement with no abnormal lumps felt. When squeezes, milk was coming out and no tenderness on squeezing

Abdomen : It was soft and not distended. The uterus felt well contracted. Fundal

height was 10cm above the symphysis pubis

Legs : They were symmetrical with good venous return on the nail beds. There

was no ankle, tibial or pedal oedema observed. No planter pallor noted

Genetalia : The vulva was clean, shaved with no oedema, no warts, no sores or

varicose veins observed. There was no perineal tear or healed episiotomy. Scar noted

Lochia : Serosa, non offensive and minimal flow

Back : No sacral oedema

All the findings were communicated to the client.

BABY

HEAD TO TOE EXAMINATION

The baby’s clothes were removed.

General condition : Good and active

Skin : Intact, no rash, no busters, pink and soft

Head : Sutures were not wide apart, fontanelles were normal and well

Formed

Head circumference : 35cm

Eyes : No slanting of eyes observed, no jaundice, no pallor no congenital

cataract, no discharge was noticed from the baby’s eyes. All the eye balls were present

Nose : There were no nasal polypse and both nostrils were clear

Mouth : The lips were pink. There was no cleft lip or palate. No false teeth

and the tongue was present

Ears : The ear cartilages were normal and not sticky. There was no ear

discharges

Neck : There was no congenital enlarged thyroid gland and no webbing of

the neck observed. The neck folds were normal

Arms : They were symmetrical, no extra digits or webbing were noted and

the nails were well formed

Chest : There was normal chest raising and failing with normal

respirations. On palpation, the breast tissues were present

Abdomen : Umbilical cord was not bleeding, no discharge the cord was

healing

Legs : Symetrical, no pallor, creases were formed

INFORMATION, EDUCATION AND COMMUNICATION

- Mrs. NK was encouraged on the importance of exclusive breast feeding to aid in good health of the baby and for her to help in quick involution of the uterus and as breast milk provides nutrition for growth of the baby.

- She was advised on the danger sings like fever, failing to breast feed and difficulties in breathing.

- She was advised on the importance of taking the baby for 6 weeks post natal so that baby can start receiving immunizations.

- She was also advised on the importance of the family planning.

POSTNATAL VISIT AT 6 WEEKS

On 6^th May 2015 I visited my client for the post natal visit at 6 weeks.

PURPOSE OF VISIT

- To check on how Mrs. NK was coping up with the baby at 6 weeks.

- To identify problems from the mother and baby during puerperium and ensure prompt care.

- To give detailed information on family planning.

PHYSICAL EXAMINATION

ON THE MOTHER

Observations

Temperature : 36.3°C

Pulse : 78 beats per minute

Respirations : 20 breaths per minute

Blood pressure : ¹⁴⁰/70mmHg

General condition : She was clean, carm and generally happy

HEAD TO TOE EXAMINATION

Head : Hair was clean and well combed. No signs of malnutrition and chronic

illness

Eyes : No jaundice, no pallor

Nose : No discharge

Mouth : No pallor, no oral thrush, lips were not cracked

Ears : No discharge, no peri auricular enlarged lymphnodes

Neck : No cervical lymphadenopathy

Hands : Venous return on the nail beds was good. No knuckle oedema

Axillae : It was clean, no enlarged lymphnodes

Breast : They were soft and lactating. No abnormal lumps felt. No engorgement

Abdomen : It was not distended. Uterus well contracted

Legs : No ankle oedema, pedal or tibial oedema. Venous return was good

Genitalia : Vulva was well shaved and clean. No warts, sores or varicose veins

observed

Lochia : There was no discharge

All the findings were communicated to the client.

ON BABY

Weight : 4.5kg

Apex beat : 128 beats per minute

Respirations : 38 breaths per minute

Temperature : 36.1°C

Baby’s clothes were removed.

General condition – Good and active

HEAD TO TOE EXAMINATION

Head : Fontanelles present

Eyes : No discharge or jaundice

Nose : No discharge was noted

Ears : No discharge

Neck : Neck folds were normal, no enlarged thyroid gland

Mouth : No oral thrush, no pallor, no jaundice

Chest : There was normal chest raising and falling with normal respirations. On

palpation the left breast was swollen and red

Bowels : Passing well

Urine : Passing well

PROBLEMS IDENTIFIED

- Baby had an abscess on the left breast.

- Baby needs to receive OPV, DPT, Rota and PCV vaccines.

- Need for health education.

- Lack of knowledge about family planning.

MANAGEMENT

- To take baby to the hospital for treatment of the abscess.

INFORMATION, EDUCATION AND COMMUNICATION

- I advised Mrs. NK on the importance of taking the baby to hospital as soon as she notices that the was unwell.

- I advised her on the importance of eating a well balanced diet to promote good health and proper lactation.

- I also advised her on the importance of regular blood pressure checking.

- I also advised her on the importance of taking the baby for under five clinic so that the baby can now start receiving immunizations that is OPV1, DPT, Rota 1 and PCV1 vaccines.

ADVICE ON FAMILY PLANNING

I explained to Mrs. NK what family planning is and its benefits to the family, community, father and children and the nation as a whole.

DEFINITION OF FAMILY PLANNING

Family planning is a voluntary decision made by an individual, or couple on the number of children they want to have, when to start having them, how to space them and when to stop having children.

BENEFITS OF FAMILY PLANNING

1. To the mother

Family planning helps the woman to space her children preventing subsequent pregnancies which predispose the woman to anaemia and complications like placenta previa.

- It reduces the incidences of ectopic pregnancies.

- It gives her time to higher her education.

- She enjoys sex without fear of getting pregnant.

- It brings back the woman’s vitality.

2. To the father

- The man enjoys sex without fear of pregnanting the woman.

- The man can have a family which he can afford to take care of and be able to provide for every child.

3. To the children

- The children feel loved because the parents will have enough time for each child.

- The children are able to go to school.

- It gives the baby an opportunity to breastfeed for a longer period hence reducing the chances of malnutrition.

4. T o the community

- The community is not over populated as each family will have a number of children they can manage hence reducing poverty.

- There will be no incidences of throwing away babies by young girls hence reducing unnecessary deaths out of abortions.

- The community is being helped to have healthy children.

5. To the nation

- The number of street kids is reduced as all children would be taken care of properly by their parents as they will have families they can manage.

- There will be proper provision of public health services as the country will not be over populated.

- There would be reduced maternal and infant mortality rate because the health care provided will be adequate.

METHODS OF FAMILY PLANNING

I talked about all the methods of family planning that is barrier methods, hormonal methods. Since my client is hypertensive and at the same time HIV positive, she opted to using barrier methods.

- Male condoms – It us a thin rubber shealth worn by males on an erect penis before coitus to prevent sperms from entering into the vagina, hence prevent pregnancy.

- Female condoms – It is also a thin rubber shealth worn by females. It is inserted into the vagina to prevent sperms from entering during sexual intercourse, hence it also prevents pregnancy and also sexually transmitted infections including HIV.

ADVICE TO THE CLIENT

I advised her to start family planning as soon as possible.

CONCLUSION

I thanked my client for the patient during physical examination and during the family planning discussion. I advised her to breastfeed exclusively and to do regular check ups on her blood pressure.

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