Ghana Health Service Nurse Case Study Report (chapter 3)
CHAPTER THREE
INTRAPARTAL CARE
The World Health Organization (WHO 2020), defines labour as; low risk throughout spontaneous in onset with the fetus presenting by vertex, culminating in the mother and infant in good condition following birth. It is also the process whereby product of conception that is the fetus, placenta, and it membranes are expelled through the birth canal spontaneously.
Here the mother is assessed with labour care guide. This chapter talks about admission, and how client was managed throughout the four stages of labour.
ADIMISSION AND MANAGEMENT OF FIRST STAGE OF LABOUR.
On the 29th August 2023, Madam M.K was admitted to the labour ward of the Aiyinase Health Centre at 10:00am. She called me to inform me that she was coming to the clinic and I informed her that she will meet me at ward, because I was on morning duty.
She was accompanied by her mother and husband. They were warmly welcomed and offered seats. Client maternal health record book was collected and quickly glanced through with the midwife on duty.
Labour history was taken and according to her; she has lower abdominal pain with rhythmic painful uterine contractions which started around 4:30am. Fetal movement was present. She said her last meal was porridge and bread.
I sent Madam M.K to the first stage room, assisted her to change into a cloth wrapped around her chest and admitted her to a warm comfortable bed. I explained all procedures to be carried out on her. Her general appearance was quickly observed and her condition was satisfactory.
I washed my hands with soap under running water and dried with a clean towel and warmed them.
Her vital signs recorded as follows;
- Temperature -36.0ºC
- Respiration-20cpm
- Pulse-84bpm
- Blood pressure-110/70mmHg
She was provided with privacy and offered her a bed pan and a specimen bottle to empty her bladder before the examination. I told her to pass the first urine into the bedpan and pass the midstream into the specimen bottle, then the rest into the bed pan.
I wore disposable gloves and then took the reagent bottle and read the instructions on it. I removed one strip and dip it into the urine and quickly removed it and tapped it at the edge of the bottle and compared the readings on the strip to that of the reagent bottle.
I measured the urine, tested for sugar and acetone. I washed and dried my hands after the procedure. The results were recorded as follows; volume 100mls, colour amber, protein negative, acetone negative.
PHYSICAL EXAMINATION
I inspected her hair and it was looking shinny without any dandruff, lice and ringworm. The face was examined and there was no oedema. The eyes were inspected; conjunctiva was pink, with no jaundice. She was engaged in a conversation in order to observe her teeth.
Her lips were moist no cracks nor inflammation were present. Gums and tongue were normal with no sores or lesions and the teeth were strong and white. Ears and nose were normally situated, equally in size and shape, and patent with no discharge. She was asked to shallow saliva and whilst swallowing, neck was inspected and examined for enlarge lymph nodes, thyroid gland and abnormality was detected.
The upper limbs were examined foe equality and they were equal, no extra digits. The hands and fingers were normal with short trimmed finger nails.
On breast examination, her breast were of normal position, nipples were prominent, secondary areola and Montgomery’s tubercles were also visible. Also palpated for terderness and enlargement of the lymph nodes but there were no abnormalities.
On abdominal examination, procedure was explained to her, privacy was provided, then exposed abdomen only, warm my hands by rubbing together, I stood on the right side of Madam M.K, on inspection the abdomen was globular in shape and fetal movement was present, presence of striae gravidarium and linea nigra was present.
The fundal height was 37cm. I faced Madam M.K and place pals on either side of the fundus, I curved my fingers around the fundus to determine what was in the fundus and it was the buttocks.
On lateral palpation, I placed the pal of my hands on both sides of the uterus, midway between the symphysis pubis and fundus. I then stabilized the uterus with one hand and examined with the other, I palpated the entire area from abdominal midline to the lateral sides and from the symphysis pubis to the fundus in a rotatory manner.
The fetal back was located at the right side of the abdomen as a smooth curve was felt. Then changed my hands, repeated the palpation for the other half of the abdomen and the limbs were palpated at the side of the abdomen. The lie was longitudinal.
I turned and faced Madam M.K’s feet, then asked her to flex her knees slightly and take in a deep breath and breath out slowly to relax her muscles. I placed my palms just below the level of the umbilicus and fingers were directed toward the symhysis pubis. A hard rounded mass was felt showing that the head was presenting and was cephalic, the position was right occipito anterior (R.O.A).
I located the anterior shoulder, below the umbilicus, approximately 2 -5cm from the linea nigra, where the limbs are located, I placed y right ulnar border just above the symphysis pubis and the anterior shoulder and it accommodated four fingers, the decent was four fifth (4/5th ) below the pelvic brim.
On auscultation, the fetal heart rate was 138 beat per minute and the volume and rhythms were also good. Findings were communicated to her and recorded into the admission sheet and labour sheet.
I monitored client contractions by sitting by her. I exposed client’s abdomen only and place y pals over her fundus, noted time contraction started and when each contraction weared off. I then reported and recorded the number and length of each contraction in ten minutes, starting from the beginning of the first contraction at 10:30am. Uterine contraction was 3 in 10minutes lasting for 20seconds.
The progress of labour was communicated to Madam M.K and helped her to lie on her left side. Permission was sought for vaginal examination of which she agreed. A sterile tray containing sterile gloves, a gallipot with sterile cotton wool swab, gallipot with diluted salvon, a sanitary pad and a receiver was set. I helped her on to the delivery bed was positioned into lithotomy position and draped her.
I washed my hands, dried and wore the sterile gloves. I asked her to open her legs, after which the vulva was inspected; the vulva was moist, free from scars, warts and varicose veins. The vulva was gently swabbed by picking swab with the right hand, dipped in the weak salvon solution (1:40), dropped the swab into the left hand and swabbed starting from the labia majora, labia minora and then the vestibule using one swab per stroke.
I entered the vagina by separating the labia minora and gently inserted my right middle finger and added the index finger of my right gloved hand pressing firmly downwards. The vagina was moist and warm and the walls were distensible. The cervix located at the center and it was thin, effaced, soft and the presenting part was well applied to the cervix.
The cervical dilatation was 2cm at 10:30am and the membranes were intact with no moulding.
The ischia spines were blunt and the sacrum well curved. I cleaned her and a new perineal pad was applied to prevent ascending infection from outside. Vaginal discharge on glove finger was normal and was not offensive. The items I used were decontaminated and I discarded my gloves, washed and dried my hands. Findings were communicated to her and recorded on the labour notes.
The back was examined and there was no abnormality seen with vertebrae column, no oedema at the sacral and no pain.
The lower limbs was palpated for oedema of the ankles, terderness, varicose vein and all were normal with short toe nails.
I thanked her for her cooperation. She was encouraged to practice deep breathing exercises and avoid premature bearing down to prevent oedematous cervix. I helped Madam M.K out of the examination couch. Findings were recorded in the admission sheet under the supervision of the midwife on duty. I then entered her particulars into the admission and discharged book, and on the daily ward sheet.
Madam M.K told me she had backache and profuse sweating at 10:30am. Emotional support was given to her that all will be well since she was in competent hands and that she will deliver soon.
- At 11:00am fetal heart rate 137bpm, contraction 3in 10minutes lasting 20seconds, maternal pulse 89bpm.
- At 11:30am fetal heart rate 138bpm, contractions3 in 10minutes lasting 25seconds, maternal pulse 78bpm.
- At 12:00pm fetal heart rate 136bpm, contractions 3 in 10 minutes lasting 20 seconds, maternal pulse 81bpm.
- At 12:30pm fetal heart rate 136bpm, contractions 3 in 10minutes lasting 20 seconds, maternal pulse 80bpm, urine volume 100ml, colour amber, protein negative, acetone negative, temperature 36.2°C.
- At 1:00pm fetal heart rate 137bpm, contraction 3in 10minutes lasting 20 seconds, maternal pulse 83bpm.
- At 1:30pm fetal heart rate 138bpm, contraction 3 in 10minutes lasting 20seconds, maternal pulse 85bpm. Madam M.K told me she has being relived of backache and profuse sweating but complained of waist pain and frequent micturition.
- At 2:00pm fetal heart rate 138bpm, contraction3 in 10minutes lasting 25seconds, maternal pulse87bpm.
PREPARATION OF BIRTH
Since client vaginal examination reveals she was in labour, I prepared for birth to receive the baby and in case of any emergency. The midwife in –charge assisted as skilled helpers. I told client relatives who came with her not to go home or anywhere in order to run errands for me when the need arise. The delivery room, couch and ventilation area were cleaned with 0.5 % chlorine solution. Lights were checked to be working and switched on to make the room lighted.
Emergency rechargeable lamp was placed at reach in case the power cut off. Curtains and doors were also drawn down and close to keep the room warm. I then washed my hands and prepared a safe at well lighted ventilation area closer to the delivery room. I wore a pair of sterile gloves to pick delivery items which were sterile.
On the examination area were, a sterile penguin suction device, a ventilation bag, ventilation mask size zero, the appropriate one for the baby that will be born. I inspected all items which were clean and free from cracks. I also set a sterile trolley, 2 sterile cot sheet, a sterile cord clamp a sterile artery forceps, 2 pair of sterile gloves, sterile penguin suction device, cord cutting scissors solely for cord cutting and a receiver.
I covered items with a sterile drape. I now picked the unsterile items such as baby’s head cap, dress, socks and stethoscope and placed at the bottom shelf of the trolley. I also added syringes and needed drugs.
MANAGEMENT OF FIRST STAGE OF LABOUR
Fetal heart rate, uterine contractions and maternal pulse will be checked every 30minutes, urinalysis and temperature every two hours, blood pressure, vagina examination and head descent every 4 hours. All findings will be communicated to her and recorded on the labour note.
I encouraged Madam M.K to walk within the room or lie on her left side to facilitate blood supply to the fetus. Also counselled her to urinate frequently to facilitate the descent of the fetal head. She was educated on the various stages of labour to relax her and also be with her as much as possible. A dilatation board [cervicogram] was used to educate her on the cervical dilatation to prevent premature bearing down.
She was reminded to do deep breathing exercise whenever there is contraction to prevent maternal exhaustion and early pushing.Also served her porridge to help gain her energy and gave her sacral massage. I encouraged client to assume a comfortable position. She was educated her to wash her hands after changing perineal pad, I encouraged client to lie on her left to improve circulation. I introduced her to some mothers who have delivered to give her assurance.
Vagina examination was done at 2:30pm, cervical dilation was 6cm, membranes was still intact, moulding was one plus, uterine contraction was 3 in 10 minutes lasting 30 seconds, head descent was two fifth [2/5th] below the pelvic brim, fetal heart rate 138bpm, temperature 36.4, pulse 84bpm, respiration 20cpm, blood pressure was 114/740mmHg, urine output was100mls and tested negative for both protein and glucose and amniotic fluid was intact, client complained of severe lower abdominal pains.
Findings were plotted on the labour care guide.
- At 3:00pm fetal heart rate 138bpm, contraction 3 in 10 minutes lasting 30seconds, maternal pulse 88bpm.
- At 3:30pm fetal heart rate 140bpm, contractions 3 in10 minutes lasting 30 seconds, maternal pulse 86bpm.
- At 4:00pm fetal heart rate 140bpm, contraction 3 in 10minutes lasting 30 seconds, maternal pulse 87bpm.
- At 4:30pm fetal heart rate 141bpm, contractions 3 in 10minutes lasting 40seconds, maternal pulse 88bpm, urine; volume 100mls, protein negative, acetone negative, temperature 36.5°C.
- At 5:00pm fetal heart rate 141bpm, contractions 4 in 10 minutes lasting 40seconds, maternal pulse 89bpm.
- At 5:30pm fetal heart rate142bpm, contractions 4 in 10 minutes lasting 42 seconds, maternal pulse 88bpm.
- At 6:00pm fetal heart rate 141bpm, contractions 4 in 10 minutes lasting 45seconds, maternal pulse 87bpm.
- At 6:10pm, Madam M.K complained of the urge to bear down. Vagina examination was done at 6:20pm and cervical dilatation was 10cm with ruptured membranes. There was moulding two pluses, uterine contraction was 4 in 10 minute lasting 50 seconds, descent zero fifth, fetal heart rate was142bpm, pulse 87bpm, respiration 21cpm, blood pressure 120/80mmHg, urine output was 80mls amniotic fluid clear and temperature 36.0ºC .
I communicated all findings to her and gave her emotional support that her baby is about to be delivered. Maternal and fetal condition remained stable. The full dilatation of the cervical Os marks the end of the first stage of labour.
MANAGEMENT OF SECOND STAGE OF LABOUR
I instructed her not to bear down but rather pant while I prepared myself. I quickly wore a plastic apron, cap, face mask and boots. I washed my hands with soap under running water to my elbow and dried them with a clean towel. I washed client abdomen with clean water, covered with a sterile cot sheet and wash hands with soap and water to reduce infection. I wore two pair of sterile gloves.
I asked my assistant to assist her into a lithotomy position at 6:20pm. I cleaned the vulva, upper thigh, the pubis and her perineum with a cotton wool swab dipped in weak antiseptic solution, and swabbed using one cotton wool per stroke.
I swabbed the labia majora, labia minora and the vestibule using one swabs per stroke and discarded it appropriately.
Confirmed full dilatation of the cervical os. A clean perineal pad was applied on the anal region and a mackintosh and a clean towel under the buttocks to make the delivery area sterile to prevent infection. I instructed my assistant to time contractions and check fetal heart rate after each contraction and told client to bear down with each contraction and rest in between contractions.
She was reminded of delivering the baby onto her abdomen and also told her at a point I would asked her to stop pushing and pant.
Client was seen raising up the buttocks from the delivery bed whiles bearing down and was told not to in order to prevent perineal trauma. As the fetal head advanced, I placed two fingers of my right hand on the fetal head to maintained flexion to allow the smallest diameter of the fetal head to distend the perineum and to prevent rapid expulsion of the fetal head and perineal trauma.
As the fetal head gradually crowned, I asked her stop pushing and pant. The occiput escaped under the symphysis pubis whiles the sinciput, face and chin swept the perineum, I passed my fingers around the neck to feel for umbilical cord which was absent and I delivered the rest of the head by extension.
I waited for restitution to occur followed by external rotation of the head which indicated internal rotation of the shoulders has taken place simultaneously with the shoulders lying in the anterior posterior diameter of the pelvic outlet.
Then placed both hands on each side of baby’s head, and instructed my client to push gently, with a downwards traction towards the mothers anus, I delivered the anterior shoulder and with an upward traction, the posterior shoulder was delivered.
The rest of the body was delivered by lateral flexion following the curve of carus onto the mother’s abdomen. At 6:40pm, an alive female baby was delivered who cried lustily immediately after birth indicating baby was in good condition, I quickly used a clean cot sheet, clean off liquor amni, change the soiled cot sheet and covered baby with a sterile warmed dried cot sheet to prevent baby from losing heat by evaporation.
I palpated the uterus to rule out undiagnosed second twin and it was empty. My assistant gave 10 international units of oxytocin injection intramuscular on the left thigh, on instruction after checking of vital signs as follows B/P 120/70mmHg, Pulse 79bpm, Temperature 36.5ºC, Respiration 20cpm.
Between 1-3 minutes, I clamped the umbilical cord with a sterile cord clamp 3 finger breath from the umbilicus and another artery forceps was used to clamped 2 finger breath from the first clamp, I used a sterile gauze to cover and cut in between the two clamp to prevent blood from splashing and separated baby from mother, cord was inspected to be clean, secured and not bleeding.
Baby was put skin to skin with mother to initiate breathing. Client was told to observe these signs such as licking mouth and eyes open. Baby’s cap and socks were worn to provide warmth. I congratulated my client and thank her for her cooperation.
IMMEDIATE CARE OF THE BABY
This started immediately baby’s head was delivered. Cord was felt around the neck which was absent. After baby delivered unto mother’s abdomen, baby was thoroughly dried to stimulate breathing and wet cot sheet was replaced with warm and sterile one. Baby was crying and breathing well.
First minute apgar score was 8/10. Hair cap and socks applied to keep warm. Within 1-3 minute cord was clamped and cut aseptically and inspected to be secured and clean. Baby was put skin to skin with mother for one hour and covered. Breastfeeding was initiated. Fifth minute apgar score was 9/10.
MANAGEMENT OF THIRD STAGE OF LABOUR
The uterus was palpated gently to find out the presence of any undiagnosed twin, but there was none.
Mother was informed that she had reached third stage of labour, where the placenta, membranes and clots must be expelled and to ensure there is no bleeding. She was encouraged to pass urine but none was produced, since bladder was completely emptied.
Within 1 minute after the delivery of the baby, 10units of injection oxytocin was administered at the right upper thigh. The soiled bed sheet was changed and a sterile receiver placed closer to the perineum in between her thighs to collect the placenta membranes and the blood loss.
The cord was re-clamped closer to the vulva. Then palpated with one hand above the uterus to feel for contraction of the uterus. The uterus was very firm to touch showing good contraction of the uterus. The non -dominant hand was placed just above the symphysis pubis with palm facing the umbilicus to provide counter traction and to prevent inversion of the uterus.
With my dominant hand, kept a slight tension on the cord and gently pulled the cord downward and forward direction but firmly and steadily to deliver the placenta. The placenta was quickly examined to ensure completeness which was complete and intact.
The time was noted to be 6:50pm. Placenta and it membranes were delivered by control cord traction. The uterus was massaged immediately until it was well contracted. Blood loss was measured and it was approximately 150mls. The genital tract and the vulva was cleaned with a dry pad, perineum, vaginal walls and the cervix were examined under bright light.
Madam M.K was cleaned up and a clean perineal pad was applied over the vulva. The client was taught how to massage the uterus every 15minute and to report if uterus becomes laxed. I congratulated and thanked her for her cooperation. I transferred her to the lying-in ward and made her comfortable on a warm bed with skin to skin care for one hour.
EXAMINATION OF THE PLACENTA
I placed the membranes together by holding the cord with one hand and allowing the membranes to hang, and all membranes that is the chorion and amnion were intact, cord was centrally situated at the fetal surface, blood vessels were radiating to the circumference of the placenta, and there were two arteries and one vein in the cord.
The fetal surface was covered with amnion with the blood vessels running through it, the surface was, greyish blue in colour. I identified the hole through which the baby was delivered and spread out my other hand inside which was single.
Placenta was examined thoroughly, by holding it with my hands, the shape on inspection was flat and roughly circular. On inspection of the maternal surface, it looked bright red in colour and the lobes or cotyledons were intact however the surface looked rough.
The amnion was peeled up to the umbilical cord and the chorion was inspected but no abnormality was detected. I then informed her if she will need the placenta and she said no. The placenta was then decontaminated in 0.5 % chlorine solution and discarded after examination into the placenta pit.
All instruments used for the delivery was decontaminated in 0.5 % chlorine solution for 10 minutes. I wore utility gloves and washed and rinsed the instrument under running water. They were dried, sterilized and stored for re-use. The delivery room was decontaminated, cleaned and set up for the next use. I dipped my gloved hands in 0.5 % chlorine solution, removed and discarded. I washed my hands and dried them.
I then completed the labour care guide in her maternal record book and all findings were documented into the delivery register and report book.
MANAGEMENT OF FOURTH STAGE OF LAB OUR
Madam M.K was sent to the fourth stage room. The care involves the mother and the baby.
She was monitored closely for the first six hours after delivery. I encouraged her to empty bladder frequently since full bladder impedes contraction of the uterus and could lead to bleeding. She was encouraged to breastfeed the baby to promote uterine contraction. Also to establish bonding as well as to prevent hypothermia since the baby will be held closer to the mother during breastfeeding.
Madam M.K was counselled to change her perineal pad whenever it is soaked to prevent infection. Lochia was red with moderate flow. The fundus measured 1 cm from symphysis pubis. Her post -delivery vital signs and baby vital signs were checked every 15minutes for one hour, half hourly for two hours and hourly for three hours till discharge. The perineum, vagina walls and cervix were examined under bright light and was clean.
Immediate vital signs checked and recorded at 7:15pm for the mother and 7:30pm for baby as follows
- Mother Baby
- Temperature 36.4ºC Temperature 36.6ºC
- Pulse 80bpm Respiration 40cpm
- Respiration 20cpm Heart Rate 136bpm
- Blood Pressure 110/60mmHg Colour pink
- Cord no bleeding
As recorded on the post-delivery observation form.
The baby was observed for signs of cyanosis and the umbilical cord was also examined for any bleeding but clamp was secured. I asked Madam M.K of the lower abdominal pains, frequent micturition, backache and the waist pain she complained of and said she has being relieved.
I ensured that the environment was quiet and very conducive for sleep after taking mashed kenkey with groundnut. All findings were communicated to Madam M.K and recorded in her maternal recorded book and also in the report book, labour care guide and delivery register.
The following drugs were served as follows:
- Tablet Metronidazole 400mg tid x7 days
- Tablet Paracetamol 1000mg tid x 5 days
- Tablet Folic acid 5mg daily x30 days
- Capsule Amoxicillin 500mg tid x 7 days
- Tablet Ferrous sulphate 200mg tid x14 days
- Tablet Multivitamin 200mg tid x14 days
ESSENTIAL CARE OF THE BABY
After 60minutes of skin-to-skin care, I explained to mother that it was time to provide essential care for the baby. I invited client mother who had come to visit at the moment. I prepared and brought all items needed for the care closer to client bed side. I washed my hands and wore examination gloves since baby had not bath yet. First of all prevented disease by; providing eye care to the baby.
I used chloramphenicol eye drop 1% and instilled drop each into lower eyelid of the baby. I told mother not to administer any drug to baby’s eye at home. I then cared for baby’s cord with chlohexidine ointment 7.1%. I removed gloves washed hands and wore sterile gloves I taught client and relatives cord care and educated them to do so at home and not to apply anything to the cord.
The cord was inspected and it was clean dry and not bleeding. I gave vitamin K1 1mg/ml to baby to help prevent any form of bleeding. The injection was given at the mid anterior lateral thigh into the vastus lateralis muscles after baby’s weight was taken. Baby was assessed by examination, measuring temperature and checking the weight.
I cleaned the thermometer when it was off with cotton wool swab soaked in methylated spirit from the bulb to the stem.
I switched it on and placed it high into baby’s armpit and supported arm. After it had beeped I removed and read the temperature to be 36.5ºC which was normal. I cleaned the scale with gauze soaked in methylated spirit in strokes. I placed a cot sheet on the scale and zeroed the scale.
I then wrapped baby in the weighted cot sheet to prevent heat loss and weighed baby. The weight become the baby’s exact weight since the weight to the cot sheet had been taken into consideration. Baby’s weight recorded 3.0kg.
The nose was well placed with normal shape and size and nostrils were patent. No cleft palate, tongue tie, cleft lip or false teeth were noticed in the mouth, and baby’s suckling and swallowing reflexes were present. The neck was easily rotated and no enlarged lymph nodes noted. On examination of the upper extremities, there were equal length of fingers with on web or extra digits, the nails were also well developed. Palma creases, Moro and palmer grasping reflexes were present
The chest was barrel-shaped, position of nipple was normal with breast tissues present. The apex beat was checked with a stethoscope and was found to be of normal rhythm. The abdomen on palpation was soft and round. The umbilical cord was centrally situated with no bleeding. The umbilical cord had two (2) arteries and one vein. There was no distension of the abdomen.
On examination the vulva was clean, and the anal region, there was no abnormalities since baby had already passed urine and meconium which indicated patency of the urethra orifice which was centrally situated and the anal canal.
On examination of the lower extremities, the length of the legs were equal, well flexed and abducted to exclude any dislocation of the hip, there was no webbed toes and extra digits, planter creases were also present. Baby was turn to lateral position to examine the back. The vertebrae was normal with no hairy patches, rashes, spinal bifida or any abnormality of the spine.
The baby’s vital signs were checked and recorded. Head circumference was 34cm, full length was 51cm and chest circumference was 34cm.
Injection Bacillus Chalmette Guerin (BCG) 0.05ml was given on the right upper arm and oral polio 2 drops was given.
SUMMARY OF LABOUR NOTES
- Date and time of delivery 29 August, 2023 at 6:40pm
- Type of delivery Spontaneous Vaginal Delivery)
- Time of delivery of the placenta and membranes 6:50pm
- Blood loss 150mls
DURATION OF OBSERVABLE LABOUR
| STAGES | TIME | PERIOD |
| First stage | 10:30am – 6:15pm | 7 hours, 45 minutes |
| Second stage | 6:15pm – 6:40pm | 25minutes |
| Third stage | 6:40pm -6:50pm | 10 minutes |
| Total | 10:30am -6:50pm | 8 hours, 20 minutes |
CONDITION OF MOTHER
- Condition of mother Good
- Condition of perineum Intact
- Fundal height 16cm
- Respiration 18cpm
- Blood pressure 110/60mmHg
- Temperature 36.3ºC
- Pulse 80bpm
- Bowel 0
CONDITION OF PLACENTA AND CORD
- Placenta Healthy
- Blood vessels Two (2) arteries and one (1) vein
- Maternal surface Dark red in colour
- Fetal surface Greyish-blue
- Placenta and membranes Intact
- Cord insertion Centrally situated.
CONDITION OF BABY
- Condition of baby Good
- Sex of baby Female
- Baby’s weight 3.0kg
- Congenital abnormalities None
- Full length 51cm
- Chest circumference 33cm
- Head circumference 34cm
- Apgar score 8/10, 9/10
| APGAR SCORE | FIRST MINUTE | FIFTH MINUTE |
| Appearance | 2 | 2 |
| Pulse | 2 | 2 |
| Grimace | 1 | 1 |
| Activity | 1 | 2 |
| Respiration | 2 | 2 |
| Total | 8/10 | 9/10 |
Post-Delivery observation of the mother.
| TIME | Blood pressure | Pulse | Bleeding | Uterus | General condition |
| 7:15 pm | 110/60mmHg | 80bpm | slight bleeding | Contracted | good |
| 7:30pm | 110/60mmHg | 80bpm | slight bleeding | Contracted | good |
| 7:45pm | 110/70mmHg | 84bpm | slight bleeding | Contracted | good |
| 8:00pm | 120/82mmHg | 79bpm | slight bleeding | Contracted | good |
| 8:15pm | 117/79mmHg | 84bpm | slight bleeding | well contracted | good |
| 8:45pm | 121/80mmHg | 85bpm | slight bleeding | well contracted | good |
| 9:15pm | 110/60mmHg | 82bpm | slight bleeding | well contracted | good |
| 9:45pm | 117/80mmHg | 80pbm | slight bleeding | well contracted | good |
| 10:15pm | 117/80mmHg | 86bpm | slight bleeding | well contracted | good |
| 11:15am | 122/80mmHg | 80bpm | slight bleeding | well contracted | good |
| 12:15am | 120/80mmHg | 78bpm | slight bleeding | well contracted | good |
| 1:15am | 117/70mmHg | 84bpm | slight bleeding | well contracted | good |
Post – delivery observation of the baby
| Time | Heart Rate | Respiratory Rate | Colour | Cord Bleeding | Suckling | Temperature | General Condition |
| 7:30pm | 136bpm | 40cpm | pink | no bleeding | yes | 36.6ºC | Satisfactory |
| 7:45pm | 140bpm | 40cpm | pink | no bleeding | Yes | 36.5ºC | Satisfactory |
| 8:00pm | 130bpm | 45cpm | pink | no bleeding | Yes | 36.8ºC | Satisfactory |
| 8:15pm | 124bpm | 42cpm | pink | no bleeding | Yes | 36.6ºC | Satisfactory |
| 8:30pm | 121bpm | 50cpm | pink | no bleeding | Yes | 36.5ºC | Satisfactory |
| 9:00pm | 142bpm | 46cpm | pink | no bleeding | Yes | 36.7ºC | Satisfactory |
| 9:30pm | 146bpm | 40cpm | pink | no bleeding | Yes | 36.5ºC | Satisfactory |
| 10:00pm | 135bpm | 42cpm | pink | no bleeding | Yes | 36.8ºC | Satisfactory |
| 10:30pm | 127bpm | 49cpm | pink | no bleeding | Yes | 36.9ºC | Satisfactory |
| 11:30pm | 145bpm | 44cpm | pink | no bleeding | Yes | 37.0ºC | Satisfactory |
| 12:30am | 120 bpm | 46cpm | pink | no bleeding | Yes | 36.9ºC | Satisfactory |
| 1:30am | 128bpm | 41cpm | pink | no bleeding | Yes | 36.5ºC | satisfactory |
NURSING CARE PLAN DURING LABOUR
PROBLEMS IDENTIFIED DURING LABOUR
- Backache 29/08/2023
- Profuse sweating 29/08/2023
- Waist pains 29/08/2023
- Frequent micturition 29/08/2023
- Lower abdominal pains 29/08/2023
- Impaired body comfort (backache) related to strong uterine contraction.
- Fluid volume deficit (profuse sweating) related to stress of labour.
- Physical pain (waist pain) related to pressure of gravid uterus pressing sacral nerves.
- Impaired bladder elimination pattern (frequent micturition) related to pressure of fetal head pressing on the bladder.
- Impaired body comfort (lower abdominal pain) related to strong uterine contractions and descent of fetal head.
SHORT TERM OBJECTIVES
- Client will cope with backache throughout labour.
- Client will be hydrated within 3 hours.
- Client will be able to cope with waist pains throughout labour
- Client will cope with frequent micturition throughout pregnancy.
- Client will be able to cope with lower abdominal pains throughout labour.
LONG TERM OBJECTIVE
Client will go through labour successfully and deliver a normal healthy baby without any complication to both mother and baby.
TABLE II: NURSING CARE PLAN DURING LABOUR
| DATE/TIME
|
NURSING
DIAGANOSIS |
NURSING OBJECTIVES/
OUTCOME CRITERIA |
NURSING ORDERS | NURSING
INTERVENTION |
DATE/TIME | EVALUATION | SIGN | |||||||
| 29/08/2023
at 10:35am |
Backache related to strong uterine contraction. | Client’s will cope with backache throughout labour as evidenced by client verbalizing relieve of pain. | 1. Give emotional support to client that pain will be over soon.
2. Explain to client the cause of the pain in simple terms.
3. Demonstrate to client to do deep breathing exercise during uterine contraction.
4. Massage the sacral region to relieve pain.
5. Educate client to assume a comfortable position. |
1. Client was given emotional support that the pain would be over soon.
2. Explanation was given to client about the cause of pain in simple terms.
3. Client did deep breathing exercise during uterine contraction.
4. Client was given sacral massage to relieve pain by companion.
5. Client was educated to assume a comfortable position.
|
29/08/2023
at 6:45pm |
Goal fully met as evidenced by client coping with backache throughout labour. | E A Y | |||||||
| DATE/ TIME | NURSING DIAGNOSIS | NURSING OBJECTIVES/OUTCOME CRITERIA | NURSING ORDERS | NURSING
INTERVENTION |
DATE/ TIME | EVALUATION | SIGN | |||||||
| 29/08/2023
at 10:40am |
Fluid volume deficit (profuse sweating) related to stress of labour. | Client will be hydrated within 3 hours as evidenced by midwife observe client having good skin turgor. | 1. Reassure client.
2. Ensure the use of damp towel.
3. Serve cold water frequently to hydrate her.
4. Change client wet clothing.
5. Put on fans. |
1. Client was reassured of safe delivery.
2. Client face and body was mopped with damp towel to relieve sweat.
3. Client was served cold water frequently to hydrate her.
4. Client wet clothing was changed and dry war clothing was given to client to wear.
5.Fans were put on to cool the room.
|
29/08/2023
at 1:30pm |
Goal fully met as evidenced by midwife observed client having good skin turgor. | E A Y | |||||||
| DATE/TIME | NURSING DIAGNOSIS | NURSING OBJECTIVES/ OUTCOME CRITERIA | NURSING ORDERS | NURSING
INTERVENTION |
DATE/TIME | EVALUATION | SIGN |
| 29/08/2023
at 1:40pm |
Physical pain (waist pain) related to pressure of the gravid uterus pressing sacral nerves. | Client will cope with waist pain till delivery as evidenced by client verbalizing she can cope with the waist pain. | 1. Reassure client that the waist pain will reduce.
2. Explain the physiology of waist pain to the client.
3. Educate client to adopt a comfortable position.
4. Tell client to use diversional therapy.
5. Give client sacral massage.
|
1. Client was reassured that the pain would reduce after delivery.
2. Physiology of waist pain was explained to client that it was due to the pressure of the gravid uterus on the sacral nerves.
3. Client was educated to adopt a comfortable position.
4. Client was told to use diversional therapy such as watching television.
5. Client was given sacral massage by companion. |
29/08/2023
at 6:45pm |
Goal fully met as evidenced by client verbalized she can cope with the pain. | E A Y |
| DATE/ TIME | NURSING DIAGNOSIS | NURSING OBJECTIVES/ OUTCOME CRITERIA | NURSING ORDERS | NURSING
INTERVENTION |
DATE/ TIME | EVALUATION | SIGN |
| 29/08/2023
at 1:40pm |
Impaired bladder elimination pattern
( frequent micturition) related to pressure of fetal head pressing on the bladder. |
Client will cope with frequent micturition throughout labour as evidenced by client verbalizing that she is coping. | 1. Reassure client that frequent micturition will be subside.
2. Explain the physiology of frequent micturition to client.
3. Serve client with bedpan.
4. Educate client to take in a lot of fluids to avoid dehydration.
5. Tell client to void frequently. |
1. Client was reassured that the frequency of micturition would be subside after delivery.
2. Physiology of frequent micturition was explained to her that it is as a result of the fetal head pressing on the bladder.
3. Client was served bedpan to reduce movement to the washroom.
4. Client took in about 500mls of water every 2 hours.
5. Client voided frequently and as when she had the urge to. |
29/08/2023
at 6:45pm |
Goal fully met as client verbalizing that she is coping with the frequent urination. | E A Y |
| DATE/TIME | NURSING DIAGNOSIS | NURSING OBJECTIVES/ OUTCOME CRITERIA | NURSING ORDERS | NURSING
INTERVENTION |
DATE/ TIME | EVLUATION | SIGN |
| 29/08/2023
at 2:35pm |
Impaired body comfort (lower abdominal) pain related to strong uterine contractions and descent of fetal head. | Client will be able to cope with lower abdominal pains throughout labour as evidenced by client enduring pain. | 1. Reassure client that the pain will end after delivery.
2. Educate client to adopt a comfortable position by lying on left side.
3. Teach client on deep breathing exercise.
4. Counsel client not to shout during contractions to avoid exhaustion.
5. Tell client to micturate frequently to aid descent of the fetal head. |
1. Client was reassured that the pain will end after delivery.
2. Client adopted a comfortable position by lying on her left side.
3. Client was taught on deep breathing exercise.
4. Client was counselled not to shout during contractions to avoid exhaustion.
5. Client micturated frequently to aid descent of the fetal head. |
29/08/2023
at 6:40pm |
Goal fully met as client coped with pains throughout labour | E A Y |
