PREFACE

Family centered maternity care study is a comprehensive study that is geared towards quality

care rendered to pregnant women during pregnancy through to labour and puerperium.

This care study helps prevent complications since the needs of the pregnant woman is

identified and the appropriate management given. During this study, the mother and her baby

are cared for by the midwife which helps facilitate teaching of good parenting to promote

family bonding. This care is also extended to the family members of the clients as well. The

client and her family members are visited in their own home following discharge and handed

over to the public health personnel to ensure continuity of care.

This study is done purposely to improve the skills and knowledge of student midwives for

professional practice.

Family centered maternity care study is a requirement of the nursing and midwifery council

of Ghana used to assess midwifery students in the awardant of diploma certificate after their

course of study.

I
 ACKNOWLEDGEMENT

I thank the Almighty God for giving me knowledge, strength, wisdom and skills to be able to

undertake this study successfully.

My greatest appreciation to the Principal, Mr. Samuel Ansu-Frimpong, my Supervising

Tutor, Mrs. Peggy Mensah and the entire Tutors of Nursing and Midwifery Training College,

Goaso for their support, guidance and co-operation which has made my care study a success.

My greatest debt of gratitude to my client Madam A.R, her husdand Mr. M.J ,her mother

madam D.A and her entire family involvement ,patience and information given to me during

my care study.

Also, my heartfelt gratitude to the entire staff of Brosankro Health Center especially the

maternity ward in-charge (Mrs. Dorwu Yayra) for her attention, guidance and support given

me throughout this care study. Furthermore, my special thanks goes to my parents, uncle and

my friends for their wonderful words of encouragement and support both financially and

constant prayers towards the completion of this care study. To crown it all, many thanks to

the authors and publishers of the books used as reference for writing this care study.

II
 TABLE OF CONTENT

PREFACE I

ACKNOWLEDGEMENT II

INTRODUCTION 1

LITERATURE REVIEW 2

WHY I CHOSE MY CLIENT 5

CHAPTER ONE

1.0 CLIENT PARTICULARS

1.1 SOCIAL HISTORY

1.2 FAMILY HISTORY

1.3 MENSTRUAL HISTORY

1.4 MEDICAL HISTORY

1.5 SURGICAL HISTORY

1.6 HOME ENVIRONMENT (PHYSICAL AND PSYCHOSOCIAL)

1.7 CLIENT’S LIFESTYLE AND HOBBIES

1.8 PAST OBSTETRIC HISTORY

1.9 PRESENT OBSTETRIC HISTORY

CHAPTER TWO

2.0 ANTENATAL CARE

2.1 FIRST CONTACT WITH CLIENT

III
2.2 FIRST ANTENATAL HOME VISIT

2.3 SUBSEQUENT ANTENATAL VISIT TO THE CLINIC

2.4 SUBSEQUENT ANTENATAL HOME VISIT

2.5 SUBSEQUENT ANTENATAL VISIT TO THE CLINIC

2.6 CARE PLAN DURING ANTENATAL

CHAPTER THREE

3.0 LABOUR

3.1 ADMISSION AND MANAGEMENT OF FIRST STAGE OF LABOUR

3.2 MANAGEMENT OF SECOND STAGE OF LABOUR

3.3 IMMEDIATE CARE OF THE BABY

3.4 MANAGEMENT OF THIRD STAGE OF LABOUR

3.5 MANAGEMENT OF THE FOURTH STAGE OF LABOUR

3.6 NURSING CARE PLAN DURING LABOUR

CHAPTER FOUR

4.0 MANAGEMENT OF PUERPERIUM.

4.1 DAY OF DELIVERY.

4.2 SUBSEQUENT CARE OF THE BABY.

4.3 FIRST DAY POSTNATAL AND PREPARATION FOR DISCHARGE

4.4 FIRST DAY POSTNATAL HOME VISIT

4.5 SECOND- AND THIRD-DAY POSTNATAL HOME VISIT

4.6 FOURTH TO FIFTH DAY POSTNATAL HOME VISIT

IV
4.7 SIXTH DAY POSTNATAL HOME VISIT

4.8 SEVENTH DAY/FIRST WEEK POSTNATAL CLINIC VISIT

4.9 CARE PLAN DURING PUERPERIUM

SUMMARY AND CONCLUSION

BIBLIOGRAPHY

APPENDICES
ANTENATAL PROGRESS RECORD
COMPLETE DIAGNOSTIC INVESTIGATIONS
PARTOGRAPH
LABOUR NOTES
NEW BORN EXAMINATION CHART
SIX HOURS OBSERVATION CHART FOR BABY
SIX HOURS OBSERVATION CHART FOR MOTHER
REPORT ON THE MOTHER
BABY’S WEIGHT CHART
PHARMACOLOGY OF DRUGS
SIGNATORIES

V
 INTRODUCTION

Family centered maternity care study is a systematic approach of care given to an expectant

mother and her family throughout pregnancy, labour and puerperium. This study is about the

care rendered to Madam A.R, a 23years old mother of gravida 2 para 1 at Brosankro Health

Center. This care is divided into four chapters of which chapter one emphasizes on the

client’s particulars. Chapter two talks about the client’s antenatal clinic records since my first

contact with her.

Also chapter three basically talks about labour from the first stage to fourth stage and chapter

four discloses all about puerperium from day one of delivery to one week postnatal.

In each chapter, identified problems were addressed appropriately with the use of the

midwifery care plan and a copy attached to its corresponding chapter. It allowed the client to

satisfactorily tell all complains that could have had an impact on her for prompt attention.

Information for the study was provided by Madam A.R. and her husband and her mother

since she now staying with them, antenatal records, observations made and textbooks. For

confidentiality’s sake, my client is represented as A.R. and her husband as M.J. and her

daughter in the study.

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 LITERATURE REVIEW

PREGNANCY

Jess Speller (2020) Pregnancy also known as gestation is the period during which one or

more offspring develops inside a woman. It typically last nine months. Coitus and conception

are the initial stages that occur in humans that allows for the establishment of pregnancy.

Sexual intercourse that results in the deposition of sperms in the vagina at the level of the

cervix is called coitus. After sperms have been deposited at the cervix, it is transported to the

uterus where it fertilizes the ovum and implants in the uterine stromal. This is known as

conception.

According to GUPTA and GUPTA (2014), pregnancy is the period from conception to the

birth. Pregnancy begins with conception, fertilization of the ovum by a sperm and subsequent

implantation of the egg. During first trimester women develop vomiting, constipation,

hemorrhoids and heartburns as minor disorders. During the second trimester ankles swell and

varicose veins may develop. Urinary tract infections are most common. Women may develop

change in moods due to hormonal effects. Light exercises and sex can continue throughout

pregnancy. Adopting different positions may make intercourse more comfortable.

According to Weller (2012), pregnancy is being with a child; the condition from conception

to the expulsion of the fetus. The normal period is two hundred and eighty days or forty

weeks counting from the first day of menstrual period?

2
Based on these reviews, I will define pregnancy as the state where there is fusion of an ovum

and spermatozoa (fertilization) which brings about a developing embryo in the body of a

female.

LABOUR

According to Speller (2020) , labour (also known as parturition) is the physiological process

by which a fetus is expelled from the uterus to the outside world. There are three separate

stages characterized by specific physiological changes in the uterus which eventually result

in expulsion of the fetus. At this point, the fetus becomes known as a neonate. Jess Speller

stated that initiation of labour depends on these three factors:

1. Cervical ripening

2. Myometrial excitability

3. The role of oxytocin.

According to Myles sixteenth Edition (International Edition) Labour in the physical sense

may be described as the process by which the foetus, placenta and membranes are expelled

through the birth canal.

According to GUPTA and GUPTA (2014), labour is the process that results in the birth of a

baby. During first stage of labour, pains are short lasting, mild and separated at intervals of

ten to twenty minutes. There will be mild discomfort in the upper sacral region and the lower

abdomen during uterine contraction. With the progress of labour, pains become frequent,

stronger and longer. With more lasting uterine contraction the head becomes engaged if it

has not so far.

3
According to Tiran (2015) normal labour occurs spontaneously after 37weeks gestation with

vertex presentation of single foetus: completed within 24hours without maternal and fetal

trauma; physiology depends on interaction between uterus, maternal pelvis and foetus.

Based on these definitions, I will say that labour is the process that starts from painful uterine

contraction to the expulsion of the foetus, placenta and its membranes.

PUERPERIUM

According to GUPTA and GUPTA (2014), puerperium is the period succeeding labour

during which certain processes take place to restore genital organs approximately to the

condition they were before pregnancy. During the first 24 hours temperature rises due to the

absorption of waste products. Pulse becomes slow. During 10 days, there may be loss of

appetite and progressive weight loss.

According to Tiran (2015), puerperium is a period of six to eight weeks following childbirth

during which the uterus and other organs and structure are returning to their non-pregnant

state.

Puerperium is defined as the time from delivery of the placenta through to the first few

weeks after delivery. This period is usually considered to be six weeks in duration

(Emedicine.medscape.com) (July 2016).

4
 WHY I CHOSE MY CLIENT

Madam A.R Gravida two Para one alive [G2P1A] came to the clinic on 15th November,

2022 . This was my first contact with her. I welcomed her to the facility , offered her a seat

and ensured that she was comfortable .I took her antenatal booklet and saw that her progress

records has been written .It was her sixth visit and was 37 weeks plus 1 day. I chose my

client because I realized she looked worried and particularly not interested in what was going

on at the clinic. After my interaction with her, she told me she has constipation but ''am not

able to drink enough water'' so i explained to her the reason why she is not able to pass stool

is due to progesterone relaxing the smooth muscles causing slow in bowel movement. I also

reassured and advice her to drink more water, add fruits and vegetables to her diet. she

thanked me and i expressed my intention of using her as my client for my care study I told

her will be taking care of her from that moment till she delivers and during postpartum

period before handling her to the community nurses.

Madam A.R agreed so i informed the midwife in-charge and introduced her and she gave me

the go ahead to continue with the routine care.

5
 CHAPTER ONE

• CLIENT PARTICULARS

This chapter basically talks about the client, her family and community. It entails client’s

particulars that is social history, family history, medical history, surgical history, menstrual

history client’s daily living and hobbies, home environment (physical and psychosocial), past

and present obstetrical history.

1.1 SOCIAL HISTORY

Madam A.R. was born on 23rd April, 1999. She is a native of in the Volta region. She stays

currently at Brosankro old town zongo in the Ahafo region. Madam B.P. is Dark in

complexion with a height of 157cm. Madam A.R went to school up to the Primary level.

She speaks Ewe and Asante Twi. She is married to Mr. M.J. Madam B.P is a food vendor

at Tepa.

She is a member of the Christian religion. Banku and okro soup is her favorite food. The

next of kin of Madam A.R is her daughter. She does not smoke or drink or take in drugs that

are unprescribed.

1.2 FAMILY HISTORY

Madam A.R is the 3rd born out of seven children of her parents who are both alive currently

according to my client. Madam A.R indicated that there is a history of twin birth in her

mother’s and father’s side of the family and no history of hereditary diseases such as

epilepsy, mental illness, hypertension and asthma in her family.

6
1.3 MENSTRUAL HISTORY

Madam A.R. experienced her first menses at age fifteen. She has a regular menstrual cycle

of 30 days with a moderate flow of blood for 4 days. Her last menstrual period was 7th

March, 2022. She practiced family planning by using contraceptives, she normally resumes

her menses nine (9) months after delivery. She does not experience any dysmenorrhea

during the monthly menstrual period.

1.4 MEDICAL HISTORY

Madam A.R. has no medical history like hypertension, diabetes mellitus, tuberculosis, heart,

kidney and liver diseases. My client has not been hospitalized before, has no allergies and

hardly falls sick. She has never been transfused with blood before.

1.5 SURGICAL HISTORY

According to Madam A.R, she has never undergone any surgical procedure abdominally or

at her pelvic region. She has never been involved in any road traffic accident before. She

has no episiotomy performed on her in her previous delivery and has never been transfused

for any surgical reasons.

1.6 HOME ENVIRONMENT (PHYSICAL AND PSYCHOSOCIAL)

Madam A.R lives in a single room with her husband and child. The house is built with

bricks and has one window on each side. The house is roofed with Aluminum sheet, there is

electricity and pipe born water which is about 3 meters from the house. She has a wooden

structure at the middle of the compound as her kitchen. The bathroom and the lavatory are

separated from the house. The bathroom is built with blocks and has a soak away in which

7
the bathwater drains into it. The lavatory is also built with wood and has been roofed. She

has a covered dustbin at the corner of her yard. There is a good drainage system in the house.

Madam A.R. has a good personal relationship with the husband, daughter and the people in

the community.

1.7 CLIENT’S LIFESTYLE AND HOBBIES

Madam A.R wakes up at five o'clock in the morning during week days. Whenever she

wakes up, she says her prayers, brush her teeth and wash her face and empty her bowels

before she sweeps her compound. She then goes to fetch water, prepares breakfast and wakes

up her child. She baths her and feed her, she then dresses her and leave her for his husband

to take her to school. She then goes and take her bath, eats her breakfast and leave for work

at7;30am .In the afternoon, she takes her lunch around 1.30pm and closes at 3.30pm to

prepare supper around 4.30pm.

8
 On Saturdays, Madam A.R does her cleaning , washing and scrubbing of the

bathroom and lavatory , prepares breakfasts ,lunch and supper at her usual time and goes to

bed at 8 o’clock in the evening .On Sundays, she goes to church together with her family at 7

o'clock and closes at 12.30 pm in the afternoon. Her favourite meal is banku and okro soup

and her hobby is cooking. She then watch movies with her family and goes to sleep. She also

make sure to empty her bladder whenever she has the urge and dependent on the fluid

intake .She neither takes alcohol nor smokes and above all sociable.

1.8 PAST OBSTETRIC HISTORY

Madam A.R, a gravida 2 para 1 alive who has never experienced abortion before whether

induced or spontaneous carried her previous pregnancy to term with no complications. In

her previous pregnancy she received four doses of the sulphadoxine pyrimethamine (SP)

and one dose of tetanus injection in her first pregnancy. She experienced some minor

disorders such as nausea, ptyalism and heart burns during her previous pregnancy. She had

spontaneous vaginal delivery of her first child at Brosankro Health Center with no

complications. Placenta and membranes were completely delivered. Blood loss was 120mls

for the first baby.

According to Madam A.R, labour starts spontaneously at home with her previous pregnancy.

She had no history of prolong labour, postpartum haemorrhage, sub involution and puerperal

sepsis in her pregnancy. She gave birth to female child. She cried at birth and was

immunized against the childhood preventable diseases. The first baby weight was 3.0kg, her

baby did not experience any ill health. She did not practiced exclusive breastfeeding but

started complementary feeding from 4 month up to two years she practiced the

9
contraceptive method and sometimes injectable method of family planning. Throughout

pregnancy, labour and puerperium her greatest support has been her husband and her mother.

1.9 PRESENT OBSTETRIC HISTORY

Madam A.R came to Brosankro Health Center for antenatal on the 14th July, 2022. For the

first time.

The baseline recording was:

Measurement Result

Blood Pressure 110/60mmHg

Temperature 36.5oC

Height 157cm

Pulse rate 82b/m

Respiration 22cpm

Weight 70kg

The following investigations were carried out and documented as;

Hemoglobin level 11.3g/dl

Urine glucose and protein Trace/negative

Blood group O

Rhesus factor Positive

Sickle cell Negative

Venereal Disease Research Lab Negative

Hepatitis B-reagent Negative

HIV/AIDS Negative (280)

10
Stool/urine examination No abnormalities detected

LMP

EDD

EDD (scan) 2nd December, 2022.

Head-to-toe examination was performed and no abnormality was detected. She was nineteen

plus two days (19+2) weeks by then.

The following routine drugs were administered.

Drug name Dosages

Tablet Multivitamin 200mg twice daily X 30 days

Tablet Fesolate 200mg once daily X 30 days

Tablet Folic Acid 5mg once daily X 30 days

Madam A.R was reminded of her next antenatal visit and her next dose of the tetanus

injection. She was educated on malaria prevention and personal hygiene. She was given an

insecticide treated net and educated on the importance to sleep under it. She complains of

nausea. She took her third tetanus injection on the 14th July, 2022. At 19+2 weeks during her

first visit. She was given a dewormer on the 14th July,

, 2022. Sulphadoxine Pyrimethamine was given to her as follows;

IPT1 14/07/2022 19 weeks+2day

IPT2 11/08/2022 23 weeks+2day

IPT3 13/09/2022 28weeks+2 day

IPT4 19/10/2022 33 weeks +2 day

IPT5 29/11/2022 39 weeks+3days

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 CHAPTER TWO

• ANTENATAL CARE

This chapter talks about the care rendered to Madam A.R. at her usual antenatal visits and on

home visits.

2.1 FIRST CONTACT WITH CLIENT

I had contact with Madam A.R on her usual visit to the antenatal clinic on 15th November,

2022 at Brosankro Health Center when she was 37 weeks plus two days pregnant. I

welcomed her and made her comfortable by offering her a seat. She looked worried so l

asked her what was wrong and she said she was having constipation and said ''am not able to

drink enough water too ''.I explain to her that the problem was as a result of the progesterone

on the smooth muscle causing slow in bowel movement and she will be relieved . I requested

for her antenatal record book and read through and realized she also has good obstetric

history and she delivered her first baby at the same facility {B.H.C} .I sought Madam A.R

permission to check her vital signs. She consented so I checked her vital signs and these

were what I recorded.

Blood Pressure - 102/72 mmHg

Temperature - 36.4oC

Pulse - 84 b/m

Respiration - 20 c/m

Weight - 71 kg

Glucose and protein in Urine - negative/negative

Haemoglobin level - 11.3 g/dl

12
I explain the findings and results to her understanding and then educated her on the need to

take in more water and add fruits and vegetables in season to her diet and continue to take

her routine drugs as prescribed to help haemogloblin level to elevate. I then decided to use

her as my client for my care study to help her eat well and choose the right and available

foods for her to help relieved her from constipation, so I expressed my intentions of using

her as my client for my care study and caring for her for the rest of her pregnancy, labour and

puerperium. She agreed after I had introduced myself to her as a student mid-wife. I

informed the midwife-in charge of my intentions to use Madam A.R as my client and she

gave me the go-ahead after going through Madam A.R record book.

The next procedure was Head-to-the examination which I explained to her in simple terms

and understandable language she agreed and complied. Madam A.R was asked to void for

the examination, privacy was provided by screens. She was helped to undress, change into

gown and lie on the examination couch on her lateral side and draped with a clean sheet. An

examination tray was set and was beside her bed, and under the supervision of the midwife

in-charge, she was examined from head - to - toe to detect any problem or abnormality in a

supine position. I washed my hands and dried them with a clean towel. On examination her

hair was inspected for lice, dandruff and scalp infection and no abnormalities were detected.

Again, the eyes were clean with no discharge or swelling. The conjunctiva was not pale. The

nose was patent with a septum between with no discharge or swelling .She had no pain in

and around the ears. There were no cracks and rashes on the lips. Her mouth was inspected

as she opened her mouth when she was asked, teeth were clean, tongue not coated and has no

sore, no gum bleeding or offensive odour from her mouth. The neck was not distended and

was palpated with no lymph nodes swollen .she had no edema on the face.
13
The upper extremities were of equal length and size. The hands, palm and nails were also

checked for pallor and no abnormalities were found. Breast examination was done too in

which she was taught breast self-examination when at home. Her nipples were patent and no

lumps were found in the breast. No edema was identified at the sacral region. On abdominal

inspection, there were no scars, size of abdomen was quite proportional to the gestational

age. Linea nigral and striae gravidarum were present. The foetal lie was longitudinal with

symphysio fundal height being 36cm. She was in 37weeks plus 2 days gestation.

The foetal back was round and smooth on lateral palpation. On pelvic palpation, the head

was felt in the lower segment of uterus thus cephalic presentation. Descent was 5/5 th above

the pelvic brim. On auscultation, the fetoscope was used to check the foetal heart beat while

comparing it to maternal pulse and it was 138 beats per minute with good rhythm and

volume. The lower extremities were also inspected and palpated for edema, varicose veins,

tenderness of the calf muscle, size equality and there were no abnormality detected.

The next procedure was vulva examination and procedure were explained to Madam A.R I

washed my hands and dried them with a towel and donned my gloves. I examined the vulva

for varicose veins, offensive discharges, warts, tenderness and edema, of which no such

abnormalities were detected. I aid Madam A.R off from the examination bed, help her to

dress up and all findings were discussed with her, I educated her on exclusive breastfeeding

and her complains were constipation and heartburns of which I explain to her that the

constipation is as a result of slowed peristalsis in the bowel by the hormone progesterone and

the heartburn is a result of the relaxation of cardiac sphincter resulting in gastric reflux. She

had some of the routine drugs at home so some were not served.

14
She was educated on the need to have enough rest and sleep. I took her number and she also

took mine and I promised to visit her at home.

2.2 FIRST ANTENATAL HOME VISIT

On 17th November, 2022, I visited Madam A.R. and her family for the first time at home at

exactly 9:00 AM. She was not going to work because her pregnancy was almost due.

I called her on phone before I left home and I was able to get through with the direction that

was given to me on arrival I called her again and she came and meet me and we both walked

home. When we got to the house, I was welcomed and she offered me a seat and water. She

introduced me to her husband and her mother. I then explain my purpose for the visit and

asked how she was doing from her previous complains and she said she was able to empty

her bowel at least once a day. She said the heartburns has also reduced a little by adhering to

my advice. Madam B.P. lives with the husband, daughter and her mother in Brosankro old

town Zongo in the Ahafo region. She lives in a two room apartment. She together with her

husband and daughter occupies one room whiles her mother also occupies the other. The

house is built with bricks and had been cemented and roofed with aluminum roofing sheets.

The windows are covered with net which prevent insects from entering the rooms. They has

a wooden structure at the middle of the compound which is used as a kitchen. I seek for

Madam A.R and her husband permission to enter their room to inspect and I was given so I

did. The room was spacious with windows at each side to ensure adequate ventilation. She

also sleeps in a mosquito net and was neat and tidy. She has her own lavatory which is built

with wood and with a good drainage system. Her source of water is from the community

tape which is about 3 meters from the house and a river. Electricity is her source of light .

15
She stores her water in a neat water containers with lids and keeps her rubbish in a covered

dustbin which she burns every day in the morning.

Madam A.R said that her husband and mother has been her support throughout her

pregnancy both physically and psychologically. I asked if she had any questions to asked and

any complain and she said no. I reminded her of her next antenatal visit and asked to take

my leave after thanking them for their hospitality. Madam A.R then saw me off.

2.3 SUBSEQUENT ANTENATAL VISIT TO THE CLINIC

Madam A.R visited the antenatal clinic on the 22nd November, 2022 . She came around

thirty minutes past nine in the morning. She was welcomed and given a seat. I asked of her

health and that of the family and she said they were doing well. Routine examinations were

done and explanations to procedures given to her. Vital signs were checked and recorded as:

Blood pressure - 98/55mmHg

Temperature - 36.2oC

Pulse - 80b/m

Respiration - 22c/m

Weight - 72kg

Urine for glucose and protein - negative/negative

Madam A.R was asked if she has emptied her bladder and she did, I helped her lie on the

palpation bed for routine examination. On abdominal inspection, abdomen was avoided in

shape. Fundal palpation was performed and symphysio fundal height was 37cm and descent

was still 5/5th.

16
On auscultation, the foetal heart rate was 132b/m with good volume and rhythm. I helped

my client off the bed and explain all findings to her and recorded in her record book.

Madam A.R complained of headache, backache and she is not able to eat. I explain to her

that the backache is a result of the relaxation the pelvic joints and ligament and she will be

relieved completely when she delivers .I also advised her to eat a well-balanced diet, stays

away from anything that makes her lose her appetite and also told her to take in lots of water

and avoid strenuous activities and also have enough rest. I informed Madam A.R. of the next

visit to the clinic made our conclusion on our next home visit and thanked her for co-

operating with me.

Routine drugs were served as;

Tablet Ferrous Sulphate - Once daily for thirty days

Tablet Folic Acid - Once daily for thirty days

Tablet Multivitamin - Twice daily for thirty days

Paracetamol tablet 1g three times daily was given due to Madam A.R. complain (headache).

2.4 SUBSEQUENT ANTENATAL HOME VISIT

I paid a second visit to Madam A.R. On the 1st December, 2022 at exactly 4 o’clock in the

evening. She welcomes me and offered me a seat after we have shared greetings. I asked

how she was doing as well as the family and she said everyone was perfectly fine .I also

asked about her previous complain and she said her headache has subside too.

I took a quick glance of the environment and it was clean and tidy so i encourage her to

continue with cleanliness and also I educated Madam A.R. on signs of true labour, birth

preparedness and complication readiness. I also asked her to bring her items for delivery so I

17
can inspect them for her. I inspected and realized some items have not yet been purchased. I

then encourage her to buy them and put all of them in one place so that reaching them will be

easy when labour set in including her antenatal record book and insurance card, She agreed

to do just as i said. . I asked her to repeat what I said earlier and she did marvelous .I asked

her if she has any complains and questions and she said no , so I take my leave and she saw

me off.

2.5 SUBSEQUENT ANTENATAL VISIT TO THE CLINIC

On 6th December, 2022, Madam A.R. visited the antenatal clinic. She came to the clinic

around nine o'clock in the morning. She was made comfortable by offering a seat. I asked

how she was doing and if her back was still aching, she said she was fine, headache subside

and she can now eat well. The following observations were made and recorded.

Blood Pressure - 110/70mmHg

Temperature - 36.8oC

Pulse - 84b/m

Respiration - 20c/m

Protein and acetone in urine - Negative/negative

Routine palpation and auscultation were done and these are the results

Symphysio fundal height 38cm

Descent 5/5th

Presentation Cephalic

18
Foetal heart rate 138 beat per minute

Weight 73kg

Madam A.R was educated on true signs of labour, birth preparedness and complication

readiness. I also encouraged her to come to the hospital if she sees anything unusual.

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2.6 CARE PLAN DURING ANTENATAL

Nursing care-plan is made up of assessment, nursing diagnosis, objectives, implementation

and evaluation.

PROBLEMS IDENTIFIED DURING ANTENATAL PERIOD

1. 15/11/2022 client complained of constipation.

2. 15/11/2022 client complained of heartburns.

3. 22/11/2022 Madam A.R complained of headache.

4. 22/11/2022 Madam A.R complained of backache.

5. 22/11/2022 Client has poor eating pattern.

SHORT TERM OBJECTIVES

1. Client will be relieved of constipation within 48 hours.

2. Client will be relieved of heartburns throughout the rest of pregnancy.

3. Client will be relieved of headache within 24hours.

4. Client will be able to cope with backache throughout late pregnancy.

5. Client will regain appetite or her appetite within improve within 48 hours.

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LONG TERM OBJECTIVE

Madam A.R. will carry her pregnancy successfully to term without any complications to the baby, mother and the entire family.

DATE/ NURSING NURSING NURSING NURSING DATE/ EVALUATIO

TIME DIAGNOSIS OBJECTIVES ORDERS INTERVENTION TIME N

15/11/22 Constipation Client will be 1. Reassure 1. Client was reassured 17/11/2022 Nursing
8:30am related to the able to free her client of of total care by 9:00am objectives fully
effect of bowel within holistic care. competent midwife. achieved as
progesterone 48 hours as evidence by
on smooth evidenced by ; 2.Client was educated on client
muscles Client 2.Educate the importance having a verbalizing that
decreasing the verbalizing that client on the good eating pattern she has been
absorption of her inability to importance of during pregnancy able to free her
fluid by the empty her having a good bowels
colon. bowel had been eating pattern 3. Client was encourage
relieved and to take in adequate fluids
she can now 3. Encourage at least 4-5 cups a day.
pass stool at client to take
least once a in adequate 4. Client was encourage
day. fluids. to visit the toilet
whenever she feels the
4. Encourage urge.
client to visit
the toilet. 5. Client was encouraged
to take in more fruits and
5. Encourage vegetable like banana,
adequate oranges, pineapple,
intake of fruits cabbage, carrots etc to
and vegetable. aid in digestion.

21
 DATE/ NURSING NURSING NURSING NURSING DATE/ EVALUATION
TIME DIAGNOSIS OBJECTIVES ORDERS INTERVENTION TIME
15/11/22 Heartburn Client will be 1. Reassure 1. Client was reassured Goal fully met as
8:30am related to the relieved of the client that heartburn will be evidenced by client
relaxation of heartburn relieved. verbalizing that
the cardiac throughout the 2. Encourage client’s
sphincter of rest of client to sleep on 2. Client was Heartburns and has
the stomach by pregnancy as extra pillows. encouraged to sleep on subside.
the effect of evidence by extra pillows to help
progesterone. client elevate the head
verbalizing that 3. Encourage
the heartburn client to prevent 3. Client was
has been foods that encouraged to prevent
subside. triggers it. foods that triggers it
such as spicy foods.

4. Explain to 4. Explanation was

client the given to client about the
physiology physiology behind
behind the heartburn.
heartburn.
5. Client was
5. Encourage encouraged not to
client not to perform any strenuous
perform any activities after meal like
strenuous exercising and even
activities. lying down immediately
after meal.

22
DATE/TIME NURSING NURSING NURSING NURSING DATE/ EVALUATION
DIAGNOSIS OBJECTIVES ORDERS INTERVENTION TIME
22/11/22 Headache Client will be 1. Reassure 1. Client was reassured 23/11/2022 Goal fully
9:30 am related to relieved of client. to allay any anxiety. 8:00am achieved as
stress of headache within evidenced by
pregnancy. 24hours as 2.Client was client verbalizing
evidence by 2. Encourage encouraged to that pain has
client client to minimize any been relieved.
verbalizing that minimize strenuous activities at
she has been strenuous home and can call for
relieved pain. activities. her husband help

3. Encourage 3. Client was

client to take encouraged to take
in enough enough water at least
water. four to six daily

4. Client was
4 .Encourage encouraged to have
client to have enough rest during the
enough rest. day at night

5. Serve
paracetamol 5. Tablet paracetamol
tablet 1g three 1g three times daily
times daily. was served.

23
DATE/ NURSING NURSING NURSING NURSING DATE/ EVALUATION
TIME DIAGNOSIS OBJECTIVES ORDERS INTERVENTION TIME
22/11/2022 Backache Client will be 1.Reassure client 1.Client was 1/12/2022 Goal fully
9:30am related to able to cope reassured of 4:00pm achieved as
relaxation of with backache 2.Encourage competent care client verbalized
ligament of throughout client to get that she is coping
the pelvis by pregnancy as adequate rest 2.Client was with the
hormones and evidence by encouraged to have backache
weight of the client 3.Explian the enough rest
gravid uterus verbalizing that cause of pain to
she is coping client 3.Explainations was
and understand given to client on the
and she will be cause of pain
relief when the 4.Encourage
baby comes out. client to assume 4.Client was
go posture encouraged to always
assume good posture
when performing any
5.Serve task
prescribed
analgesics 5. Client was served
one gram of
6. Give back rob paracetamol tablet
and apply
pressure to the 6. Back robs and
painful area. pressure was given
and apply
respectively to
painful areas.

24
DATE/ NURSING NURSING NURSING NURSING DATE/ EVALUATION
TIME DIAGNOSIS OBJECTIVES ORDERS INTERVENTION TIME
22/11/2022 Poor eating Clients appetite 1.Reassure 1.Client was 24/11/2022 Goal fully met as
9:30am pattern related improve within client reassured to allay all 10:00am evidence by
to persistent 48hours as anxieties client verbalized
loss of appetite evidence by 2.Encourage that her appetite
client client to eat in 2.Client was has now
verbalizing that bit encouraged to eat in improved and
she is able to bit at regular interval she now eat 2/3
eat 3. Allow client of a meal served.
to cook 3. Client was
favourite meal encourage to cook
favourite meal

4. Educate client 4.Client was

on the important educated on the
of having good important to have
eating pattern good eating pattern

5. Client was
5. Serve food encourage to serve
attractively food attractively to
boost her appetite.

25
26
 CHAPTER THREE

3.0 LABOUR

Labour is the process by which the product of conception (fetus, placenta and it’s

membrane) are expelled through the birth canal. Labour may be normal or abnormal

.3.1 ADMISSION AND MANAGEMENT OF FIRST STAGE OF LABOUR.

First stage of labour is the onset of regular painful rhythmic uterine contractions then taking

up of the cervix till full dilatation of the cervical or thus 10 cm.Madam A.R. reported to the

maternity ward on the 8th December, 2021 at 9:30am, in the morning with the complains of

labour pains and waist pains accompanied by the mother. I welcomed them and made them

comfortable by offering them a seat. Her items were collected and her antenatal card was

taken and read through. A comprehensive history was taken and I asked if she had seen

blood stain or mucous discharge (show) from her vagina which she said yes. According to

my client she started feeling labour pains around 5:30am in the morning after the appearance

of show. Her last meal was banku with okro soup. Madam A.R. was given a urine bottle to

take her urine sample for protein, sugar and acetone test.

The protein and sugar test were negative and urine amount was 200 mls.

Further observations made on admission are as follows: -

Temperature - 36.7oC.

Blood Pressure - 110/70mmHg.

Pulse - 75 beat per minute.

27
Respiration - 19cycles per minute.

I explained procedure and provided privacy and help her in the supine position unto the bed.

I washed my hands and dried them with a clean towel. Physical examination from head to

toe was performed and no abnormalities were detected. Scalp was clean with no dandruff.

The eyes were bright and clear with no discharge, the mouth, tongue and teeth were clean.

There was no swollen lymph node around the neck. The upper extremities were examined

and were of equal size and length with no abnormalities. The breasts were examined and no

lump was found, nipple was prominent and areola darkened. On abdominal palpation, the lie

was longitudinal. The presentation was cephalic and descent of foetal head was 3/5th above

the pelvic brim. The symphysio fundal height was 38cm with gestational age of 40 weeks

plus 4 days. On Auscultation, foetal heart rate was 132b/m with good volume and it was

regular. The uterine contraction was 2:10:21seconds.I sought Madam A.R. permission to

perform vagina examination and explained procedure to her of which she consented. I placed

five cotton wool swabs in a gallipot and soaked them in savlon solution after wearing sterile

gloves. The vulva was inspected for scars, warts, bleeding, varicose veins and edema of

which no such thing was detected. I squeezed the swabs gently and swabbed the vulva. First,

the right and left labia majora and then the right and left labia minora and finally the

vestibule. I gently parted the labia minora with my left hand and examined the vagina with

my two index fingers of my right hand. The vagina was moist and warm. The cervix was

soft, thin and effaced with dilatation of four centimeters (4cm). Membranes were intact. The

promontory of the sacrum was not reached and ischial spines were blunt ,with no molding. I

withdrew my fingers and observe the vagina fluid and it was clear with no odour. I applied a

28
new perineal pad on the vulva. I remove my gloves, washed my hands. The lower extremities

were examined and we're of equal lenght , size and no varicose veins. Findings were

communicated to her, documented and plotted on the partograph. Madam A.R was admitted

in the admission and discharge book. She was encouraged to pass urine frequently when she

feels the urge, to aid in descent of foetal head. Her permission was sought to check her vital

signs every 30 minutes, Blood pressure and vagina examination every 4hourly, contractions ,

maternal pulse ,foetal heartbeat every 30minutes and temperature every 2hourly. Madam A

R was assured of quality care to allay any anxiety and fears. She was giving sacral massage

during painful uterine contractions. She was encouraged her to shower to keep her

comfortable. These were what I recorded on the partograph.

At 10:00am foetal heart rate was 136bpm, maternal pulse 82bpm, contractions 2:10 lasting

23seconds.

At 10:30am foetal heart rate was 140bpm, maternal pulse 78bpm, contractions 2:10 lasting

25seconds

.At 11:00am, foetal heart rate was 138bpm, maternal pulse rate was 81bpm contractions 2:10

lasting 28seconds.

At 11:30 am, foetal heart rate was 128bpm, maternal pulse rate was 80bpm, contractions

2:10 lasting for 28-30 seconds and temperature 36.5oC

12:00pm, foetal heart rate was 140bpm, maternal pulse rate was 76bpm, contractions 3:10

lasting 30-38seconds.

29
12:30pm, foetal heart rate was 142bpm, maternal pulse rate was 85bpm, contractions 3:10

lasting for 31 seconds.

At1:00pm foetal heart rate was 140bpm, maternal pulse was 82bpm, contractions 3:10

lasting 32seconds.

At 1:30pm second vaginal examination was performed aseptically, cervical dilatation was

7cm, membranes were intact and bulging. Descent was 2/5 above the pelvic brim, moulding

was +, foetal heart rate was 145bpm, maternal pulse was 82bpm, contractions were

3:10:34seconds, temperature was 36.6C Urine passed was tested for protein and acetone and

the result was negative. Amount was 150mls. Madam A.R. looked very anxious and was

sweating profusely. I reassured her to allay her anxieties and wiped her sweaty face and body

with gauze and served her fluids to hydrate.

PREPARATION TOWARDS DELIVERY.

The delivery room was prepared by closing the windows and putting off fans to prevent

drought of both mother and baby. I also prepared the delivery bed by spreading delivery mat

on it after I have spread mackintosh to completely cover the bed. Good lighting was ensured.

Baby’s cot was made ready by cleaning it. A delivery trolley was set up and brought to

second stage room containing the following items;

Top shelf.

Kidney dish containing (2) artery forceps

One sponge holding forceps,

30
One (1) cord scissors

Episiotomy pack 1.

Sterile gallipot with savlon solutions.

Sterile cotton wool swabs in a gallipot.

One (1) gown.

Two (2) draping sheets and oxytocin 10units in 2cc syringe.

Bottom Shelf

Surgical gloves

.Syringe and needles.

Perineal pad.

Cord clamp.

Drug tray containing vitamin K, Chloramphenicol eye drop, , water for injection, infusions,

disposable gloves and a receiver.

A resuscitation tray was set containing

;An ambu bag.

Penguin.

Face mask of different sizes.

A clean cot sheets.

31
 At 2:00pm foetal heart rate was 136bpm, maternal pulse 79bpm, contractions 3:10 lasting

36 seconds.

At 2:30pm, foetal heart rate was 140bpm, maternal pulse 81bpm, contractions 4:10 lasting 38

seconds.

At 3:00pm foetal heart rate was 140bpm, maternal pulse 77bpm, contractions 4:10 lasting

41seconds.

3:30pm foetal heart rate was 142bpm, maternal pulse was 83bpm, contractions 4:10 lasting

43seconds.

At 4:00pm, foetal heart rate was 142bpm, maternal pulse 80bpm, contractions 4:10 lasting

43seconds.

4:30pm, client complained of bearing down and fatigue. Foetal heart rate was 130bpm,

maternal pulse was 84bpm, contractions 4:10 lasting 45seconds. Madam A.R was still

complaining of bearing down so vagina examination was performed and the cervical

dilatation was 10cm with descent of 0/5th and molding two plus (++). Membranes ruptured

spontaneously and clear colour liquor was observed. Madam A.R. was sent to the second

stage room. Second stage started at 4:38pm.

3.2 MANAGEMENT OF SECOND STAGE OF LABOUR.

This stage of labour begins when the cervix is fully dilated and ends immediately after the

expulsion of the baby. I explained procedure to Madam A.R and reassured her of quality

care. Madam A.R. was asked of the position she prefer for delivery and she chose lithotomy

position. I then prepared by wearing my mackintosh apron, theatre cap, goggle, face mask
32
and boots. I went to wash my hands with water and soap and dried them with a clean towel. I

put on a sterile glove swabbed her vulva and upper thigh. I draped her nicely with sterile

drapes, after which the midwife around confirmed full dilatation of the cervix. I helped her to

empty her bladder by passing a catheter. I explained the progress of labour to her and

encouraged her to rest between contractions and push with contractions. I asked my assistant

(the midwife around) to check foetal heart rate after each contraction. I applied a new

perineal pad at her perineum to prevent any fecal matter from messing and contaminating the

delivery field and encouraged her to push with all her energy and breathe through her mouth.

Madam A.R tried to raise her buttocks but I encouraged her not to as she can have a tear. I

told my client the baby will be delivered unto her abdomen. As the head advances, I aided

flexion with two fingers of my right hand by placing them gently on the head to allow the

smallest diameter to escape the pelvic outlet. My left hand was used to support the perineum

with a pad. Immediately crowning took place, I told Madam A.R. to stop pushing and pant to

prevent rapid expulsion of the head. The sinciput, face and chin swept the perineum as the

head was delivered by extension. I used a sterile swab to clean the eyes from inside out. I

suctioned the mouth then the nose. The neck was felt for cord around neck and there was

none. Restitution took place following external rotation of the head, I held the baby’s head

between my palms on each side of the parietal bones. With gentle downward traction of the

head toward the anus, the anterior shoulder was escaped the symphsis pubis and the posterior

shoulder also swept the perinuim by upward traction, followed by the rest of the body by

lateral flexion following the curve of carus onto the mother’s abdomen. A male child was

born at exactly 5:00pm in the evening. Baby cried at birth and first minute Apgar score was

8/10. I palpated the abdomen for a second undiagnosed twin and there was none. Oxytocin
33
ten units was given intramuscularly to the mother to help contract the uterus. Baby was

wiped off liquor and placed on the mother’s abdomen to provide warmth, ensure skin contact

and create bonding for an hour. Madam A.R was asked to confirm the sex of her baby and

she was congratulated. Two pairs of gloves are used for delivery, the first one is used to

deliver the baby and the second one is used to cut the cord.

3.3 IMMEDIATE CARE OF THE BABY

Immediately the baby was delivered, baby’s eyes and face were cleaned with a sterile gauze,

mouth and nose were suctioned using penguin ,while baby was on the mother’s abdomen,

liquor was wiped off the baby’s body and a clean sheet was used to cover baby on the

mother’s abdomen. The cord was clamped with artery forceps 5cm away from the baby’s

umbilicus and another clamped 3cm away from the first directed towards the mother’s vulva.

Cord scissors was used to cut halfway between the clamped areas covered with a sterile

gauze to prevent splashing of blood from the cord. Vitamin K was given to the baby

intramuscularly as a prophylaxis to prevent bleeding. An identification band was placed on

the baby’s left wrist with mother’s name and date of delivery inscribed on it.

3.4 MANAGEMENT OF THIRD STAGE OF LABOUR.

This stage begins with the expulsion of the placenta and its membranes and ends with the

arresting of haemorrhage. Explanation was given to Madam A.R. on the delivery of the

placenta. A receiver was placed in between her thigh close to the vulva. After the first

contraction had come, I placed the cut end of the cord into the receiver and clamped the

forceps closer to the vulva and placed my left hand on the symphysis pubis with my palm

34
facing the mother’s abdomen to prevent uterine inversion. I held the forceps with cord in

between my fingers (right hand) and with control cord traction, I pulled the placenta by

downward and upward traction. When the placenta was visible at the introitus with the foetal

surface indicating the Schultze method of placenta separation, I let go of the forceps and

cupped it into both hands and twisted it gently to ease pressure on the membranes. The

placenta and its membranes were delivered at 5:10pm in the evening. A quick examination of

placenta for possibly retained product of conception was made but everything was intact. The

uterus was massaged to expel clots and help stimulate contractions to prevent bleeding. I

taught her how to massage it herself. I examined the cervix, vagina and perineum for bruises,

tears and lacerations and none were detected. Bleeding was minimal indicating no trauma or

severe bleeding. Blood loss was drained into a measuring jug and it was 250mls in amount. I

cleaned her and changed soiled linen into clean ones and applied a new and clean perineal

pad to the vulva. Blood was flushed away. Reusable equipment’s were washed and put in

0.5% chlorine solution to be decontaminated and made ready for sterilization. I thanked her

for co-operating with me and sent the placenta to the sluice room for examination.

3.5 PLACENTA EXAMINATION

During placenta examination, I held the placenta in my palms with the maternal surface

facing upward to check for completeness. All lobes were intact ,was darked red colou ,rough

and has no infarction. I held the placenta by the cord for membranes to hang. The hole

through which baby was delivered was not rugged denoting completeness. I examined the

blood vessels of the cord and two arteries and a vein was seen. I placed my hand inside the

membranes spreading my fingers out to make sure that the membranes were complete by

35
peeling the amnion from the chorion right up to the umbilical cord for full view of the

chorion and membranes were complete. Foetal surface was smooth, shiny and greyish blue in

colour.Cord was of normal length thus 48cm with insertion at the center. The placenta had a

diameter of 22cm. I checked where the blood vessels were radiating to on the foetal surface

but they were diminish at the edges. Placenta weighed 500grams. It was roughly circular in

nature. Placenta was decontaminated into 0.5% chloride solution and discarded after ten

minutes. Gloves were removed and disposed off properly. Reusable equipment was washed

and prepared for sterilization. Findings were recorded and communicated to Madam A.R

after I had reported to the midwife around.

3.6 MANAGEMENT OF THE FOURTH STAGE OF LABOUR

This stage talks about the first six hours of vigilant observation and monitoring of the mother

and baby after the delivery of the placenta. Madam A.R. and her baby were examined every

15 minutes for the first two hours and 30 minutes for the next hour and an hour for the rest of

the three hours. This monitoring is very important to ensure stability in the health of the

mother and baby. I encouraged her to frequently urinate to help with involution of the uterus.

I assisted Madam A.R. to fix her baby to breast to establish lactation and create bonding.

Baby’s swallowing and sucking reflexes were good. Madam A.R’s first 15minute vital signs

were checked and recorded at 5:35pm.

Blood pressure - 110/80mmHg.

Temperature - 36.8oC.

Pulse - 75bpm.

36
Respiration - 22cpm.

Fundal height - 18cm.

Weight - 69kg.

Baby A.R vital signs were checked and recorded as

;Temperature - 36.2oC.

Respiration - 44cpm.

Apex heart rate - 134bpm.

Madam A.R.. was given malt to drink as she was waiting for her husband to bring her a

heavy meal after her labour. She had the rubra type of lochia and the flow was moderate.

Madam A.R. was encouraged to change her perineal pad frequently when soak to improve

comfortability and prevent infection. The neonate and his mother were in good condition.

Baby passed meconium and urinated.

MEASUREMENTS OF BABY

Weight of baby - 2.8kg

Full length - 51cm

Chest circumference - 30cm.

Head circumference - 34cm

3.7 SUMMARY OF LABOUR

Date of delivery - 8th December,2022.

37
Time of delivery - 5:00pm.

Mode of delivery - Spontaneous vagina delivery Time of

placenta - 5:10pm.

Time oxytocin was given - 5:01pm.

Estimated blood loss - 250mls.

Perineum - Intact.

DURATION OF LABOUR.

First stage of labour - 7 hours .

Second stage of labour - 22minutes.

Third stage of labour - 10minutes.

Total stage - 7 hours 32minutes.

3.9 NURSING CARE PLAN DURING LABOUR PROBLEMS IDENTIFIED.

On 8th December, 2022 Client complained of waist pain.

8th December 2022 Madam A.R was sweating profusely.

On 8th Decemberr, 2022 Madam A.R was anxious.

8th December, 2022 , Client complained of fatigue.

8th December, 2022 Madam A.R. was at risk for genital tear.

SHORT TERM OBJECTIVES.

38
 1. Client will be able to cope with waist pains after 48 hours.

2. Client will be hydrated within 24 hours to restore fluid loss through sweating.

3. Client will be allayed of anxiety within 2 hours .

4. Client will proceed to the second stage of labour with minimal exhaustion within 2

hours.

5. Client will go through the second stage of labour successfully without sustaining any

genital tears within 1 hour.

LONG TERM OBJECTIVES.

Client will be able to go through all the stages of labour successfully without any

complications to the mother, baby and the entire family.

CHAPTER FOUR.

4.0 MANAGEMENT OF DURING PUERPERIUM.

Puerperium is the period of six weeks right after the delivery of the placenta and membranes

from the birth canal. During this period, reproductive organs (uterus, vagina, cervix) return to

their pre-pregnant state..

4.1 DAY OF DELIVERY. .

Madam A.R. a gravida 2 para 1, came to the ward with the mother with the complains of

labour pains. She came in the first stage of labour and was managed accordingly, second

stage of labour was successful with the expulsion of a live male neonate. Placenta was

39
delivered under active management of third stage of labour. Mother and baby are doing well.

I transferred Madam A.R. to the lying-in ward. I continuously encouraged her to change her

perineal pad when soaked and also breastfeed her child on demand and empty her bladder

frequently and ambulate early to prevent pull up of lochia in the uterus. I encouraged her to

keep her baby warm and dry and also wash her hands before and after changing her baby’s

diapers, visiting the toilet and after changing her perineal pad. I encouraged her to massage

her uterus to aid in involution. I explained to Madam A.R. that I have to examine her from

her head to toes of which she consented. I provided privacy by screening the bed and closing

windows. I encouraged her to empty her bladder after which head to toe examination was

done. The hair was nicely kept clean with no pediculosis and dandruff. The eyes were bright

and clear, the conjunctiva was pink with no discharges, the mouth, tongue and gum were

clean with no odour, the nostrils and nose were clean with no discharges. The neck was

examined and there were no swollen lymph nodes and enlarged glands. The upper and lower

limbs were examined which were of equal size and length with no edema. The nail beds were

clean and not pale. The breasts were normal and lactation was established, the nipples were

prominent and colostrum was expressed without abnormalities seen. On abdominal

palpation, the symphysio fundal height was 18cm and the uterus was well contracted. The

back was examined for sacral edema or rashes but none was detected. I asked the permission

to inspect the vulva and she agreed. I washed my hands, dried them and wore sterile gloves.

The vulva was inspected and it was clean and neat, the perineum was without any swelling,

sore or offensive discharges. Perineal pad was inspected; lochia was rubra, moderate in

amount. A new perineal pad was applied to the vulva. There was neither vesicovaginal nor

40
recto-vaginal fistula seen because client said she has passed faeces and urine early in the

morning before taking her bath. Her vital signs were checked and recorded at 5:50pm.

Blood pressure -107/70mmHg.

Temperature - 36.8oC.

Pulse - 78beat per minute.

Respiration 22cycles per minute.

Weight - 69kg.

BABY MEASUREMENT.

Temperature - 37.1c.

Respiration 40bpm.

Apex heart rate 136.

Bleeding moderate.

RECORDINGS AT 6:05PM.

MOTHER.

Blood pressure 110/60mmhg.

Pulse 80bpm.

Temperature 36.4c.

Respiration 20cpm.

41
Bleeding moderate.

BABY.

Temperature 37.1oC

Respiration 42cpm.

APHR 140.

RECORDINGS AT 6:20PM.

Blood pressure 110/62mmhg.

Pulse 75bpm.

Respiration 18cbm.

Temperature 37.1 c.

Bleeding moderate.

BABY.

Temperature 37.1 c.

Respiration 43cbm.

Apex heart rate 138.

Madam A.R.’s husband Mr. M.J. came with the heavy meal thus" Ample"and okro soup ,

which she ate..

4.2 SUBSEQUENT CARE OF THE BABY..

42
I performed a general examination on Baby A.R. at 7:20am in the morning. This was done to

rule out any birth injuries, congenital anomalies. This examination is very important as it

serves as a baseline record for the baby. I started by preparing a tray which contained;.

 A gallipot containing sterile cotton wool swabs.

 A receiver for used swabs.

 Examination gloves.

 A mackintosh aprons.

PROCEDURE.

I explained procedure to Madam A.R. of which she consented. I wore the mackintosh apron

and put off fans, closed all windows, drew down curtains to prevent loss of heat from the

baby. I placed the baby on a flat surface and put on a bright light to provide heat for the baby.

I washed my hands with soap and water and dried them with a clean towel. I wore

examination gloves. Baby had not wet himself so I unwrapped the baby and made a quick

observation. Baby A.R. looked healthy. I made sure I exposed only the part I will be

examining. I started by examining the scalp and hair for cleanliness, rashes and bruises but

no abnormalities were detected also I examined the head for carput succedaneum and cephal

hematoma. I examined the anterior and posterior fontanelles of which they were pulsating ,

not sunken and not bulging as well. Suture were felt and they were not so wide apart. I

examined the face; the eyes were in alignment with clear sclera and no discharge. The nose

had a septum and it was patent with no discharges. The mouth was examined to rule out cleft

palate or lip, tongue tie of which none was detected. I examined the ear to check for

43
discharges and shape of pinna of which no abnormalities were detected. I palpated the neck

for enlarged glands, lymph nodes and congenital goiter and none was found. I checked the

limbs for equality, length and size and also, I checked for extra digit and everything was

normal. The chest was examined to rule out pain in breathing and position of the nipple and

everything was normal.I examined the abdomen and it was soft and slightly protruding.

There was no noise when the abdomen was slightly tapped. Cord was well secured with no

bleeding. Two arteries and a vein were visible in the cord. I examined the back for anomalies

such as spinal bifida and no such thing was detected. The genitalia were examined for penile

defects like Epispadias and hypospadias and no such thing were found. I palpated the

scrotum gently to check if the testis had descended and they were present. The testis was

slightly large and looked normal. There was no rash seen at the genital area. Baby’s urethra

and anus were patent as baby urinated and passed out meconium. There were no

abnormalities detected at the genitalia. I examined the lower limbs for equality, webbed toes

and extra digits of which no abnormalities were found. There was no hip dislocation as well.

Plantar creases were normal and reflexes were good. Findings were communicated to

Madam A.R.

.BABY’S FIRST BATH AND CORD CARE.

After the examination, baby was taken to be bath after procedure was explained to Madam

A.R and she consented at exactly 7:40am in the morning. A trolley was set with the

following items;.

TOP SHELF.

44
  Baby’s soap in a soap dish.

 Sponge and two small towels.

 Baby’s dress, pomade, comb, cot sheet and diapers.

 Tray containing the following.

 Sterile swabs in a gallipot with a lid.

 Sterile glovesReceiver for used swabs.

 Methylated spirit in a gallipot.

BOTTOM SHELF

 Two bowls for mixing water..

 Two jugs; one with warm water and the other with cold water.

 Mackintosh.

 Receptacle for soiled items..

 Plastic apron.

PROCEDURE.

I wore a mackintosh apron, washed my hands and put on an examination gloves. I took the

baby, undressed him and placed him on a flat surface. I wrapped him in a cot sheet. I cleaned

his eyes from the inner canthus using a sterile gauze soaked in warm water. I cleaned the face

with a wet towel. I washed the baby’s head with soap and rinsed the head with water by

supporting the nape of the baby’s neck with my middle and thumb finger plugged in the ears

to prevent water from entering the ears. I then dried the hair with the baby’s towel. I exposed

the baby’s arms, trunk and feet and washed them including the genital area paying much

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attention to folds like neck, armpit and groins to clean dried liquor and vernix caseosa. I then

turned the baby’s back with one arm supporting his chest and bathed his back from the neck

down to the feet and sole. Baby’s body was immersed in a basin of warm water with the head

supported with my left arm. After rinsing him, I placed him on a dry clean towel and a small

towel was used to dry the baby paying attention to the skin folds. I smeared baby oil on his

body to prevent skin dryness. I dressed him up. The next procedure was cord dressing so I

removed the examination gloves and washed my hands, and dried them with a clean towel

and wore a sterile glove. Exposing the abdomen of the baby, I observed the cord for any

bleeding. I took one cotton wool swab soaked in methylated spirit and held the end of the

cord with the clamp. I then swabbed the base of the cord using two cotton wool swabs on

each side. The stem of the cord was swabbed from the base upwards using a swab for each

wipe. I then swabbed the tip of the cord and wiped the clamp with the first cotton wool swab.

Cord was left to dry. I wrapped baby A.R. in a clean sheet and gave him to the mother to be

breastfed after disposing off my gloves and washing my hands. I communicated all findings

to Madam A.R. I expressed my gratitude to my client and her husband for allowing me to

manage her and her baby. I explained to Madam A.R. on the the need to report any

abnormalities like bleeding cord, skin or eye colour changes.Baby’s vital signs were checked

and recorded as.;.

Temperature - 36.6oC.

Apex heart beat - 140beat per minute.

Respiration - 40 cycles per minute.

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4.3 FIRST DAY POSTNATAL AND PREPARATION FOR DISCHARGE.

On 9th December 2022, was the first day after the delivery of a male child by Madam A.R. I

asked if she slept well and she said she did. She looked very healthy and active. Baby’s

condition was satisfactory as well. Madam A.R. brushed her teeth, took her bath and then

took her breakfast afterwards. Madam A.R’s vital signs was checked and recorded as;.

Blood pressure - 110/68mmHg.

Temperature - 36.4oC.

Pulse - 78beat per minute.

Respiration - 20cycles per minute.

Lochia - Rubra.

My client , her mother and her husband were educated not to apply anything on the cord to

prevent infections and any complications. Madam A.R was encouraged to ask questions and

she lodged a complaint of headache and after pain at 10:00am. She was reassured and I

explained the physiology of headache to her that; the stress and strains she went through in

labour and that the after pains is as a result of the involution of the uterus and that the pain

will be relieved as time goes on. She was encouraged to breastfeed exclusively for six (6)

months and I educated her on personal and environmental hygiene to prevent infection. She

was also encouraged to have enough rest and eat nutritious diet and take a lot of fluids to

prevent constipation and dehydration. She was given these drugs to take home.The drugs

include.:.

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Tablet Amoxicillin 500mg tdsx 7 days.

Tablet Metronidazol 400mg tds x 5 days.

Tablet ferrous sulphate 200mg daily for 30 days.

Paracetamol 1g bd x 5 days .

Bacillus Calmette Guerin (BCG) and polio were available so it given to baby A.R. She was

discharged in the admission and discharge book at 2:00pm and I informed her about the

postnatal home visits, what to expect during the visit and she looked very excited to hear

that. I helped her pack her belongings, saw them off and promised her that I will come to

their house in the morning and evening for the next three days and every morning the

following three days before handing her over to the public health nurse. .

4.4 FIRST DAY POSTNATAL HOME VISIT.

Madam A.R and her family on10th December, 2022 at 8:00am in the morning and 5:30pm

in the evening. After exchange of greetings, I inquired about their health and that of the baby

and they said everyone was doing well. Madam A.R.complained that she did not get enough

sleep as baby cries at night and feeds at night as well. She also complained of breast

engorgement. I encouraged her to keep on breastfeeding exclusively and on demand. She

was also educated on proper positions to assume when breastfeeding. I examined baby A.R

from head to toes both in the morning and evening and no abnormalities were detected.

Madam A.R was examined as well both in the morning and the evening. She and her baby

looked fine and healthy. No abnormalities were detected after each examination of my client.

Lochia was normal in flow and not offensive. I asked her to assemble the things for me to

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bath her baby. Baby was topped and tailed and dressed up. Explanation was given to the

mother that baby will be top and tail till cord is off to keep the cord clean and dry so as to

prevent the cord from been infected.Cord was dressed with sterile cotton and methylated

spirit, Madam A.R. was confused as to why I did not apply hot massages with hot water on

the baby’s fontanelles and so she asked why. I explained that, the application of hot water on

baby’s fontanelles damage the meninges of the brain. I also told her that the fontanelles will

close on their own; the anterior fontanelle by 18months and the posterior by 6 weeks. She

was excited and promised not to apply hot water or anything on the fontanelles. In the

evening, baby was topped and tailed and examined from head to toe but no abnormalities

were detected.Vital signs taken and recorded for baby B.P. both in the morning and evening

are as follows:.

EXAMINATION

MORNING EVENING.

Temperature 36.6 degrees Celsius 36.8 degrees.

Respiration 38 cycles per minute 40 cycles per minute.

Apex heart beat 132 beats per minute 138 beats per minute.

Weight 2.8kg.

After the vital signs, I wrapped the baby in a clean cloth and placed him on the bed. Mother’s

vital signs were checked and recorded as well:.

EXAMINATION

49
 MORNING EVENING.

Temperature 36.2 degrees Celsius 36.2 degrees Celsius.

Blood pressure 110/70mmHg 110/69mmHg.

Pulse 78 beats per minute 76 beats per minute.

Respiration 21 cycles per minute 22cycles per minute.

Fundal height 17cm

Lochia Rubra Rubra I

encouraged her to have enough rest and sleep especially when the baby is sleeping. I also

encouraged the husband and two daughters to help in the care of the baby so that the mother

can have enough rest periods. I encouraged her to take in her drugs as prescribed. I recorded

and discussed all the findings to them and thanked them and also promised to visit the next

day. I asked to take my leave and her husband saw me off.

. 4.5 SECOND- AND THIRD-DAY POSTNATAL HOME VISIT.

Madam A.R. and baby were visited on 11th and 12th December, 2022, both in the morning

at 8:00am and 5:30pm in the evening. During each visit, my client and her family were in

good health. The procedures to be carried out on Madam A.R. and her baby were explained

and permission was granted on every occasion. Head to toe examination was performed on

my client and her baby during each visit and no abnormalities were detected. I topped and

tailed baby and dressed the cord with sterile cotton wool swab and methylated spirit during

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each visit. Vital signs of both mother and baby were checked and recorded below during

each visit both in the morning and evening..

MOTHER.

SECOND DAY (11th December,2022)

OBSERVATION MORNING. EVENING.

Temperature 36.4 degrees Celsius 36.6 degrees Celsius.

Blood pressure 110/68 mmHg 107/70 mmHg.

Pulse 76 beats per minute 78 beats per minute.

Respiration 20 cycles per minute 21 cycles per minute.

Fundal height 16cm .

Lochia Rubra Rubra.

THIRD DAY (12th December, 2022)

OBSERVATION MORNING EVENING.

Temperature 36.8 degrees Celsius 36.6 degrees Celsius.

Blood pressure 110/70mmHg 109/68mmHg.

Pulse 75 beats per minute 80 beats per minute.

Respiration 20 cycles per minute 20 cycles per minute.

Fundal height 15cm .

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Lochia Rubra Rubra.

BABY.

SECOND DAY ((11th December,2022).

OBSERVATION MORNING EVENING.

Temperature 37.0 degrees Celsius 36.8 degrees Celsius.

Respiration 40 cycles per minute 38 cycles per minute.

Apex heart beat 138 beats per minute 140 beats per minute.

Weight 29kg.

THIRD DAY (24TH OCTOBER, 2020)OBSERVATION MORNING

EVENINGTemperature 36.6 degrees Celsius 36.7

degrees CelsiusRespiration 40 cycles per minute 40 cycles per

minuteApex heart beat 142 beats per minute 140 beats per minuteWeight

3.4kgMadam B.P. complained of frequency of micturition on the

second day. I explained to her that it was as a result of the fluid she gained during pregnancy

that is being excreted. I encouraged her to urinate whenever she feels the urge and also take

in lots of fluid. I also encouraged her to eat well balanced diet and take in fruits as well and

also engage in postnatal exercises such as Kegel’s exercise to help strengthen the muscle of

the pelvic floor. Findings on both mother and baby were communicated to them. I also

educated her on how to cloth the baby. I then encouraged her to feed the baby with only

breast milk, feed on demand and feed at night to improve baby’s weight. I thanked her for

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the co-operation and sought permission to leave. 4.6 FOURTH TO FIFTH DAY

POSTNATAL HOME VISITMother and baby were visited every morning from the fourth

day post-delivery. So, on 25th and 26th October, 2020 I visited Madam B.P. and her family

again every morning. My purpose was to ensure continuity of care and to know the health

status of the family members. My client and her family were in good health and looked

cheerful. We exchanged greetings. I explained routine procedures and consent was given on

every occasion. Physical examination was done and everything was normal. Baby’s cord fell

off on the fifth day (25th October, 2021) in the afternoon. Baby was given a bath the next

day since cord was off. Stump was dressed. Mother was supervised to bath the baby and

dress the stump since she will continue the next day. She did it well and I congratulated her.

Vital signs were also checked for both mother and baby and recorded on the assessment

sheet as follows;MOTHER OBSERVATION Fourth day

Fifth dayBlood pressure 115/70mmHg

115/70mmHgTemperature 36.0-degree Celsius 36.6 degree

CelsiusPulse 77beat per minute 78beat per

minuteRespiration 20cycles per minutes 20cycles per

minutesLochia Serosa Serosa Fundal height

14cm 13cmBABY Fourth day

Fifth dayTemperature 36.5oC 36.8oC

Apex heart beat 134bpm 132cpmRespiration

40cpm 42cpmWeight 3.5kg

3.5kg Findings were communicated to the mother. I educated the couple on family planning

so as to space their children and decide when to give birth. She was also encouraged to
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practice hand washing before and after attending to the baby to prevent infections. I informed

my client about the baby’s circumcision and its importance. Madam B.P. agreed to

circumcise her baby and I encouraged her to prepare financially since the procedure is not

covered by the health insurance. Baby’s circumcision was scheduled on the 29th October,

2021 thus the first day postnatal visit to the clinic. I educated my client on immunization and

how important it is for her to immunize her baby against the childhood preventable diseases.

I informed the family that tomorrow which is on the sixth (6th) day will be my last postnatal

home visit. I then thanked them for their full co-operation and asked permission to leave. 4.7

SIXTH DAY POSTNATAL HOME VISIT (27TH OCTOBER, 2020)On 27thOctober, 2021

I visited my client and her family for the last time; the family was doing well. They

welcomed me warmly and all procedures were explained to them and permission was

granted. Mother and baby were examined from head to toe with no detected abnormalities.

Breasts were lactating well. Fundal height was measured as 12cm and sleep pattern was

good. Lochia was moderate in amount without offensive smell and discharges. Bowel and

bladder action were normal. I assisted my client to bath the baby, after which baby was

wrapped in a clean sheet. I encouraged Madam B.P. to dress the baby according to the

weather; not to expose baby or over dress the baby. I then educated her to register the baby at

birth and death registration center to obtain a birth certificate for the baby. Mother and

baby’s vital signs were checked and recorded as follows:MOTHER

OBSERVATIONTemperature 36.5degrees CelsiusBlood

pressure 116/70mmHgPulse 76 beats per

minute Respiration 22 cycles per minuteFundal height

12cm Lochia
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 SerosaBABYOBSERVATION Temperature

36.5 degrees CelsiusApex heart beat 140 beats per

minuteRespiration 40 cycles per minuteWeight

3.6kg Findings were communicated to them. They were encouraged to ask

questions and she asked when she can resume sex and I answered them from six (6) weeks

onwards. I also emphasized on the family planning and the need for exclusive breastfeeding

and demand feeding especially at night. I again emphasized on personal hygiene, good

nutrition, rest and sleep as well as performing mild exercise. Client was encouraged to report

any abnormalities to the hospital on herself and the baby for early treatment to prevent

complications. Madam B. P’s husband was involved in all discussions during the visitation

so that he can help my client to care for the baby as well as to prevent any ill health in the

family. I reminded her of the seventh day postnatal visit to the clinic which was the next two

days for continuity of care. I made client and family aware that the postnatal home visits had

come to an end. The family were pleased for the care and expressed their sincere gratitude. I

also expressed my gratitude to them especially Madam B.P for allowing me use her as my

client. I thanked the family for their co-operation and time. She was very happy since this

was the first time, she had been treated in such a special way. I asked to take my leave and

headed home. 4.8 FIRST WEEK POSTNATAL CLINIC VISITMadam B.P and husband

reported at Goaso municipal Hospital on Tuesday, 29th October, 2020 at 8:30 am in the

morning. They were warmly welcomed and made comfortable by me as I went ahead of

them to the hospital. All procedures to be carried out on the mother and baby were explained

to her. I told the in charge that my client would like to circumcise her son, the midwife in

charge of circumcision was called upon and she agreed to do it after I have examined both
55
mother and baby. I educated Madam B.P. on nutrition and diet, personal and environmental

hygiene and exclusive breastfeeding. Her Vital signs were checked and recorded as

follows:Temperature 36.2 degrees CelsiusBlood pressure

110/70mmHgPulse 76 beats per

minuteRespiration 19 cycles per minuteFundal height

11cmLochia Alba She was asked to empty her bladder

for examination to be done. A specimen bottle was given and the midstream urine was

requested to check for protein and glucose and results came out negative. On blood

examination, her haemoglobin was 12.4mmol/dl. Head to toe examination was done after I

had washed my hands and dried them and no abnormalities were detected. The hair was

nicely combed with no pediculosis or dandruff. The eyes were bright and clear, the

conjunctiva was pink with no discharges and the mouth, tongue and gum was clean with no

sore and odour, the nostrils and nose were clean with no discharges. The neck was examined

and there were no swollen lymph nodes and enlarged glands. The upper and lower limbs

were examined which were of equal size and length with no edema. The nail beds were pink

and not pale. The breasts were normal and lactating well, the nipples were prominent and

breast milk was expressed without abnormalities seen. On abdominal palpation, the

symphysio fundal height was 11cm and the uterus was well contracted. The back; sacral

region and legs were examined for sacral edema, pain or rashes but no abnormalities were

detected. I asked the permission to inspect the vulva and she agreed. I washed my hands,

dried them and wore sterile gloves. Client was instructed to flex her knees and open her

thighs, the vulva was inspected and was clean, neat and perineum was without any swelling,

sore or offensive smell and discharges. A new pad was inserted. Client was assisted to
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redress and made comfortable. I then washed my hands and dried them with a clean towel.

Findings were communicated to her and documented. Baby’s vital signs were checked and

recorded as follows:OBSERVATION MORNINGTemperature

36.5 degrees CelsiusApex heart beat 138 beats per

minuteRespiration 40 cycles per minuteWeight

3.6kgBaby was examined on a flat surface which was warm and dry and under a

good lighting system and no abnormalities were detected. I closed all nearby windows and

fans. I then washed my hands and dried them. Baby looked healthy. I undressed baby and

wrapped him in a sheet and began by rubbing my palms together to produce heat so that I do

not shock baby’s body with my cold hands. I placed his occiput in my left palm and moved

my examining fingers of the right hand gently to feel the fontanelles whether they were too

close, wide or abnormally shaped even sunken but there was none. Sutures were closed.

Baby eyes were observed and it was not jaundiced, blood stained or discolored. Ears and

nose were patent with no discharges. Nose was separated by a septum. Mouth was well kept

and his face showed no sign of facial palsy. Baby’s hands were brought together to check for

equality, size and shape and everything was normal. Palmer creases were present with no

extra digits of the hands. Baby’s breathing pattern was normal with no sounds. Abdomen

was not distended. I examine the back for any swelling or curvature and none was detected. I

inspected baby’s genitals and everything was normal as seen during first examination; anus

and urethra were patent with no penile deformity like epispadias or hypospadias. The legs

were examined for equality, size and shape and everything was normal. Barlow’s test was

performed to look out for pelvic and femur abnormalities in case there was a “click” sound

or baby would cry during the test but no such thing was seen. I dressed baby up and gave
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him to my client. I then introduced Madam B.P. to the midwife in charge of circumcision

who gladly received her and explained the procedure to her before performing the

circumcision. She performed the procedure aseptically with me as her assistant. After the

circumcision, my in-charge informed my client not to apply any localized herbs on it but

apply shea butter on it. She was advised to give the child paracetamol syrup 2-5mls in case

the child has elevated temperature. She was also informed to visit the health facility when

any problem arises. Client was educated on personal hygiene, exclusive breastfeeding for six

months, family planning method. I educated her on the need to attend child welfare clinic to

monitor the growth of the baby and to detect any infections and the need to complete all

immunization. Baby was given Bacillus Calmette Guerin 0.005mls and oral polio two drops.

She was handed over to the public health nurse and midwife in-charge for continuity of care.

She was congratulated and thanked for her co-operation, support and time spent with me.

Findings were communicated to client and documented. 4.9 CARE PLAN DURING

PUERPERIUMPROBLEMS IDENTIFIED DURING PUERPERIUMOn the 21/10/2021

client complained of afterpainsOn the 21/10/2021 client complained of headacheOn the

22/10/2021 client complained of not getting enough sleep.On the 22/10/2021 client

complained of backpainsOn the 23/10/2021 client complained of frequency of

micturitionSHORT TERM OBJECTIVESClient will be relieved of after pains within 48

hoursClient will be relieved of headache within 24 hoursClient will be able to rest at rest at

least 8 hours a dayClient will be relieved of back pains within 72 hours post deliveryClient

will understand the physiology of post-delivery micturition within 30 minutesLONG TERM

OBJECTIVESMadam B.P., her baby and the entire family will pass through the puerperal

period safely and without any complications.

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