MALARIA CASE STUDY

INTRODUCTION Client/ family centered maternity care study is a program introduced by the Nursing and Midwifery Council of Ghana for each midwifery student to give obstetric care to a client and intact with her as well as the entire family. It also help the student midwife to display all the knowledge and the skills she has acquired theoretically. I remind client on what she will go through during pregnancy, labour and puerperium. The client/ family centered maternity care study is therefore setup to prepare the student midwife with the requisite knowledge and personal attitude to be able to manage a pregnant woman with the aim of reducing maternal and prenatal morbidity rate. It also promote good interpersonal relationship between the student midwife and expectant mother and her family. Client/ family care study was rendered to my client Madam D. O. D. Gravida 2 para 1 alive (G2P1A) whom I met at Anhwiaso Health Center, TEPA on the 11th July 2019 with a 36 weeks pregnancy. She was cared for throughout the pregnancy, labour and puerperium until she was handed over to the public health nurse on the 4th August 2019 for continuity of care. The script is grouped into four chapters with details of client particulars, antenatal care, labour and puerperium respectively. Problems encountered by the client were identified and addressed accordingly using nursing process with respect to each chapter. I also talked about bibliography, antenatal record, and pharmacology of drugs, complete diagnostic investigations, signatories, partograph, maternity chart and baby sheet. For confidential sake all names of client and family members in the care study have be abbreviated. LITERATURE REVIEW This literature gives detailed information on what various authors, publishers and midwifery tutors say about pregnancy, labour and puerperium. PREGNANCY According to Jacob (2013), pregnancy is the state of a female after conception and until the termination of gestation. Conception is the act of conceiving – the implantation of a blastocyst in the endometrium. Oduro-Kwarteng (2015) also defined pregnancy as the condition of having a developing embryo or fetus in the body as a result of the union of an ovum and spermatozoon (conception). Pregnancy can occur any time after a female begins menstruating (menarche) in conjunction with ovulation until she reaches menopause where ovulation ceases. Oduro-Kwarteng (2015) further state that the duration of pregnancy as the length of pregnancy averagely 280 days from the time of fertilization but normally is counted from the first day of menses prior to conception (approximately 284). Furthermore, a full term pregnancy is 40weeks or 9 calendar months or 10 lunar months. Generally the period of pregnancy is divided into three trimesters as first (0 – 12weeks), second (13 – 24), and third trimester (25 – 36weeks). Tiran (2015) stated that pregnancy is from conception to delivery of baby; normal duration 280days (40 weeks or 9months and 7 days), counted from the first day of the last menstrual period to delivery, or 265days, from conception to delivery. Oduro-Kwarteng (2012) again said that, the growth and development of the fetus is affected by many aspects of the mother’s health; poor nutritional status, uses of drugs, alcohol and cigarettes, uses of unprescribed or some medications, herbal remedies, medical conditions, age at time of pregnancy and prenatal care. Tiran (2015) stated that, antenatal care is a bio-psychosocial care provided by midwives and obstetricians during pregnancy to ensure satisfactory foetal and maternal health, enable early detection and treatment of any deviation from normal. Frazer, Cooper & Nolte (2006) also stated that antenatal care refer to the care that is given to a pregnant woman from the time that conception is confirmed until the beginning of labour. The midwife will provide a woman – centred approach to the care of the woman and her family by sharing information with the woman to facilitate her to make informed choice about her care. LABOUR According to Tiran (2015) Normal labour occurs spontaneously after 37 weeks’ gestation with vertex presentation of single foetus; completed within 24 hours without maternal and foetal trauma; physiology depends on interaction between uterus, maternal pelvis and foetus. According to Chapman & Durham (2010), labour begins with the onset of regular uterine contractions and lasts until the expulsion of the placenta or the process in which the foetus, placenta and membranes are expelled out of the uterus through the birth canal. It further divides labour into four stages; Stage one begins with the onset of labour and ends with complete cervical dilatation. Stage two begins with complete dilatation of the cervix and ends with delivery of the baby. Stage three begins after delivery of baby and ends with delivery of the placenta Stage four begins after delivery of the placenta and is completed 4 hours later; it is the immediate postpartum period. (Mattson & Smith, 2004); Simpson & Crechan, 2008) as cited in (Chapman et al, 2010) says these stages are triggered by both maternal and fetal factors. Also, Simpson & Crechan , 2008 as cited in (Chapman et al , 2010), because labour is a natural process, care should move forward on a continuous process from non-invasive to least invasive interventions according to the desires of the woman and assessment of health care providers based on individual clinical situations. According to Annama (2013), labour is the process that involves a series of integrated uterine contractions that occurs over time , and work to propel the product of conception (foetus, placenta and amniotic fluid) out of the uterus though the birth canal Philip, N.B., & Louise, C.K. (2011) defines labour as process by regular painful contractions bring about effacement and dilatation of the cervix and decent of the presenting part ultimately leading to expulsion of the foetus and the placenta form the mother. PUERPERIUM According to Tiran (2015), puerperium is a period of six to eight weeks following childbirth during which the uterus and other organs and structures are returning to their non-pregnant stated. Puerperium is defined by Pfeifer (2012) as the period of 4-6weeks which starts immediately after delivery and ends when reproductive organs has returned to its non-pregnant condition. Multiple anatomic and physiological changes occurs during this time and the potential exists or significant complications such as infection or haemorrhage. According to Jacob (2013), puerperium is a period following childbirth during which the body tissues especially the pelvic organs revert back approximately to the pre-pregnant state both anatomically and physiologically. He further explained that, the post-partum period is divided in; Immediate puerperium thus, the first 24hours. Early puerperium from the end of 24hours up to 7days. Remote puerperium is from the end of day 7 up to 6weeks. Oduro-Kwarteng (2015) defined puerperium as a period that starts immediately after the delivery of the placenta up to 6-8weeks. This period is characterized but a lot of physiological changes some of which may include the following: Lactation is well established. The reproductive organs return to the non-pregnant. Other physiological changes which occurred during pregnancy are revised. The foundations of the relationship between the infant and its parents are laid. The mother recovers from physical and emotional stresses of pregnancy and delivery and assumes responsibility for the care and nurture of her infant. WHY I CHOSE MY CLIENT Madam D. O. D gravida 2 Para 1 alive was met on the 11th July, 2019 at Anhwiaso Health Center TEPA, during one of her routine antenatal visit when she was 36weeks pregnant. I met my client during the antenatal session when she was having her physical examination. I took the opportunity to educate madam D. O. D on prevention of malaria .While I was educating her ,she made a statement that she finds it difficult to sleep under a treated mosquito net because she feels uneasy when sleeping under the net and has stopped sleeping in it. I used this opportunity to educate her thoroughly on the importance of prevention of malaria and the need to sleep under a treated mosquito bed net .I took her maternal record booklet and found out that she was 36 weeks .She had a good past and present obstetric history which created joy in me to seek her consent to use her for my care study and she gladly accepted. This platform gave me the opportunity to educate her more on prevention of malaria. I then informed my in charge and she accepted after glancing through her maternal record book. CHAPTER ONE 1.0 CLIENT PARTICULARS 1.1 SOCIAL HISTORY Madam D. O. D is a 28 year old born on the 22nd March, 1991 She comes from Tanoso in the Western north region of Ghana. She speaks Sefwi and Twi Language. She stays at Tanoso near Methodist primary and junior high school . She stays in a three bed room house with her husband and one tenant. She is a Christian and a member of Anglican Church of Ghana. She had her education to the Junior High School level and she is a farmer, Madam D. O. D weighs 64kg and she is 157 centimeters tall,on the 11th /july/2019.My client got married to Mr. B. D at the age of 22 years and they have stayed for six years now with one child who is a male and he is called C. D. My client is dark in complexion. Madam D. O. D next of kin is her sister, Madam B.O 1.2 FAMILY HISTORY Madam D. O. D is the second born out of five children of Mr. B.B and Madam A.A who are both alive. They are both Christians by religion. She has four siblings, two females and two male and they are all alive. According to her, there are no known hereditary disease in her family likewise the husband like Hypertension, Diabetes, Sickle Cell Disease, Asthma, Mental illness ,epilepsy and any birth defect. She does not know of any family member of hers or that of her husband who is suffering from any communicable disease like Tuberculosis or Leprosy. She also said there is a history of multiple pregnancies in her family. 1.3 MEDICAL HISTORY Madam D. O. D has no history of severe or chronic illness such as diabetes mellitus, hypertension, heart disease, sickle cell disease, Jaundice, Respiratory disease, Tuberculosis, Epilepsy and mental illness. Madam D. O. D said she has never had any disease by which she ended up being admitted at the hospital but she occasionally suffer minor ailment which are treated at the outpatient level. She has never had chronic lower abdominal pains and swelling at her vulva. She has no abnormal vaginal or urethral discharges, genital sores, painful urination or genital warts. She said she has no known allergies to any substance, drug or food. 1.4 SURGICAL HISTORY According to my client, she has never donated or received blood through blood transfusion or undergone any surgery be it on the uterus, pelvic floor, breast or any part of the body. She has never been involved in any road accident that could have affected her pelvis. She has no scars as indicative of tears or episiotomy. 1.5 MENSTRUAL HISTORY My client said she had her menarche at the age of 16 years and since then she has been having regular menstrual cycle of 28days with moderate bleeding which lasts for 5 days. She also said she does not experience any pain or discomfort such as dysmenorrhea or menstrual cramps during her menstruation. Her last menstrual period was on the 20th October, 2018 and her expected date of delivery was calculated as 27th July, 2019. Her expected date of delivery was revealed to be on the 21st,July, 2019 by ultrasound scan. 1.6 CLIENT HOBBIES AND LIFESTYLE Madam D. O. D said she wakes up around 5:30 am, pray, wash her face, sweeps her house, brushes her teeth and then put water on fire to bath her child. After that, she prepares breakfast for the family and help her child to prepare for school. Madam D. O. D then takes her bath and leaves the house to the farm with her husband around 8:30 am. She return back to the house at3:30pm with her husband in other to prepare supper for the family. Her favourite food is fufu with light soup and she takes three square meals a day. She likes spending time with her husband. She practice no risky behavior such as substance abuse be it alcohol or cigarette which may cause a threat to her pregnancy or health. Her lifestyle is very healthy. After supper, she converse with her husband and encourage her son to read books. She washes the family clothing every four days. On Saturday, she does her laundry if she is not able to wash within the week days. On Sunday, she goes to church service with her child and husband. She enjoys listening to music and conversing with her friends and husband. My client empties her bowel twice daily and whenever the edge comes. 1.7 HOME ENVIRONMENT (physical,psychosocial) Madam D. O. D lives in her own house which is built with cement block and roofed with aluminum roofing sheet. The house is not painted. The house has three rooms and she occupies one with her husband and her child. One room is occupied by a tenant and the remaining one is empty. The room has one window but spaced and well ventilated. Their source of water is from a pipe which is just by their house. Their source of light is electricity. They use a public toilet around the area. They have one bathroom in the house which is shared by the entire household. She keeps her refuse in a plastic container and later disposes off at the refuse dump. Her house was neat and had a good drainage system. She has a good relationship with her tenants and neighbours as well. 1.8 PAST OBSTETRIC HISTORY Madam D. O. D, gravida 2 para 1 with no history of abortion in her previous pregnancy since she attends clinic regularly at Anhwiaso Health center, Bibiani Anhwiaso Bekwai until she delivered at term. She said she did not experience any minor disorder such as morning sickness, heart burns, and faintness during her last pregnancy; she also said she received three doses of tetanol injections in her previous pregnancy as well as three doses of Sulphadoxine Pyramethamine. All laboratory investigations carried on her were normal and she tested negative for HIV. According to her, she delivered at 1:28 pm in the afternoon on 10th February 2014 but labour pains started around 12:00 am at dawn. She said she had spontaneous vagina delivery and her baby cried loud with an Apgar score 8/10, 9/10 for 1st and 5th minute respectively according to her last antenatal record book. She had a male infant with birth weight of 3.0kg and duration of labour was 13hours, 30 minutes. Placenta and membranes were delivered normal and was intact and she did not have any heavy bleeding after delivery. She did not have any tear or episiotomy done on her. She did not experience complication like puerperal sepsis and breast engorgement since she initiated breastfeeding early. She breast fed her baby exclusively for six months. Madam D. O. D used the calender based method until she conceived again . According to her, she never missed any of her postnatal and child welfare clinics because she wanted her child to receive all immunizations against the childhood killer diseases such as Tuberculosis, Whooping cough, Measles, and Pneumonia. She weaned her child at age two and she resumed menstruation after six weeks. 1.9 PRESENT OBSTETRIC HISTORY Madam D. O. D gravida 2 para 1 attended her first clinic on 25th February 2019 , when she was 16 weeks pregnant at Anhwiaso Health Center .According to my client, her last menstrual period was 20th October 2018 and her expected date of delivery (EDD) was calculated to be on 27th July 2019 but was confirmed by ultrasound scan to be on the 21st July, 2019. Her past medical, surgical, obstetric, family and menstrual history were taken and recorded. A specimen bottle was used to take her midstream urine to check for the presence of albumin (protein) and sugar in her urine. She also had some laboratory investigations done as follows: Test Result Haemoglobin 11.6g/dl Sickling Negative Blood Group AB Rhesus Factor Positive G6PD Defect Negative Protein in Urine Negative Glucose Negative Vital signs taken on 25th,February, 2019 were; Height 157 centimetres Weight. 63 kilograms Blood Pressure 100/60 millimetres of mercury (mmHg) Temperature 36.6oC Respiration 20 cycles per minute Pulse 80 beats per minute Physical examination from head to toe was done on her and no abnormalities were detected. All these assessments were to serve as baseline information and would be compared with the subsequent ones which would help to detect any deviation from normal. Routine drugs were served as follows; Tablet Folic Acid-5mg daily for 30days Tablet Multivitamin- 200mg daily for 30days Tablet Ferrous Sulphate- 200mg daily for 30 days Everything done on her was recorded in her maternal health record book and the midwife in charge communicated to her of her next visit. CHAPTER TWO 2.0 ANTENATAL CARE This chapter deals with first interaction with client during antenatal period, subsequent visits to the clinic and home visits as well as nursing care plan for the client during the antenatal period. 2.1 FIRST CONTACT WITH CLIENT Madam D. O. D was a regular attendant at Anhwiaso Health Center, TEPA until I met her on her seventh visit on 11th Jully,2019 which was her seventh visit, then she was 36 weeks pregnant. I approached and greeted her as a student midwife from Nursing and midwifery training college, Goaso. I took her maternal recorded book glanced through it and noticed she was gravida 2 para 1A with no bad obstetric history. During the antenatal session when she was having her physical examination, she made a complain that she finds it difficult to sleep under treated mosquito net and has stopped sleeping in it. I took this opportunity to educate her more on the importance of sleeping under a treated bed net and the effect of malaria on both mother and baby .I glanced through her maternal health record book again and saw that she qualifies to be chosen as my client for the family centered care study .I then told my in charge and she helped convinced madam D. O. D which she agreed to be my client .This platform gave me the chance to educate her more on the prevention of malaria. I informed her that I will take care of her throughout the rest of her pregnancy, labour and puerperium. I then explained to her the care I will be rendering to her and her family and she gladly accepted. All procedures and examinations were explained to her and privacy was provided. Client was informed that our interaction would be temporal and that she would be handed to public health nurse after one week of her delivery. Her vital signs were checked and recorded as Temperature 36.7oC Pulse 76 beats per minute Respiration 20 cycles per minute Blood Pressure 113/66 mmHg Weight 65 Kg Laboratory investigations Urine protein negative Urine glucose negative Haemoglobin 11.8g/dl After recording her vitals, I took her urine to the laboratory to test protein and glucose which tested negative. I took the opportunity to congratulate and educate her to take more green leafy vegetables and fruits such as kontomire and water melon. I also educated her on the need to take the routine drugs in order to help her maintain her haemoglobin level. I explained to her that I was going to carry out a general head to toe examination on her to find out about her health and that of the unborn baby and to detect any deviation from normal. I asked her to empty her bladder after which I provided privacy by closing the door and nearby windows and only exposed the part to be examined making sure all other parts were covered. I helped her lie on her side then I washed and dried my hands with a clean towel. I rubbed my palms to warm them and I calmly instructed her to lie in dorsal position. On physical examination from head to toe, her hair was neatly washed and nicely plaited and free from dandruff. Her face was inspected and there was no oedema and conjunctiva was pink. Her eyes were clean with no discharges. Her ears and nose were not discharging and were situated normally and of normal size. Her gums were not bleeding and she had clean teeth and good smell in the mouth. The neck had no distended veins, no enlarged lymph nodes and no goiter. Her limbs were equal length and size. Her finger nails were neatly trimmed. The nail beds and the palm were pink in colour with the presence of palmer creases. I examined the chest and breast which were normal. I then took one breast at a time, inspected the size and shape in which the size were normal and had hemispherical shapes. The nipples were not cracked, no discharges and were normal in length. The skin around the breast was smooth and had no rashes. I also palpated the breast to find out if there were masses but on palpation, there were no lumps neither did she complained of any pain in the breast and she was taught how to examine her own breast either lying down or in an upright posture. On abdominal examination, the abdomen was inspected and was globular in shape, normal in size; there were striae gravidarium and a clear linea nigra. The lie was longitudinal with visible foetal movement. The symphysio fundal height was 32cm and the gestational age was 36weeks+. On fundal palpation, I faced her, warm my palms by robbing them and placed my palms on either side of the fundus, curved my fingers around the top of the fundus to determine what was occupying the fundus and a soft non-ballotable mass was felt, indicating the fetal buttocks. Lateral palpation was done by placing my palms on both sides of the uterus, midway between symphysis pubis and the fundus. I stabilized the abdomen with one hand and examined with the other hand and then palpated the entire area from the abdominal midline to the lateral side which was in a rotary manner. I located the fetal back which was smooth curved at the right hand side of my client, while the limbs were in the opposite direction, indicating cephalic. On pelvic palpation, I then asked her to flex her knees slightly and helped her to relax by guiding her to breathe slowly. I placed my palms on either side of the abdomen, just below the level of the umbilicus with my finger directed towards the symphysis pubis and the thumbs almost meeting to determine presenting part of the foetus. I located the anterior shoulder, approximately 2.5cm from the linea nigra. I kept two of my fingers over the anterior shoulder noting the number of finger breath that can be accommodated to determine the descent and it was 5/5th. On auscultation, foetal heart rate was 132bpm with good volume and rhythm. Upon examining the vulva, I asked her to flex her legs. On examining the vulva, there were no discharges and abnormalities such as previous scars, vulva warts, edema and varicosities. Quick observation was done at the anus for scars and haemorrhoids but there was none. The lower limps were examined for equality and shape. On examining the legs, I found out that the legs were of the same length, no varicose veins were found, no oedema and no tenderness in the calf muscle. Her toe nails were well trimmed and kept clean. Her feet was inspected for oedema, and the nail bed for pallor but no abnormalities were detected. I inspected her back for abnormalities like oedema of the sacral region; curvature and pain but no abnormality was seen. After examination, I thanked her and helped her to lie on her side; sit up and then helped her out of the bed to dress up after which I asked her to sit in a chair. Findings were communicated to her and documented all findings in her maternal health record book. I thanked her again for her cooperation. She was encouraged on rest and sleep and to take all her routine drugs as prescribed. Health education was given on the importance of prevention of malaria and the client was advised to sleep under insecticide treated net . She was also educated to keep her surroundings clean by weeding and sweeping there to prevent breeding of mosquitoes. I also educated her on the importance of attending antenatal clinic. Intentions for visiting her was made known to her and client gave the direction to her house and her phone number. An appointment was booked to visit her at home on 12th July, 2019. The following drugs were given to her; Tablet Multivitamin 5mg daily × 30days Tablet Folic Acid 5mg daily × 30 days Tablet Ferrous Sulphate 200mg daily ×30 days Client was scheduled for her next visit on 18th,july, 2019. However, she was told to report to the clinic if she sees anything unusual such as vaginal bleeding, severe vomiting and blurred visions. 2.2 FIRST ANTENATAL HOME VISIT 12th,july 2019 , I visited madam D. O. D at 10:00am using the directions she gave to me at tanoso.When I got to her area, I asked someone of her and I was directed to her house. The aim of my visit was to know her house, observe her home environment in order to rule out any health threatening conditions such as malaria in pregnancy and also offer continuous care after delivery and also establish good relationship with her family. On arrival, madam D. O. D welcome me and led me to her veranda and offered me a seat and offered me water. She introduced me to her tenant who has been supporting her with household chores. She also introduced me to her husband. They were happy because madam D. O. D already informed them about my coming. After the introduction, I told them my reason of being there and I asked about her general health and she told me she was better .She added that the tenant has been helping her with the household chores so that she could have enough time to rest and sleep. I told her husband that I want to take his wife as a special client to take her throughout the rest of her pregnancy, labour and puerperium and the care of the baby which he permitted. The environment was neat; the building is built with cement block and roofed with aluminum sheets. The house has three rooms and my client occupies one with her husband and child. They had one bathroom which was built with wood and was sited 40 metres away from their house. She uses electricity as her source of light. Her source of water was from a pipe which was just behind her house. She kept her refuse in a well-covered plastic and empties it daily at the town refuse damp which is about 70 metres away from the house. They have no toilet facility in the house so they use a public toilet around the area. I asked her if she is still sleeping in the insecticide treated mosquito net which she said yes. I ask for her permit to go to her room to inspect whether what she was saying was true of which she granted me the permission and she was telling the truth. I encouraged her keep sleeping in it and also to prevent staying outside during the evening to prevent mosquito bite. I encouraged her to continue keeping her environment clean to prevent the breeding of mosquitoes. I educated her on signs of true labour which are painful contraction, show (blood stained mucus discharge) and rupture of membranes. She complained of constipation,and backache which I explained to her that it was as a result of weight of the gravid uterus and the activities of certain pregnancy hormones. She was encouraged to have enough rest and sleep of eight hours in the night and two hours in the afternoon, take in adequate nutritious diet and water with enough fruits. She was encouraged to take in more roughage diet and water which will help to ease the constipation and promote good health for both mother and fetus. I asked about her routine drugs which she said she was taking them. I asked her to bring them for me to see and I realized she was really taking them. I inspected the items for delivery and they were neatly packed in a bag at a safe and easily reachable place. I thanked them and reminded her of her next visit to the clinic as scheduled and earlier than that if she feels unwell. I thanked them and left. 2.3 SUBSEQUENT ANTENATAL CLINIC VISIT Madam D. O. D visited the antenatal clinic again on 18th July 2019. I welcomed her and offered her a seat. I asked her about her health and that of the family which she said they were fine. I took her vital signs and recorded them as follows: Blood Pressure 100/60 mmHg Temperature 36.7oC Pulse 81bpm Respiration 36cpm Weight 65kg I informed her I wanted to carry out a general head to toe examination on her as I did the first day and she agreed. I asked her to empty her bladder after which I helped her onto the examination couch. Urine tested for glucose and protein was negative. I helped her onto the examination couch. I carried out general examination from head to toe under supervision of the midwife in charge and no abnormality was detected. On abdominal inspection, the shape was ovoid with linea nigra and striae gravidarium. On palpation, the symphysio- fundal height was 33cm and gestational age was 37+ weeks. The lie was longitudinal, presentation was cephalic and the descent 5/5. On auscultation, the fetal heart beat was 134bpm which was regular with good volume and rhythm. I reassured her once again and I told her my finding. Her urine for protein and glucose were negative. I recorded them in the maternal health record book. I encouraged her to promote good personal and environmental hygiene to prevent malaria and other infection. I asked of her previous complains which she said it has subsided. I finally reminded her of the signs of true labour which are painful contractions, blood stained mucus discharge and rupture of membranes.. I also asked her to report to the facility when the signs of true labour starts. She was served with routine drugs as follows; Tablet Multivitamin 5mg daily ×7 Tablet Folic Acid 5mg daily ×7 days Tablet Ferrous Sulphate 200mg daily ×7 days I reminded her of her next visit to the clinic in a week time if labour did not start. I asked her to come to the hospital if she notices anything unusual. I informed her I will be visiting her the next day at home. I thanked her and bid her farewell. 2.4 SUBSEQUENT ANTENATAL HOME VISIT I visited my client on 19th July 2019 at 3:00pm as arranged on her previous attendance to the clinic. I was welcomed and offered a seat. I asked about her health and that of her family and she said they are fine. I took the opportunity to educate her on personal hygiene. I told her to keep her fingers and toe nails short and clean because when they are grown they harbor dirt which contains germs and these germs are harmful to both her and her unborn baby. I also encouraged her to keep her under wears clean by washing them regularly and drying them under sun. I told her to shave the armpit and vulva frequently to prevent bad smell. I also educated her on birth preparedness and complication readiness by telling her that every labour may or may not develop complications but these complications may be detected early and managed on time if only she comes to the hospital to deliver on time and does not deliver at home. I also told her to gather the items she would need for the delivery into one bag, including clean bed linen, clean clothing for her own use, rubber mackintosh which will be spread on the delivery bed during delivery and perineal pad. For the baby, she needs to get cot sheets, baby clothes, napkins or diapers, sponge, soap, baby oil and towel. I asked her to keep the bag containing the items at the place where it can be easily reached when needed. I also stressed the need on how she will get to the hospital when labour starts and also in preparation for blood donor in terms of complication and support person who would help her during and after labour. She was also asked to plan how she will be conveyed to the hospital when labour begins and save some money in case of any emergency. I educated her on exclusive breast feeding and its importance to her and the baby by telling her that the breast milk contains essential nutrients which fight against infections hence making the baby grow well. I also made her aware that the more she breastfeed the baby, the more the bond between her and the baby becomes stronger. I made it known to her that if she continues to breastfeed the baby exclusively for six months, it will delay the onset of ovulation or suppressed ovulation and this can be use as a family planning method. I added that exclusive breastfeeding help in the involution of the uterus to its non-pregnant state. I asked her to tell me something about any of the teachings I had told her previously and she said what I told her about signs of onset of true labour. I was so happy she remembered the discussion very well and I congratulated her. She complained of sleeplessness at night due to frequency of micturition and heartburns. I reassured and explained to her that the frequent micturition usually occurs because her baby was descending therefore exerting pressure on her bladder to hold urine. I encouraged her to reduce her fluid intake at night. I told her to get a container beside her bed so that she can void in it during the night. I educated her to sit down when doing household activities or bathing and also to reduce intake of spicy foods to reduce the heartburns. Her vital signs were checked and recorded as; Blood pressure 100/60mmHg Temperature 36.7oC Pulse 78bpm Respiration 20 cycles per minute 2.5 SUBSEQUENT ANTENATAL VISIT TO CLINIC Madam D. O. D reported to the clinic on 25th july 2019 which was her 9th visit around 11:30am. Her vital signs were checked and recorded as follows; Blood pressure - 100/60 mmHg Pulse - 90bpm Respiration - 38cpm Temperature - 36.7oC Weight - 66kg Lab investigations Urine protein negative Urine glucose negative She was then asked to empty her bladder. Protein and glucose tested negative. I helped her onto the bed. General examination from head to toe was done under the supervision of the midwife in charge. On abdominal inspection, the shape was normal and fetal movement present. The shape was ovoid with linea nigrea and striae gravidarum was present. On palpation, the symphysio-fundal height was 34cm and gestation age was 38 weeks. On palpation, the buttocks of the fetus were occupying the lower pole of the uterus. On lateral palpation, the back and limbs were located on both sides of the mother’s abdomen and lie was longitudinal. On pelvic palpation, the presentation was cephalic and descent was 4/5th, and a hard ballotable mass was felt. On auscultation, the fetal heart rate read 133bpm. All findings were explained to her and recorded. I assisted her off the bed and helped her to dress up. She complained of waist pain .She was encouraged to have enough rest and sleep for at least 8hour in the night and 2hrs in the day and the physiology behind it was explained to her. She was educated again on signs of labour which are thick mucus with blood stain, waist pain and painful rhythmic contractions. She was to continue treatment. 2.6 NURSING CARE PLAN FOR ANTENATAL VISIT I identified problems on madam D. O. D through her history and home visits. Specific and broad objectives were set and evaluated to see if the goals had been met. PROBLEMS IDENTIFIED On 11th July 2019 at 10:00am client complained of difficult to sleep under treated mosquito net . 2. On 12th July 2019 at 11:00am client complained of constipation. 5. On 19th July 2019 at 3:00pm, client complained of sleepless at night (insomnia). 4. On 19th July 2019 at 3:00pm, client complained of heartburns. 3. On 12th July, 2019 at 11:00am, client complained of backache. SHORT TERM OBJECTIVES 1. Madam D. O. D will be able to sleep under treated mosquito net within 24hours. 2. Client will have normal bowel movement habits at least once daily within 24 hours. 3. Client will be relieved of backache within 24 hours. 4. Client will be relieved of heartburns within 24 hours. 5. Madam D. O. D will have normal sleep pattern (insomnia )at least 6-8 hours within 24hours. LONG TERM OBJECTIVES Client will go through pregnancy successfully and have a safe delivery and a live baby without any complication to both mother and baby.  DATE/TIME NURSING DIAGNOSIS NURSING OBJECTIVES NURSING ORDERS NURSING INTERVENTIONS DATE/ TIME EVALUATION SIGN 11th / July 2019 at 10:00am Difficult to sleep under treated mosquito net, (Alteration in sleeping pattern related to environmental barrier. Hot temperature) Madam D. O. D Will be able to sleep under treated mosquito net within 24hours as evidence by client, Verbalizing that she is able to sleep comfortable in the mosquito net 1. Reassure Madam D. O. D that she will be able to sleep comfortable in mosquito net . 2. Nurse client in a conducive (quite) environme0nt. 3. Encourage client to sleep in a well ventilated room 4. Encourage client to avoid strenous activities before bed. 5. Encourage client to take in more fluids. 1. Madam D. O. D was reassured that she will be able to sleep comfortable in treated mosquito net 2. Client was nursed in a conducive (quite) environment. 3. Client was encouraged to sleep in a well ventilated room. 4. Client was encouraged to avoid strenous activities before bed. 5. Client was encouraged to take in more fluids. 12th July 2019 at 10:00am Goal fully met as evidenced by Madam D. O. D verbalized that the pain has subsided. H. H DATE/ TIME NURSING DIAGNOSIS NURSING OBJECTIVES NURSING ORDERS NURSING INTERVENTIONS DATE/ TIME EVALUATION SIGN 19th July 2019 at3:00 pm Insomnia related to frequency of micturition. Madam D. O D will have normal sleep pattern at least 6-8 hours within 24hours as evidenced by client verbalizing that she is able to sleep for 2 hours during the day and 6 hours at night. 1. Reassure client that she is going to regain her normal sleeping pattern. 2. Explain the physiology of frequency of micturition to the client. 3. Advice client to reduce fluid intake at night. 4. Encourage client to empty her bladder before going to bed. 1. Client was reassured of her condition. 2. It was explained to the client that pressure of the gravid uterus on the bladder reduces its holding capacity resulting in frequent micturition. 3. She was advised to reduce fluid intake at night. 4. Client was encouraged to reduce the intake of fluid before bed. 20th July 2019 at 3:00 pm Goal fully met as evidenced by client verbalizing that she can now have adequate sleep at night. H. H DATE/ TIME NURSING DIAGNOSIS OBJECTIVES/ OUTCOME NURSING ORDERS NURSING INTERVENTIONS DATE/ TIME EVALUATION SIGN 19th ,July, 2019 at 3:00 pm Heartburns related to esophageal reflux of gastric content. Client will be relieved of heartburns within 24hours as evidenced by client verbalizing that she has been relieved of heart burns. 1. Reassure client that she will be relieved of heartburns. 2. Educate client on the physiology of heartburns. 3. Educate client to eat less spicy foods. 4. Encourage client to take sips of milk or water frequently. 5. Encourage client to take small meal at a time. 6. Serve prescribed drugs. 1. Client was reassured that she will be relieved of heartburns 2. Client was educated on the physiology of heartburns. 3. Client was educated to eat less spicy foods. 4. Client was has been encouraged to take milk or water frequently. 5. Client was encouraged to a small meal at a time. 6. Antacid was given as prescribed. 20th,july,2019 at3:00pm Goal fully met as client verbalized that heartburn has stopped. H. H DATE/ TIME NURSING DIAGNOSIS NURSING OBJECTIVES NURSING ORDERS NURSING INTERVENTIONS DATE/TIME EVALUATION SIGN 12th July, 2019 at 11:00 am Backache related to relaxation of the pelvic and sacral ligaments. Client will be relieved of backache within 24hours as evidenced by client verbalizing that pain has reduced. 1. Reassure client that she would be relieved of backache with good sitting or standing posture. 2. Explain the cause of backache to client. 3. Educate the client to support her back with pillows when sitting. 4. Educate client to sit on chair that would support her back. 5. Encourage client to sit when washing and raise washing basin on a stool instead of squatting. 1. Client was reassured that backache will stop with good sitting and standing posture. 2. Client was educated on the physiology of backache been as a result of poor posture. 3. Client was educated to sit on chair that supports her back with pillow when sitting. 4. Client was encouraged to sit on chair that supports her back. 5. Client was encouraged to sit when washing and raise washing basin on a stool instead of squatting. 13 July, 2019 at 11:00 am Goal fully met as evidenced by client verbalized that she has been relieved of backache. H. H DATE/ TIME NURSING DIAGNOSIS NURSING OBJECTIVES NURSING ORDERS NURSING INTERVENTIONS DATE/ TIME EVALUATION SIGN 12th July, 2019 at 11:00 am Constipation related to inadequate intake of fruit and roughages. Madam D. O. D will be able to move her bowels within 24 hours as evidenced by the client verbalizing that she could empty her bowel. 1. Reassure Madam D. O. D that she will be relieved of constipation within 24hours. 2. Educate client on the cause of constipation during pregnancy. 3. Encourage client to drink enough water at least 8 cups a day. 4. Encourage client to eat more fruit and roughage. 5. Encourage client to cultivate the habit of emptying her bowel at least once a day or when the edge is felt. 1.Client was reassured that she will be relieved of constipation within 24hours 2.Client was educated on the causes of constipation 3. Client was encouraged to drink enough water at least 8 cup a day. 4. Client was encouraged to eat more roughage and fruits. 5. Client was encouraged to cultivate the habit of emptying her bowel at least once a day or when the edge is felt. 13th July, 2019 at 11:00am Goal fully met as evidenced by Madam D. O. D verbalized that she can now move her bowel at least once daily. H. H  CHAPTER THREE 3.0 LABOUR This chapter deals with the introduction of labour, admission and management of first, second, third stage of labour and immediate subsequent care of the baby after delivery and care plan. 3.1 ADMISSION AND MANAGEMENT OF THE FIRST STAGE OF LABOUR Labour is described as a process by which the foetus, placenta and the membranes are expelled through the birth canal. Labour is said to be normal when it begins spontaneously at term with the foetus presenting by vertex and labour not lasting more than 18 to 24hours in primiparous and 12hours in multiparous without any complication or injury to both mother and baby. I had a call from madam D. O. D at 9:30pm on 26th ,July, 2019 that she has seen a blood stained mucus and complained of painful uterine contraction of which I asked her to come to the clinic because I was quite certain, Madam D. O. D was in true labour. I told her that I was already at the hospital and I would be waiting for them. Madam D. O. D reported at the hospital around 10:15 pm. She was accompanied by her husband and her sister. I welcomed them warmly and offered them a seat. I took her antenatal book and glanced through it and her gestational age was 38 weeks. I asked about the onset of labour and she said it started around 8:30pm on that sameday. I gave madam D. O. D, her husband and her sister the assurance that they were in competent hands and that everything would be fine as far as her delivery is concerned. I reassured her that the pains she was going through would soon come to an end after she had delivered and the contractions would help the foetus to descend. Items needed for delivery were collected from the husband. I therefore admitted her into a comfortable bed at the first stage room after she had changed into a delivery gown. All procedures on examination were explained to her understanding, her consent sought and curtains drawn to ensure privacy. On observation, her vital signs were checked and recorded as follows; Temperature 36.8oC Pulse 78bpm Blood Pressure 110/70mmHg Respiration 21cp I asked madam D. O. D to empty her urinary bladder into a clean bed pan. A specimen of midstream urine was collected and sent to the laboratory to be tested for protein and acetone and the results were all negative. The volume of urine was 100mls. I washed, dried and warm my hand and conducted a physical examination from head to toe and no abnormalities were detected. On inspection, the abdomen was oval, with the presence of striae gravidarium and linea nigra. Foetal movement was visible. The following were also recorded; Maturity 38.weeks Symphysio-fundal height 36cm Presentation cephalic Position left occipito-anterior Lie longitudinal Descent 3/5th Foetal Heart Rate 135bpm Contraction 2:10 lasting 25 seconds Urine 100mls Urine protein negative Urine glucose negative I explained the procedure for vaginal examination to madam D. O. D her consent sought and a tray containing the following items was prepared. 1. A sterile gallipot with sterile cotton wool swabs 2. A sterile gallipot with savlon solution 3. A pair of sterile gloves 4. A receiver for wet swabs 5. A sterile drape I assisted madam D. O. D to lie in the lithotomy position and I drape her. I quickly washed and dried my hands and put on sterile gloves and instructed her bend her knees and separate her legs. On vulva inspection, the vulva was neat. Abnormalities like scars, oedema, varicose veins, warts, rashes, discharges were absent. At 10:30pm vaginal examination was done which revealed a warm and moist vagina, cervix was well effaced, soft and thin and well applied to the presenting part. Cervical dilatation was 4cm with membranes intact. Ischial spines were blunt and sub pubic arch was wide with sacrum well curved. My findings were confirmed by the senior midwife on duty and I communicated my findings to my client that she was in labour. I explained cervical dilatation to my client with the aid of dilatation board. I therefore applied a clean pad on her vulva. All used items were discarded and gallipots and receiver were decontaminated in 0.5% chlorine solution and washed after 10 minutes. I told her that she would be due for the next vaginal examination at 2:30am and foetal heart rate, maternal pulse and contraction will be due every 30minutes. I informed her that her blood pressure will be checked 4hourly and temperature will be checked 2hourly. I also informed her to change her perineal pad anytime it was wet and also to urinate frequently to allow the descent of the foetus head. I recorded all findings into the Nurse’s notes and plotted on a partograph sheet . Madam D. O. D was taught deep breathing exercise and to pant when there was the presence of contractions. Client was told to avoid pushing prematurely which could cause cervical tear and bleeding. She was told to lie in the left lateral position and to walk around the room if her condition would allow. Her sister was orientated to the ward by showing her the toilet room, the bathroom .My client was introduced to the other staff on duty. I observed that madam D. O. D was anxious about the outcome of her condition and she complained of waist pains. She was reassured that she was in competent hands and that she would deliver safely without complications. I kept on reassuring her that she was going to have a safe delivery and the whole process was going to end up in a few hours and that she would be relieved of her pain. Her maternal pulse, fetal heart rate and uterine contractions was monitored every 30 minutes; blood pressure, vaginal examination and descent every 4hourly and temperature every 2 hours. These results were recorded on the partograph. At 10:30pm ,pulse 78bpm ,contraction 2:10lasting 20seconds ,descent 3/5th , Dilatation 4cm, Blood pressure (BP) 110/70, temperature (temp) 36.8 , urine 100mls Foetal heart rate (FHR) 135bpm. At 11:00pm FHR 136bpm, contraction 2:10 lasting 25seconds, pulse 80bpm. At 11:30pm FHR 138bpm, contraction 2:10 lasting 28seconds , pulse 80bpm. At 12:00am FHR 133bpm, contraction 3:10 lasting 30seconds, pulse 85bpm. At 12:30am FHR 133bpm ,contraction 3:10 lasting 32seconds, pulse 88bpm, temp 36.8 , urine 90mls. At 1:00am pulse 90bpm, contraction 3:10 lasting 35seconds, FHR 140bpm. At 1:30am FHR 140bpm, contraction 4:10 lasting 41seconds, pulse, 88bpm. At 2:00am pulse 88bpm, contraction 4:10 lasting 45seconds, descent 1/5th ,Dilatation 8cm, FHR 137bpm. At 2:30am BP 110/60mmHg, urine 80mls, pulse 90bpm, contraction 4:10 lasting 46seconds, FHR 137bp. At 3:00am FHR 140bpm, contraction 4:10 lasting 47seconds, pulse 96bpm. At 3:30am FHR 135bpm, contraction 4/10 lasting 48seconds, pulse 95bpm, Normal saline Iv 500mls. 4:00am FHR 135bpm, contraction 4/10 lasting 48seconds, pluse 90bpm, descent 0/5th , Dilatation 10cm. At 12:00 am on 27th July 2019, She was served with malt of which she accepted and drunk it. She complained of fatigue and abdominal pain I took the opportunity to educate her on physiology of abdominal pain and encouraged her to do deep breathing exercise. At 12;30am urine was passed and measured 90mls.Protien and glucose tested negative. Temperature checked and recorded as 36.7 There was spontaneous rupture of membranes at 2;30am and vaginal examination was done and cervical dilatation was 8cm,liquor was clear ,there was no cord prolapsed, moulding was +, cervix was thin and soft, head descent was1/5th, blood pressure was 110/60mmHg, temperature of 36.5oC, and pulse of 80bpm, fetal heart rate136bpm and contraction 4:10 seconds lasting 41 seconds and her urine measured 80mls. Urine testing for protein and glucose tested negative .I reassured her and told her my finding and then recorded them on the partograph. Foetal and maternal condition as well as progress of labour was monitored continually and recorded on the partograph. I realized she was sweating excessively so I cleaned her face and body with wet towel; She was given sips of water to replace the lost fluid. Preparation for delivery The midwife incharge was chosen as the skilled personnel and informed to assist in case help will be needed. Her sister who was the unskilled helper was told to stay around in case she will be needed to run errands during delivery. The area for delivery was prepared by drawing the curtains for privacy and warmth, switching off fans and air condition. A delivery trolley was set with the following items on the top and down shelf as , Top Shelf 2 artery forceps Penguin Cord clamp Episiotomy set Perineal pad Syringe and needle Sterile gloves Injection oxytocin Resuscitation trays Sterile receiver for placenta Gallipot with sterile cotton wool swabs Sterile gauze. Bottom shelf Disinfectant Bed pan Receiver for soiled linen Fetoscope I transferred my client to the second stage room. Client complained of strong urge to bear down at 4:30am. I did vagina examination and the cervix was fully dilated (10cm), head descent was 0/5th, moulding + and uterine contraction4:10 lasting 43 seconds. Fetal heart beat was 139beats per minute blood pressure 110/60mmHg and maternal pulse was 78 beat per minute.All were confirmed by the midwife in-charge after that, I explained my findings to her and recorded them on the partograph . 3.2 MANAGEMENT OF SECOND STAGE OF LABOUR Madam D. O. D . Was helped to lie in the dorsal position with her knees flexed and thigh abducted on the delivery bed after reassuring her that she was going to have a safe delivery and explaining to her that , the baby is about to be delivered therefore she would be required to co-operate. I informed the midwife in-charge who confirmed full dilatation of the cervix. After the confirmation, I quickly wore a mackintosh apron, cap and boots, and face mask. I washed and dried my hands and wore sterile gloves to conduct the delivery with the midwife in-charge as my supervisor and a staff nurse been my assistant. I first of all cleaned my client’s vulva, perineum and thighs with a cleaning lotion, draped her on the abdomen, thighs and buttocks and applied a clean perineal pad to the anus to prevent feaces from contaminating the delivery field. I encouraged my client to bear down with each contraction and rest in between contraction. She complained of tiredness and I encouraged her to rest in between contraction. I asked my assistant to monitor the foetal heart beat after each contraction. I informed madam D. O. D that the baby will be delivered unto her abdomen. As the head advanced, I placed my 2 finger on it to aid flexion so that the smallest diameter of the head distends the perineum to prevent rapid expulsion of the head and perineal tear. As the head crowned, I asked her to stop pushing and breath through her mouth since the baby’s head was born slowly. I extended the head as the the sinciput, face and chin swept the perineum area the head was born. I quickly cleaned the eyes with a sterile cotton wool swab from the inner canthus on both eyes gently; mouth and nose were suctioned with a penguin respectively. I felt for the umbilical cord around the baby’s neck but no cord was found around the neck. I waited for restitution and external rotation of the head. I placed one hand on each side of the baby’s head and asked my client to push gently as I gently moved the baby’s head towards mother’s perineum to deliver the anterior shoulder first and then upward traction towards the mother’s abdomen to deliver the posterior shoulder and finally the rest of the body was delivered by lateral flexion unto my client’s abdomen. A life female infant cried immediately at birth at 4.55am. The baby was quickly cleaned up and covered with another clean, dry and warm towel and place her on the mother’s abdomen. I palpated the abdomen for undiagnosed twin. I asked my assistant to administer 10 units of oxytocin injection on my client’s thigh at 4:57am. I waited for about three minutes before clamping the cord to prevent fetal anemia. I clamped the cord at two places, three centimeters from the baby’s abdomen and two centimeters from the first clamp. I clamped the cord at two phases, 3cm from the baby’s abdomen using artery forceps and 2cm from the first clamp using an artery forceps to separate the baby from the mother. In cutting the cord, I covered the space between the two forceps with a gauze swab to prevent the blood splashing and cut to separate the baby from the mother. Placenta was delivered at 5:02am. 3.3 IMMEDIATE CARE OF THE BABY Immediately the baby’s head was born, I cleaned the eyes with sterile cotton from the inner canthus to the outer canthus, Suctioned the mouth and nose with a penguin respectively to clear airway. The baby was delivered fully onto the mother’s abdomen and was dried up. After the baby was separated from the mother, I cleaned the liquor on her body properly and kept her in a clean dry cloth to keep her warm. I clamped the cord 3cm away from the baby’s abdomen and 2cm away from the first clamp using two artery forceps to separate the baby from the mother. The space between the two clamps was covered with gauze swab to prevent blood from splashing and cord was cut to separate the baby from the mother. I placed a wrist band which bore her mother’s name, her weight, sex, date and time of delivery on her for identification and I showed her to the mother. The APGAR SCORE for the first and fifth minute was 8/10 and 9/10 respectively. Baby was made comfortable on mother’s abdomen.Vitamine K injection 0.5cm was also given on that same day .Baby’s colour, respiration, temperature and cord bleeding was checked every 15minute. 3.4MANAGEMENT OF THE THIRD STAGE OF LABOUR Third stage of labour starts after the delivery of the baby and ends with the expulsion of the placenta and it's membranes and the control of bleeding. After the delivery of the baby, the uterus was palpated through the mother's abdomen to exclude the presence of a second twin but none was present. Ten units of injection oxytocin was given intramuscularly on the left thigh to help in the contraction of the uterus and the expulsion of the placenta and it's membranes. The method of delivering the placenta was done by controlled cord traction and counter pressure. The cord was re-clamped closer to the perineum with the use of artery forceps and a receiver placed in-between her thighs. The bladder was checked and it was empty. The non-dominant hand was placed on the fundus to feel for contractions. Immediately there were contractions, the non-dominant hand was placed above the symphysis pubis with the palm facing the mother's abdomen to stabilize the uterus to prevent inversion of the uterus. At the same time, the clamped cord held in the dominant hand and a gentle downward and outward traction was applied to the cord. The process was repeated until the placenta was visible at the vulva. Both hands were released to receive the placenta. The placenta was visible gently twisted to ensure complete delivery of the membranes. At 5;02am, the placenta was delivered. A quick examination of the placenta was done for completeness of lobes and membranes and presence of the two arteries and one vein to exclude any retained product of conception but no abnormality was found,the placenta weighs 0.5kg on examination. It was placed in a receiver sent to the sluice room for thorough examination. The uterus was massaged to expel blood clots and to aid in uterine contractions. The vulva was cleaned and the sterile gauze was placed around the middle and index fingers of the right hand to examine for tears and lacerations of the vagina and perineum. The perineum was intact with no tears . Client was cleaned; a sterile pad was placed on the perineum and she was made comfortable in bed and the amount of blood was 150ml. Madam D. O. D was encouraged to urinate frequently to help the uterus to contract well and was told also to report any bleeding immediately. All findings were recorded on the partograph and in the maternal record book  EXAMINATION OF THE PLACENTA AND MEMBRANES The placenta was immersed in a 0.5 chlorine solution for decontamination before it was examined. The placenta was held by the cord with the membranes hanging, and the membranes were examined for completeness and it was intact. The placenta was placed on a surface for further examination. The amnion was peeled from the chorion up to the umbilical cord and was fully viewed. The length of the cord was checked and it was of normal length. The fetal surface was examined and the cord was situated at the centre of the placenta containing one vein and two arteries and no abnormality was detected. Placenta was then turned to examine the maternal surface. The lobes fitted together without any gap, the edges also formed a uniform circle. There was no abnormality detected. The placenta was turned discarded. The instruments and equipment used were soaked in a 0.5% chlorine for 10 minutes. After that, it was washed, rinsed, dried and repackaged for sterilization. Hands were then washed with soap and clean running water and dried with a clean towel. Client was encouraged to urinate frequently for the uterus to contract and she was also told that if she feels any changes, she should not hesitate to report. She was told that she would be taken to the post natal ward and would be observed for six hours.  3.5 MANAGEMENT OF THE FOURTH STAGE OF LABOUR This is the period of six hours after delivery of the placenta during which both the mother and her baby were put under observation in order to detect and treat early complications if there were any. Madam D. O. D and her baby were monitored every 15minutes for the first two hours, 30 minutes for the next hour and then hourly for next three hours. Post delivery vital signs were checked and recorded as follows; Temperature 36.8oC Pulse 80bpm Respiration 20cpm Blood pressure 110/60mmHg Urine output after delivery was 150mls. Her uterus was well contracted. Her fundal height was 18cm above the symphysis pubis. Lochia was inspected and it was rubra in colour and the flow was moderate. Client was taught how to massage the uterus which could aid in involution. I encouraged madam D. O. D to urinate frequently to prevent post-partum haemorrhage. She was also encouraged to change perineal pad whenever it was soiled to prevent infection. She was encouraged to have enough rest and sleep and to practice proper hand hygiene by washing her hand with soap and water before and after handling the baby. She was told to breastfeed the baby on demand. I assisted her to put baby to breast to breastfed and also assisted her in the performance of minor task such as serving of meals. The baby was also monitored for the first one hour and the following were recorded; Temperature 36.2oC Apex 133bpm Respiration 40cpm Skin Pink Cord Not bleeding Urine Passed Meconium Passed General activity Active Abnormalities None detected General condition Good Duration of labour Stage Duration First stage 6 hours Second stage 25 minutes Third stage 10 minutes Total duration of labour 6 hours,35 minutes 3.6 SUBSEQUENT CARE OF THE BABY Examination of the new born Breastfeeding was initiated within the first 30minutes after delivery. I explained to my client I was going to perform a head to toe examination on her baby in order to identify the presence of any defect and provide prompt intervention and that I needed her permission which she granted me. I examined the baby in the presence of my client by closing all doors, windows and screened the bed. Baby was placed on a warm film flat surface. I exposed the baby wholly and did a quick examination thereafter kept her warm by covering the non-examined part. The baby looked alert, the cry was normal, breathing was normal, skin colour was pink and there were no lesions on the skin. The hair was curled and silky, the anterior and posterior fontanelles were normal and not bulging and no cephal haematoma found. There was no discharge from the nose, mouth, eyes and ears. There were no cleft palate or lip on the mouth and the abdomen was normal with no bleeding from the cord. The urethral orifice and anus was patent as mother confirmed that baby has passed urine and meconium. The baby had a normal vulva and the vagina was patent with no false menstruation. The extremities were also examined and there were no webbed fingers or extra finger on the hands. The lower extremities were normal and equal with no abnormalities such as to lips, club foot etc. The back was examined and abnormalities such as spinal bifida were absent. The weight was 3.1kg, head circumference was 34cm, full length was 50cm and chest circumference was 32 cm. 0.5mg vitamin K injection was administered intramuscularly. Tetracycline ointment was also applied to the eye to prevent infection. BABY’S FIRST BATH After six hours of rest, baby was given her first bath. Warm water was provided and tested with the elbow. All procedures were explained to the mother and the needed items were collected from her. A sterile tray for cord dressing was also made ready and the items included methylated spirit, sterile cotton wool swabs, surgical gloves and cord clamp. Nearby windows and fans were closed and turned off respectively. I wore my gloves and baby was undressed and skin colour was pink. She was then covered with cot sheet to prevent heat loss. Baby’s eyes were cleaned with sterile cotton wool swabs soaked in clean distilled water. I cleaned from the inner contour outward using each cotton wool swab once and the face and ears were cleaned with face towel. Baby’s ears were plucked with my thumb and the middle finger, the head was bathed with a mild soap and sponge thoroughly. The hair was then rinsed and dried with a towel. The baby arms and front of trunk to the feet were bathed. The baby was turned to the back with one arm supporting the chest and the back was washed down to the feet. I immersed her in the warm water with the head been supported above and I rinsed her. Baby was then dried with towel and much attention was paid to the skin folds. Baby was wrapped with a clean cot sheet to prevent heat loss. After dressing the baby up, the cord was exposed and surgical gloves were worn for the dressing of the cord after washing the hands with soap and water. With a pair of sterile gloves on, I inspected the cord for bleeding but there was no bleeding. I held the stem of the cord with a swab in chlorexidine gel swab 5cm away and around the base of the cord. I swabbed the stem from base upward using a swab for each stroke until the cord was well cleaned and I swabbed the tip of the cord with another swab. The cord was left exposed to dry and heal by dry gangrene. The baby was dressed up, covered and given to her mother to breastfeed to aid involution of the uterus. All findings were communicated to madam D. O. D by telling her that, her baby was healthy and had no problem. I thanked the mother for her cooperation. All used instruments were decontaminated in 0.5% chlorine solution for ten minutes, washed with soap and sponge, rinsed under running water, allowed to dry and was packed for sterilization. I washed my hands and dried them and I recorded my findings into the delivery book and client maternal record book. I immersed my gloved hands in the chlorine solution before discarding it. I then washed my hands with soap under running water and dried them with a clean towel. I recorded my findings in the mother’s folder. Baby was well groomed, dressed and wrapped in a clean cot sheet to provide warmth and given to the mother. Madam D. O. D was advised to feed baby on demand. Maternal vital signs were checked and recorded frequently to detect any deviation from normal. The condition of the mother and the baby was satisfactory. All findings were recorded into the delivery book and client’s maternal record book. 3.7 NURSING CARE PLAN ON LABOUR PROBLEMS IDENTIFIED DURING LABOUR 3. On 27th July, 2019 at 12:00 am, Madam D. O. D complained of abdominal pains 5. On 27th July, 2019 at 12:30 am, client complained of excessive sweating 1. On 26 July, 2019 at11:40 pm, client complained of waist pain 4. On 27th July, 2019 at 12:00 am, client complained of fatigue 2. On 26th July,2019 at 11:40 pm, client was seen to be anxious SHORT TERM OBJECTIVES 3. Client will be able to cope with abdominal pains within 10 hours throughout the period of labour. 5. Client will remain hydrated throughout the period of labour. 1. Client’s waist pain will be relieved within 24 hours. 4. Client’s fatigue will be relieved 2 hours after delivery. 1. Madam D. O. D’s anxiety will be allayed within 2 hours of her labour period. LONG TERM OBJECTIVES Madam D. O. D will be able to go through all the stages of labour without any complication to both mother and baby after birth.  DATE/TIME NURSING DIAGNOSIS NURSING OBJECTIVES NURSING ORDER NURSING INTERVENTION DATE/ TIME EVALUATION SIGN 27/7/19 at 12:00 am Lower abdominal pains related to strong uterine contraction and descent of foetal head Madam D. O. D will be able to cope with her lower abdominal pains within 4hours of labour as evidenced by client verbalizing her endurance of labour pains 1. Reassure Madam D. O. D that she is in competent hands and her pain will be relieved after delivery. 2. Explain the physiology of abdominal pains to client. 3.Encourage deep breathing exercise 4. Help client by massaging the sacral region r 5. Provide diversional therapy such as engaging the client in a conversation to take her mind off the pain. 1. Madam D. O. D was reassured that she was in competent hands and that her pain would be relieved after delivery. 2. The physiology of abdominal pains was explained to client. 3. Client was encouraged to do deep breathing exercise. 4. Client’s sacral region was massaged 5. Client was engaged in a conversation to take her mind off the pain. 28/7/19at 4:00am Goal successfully met as client was able to cope with her abdominal pains within 4hours of labour. H. H DATE/TIME NURSING DIAGNOSIS NURSING OBJECTIVES NURSING ORDER NURSING INTERVENTION DATE/ TIME EVALUATION SIGN 27/7/19 at 12:30am High risk for fluid volume deficit (dehydration )related to excessive sweating Client will remain hydrated throughout labour as evidenced by 1.client passing adequate urine 2. Midwife observing that client has a good tone skin. 1. Reassure client that dehydration can be prevented 2. Encourage client to take sips of water. 3. Check vital signs to detect signs of dehydration 4. Administer prescribed IV fluids. 5. Check for signs of dehydration. 6. Monitor input and output 1. Client was reassured that dehydration can be prevented 2. Client was encouraged to sip water or take in oral fluid. 3. Vital signs were checked and recorded every 30 minutes 4. Prescribed IV fluids were served. 5. Signs of dehydration were checked. 6. Intake and output was monitored accordingly. 28/7/19 at 2:00am Goal fully met as evidenced : 1. Client passed adequate urine 2.Midwife observed that client has good skin tone. H. H DATE/TIME NURSING DIAGNOSIS NURSING OBJECTIVES NURSING ORDER NURSING INTERVENTION DATE/ TIME EVALUATION SIGN 26/7/19 at 11:40 pm Waist pain related to descent of foetal head Client’s waist pain will be relieved within 24hours of her labour period as evidenced by: 1 client verbalizing that her pain has subsided. 2.Midwife visualising that client feels comfortable in bed. 1. Reassure client that she is in competent hands and her waist pain will be relieved after delivery. 2. Explain to the client the physiology behind her waist pain. 3. Provide a sacral massage or back rub to relieve pain. 4. Encourage client to do deep breathing exercise. 5. Encourage client to adopt a comfortable position. 1. Client was reassured that she was in competent hands and that her pain would be relieved after delivery. 2. Physiology of waist pains was explained to client as due to descent of foetal head. 3. A sacral massage was done to provide relieve to pain. 4. Client was encouraged to do deep breathing exercise 5. Client was also encouraged to adopt a comfortable position. 27/7/19 at 11:40am Goals fully met within 24hours H. H DATE/TIME NURSING DIAGNOSIS NURSING OBJECTIVES NURSING ORDER NURSING INTERVENTION DATE/ TIME EVALUATION SIGN 27/7/19 at 12:00 am Fatigue related to physiological demands of labour Client will be relieved of her fatigue within 2 hours of her labour period as evidenced by 1. Client verbalizing that she is relieved of fatigue. 2. Midwife observing client showing energy in pushing during labour 1. Reassure client that she will go through her labour period smoothly. 2. Encourage client to do deep breathing exercise 3.Serve client with energy giving beverages 4. Encourage client to rest in between contractions 5. Put client in comfortable position 1. Client was reassured that she would go through her labour period smoothly 2. Client was encouraged to do deep breathing exercise. 3. Client was served energy giving beverages (Malt) 4. Client was encouraged to rest in between contractions 5. Client was put in comfortable position 28/7/19 at 12:00am Goal successfully met as evidenced by client relieved of fatigue within 2 hours of her labour period and midwife observed that client had energy to bear down during second stage of labour. H. H DATE/TIME NURSING DIAGNOSIS NURSING OBJECTIVE NURSING ORDER NURSING INTERVENTION DATE/ TIME EVALUATION SIGN 26/7/19 at 11:40pm Anxiety related to unknown outcome of labour Client’s anxiety will be allayed within 1 hour of her labour period as evidenced by client exhibiting a relaxed attitude during the course of labour as per midwife observation 1. Reassure client that she is in competent hands and that she will deliver without any complication to herself and the baby. 2. Explain procedure to the understanding of the client. 3. Encourage client to ask questions about the progress of labour. 4. Answer client’s questions politely to do away with any misconceptions on the mind of the client. 5. Involve family in the care of the client. 1. Client reassured that she was in competent hands and that she would deliver without any complications. 2. All procedures were explained to client. 3. Client was encouraged to ask questions about her condition and progress of labour. 4. Client’s questions were answered politely to do away with any misconception. 5. Client’s family was involved in the care of the client. 26/7/19 at 12:40 pm Goal successfully met as evidenced by client showing a relaxed facial expression and attitude throughout the period of labour as observed by the midwife. H. H  CHAPTER FOUR 4.0 MANAGEMENT OF PUERPERIUM Puerperium is a period from 6weeks following childbirth, during which the genital organs return to their pre-pregnant state both anatomically and physiologically. Chapter four deals with introduction to puerperium, day of delivery, management, and care from first to tenth day postnatal both at the clinic and at home. 4.1 DAY OF DELIVERY After one hour observation, madam D. O. D and her baby’s general condition were reassessed and when they were stable they were transferred to the lying-in ward. She and her baby were put into a warm bed to make them comfortable. I continued to observe them clearly to detect any deviation from normal. Her vital signs were checked and recorded as follows; Examination. Results. Blood pressure 110/60mmHg Temperature 36.8oC Respiration 20cpm Pulse 80bpm Fundal Height 18cm Lochia Rubra Uterus contracted On abdominal examination, the uterus was firm and well contracted and fundal height measured 18cm above the symphysis pubis. I explained the procedure to her and sought her permission to inspect the lochia and it was bright red in colour on inspection and the flow was moderate with clots. She was advised to keep the perineum clean and dry it by changing the perineal pad as often as possible when it was wet. I also educated her to wash her hands before and after changing the pad to prevent the transfer of germs from the vulva to the internal organs which can lead to genital tract infection. I again encourage her to have enough rest and sleep.. I educated her to take in diet rich in fibre, protein and also fruits and vegetables to help regain her health and repair worn out tissues and also to improve her bowel movement. I encouraged her to empty her bladder frequently and to continue breast feeding the baby. She complained of after pains especially when breast feeding her baby. So I reassured her and explained the physiology of lactation.lactation is the production of milk in the breast after delivery.we have production of milk and this involves the synthesis and secretion of milk from the breast. Two tablets of paracetamol were served to relieve her of pain. She was also given amoxicillin capsule 500mg, tablet ferrous sulphate 200mg, tablet folic acid 5mg. Baby’s condition was good .vital signs checked and recorded as follows Examination Temp-36.9 oC Heart Rate-135 bpm Resp-42cpm Colour-Pink Wieght-3.1kg 4.2 FIRST DAY POSTNATAL AND DISCHARGE The first day postnatal was 28th July, 2019 On my arrival, madam D. O. D and family were greeted and asked how they spent the night which they said was peaceful and sound because they did not encounter any problem during the night but the baby cried a lot. After taking her bath, her consent, was sought and her head to toe examination was done and there were no abnormalities detected. Her breast was firm and lactating as well. The uterus was firm and well contracted and measured 17cm. Her pad was inspected and the flow of the lochia was moderate and the colour was red (rubra) with no odour. Her vital signs were checked and recorded as follows; Examination. Results Temperature 36.8oC Pulse 80bpm Respiration 19cpm Blood Pressure 110/70mmHg The baby was given a warm bath, cord dressed with sterile cotton wool and swab with methylated spirit. There was no cord bleeding. Head to toe examination of the baby was done in the presence of the mother and they were no abnormalities detected. The colour of the baby was pink all over. The baby urinated and passed meconium. Mother was taught how to dress cord with methylated spirit and not to apply any herbs on it. Baby was active, dressed up and vital signs were checked and recorded as follows; Examination Temperature 36.9oC Respiration 41cpm Apex beat 139bpm Weight 3.1kg She was given oral polio vaccine 0.5mls and Bacillus Calmette Guerin (BCG) 0.5mls at the right upper arm. This drug help prevent tuberculosis. I educated her not to apply any hot water or herbs on it but should always keep the place clean and dry. I informed them that they would be discharged. Their things were gathered and packed neatly into their bag and since she was having health insurance, she paid for only the ward funds. I served her routine drugs and educated her on proper personal hygiene and good care of the baby. Again, I advised her to keep proper care of the vulva by washing her hands before and after changing perineal pads. I also taught her proper position and attachment of baby to the breast. She was also encouraged to continue exclusive breast feeding and to report to the hospital when she had any fever or offensive lochia. I explained and educated her sister and husband to assist her in taking care of the baby. I told them I will be visiting them in the evening in her house and she agreed. Madam D. O. D and her sister thanked the staff for their good work done. After all these, I saw them off. She was given the following prescribed medications; Capsule Amoxicillin 500mg tds ×7 Tablet Ferrous Sulphate 200mg daily ×30 Tablet Multivitamin 200mg×30 Tablet Folic Acid 5mg daily×30 Tablet Paracetamol 1000mg tds×3 After she was discharged the linens used by her were removed from the bed and sent to the laundry and the bed was carbonized. 4.3 FIRST DAY POSTNATAL HOME VISIT On 29th ,July, 2019, I visited madam D. O. D and family in the morning and evening at 8:30am and 4:00pm respectively as promised. The entire family was in good condition especially the mother and the baby. She was examined from head to toe and no abnormalities were detected. On abdominal examination, the uterus was firm and well contracted and the fundal height was 16cm and the lochia was bright red with moderate flow. Her vital signs were checked and recorded as follows; Examination Morning Evening Temperature 36.7oC 36.6oC Pulse 79bpm 79bpm Respiration 20cpm 20cpm Blood Pressure 110/60mmHg 110/60mmHg The baby was top and tailed and head to toe examination was done. The cord was dressed with methylated spirit and sterile cotton wool swabs. The baby’s colour was pink with no bleeding from the cord. The fontanelles were not bulging. Respiration was regular with good rhythm volume. Fontanelle is a membranous area of the foetal skull where two or more sutures meet There are two important fontanelles in obstetrics, there are, anterior and posterior fontanelle . Anterior fontanelle is found at the junction of the sagittal, coronal and frontal sutures. It is diamond or kite shaped and measures 2.5- 4cm in length and 1.3cm wide. It closes by the time the child is one and half years (18month). Posterior fontanelle is found at the junction of the lambdoidal and sagittal sutures. It is small and triangular in shape when felt on examination, it also closes by the time the child is six weeks old Examination Morning Evening Temperature 36.8oC 36.7oC Pulse 138bpm 137bpm Respiration 40cpm 40cpm Weight. 3.0kg I thanked madam D. O. D and sought permission to leave. 4.4 SECOND AND THIRD DAY POSTNATAL HOME VISIT On the 30th and 31st July, 2019 which was her second and third day postnatal, I visited madam D. O. D and her baby around 7:00 am and evening 4 :30pm. All procedures to be done on her and her baby were explained to madam D. O. D I washed my hands and dried them, took the baby vital signs, examined and top and tailed baby and dressed the cord. The baby was always examined on a flat surface covered with a big towel and no abnormalities were detected and fontanelles were not bulging. All findings were communicated to madam D. O. D and family. The family was encouraged to continue with the care of both the mother and the baby. The baby’s weight was 3.0kg on the second day and the baby was looking active and healthy. After finishing with the baby, I washed and dried my hands in order to examine the mother and there were no abnormalities detected. The breast was examined, noting the amount of milk flow and condition of the nipple of which all were normal and the breast were heavy. She was advised to continue breastfeeding her baby exclusively. The uterus was firm and well contracted and the fundal height measured was 15cm on the second day and 14cm on the third day. Her calf muscles were not tender and examination in the back revealed no tenderness. The lochia was red and amount of flow was moderate. All these examinations were done on the second and the third day. During the second day, the vital signs for morning and evening were checked and recorded as follows; MORNING (MOTHER) – 30th July, 2019. Temperature 36.6oC Pulse 79bpm Blood Pressure 105/60mmHg Respiration 20cpm Fundal Height 15cm BABY Temperature 37.0oc Apex Heart Beat 140bpm Respiration 41cpm Weight 3.0kg EVENING (MOTHER) Temperature 36.7oC Pulse 80bpm Blood Pressure 109/65mmHg Respiration 20cpm BABY Temperature 36.5°C Apex Heart Beat 139bpm Respiration 40cpm 31st July 2019, 3rd DAY (MORNING) Mother Temperature 36.8oC Pulse 80bpm Blood Pressure 108/60mmHg Respiration 20cpm BABY Temperature 36.9oc Apex Heart Beat 138bpm Respiration 33cpm EVENING (MOTHER) Temperature 36.6oC Pulse 80bpm Blood Pressure 110/70mmHg Respiration 20cpm BABY Temperature 37.0oc Apex Heart Beat 139bpm Respiration 41cpm I supervised her to do postnatal exercise daily. Also, I educated her to support her breast with a well-fitting brassiere with broad straps. I supervised her to position the baby to her breast and educated her on the effects of applying anything such as herbs or traditional medicine to the cord or the fontanelles. Madam D. O. D complained of constipation on the second day. I reassured her and advised her to eat food containing fiber and roughage such as fruits and vegetables. I also encouraged her to take a lot of fluid. She was encouraged to have mild exercise and also advised her to take her drugs. 4.6 FOURTH AND FIFTH DAY POSTNATAL HOME VISIT On the fourth to fifth day which was 1st and 2nd August 2019, I visited madam D. O. D and her baby at home to continue with the care. Her sister and husband were all happy to see me once again. They welcomed me and offered me a seat. I checked the baby’s vital signs and examined her and found out she was very well. There were no skin infections like pemphigus and no oral or anal thrush. The mother was supervised to bath the baby and dressed the cord with cotton wool soaked in methylated spirit. According to the mother, the baby urinate several times both day and night and moved bowel at least twice a day. The weight was 3.0kg on the fourth day.. ON THE FOURTH DAY, 1st AUGUST, 2019 MORNING (BABY) Temperature 36.7oC Apex Beat 139bpm Respiration 38cpm Weight 3.0kg She was advised to change the baby’s diapers regularly and ensure that the baby is always clean. Madam D. O. D was also examined daily. Her vital signs recorded on the fourth day were; Temp 36.5 Pulse 79bpm Respiration 20cpm Blood Pressure 110/70mmHg Fundal Height 13cm Her uterus was firm. The colour of her lochia was red on the fourth day and changed to pink on the fifth and the flow was moderate. I asked about her previous complain of which she said she can now empty her bowel but complained of severe backache and sleepless night as her baby cries more during the night . She was encouraged to continue breastfeeding the baby exclusively and was taught to sit straight and support her back with a pillow anytime she sits up to breast feed the baby. I told her to make sure that the baby’s diapers are changed whenever it is wet. Both mother and baby’s vital signs were checked and recorded as; ON FIFTH DAY (2nd AUGUST, 2019) MORNING (MOTHER) Temperature 36.6oC Pulse 79bpm Respiration 20cpm Blood Pressure 110/60mmHg Fundal Height 12cm BABY Temperature 37.1oc Apex Heart Beat 138bpm Respiration 38cpm Weight 3.2kg 4.7 SIXTH DAY POSTNATAL HOME VISIT My client and her family were visited on 3rd August, 2019,they were in good health. I observed that the baby’s cord had fallen off and the mother said it happened earlier that morning. When I got there, she told me they had already bathed so I washed my hands and started my routine examination on both the mother and the baby and no abnormalities were detected. I checked and recorded their vital signs. The mother’s fundal height was 11cm. Lochia was pink in colour with less flow .She complained of heaviness of breast. I told her to breastfeed the baby exclusively and also to empty one breast before offering the other one to the baby. I told them that my regular visit to them had ended. I also told them not to hesitate to inform me of any deviation in condition. I advised madam D. O.D to vaccinate the baby against the childhood killer diseases, register her baby with the birth and death registry and report to the postnatal clinic on 4th August, 2019 which was the 1st postnatal visit to the clinic. I encouraged her to continue postnatal exercise and take proper care of her baby and also educated her to practice good personal hygiene, take in nourishing diet, have enough rest and sleep and take her drugs and exercise to make her recover from stress of pregnancy, labour and puerperium. I told her to send for me if she needs any assistance. Their vital signs were checked and recorded as follows; MOTHER Temperature 36.8oC Pulse 76bpm Respiration 19cpm Blood Pressure 110/60mmHg BABY Temperature 36.9oc Apex Heart Beat 138bpm Respiration 39cpm Weight 3.2kg I thanked them and took my leave. 4.8 FIRST WEEK POSTNATAL VISIT TO THE CLINIC Madam D. O. D and her baby reported at the hospital on the 4th August, 2019 .They looked very healthy and were neatly dressed. I welcomed them and gave her a seat to make herself comfortable. I asked about their general health and she said they were fine. At the postnatal clinic, they gave health talk on breastfeeding, family planning and the need to immunize their children against the childhood killer diseases such as tuberculosis, whooping cough, poliomyelitis, measles, yellow fever, diphtheria and tetanus. I did routine examination from head to toe on her and also took her vital signs and the findings were recorded as follows; MOTHER Temperature 36.6oC Pulse 80bpm Respiration 20cpm Blood Pressure 110/70mmHg Fundal Height 10cm Lochia serosa Weight 70kg Haemoglobin level 12.1g\dl Urine protein negative Urine glucose negative BABY Temperature 36.8oc Apex Heart Beat 141bpm Respiration 41cpm Weight 3.3kg Madam D. O. D was asked to empty her bladder. A specimen bottle was given and midstream urine requested and tested for sugar and proteins which were all negative. Her haemoglobin level was 12.7g/dl. She said the baby was exclusively breastfed and moves her bowels at least twice a day and urinates as often as possible. I washed my hands and dried them to examine the baby. I undressed and wrapped her in a clean cot sheet and examined her on a flat surface in the presence of her mother. The eyes were normal with no jaundice and conjuctiva was not pale,ears, nose and mouth were clean and I found no discharges. The skin as pink all over with no rashes and the skin folds were clean. Baby’s hands were equal in length, size and shape. Palma crease was present and there was no web finger or any extra digits The abdomen was not distended and umbilicus had completely healed .The back was examined and there was no malformations. Baby’s legs were examined and they were normal ,barlow’s test was done and the hip and femur were normal. The vaginal was patent with no false mensuration. She registered her baby with the birth and death registry. All findings on her and the baby were communicated to her and I congratulated her for taking good care of the baby. Detailed head to toe examination was done on my client. Privacy was provided and I explain to her that head to toe examination was going to be done on her .I asked her to go and urinate .After that I help her to change he self and helped her into the bed were normal and jaundice and anaemia was absents .her hair was neatly plaited .her eyes and conjuctiava .The hands were equal, and nails were shortly trimmed .Breast was examined and noting abnormal was detected. Lactation was fully established. The uterus was not palpable abdominally and her lochia was pale in colour. The vulva was inspected and nothing abnormal was detected. Her legs were examined and no abnormalities were detected. She said she had regular bowel movement and passed urine without any pain or discomfort. I encourage her to continue breastfeeding the baby exclusively and on demand. She was later handed over to the community health nurse in-charge of the child health unit of the facility to continue the care. I expressed my sincere thanks to my client and her family for their support and co-operation. 4.9 PUERPERIUM CARE PLAN PROBLEMS IDENTIFIED DURING PUERPERIUM 1 On 27th July,2019 Madam D. O. D complained of Lower abdominal pains (after pains) 5.On 3rd August, 2019 Madam D. O. D complained of Heaviness of breasts 4. On 1st August, 2019 Madam D. O. D complained of Sleepless at nigh (insomnia) 2.On 30th July 2019 Madam D. O. D complained of Constipation 3.On 1st August, 2019 Madam D. O. D cmplained of severe Backache SHORT TERM GOALS 1. Madam D. O. D will be relieve of lower abdominal pain (after pains) within 72 hours 5. Client’s heaviness of breast will be relieved within 72 hours 4. Client will have at least 6-8 hours sleep in the night within 48 hours. 2. The woman will have normal bowel movement within 24hours. 3. Client will be relieved of backache within 24hours. LONG TERM OBJECTIVES To maintain the physical and psychological wellbeing of the mother and her baby throughout puerperium  DATE/TIME NURSING DIAGNOSIS NURSING OBJECTIVES NURSING ORDERS NURSING INTERVENTION DATE/ TIME EVALUATION SIGN 27th /7/19 at 6:30pm Lower abdominal pain (after pains) related to involution of the uterus Client’s after pains will subside within 12 hours as evidenced by client verbalizing that her pains have subsided. 1. Reassure client that her pains will be relieved soon with rest and analgesic 2. Educate client on the cause of the lower abdominal pain 3. Encourage client to breastfeed baby to prevent breast engorgement 4. Encourage client to apply warm compress to the lower abdomen to relieve pain 5. Tablet paracetamol 1g was served to reduce pain 1. Client was reassured that her pain will be relieved with rest and analgesic 2. The cause of the pain was explained to the client as a result of the uterus return to its pre-pregnant state 3. Client was encouraged to continue breastfeeding baby 4. Client was encouraged to apply warm compress to the lower abdomen 5. Tablet paracetamol 1g was served three times daily 28th /7/19 at 6:30 am Goal successfully met as evidenced by client verbalized that the pain has decreased. H. H DATE/ TIME NURSING DIAGNOSIS NURSING OBJECTIVES NURSING ORDERS NURSING INTERVENTIONS DATE/TIME EVALUATION SIGN 3rd /8/19 at 11:00am Heaviness of the breasts related to increase production of breast milk Breast discomfort(heaviness) will be relieved within 24hours as evidenced by client verbalizing that her breast are no more heavy 1. Reassure client that her breast will be relieved of the heaviness/fullness soon 2. Explain the physiology of the heaviness to the client 3. Educate client to practice expressed feeding and to express the remaining milk and store it nicely 4. Tell client to empty one breast at a time before switching to the other 5. Encourage client to put on a well fitting brazier with broad straps 1. Client was reassured that her heaviness of breasts would be relieved soon 2. Physiology of heaviness of breast was explained to client as due to increase milk production and less feeding. 3. Client was educated to practice expressed feeding and to expel the remaining milk for storage 4. Client was told to empty one breast at a time before switching to the other one. 5. Client was encouraged to put on a well fitting brazier with broad straps 4th /8/19 at 11:00 am Goal fully met as evidenced by client verbalized that the heaviness of the breast has been relieved. H. H DATE/ TIME NURSING DIAGNOSIS NURSING OBJECTIVES NURSING ORDERS NURSING INTERVENTIONS DATE/TIME EVALUATION SIGN 1st /8/19 at 11:00am Sleepless at night (Insomnia) related to baby crying more at night Client will have 6hours of uninterrupted sleep at night and 2hours during the day within 48hours as evidenced by client verbalizing she has been able to sleep 1. Reassure client that she will be able to sleep at least 6hours in the night and 2hours during the day 2. Encourage client to breastfeed baby before she goes to bed 3. Tell client to sleep whenever baby sleeps 4. Educate client to change baby’s soiled clothing before going to bed. 5. Encourage client to sleep in a noise free environment. 6. Encourage client family to help in the care of the baby to allow client have enough rest periods 1. Client was reassured that she will be able to sleep at least 6hours in the night and 2hours during the day 2. Client was encouraged to breastfeed baby before she goes to bed 3. Madam TL was told to sleep whenever baby sleeps 4. She was educated to change baby’s soiled clothing before going to bed. 5. She was encouraged to sleep in a noise free environment. 6. Client’s family was encouraged to help in the care of the baby to allow client have enough rest periods 2nd /8/19 at 11:00 am Goal fully met as evidenced by client verbalizing that she has been able to sleep at least 6hours during the night and 2hours in the day H. H DATE/ TIME MIDWIFERY DIAGNOSIS NURSING OBJECTIVES NURSING ORDERS NURSING INTERVENTIONS DATE/TIME EVALUATION SIGN 30th /7/19 at 7:45 am Constipation related to less intake of fiber diet Client will have a normal bowel movement within 24hours as evidenced by client verbalizing that she has been able to empty her bowel at least once within 24hours 1. Reassure client that she will be able to empty her bowel within 24hours 2. Encourage client to take more food rich in fiber to aid bowel movement 3. Encourage client to do mild exercises such as walking 4. Encourage client to eat more fruits and vegetables 5. Encourage client to take in more fluid 1. Client was reassured that she will be able to empty her bowel within 24hours 2. She was encouraged to take foods rich in fiber to aid bowel movement. Example is food prepared with unpolished maize 3. Client was encouraged to do mild exercises such as walking 4. Madam TL was encouraged to take in more fruits and vegetables 5. Client was encouraged to take in more fluid 31st /7/19 at 7:45am Goal fully met as evidenced by client verbalizing that she can move her bowel at least once within 24hours H. H DATE/ TIME NURSING DIAGNOSIS NURSING OBJECTIVES NURSING ORDERS NURSING INTERVENTIONS DATE/TIME EVALUATION SIGN 1st /8/19 at 8:45 am Backache related to poor posture during feeding of baby Client’s backache will reduce within 24hours as evidenced by client verbalizing that the pain has reduced. 1. Reassure client that her condition is manageable 2. Teach client the proper position to adopt during breast feeding 3. Inform client to step on a stool when breastfeeding 4. Encourage client to support her back with a pillow while feeding the baby 5. Educate mother and husband to assist in the care of the baby for the mother to rest 1. Client was reassured that she will be relieved from pain 2. Client was taught the proper position to adopt during breastfeeding 3. Client was informed to step on a stool when breastfeeding 4. Client was encouraged to support her back with pillow when sitting 5. Mother and husband were advised to assist in the care of the baby 2nd /8/19 at 8:45am Goal fully met as evidenced by client verbalizing that the backache has reduced  SUMMARY AND CONCLUSION This client and family centered maternity care study was rendered to Madam D. O. D a 28 year old gravida 2 Para I alive (G2P1A). She was an antenatal clinic attendant at Anhwiaso Health Center, TEPA I met her on the 11th July, 2019 at Anhwiaso Health Center on her 7th visit to the antenatal clinic with 36 weeks gestation. She receive a focus maternal care from her first day she was met through pregnancy ,labour and puerperium .Madam D. O. D had a spontaneous vaginal delivery to a live female infant on the 27th July, 2019 without any complication to both mother and baby due to good monitoring and management of labour and pregnancy. She went through puerperium normally and all home visits and examinations were carried on her on her as required The baby was normal with no abnormalities. Although she encountered minor disorders during pregnancy, labour and puerperium, they were managed by the use of nursing process. In conclusion, the care helped me to put into practice the knowledge I received from the classroom and also built my confidence. The care given to Madam D. O. D and her family has broadened my knowledge and capabilities on the concept of individualized nursing care and has improved my midwifery skills to manage individuals effectively and efficiently during pregnancy, labour and puerperium. The client/ family centered maternity care study served as a managerial tool in the care of an expectant mother and should be passed on by the Nursing and Midwifery council of Ghana, since it will enhance quality midwifery care to help reduce maternal and infant mortality and morbidity rate in Ghana. BIBLIOGRAPHY Annaman, J. (2013). Midwifery care book. (3rd ed.). New Delhi; Jay Pee Brothers medical Publication. Chapman, L., & Durham, R. F. (2010). Maternal New Born Nursing. (1st ed.). Unite States of America; F.A Davis publication. Frazer, D.M., & Cooper, M.A., & Nolte, A.G.W. (2009). Textbook s for midwives. (African ed.) London;Churchill Livingstone Elsevier Limited. Jacob, A. (2013). Midwifery case book; A practical record of maternal and newborn nursing. (2nd ed.). India; Jaypee brothers medical publishers. Oduro- Kwarteng .V. (2015). Obstetrics for Nurses & Midwives. (2nd ed.). Kumasi; Robee Printing Press. Oduro- Kwarteng. V. (2012). Obstetrics for Nurses & Midwives. (3rd ed.). Kumasi; Robee Printing Press. Philip, N.B., & Louise, C.K. (2011). “Obstetrics by Ten Teachers”. (19th ed.). U.K; Hodder Arnold and Hachette company Tiran, D. (2015). “Bailliere’s Midwives Dictionary”. (12th ed.). London; Bailliere Tindal, Elsevier.  APPENDIX III MOTHER PHAMACOLOGY OF DRUGS DRUGS CLASSIFICATION DOSAGE ROUTE OF ADMIIN ACTION AND USE ACTUAL EFFECT SIDE EFFECT OF DRUGS SIDE EFFECT EXPERINCE Tablet Folic acid Haematinics 5 mg daily for 30 days Oral Formation of red blood cells Haemoglobin level increased Nausea and vomiting None Tablet ferrous sulphate Haematinics 200mg three times daily for 30days Oral Formation of red blood cells Haemoglobin level increased Black stool, gastro intestinal disturbance Black stool. Tablet multivitamin Vitamin supplement 1 twice daily for 30 days Oral formation of red blood cells Haemoglobin level increased Nausea and vomiting None Tablet sulphadoxine pyrimethamine Antimalaria prophylaxis Three tablets monthly for five times Oral Prevention and treatment of malaria Malaria prevented Itching, nausea and vomiting None Injection Tetanol Anti tetanus vaccine 0.5 milliliters Subcutaneously Prevent tetanus Protect against tetanus infections Slight fever and chills None Injection oxytocin Oxytocic drug 10units Intramuscularly Stimulates uterine contraction Good uterine contraction hypotension and hyper stimulation None Capsules vitamin A Vitamin supplement 200,000 International units for 2 days Oral Growth development Normal vision and healthy skin Vomiting None Tablet paracetamol Analgesic 100mg three times daily for 5 days Oral Relieve of pain Pain relieved Liver damage None Capsule Amoxicillin Broad spectrum antibiotic 500mg three times daily for 7days Oral Prevent infection Infection prevented Nausae, vomiting, rashes None APPENDIX III BABY PHAMACOLOGY OF DRUGS DRUGS CLASSIFICATION DODAGE ROUTE OF ADMIINSTRATION ACTION AND USE ACTUAL EFFECT SIDE EFFECT OF DRUGS SIDE EFFECT EXPERINCE Injection Bacillus Calmette Guerin Antigen Vaccine 0.05 Milligram Intradermal Production of antibodies and prevention of tuberculosis Tuberculosis prevented Blister formation Blister noticed Tetracycline eye ointment Antibiotic Instillation Prevention of eye infection Eye infection prevented Decreased visual activity None Oral poliomyelitis vaccine Antigen vaccine 2 drops Orally Production of antibodies Poliomyelitis prevented There may be diarrhea None Injection Vitamin K Anti- haemorrhagic 0.5 milligram Intramuscularly Enables blood clotting and prevents bleeding Helps in blood clotting Swollen at the injection site or pain None APPENDIX I COMPLETE DIAGNOSIS INVESTIGATION DATE SPECIMEN INVESTIGATION NORMAL VALUES FINDINGS REMARKS 27th /2/2019 Blood Blood Blood Blood Blood Urine Urine Blood Haemoglobin level Sickling Groupings Rhesus factors Hepatitis B Sugar Protein HIV test 11.6- 16g/dl Negative ‘0’ Positive Negative Negative Negetive Negative 10.9g/dl Negative ‘0’ Positive Negative Negative Negative Negative Normal Normal Normal Normal Normal Normal Normal Normal 28th /3/19 Blood Urine Urine Haemoglobin level Sugar Protein 11.6- 16g/dl Negative Negative 11.6g/dl Negative Negative Normal Normal Normal 23rd /5/19 Blood Urine Urine Haemoglobin level Sugar Protein 11.6 -16g/dl Negative Negative 11.9g/d Negative Negativss e Normal Normal 11/7/2019 Urine Urine Sugar Protein Negative Negative Negative Negative Normal Normal 25/7/2019 Blood Urine Urine Hemoglobin level Sugar Protein 11.6-16g/dl Negative Negative 12.4g/dl Negative Negative Normal Normal 31/7/2019 Urine Urine Sugar Protein Negative Negative Negative Negative Normal Normal 26/7/19 Urine Urine Sugar Protein Negative Negative Negative Negative Normal Normal  30 77