ACKNOWLEDGEMENTS Successful completion of this case study is as a result of generous contributions and assistance of some individuals worthy mentioning.

Heart felt appreciation go to Chifundo Siyasiya the subject of this study for consenting to be the subject of this study. The form and flow of this paper should not have been the same if it were not for her kind consent and cooperation during the period of the study. We extend our appreciation to rs. !hiri our clinical supervisor for her guidance" contributions" understanding attitude and above all for her patience and flexibility that enabled us carry out the study and come up with this write up in a thorough manner. We would all like to acknowledge the guidance of the ward in#charge midwives working in high risk pos#natal ward. %astly but by no means the least we thank &'( for the gift of life. rs. $jinga and all

INTRODUCTION This !aper presents a case study of rs. Chifundo Siyasiya hereafter addressed as rs. C.S. She was gravida * now para *. She was identified as an ideal patient for post natal study on +,-,.- because she had failed trial of labor and undergone caesarian section. !ost#natal period /puerperium0 is the interval between birth of the newborn and the return of the reproductive organs to their normal non#pregnant state /1ames (.2." Steer" !.1." Weiner" C.!. 3 &onik" 4. /*...0 0. !ost#natal care starts immediately after the birth of the baby and placenta in the delivery room and continues in post#natal ward. Caesarian section is a surgical procedure which may be performed under general" epidural or spinal anaethesia or" rarely" local infiltration in which the fetus" placenta and membranes are delivered through an incision in the abdominal wall and in the uterus. /Sweet 4. 3 Tiran (" *...0 This paper focuses on the care she received while in post#natal ward but for the sake of easy follow up" care given during antenatal period" labor ward and theatre have also been presented and analy5ed. Challenges and limitations encountered during the care period have also been presented. SUBJECTIVE DATA Personal details rs. C.S was aged *+ years" married" with two children. She was a $goni by tribe and she was from 6neya village" Traditional authority 2wataine" $tcheu district. Her residential area was in 7rea *8" %ilongwe. rs. C.S. was a business lady who owns a saloon in 7rea *8" %ilongwe. Her next of kin was her mother. She belongs to 7ssembles of &od church. 'n education she went up to form 8. Menstr al! "#ne$olo"i$al %istor# rs C.S said that she reached menarche when she was )9 years old. She said that she had regular menses and that she was menstruating for four days. The flow was moderate but sometimes she was having painful menses and she reported of never having an abortion. &a'il# (lannin" %istor# She said that she had never used any family method but she heard about them at antenatal clinics. She also said that she is ready to start using one of the methods. 7t first she was not using because the husband was away in $tcheu. rs. C.S said that she wants to have three children so she is planning to give birth to the third child after three years.

Ps#$%olo"i$al %istor# rs C.S said that the pregnancy was not planned but was accepted by both parents. She said that they prepared clothes" rappers and all necessary materials for child birth and also for her own care after delivery. Se) al %istor# She said that she stopped having sex when she was six months pregnant because they believed that the baby could be injured and they have prepared to stay for three months post delivery so that the child should grow well. Medi$al %istor# She said that she had never suffered from medical disease like 7sthma" Hypertension and (iabetes ellitus. She also said that there are no diseases that run in her family. S r"i$al %istor# She said that she has had one caesarian section due to Cephalo pelvic disproportion in *..9 at 4waila hospital and the baby weighed :8.. grams. She had been done another caesarian section on +th 7ugust *..- due to fetal distress at 4waila hospital and the baby weighed :...grammes. &a'il# %istor# She said that in her family there are eight children" in which four are girls and the others are boys. She said that she is the forth born and that there was no history of twinning or other hereditary problems. So$ial %istor# She said that she is married to a husband who does a tinsmith business. She went up to form four as well as the husband. She said that she is a business lady who owns a saloon. She said that her husband does neither smoke cigarette nor take alcohol so does she. N tritional %istor# rs. C.S knew the six food groups and she was able to mention them and the examples of each food group. She also said that she has ade;uate food at her home and makes sure that she had a balanced diet by the end of the day. She said that in her culture there are no food restrictions. Her *8 hour dietary recall< yester day morning she took porridge" nsima with matemba at lunch" and at supper she took nsima with eggs and she had banana in between the meals. The following morning she took tea and bread before coming to the hospital. Pre*io s o+stetri$ %istor# rs C.S. said that she gave birth once in her life through caesarian section and the child is alive. She said that the first child is a girl and was born on )=th 7ugust *..9 and she cried after birth. The baby weighed :8.. grams. She said she had no problems during pregnancy.

Present o+stetri$ %istor# She said that she had forgotten the date of her last normal menstrual period. (uring pregnancy she was not bleeding or draining li;uor. She had now given birth to a second child to cephalo pelvic disproportion. ANTENATAL CARE rs. C.S attended antenatal clinics three times at 4waila hospital. She started antenatal clinics when she was *. weeks pregnant. The purpose of starting the antenatal clinics at first time was to know if she was pregnant. 4elow is the summary of rs. C.S>s antenatal visits and treatment received. ?undal height *. weeks *8weeks :: weeks presentation weight 4!/mmHg0 H&4 $ot defined Cephalic cephalic =. 2g =: 2g =- 2g )).,+. )*.,+. )*.,-. )*.9g,dl $ot checked $ot checked Treatment ?errous sulphate *..mg once daily for :. days.S,! : tablets stat ?errous sulphate *..mg once daily for :. days.S,! : tablets stat ?errous sulphate *..mg once daily for :. days.S,! : tablets stat

@rinalysis#albumin was negative. #&lucose was not done. A(B% came out negative. HCT came out negative. Anal#sis o, antenatal $are (uring the three visits that she attended antenatal clinic that was from *. weeks to :: weeks she gained -kg. Cn normal pregnancy the normal range of weight gain is )8kg with an average of )*.9kg. (uring her first visit at *. weeks she weighed =.kg and this weight was used as the baseline data to compare with the subse;uent weight readings as the non pregnant weight was not known. 'n her second visit at *8 weeks /four weeks after first visit0 she weighed =:kg. This means that she gained :kg 7 woman is supposed to gain )#*kg during the first *. weeks and then ..9kg per week in the second and third trimester. 7t *8weeks she was in the second trimester and she was supposed to gain *kg during the four week period but :kg was acceptable as it is slightly above ..9kg per week

'n her third visit at :: weeks she weighed =-kg. This means she gained 9kg during the D weeks. This weight gain was also slightly above the normal weight gain but within the normal range because she was supposed to gain 8.9kg in the D weeks. This means that rs. C.S was gaining weight ..=kg per week which is normal. This increase in weight might be due to intake of ade;uate and well mixed diet &estation by dates was not calculated as she did not remember her last normal menstrual period hence making it difficult to correlate the gestation age by dates and fundal height. 'n laboratory investigationsE hemoglobin level was )*.9g,dl and this was within the normal range of )*g,dl to )-g,dl. 2nowing the heamoglobin level would help to estimate how the hemoglobin level would be during the puerperium and the need for blood transfusion. A(B% and HCT were negative and this meant that rs. C.S did not have the syphilis and HCA which could pass through the placental barrier and cause detrimental effects to the unborn baby. @rine albumin was also negative meaning that she did not have diseases such as pre# eclampsia or any kidney problem. The blood pressure remained within the normal range of systolic pressure of D.# )8.mmHg and diastolic pressure of =.#D.mmHg through out the three visits.

LABOR AND DELIVERAd'ission and A+do'inal E)a'ination CS was admitted in labor ward at +E*- a.m. on 7ugust +" *..- after labor had started spontaneously at a time not indicated on the labour chart. !rior to admission she had taken food but did not have ade;uate sleep. She reported not to have taken home made medicine which can induce labor. She experienced no per vaginal bleeding and had no pre#eclampsia. embranes were intact on admission. She was generally healthy looking with blood pressure of )..,=. mmHg with : moderate contractions in ). minutes. She was := weeks gestation by fundal height and one finger below the ximphsternum. %ie was longitudinal with a cephalic presentation and left occipital anterior position. Her urinary bladder was empty and fetal heart was within the normal range )*.#)=. beats per minute. &irst Va"inal E)a'ination Show was seen and soft tissues were warm and moist. The cervix was thin" )..F effaced and =cm dilated. The cervix was also well applied to the presenting part. embranes were intact and the cord was not felt. Aertex was presenting but position of sutures and fontanels could not be defined on examination. The vertex was above the ischial spines and caput was not felt.

Pel*i$ Assess'ent The shape of the pelvic brim could not be followed by the examiner>s fingers. The sacrum was well curved and the sacro#promontory could not be tipped by the examiner>s finger at ): cm. Sacro#spinous ligaments were flexible. Cschial spines were not prominent. Sub#pubic arch was more than D.o and the inter#tuberous diameter was more than -.9 cm. The pelvis was deemed by the examiner as being roomy enough for a vaginal delivery. LABOR PROGRESS 7t DE9. am the cervix was fully dilated at ).cm. The descent however remained high at 8,9 and fetal heart rate had reduced to ).. beats per minute. She was experiencing : contractions in ). minutes. Her pulse rate was -= beats per minute and blood pressure was )*.,-. mmHg. 7rtificial rupture of membranes was effected which revealed meconeum stained li;uor. 7 diagnosis of fetal distress was made and the patient was prepared for an emergency caesarian section. CAESARIAN SECTION 7t ))E:.am the patient was given general anesthesia and an intra#umbilical midline abdominal incision was made. 7 live full term male infant was extracted from the uterus with an 7pgar score of D,). after a minute and ).,). after five minutes. The neonate weighed :)..g. !lacenta and membranes were extracted in their complete forms. 4lood loss was estimated at 9..ml. The incision was closed and the following post operative orders were madeE

!ethidine )..mg every = hours for the first *8 hours and then as necessary. etronida5ole 9..mg intravenously -hourly for the first 8-hours then 8..mg orally for the following 9 days. 7mpicillin 9.. mg every - hours intravenously for the first 8- hours then orally for the following 9 days. &entamycin *8.mg once a day for the first 8- hours. Catheter to remain in situ for the first *8 hours post#operatively. Cntravenous infusion of lingers lactate or normal saline :litres in *8 hours plus 8. ml of 9.F dextrose every = hours and Counseling on management of future pregnancies

ANAL-SIS O& CARE GIVEN IN LABOR 7ccording to the patograph" the period in between assessments of maternal and fetal conditions is too long /i.e. after * hours0 to enable prompt detection and reversal of changes with adverse effects on fetal and maternal conditions.

&etal Condition The pattern of fetal heart rate was not monitored according to 'bstetric %ife Skills Training anual for alawi of half hourly. 7ccording to partograph after initial assessment of fetal heart rate at +E*.am" reassessment was done at DE*.am. 7nother assessment of fetal heart rate was correctly done at DE9. am when it was discovered that the fetal heart rate was between D. #).. beats per minute" below the minimum normal rate of )*. beats per minute signifying fetal distress. Cf monitoring was done half hourly the decelerating pattern should have been noticed earlier and a decision for caesarian section should have been made earlier. 7 second vaginal examination was planned to be done at ).E*. am" at a three hour interval but it was done at DE 9.am after reali5ing that the fetus was compromised. State of membranes and li;uor were recorded accordingly. %i;uor was meconeum stained which further helped in confirming fetal distress and emergency caesarian section was planned. 'n the partograph there was nothing indicating the state of fetal skull. 7ccording to 'bstetric %ife Skills Training anual for alawi moulding is an important indicator as it shows how well the pelvis will accommodate the fetal head. ?ailure to observe for moulding can among others lead into failure to treat the neonate accordingly in cases of cerebral injuries resulting from excessive moulding. Maternal Condition 7ccording to 'bstetric %ife Skills Training anual for alawi pulse rate and blood pressure are supposed to be monitored and recorded hourly" body temperature should be checked every four hours and urine should be monitored every two hours for volume and for presence of albumen and acetone. The labor chart indicates that only blood pressure was checked at +E*.am and DE*.am. This is dangerous as deterioration in maternal condition can not be noticed early to initiate treatment to revert the condition. 4ody temperature of the patient was not monitored throughout her stay in labor ward. This is an anomaly as it jeopardi5es evaluation of maternal well being during labor. The woman is supposed to empty her bladder * hourly and urine examined for color" concentration and amount. $othing of the sort was recorded on the labor chart meaning nothing to this effect was done. This jeopardi5es the woman>s condition as prompt treatment can not be effected to reverse any problems that might develop and manifested by the state urine. The 'bstetric %ife Skills Training anual for alawi also recommends that abdominal examinations should be done hourly to monitor for contractions and fetal descent. Contractions were supposed to be assessed for duration" fre;uency and intensity but it was monitored after two hours making it difficult to assess whether labour was progressing or not. ?etal descent remained 8,9 since rs. C.S was admitted in the labour ward and it was assessed after two hours making it difficult to note whether the presenting part was descending into the pelvis or not as the presenting part is estimated to descend ),9 per hour.

The time when rs. C.S. started labour was not indicated on the labour chart making it difficult to assess for how long she had been laboring and whether it was a normal or prolonged labour. Caesarian section was successful and resulted in a live full term male infant weighing :).. grams indicating that the baby had a normal weight within the normal range of *9..g to 8...g. Cn conclusion care given during labor leaves a lot to be desired as it falls short of standards recommended in 'bstetric %ife Skills Training anual for alawi. The subject of this study having had a previous scar and undergoing trial of labor re;uired close monitoring in order to detect early any changes with adverse effect on fetal and maternal conditions.

DA- .ERO POSTNATAL ADMISSION AND PROGRESS NOTES /T0 AUGUST 1223 45622PM Beceived mother from operating theatre. S +7e$ti*e data6 rs. C.S. said she was feeling very cold. She said she was not feeling any pain from the incision area. She asked where her baby was and she wanted to see her baby. O+7e$ti*e data6 rs. C.S. was fully awake and covered with one blanket. She had an intravenous infusion of normal saline running and a urinary catheter in situ with urine draining which was reddish in color. There was 89.mls of reddish urine in the catheter bag. Her body was cold to touch. Aital signs were< temperature was := degrees Celsius" respirations were 8. breaths per minute" pulse rate was 98 beats per minute and blood pressure was )..,+.mmHg. Her conjunctiva was pink" her lips were soft and oral mucus membranes were pink with no lesions. The incision dressing was clean and dry there was no bleeding observed. The bladder was empty. The sanitary pad was mildly soaked with lochia and the lochia was moderate. I'(ression6 high risk post caesarean mother" * hours :. minutes post#natally. Assess'ent!(ro+le's identi,ied6 altered thermoregulation hypothermia" high risk for hemorrhage" infection" nutrition" knowledge deficit" and anxiety. Plan6 refer to care plan I'(le'entation6 rs. C.S. was positioned in bed in supine position for comfort and more dry clean linen was added to her in order to provide warmth to her body. Her bed was situated at a place far way from the window in#order to avoid droughts which may

cause heat loss from the body through convection. She was taught on how to do deep breathing exercise and was encouraged to be doing them in#order to be taking in ade;uate oxygen for metabolism and helps in relaxing the muscles hence reducing pain. She was advised to report any changes that she may feel such as di55iness" heart palpitations and bleeding from the incision dressing. She was also told that the intravenous fluids will still be given to her in#order to hydrate her body and give her glucose since she will not eat until her bowel sounds return. She was told that the urinary catheter will also still be in situ in#order to be monitoring the amount of output and functioning of the bladder. She was also advised that she should not be touching the wound dressing with her hands to avoid introducing infection on the wound and that the wound dressing will be kept in situ for 8- hours to avoid introduction of micro#organisms on the fresh wound. She was assured that all the necessary care will be provided to her and that if she had any ;uestions she was free to ask. She was also assured that her baby was well and that he will be brought to her since at that time the baby was still in labor ward with the midwives there. !rescribed antibiotics flagyl 9..mg and ampicillin 9..mg were given intravenously and gentamycin *8.mg was given intramuscularly as prophylaxis for bacteria. E*al ation6 45648 (' ?ound rs. C.S. fully awake and she was charting with her mother since it was visiting hour. S +7e$ti*e data6 rs. C.S. said she was felling slightly cold and better as compared to first. She said she was not feeling any pain from the incision area. O+7e$ti*e data6 body temperature was :=.* degrees Celsius" respirations were :. breaths per minute" pulse rate was 9D beats per minute and blood pressure was )..,+.mmHg. There was no bleeding observed from the incision dressing. The sanitary pad was slightly wet and lochia was still moderate and there were no blood clots. I'(ression6 high risk post caesarean mother" * hours 89 minutes post natally" doing well post#natally. Assess'ent!(ro+le' identi,ied6 as per care plan Plan6 to continue with the plan of care. I'(le'entation6 rs. C.S. was advised not to be exposing herself unnecessarily to cold weather to avoid body heat loss through convection. E*al ation6 45652(' Beceived baby Siyasiya from labor ward midwife who said that the baby was fine and that his condition was stable whilst in labor ward and he was adapting well to extra uterine life. He was then taken to the ward where his mother was. ?ound rs. C.S. resting in bed and she was fully wake. Her mother was sitting next to her and she was looking happy.

MOT0ER S +7e$ti*e data6 rs. C.S. said she was much better and feeling warm. She said she was still not feeling any pain from the wound. She said she was happy to see her child and that he was well. Her mother said she was happy that her child was well and that she now has a grandchild who is a boy. O+7e$ti*e6 rs. C.S. was so happy and she was cuddling her child. Aital signs were< body temperature was :=.* degrees Celsius" respirations were *- breaths per minute" pulse rate was =) beats per minute and blood pressure was )..,+.mmHg. There was no bleeding observed from the incision dressing. The sanitary pad was slightly wet and lochia was still moderate and there were no blood clots. I'(ression6 high risk post caesarean mother" : hours post natally" doing well post# natally. Assess'ent!(ro+le' identi,ied6 as per care plan Plan6 to continue with the plan of care. I'(le'entation6 rs. C.S. was helped with positioning and attachment of the baby to the breast in a lying position. She was advised to continue breast feeding the baby in# order to initiate lactation and help in contraction of the uterus hence preventing hemorrhage. BABS +7e$ti*e data6 the midwife from labor ward said the baby was fine and that his vital signs were stable. She said the baby has not breast feed since birth. O+7e$ti*e data6 body temperature was :=.= degrees Celsius heart rate was )*= beats per minute and respirations were 8. breaths per minute. The baby>s body was warm to touch and pink. He was awake and active. There was no nasal flaring. There was no bleeding from the umbilical cord and the cord ligature was still in situ. He had already passed meconeum and urine. I'(ression6 low risk post natal baby" : hours post#natally and adapting well to extra uterine life. Assess'ent!(ro+le's identi,ied6 high risk for hypothermia" risk for hemorrhage from the cord" risk for infection" risk for hypoglycemia and risk for poor bonding. Plan6 refer to care plan I'(le'entation6 initial assessment of the baby was not done in labor ward according to the labor and delivery notes in the case file. 7nd at this time in post natal ward the initial assessment was also not done because the baby had spent the first : hours post delivery without being initiated to breastfeeding. So in#order to initiate breastfeeding and

).

lactation" the baby was left with the mother to breast feed for some time. The mother was advised to continue breast feeding the baby and she was taught on the comfortable positions and proper attachment of the baby to the breast when breast feeding. The baby was worn in a woolen hat and a jersey. 6xtra warm linen was also added on the baby>s body from head to toe in#order to provide warmth. The mother and guardian were advised to keep the baby warm by avoiding unnecessary exposure to cold environment and removing any wet linen from the baby>s body. They were also advised not to bath the baby before *8 hours to avoid body heat loss through evaporation. rs. C.S. and her mother /guardian0 were advised to be monitoring the umbilical cord for bleeding and notify the midwife immediately if it /bleeding0 occurs. They were also advised not to put anything on the baby>s umbilical cord such as traditional medicine to avoid introducing micro#organisms on the cord which causes infection. She was advised to be washing her hands before breast feeding the baby and after visiting the toilet to avoid cross infection. The baby was put in the same bed with the mother in#order to promote rooming in and bonding. E*al ation6 45698(' E*al ation o, t%e 'ot%er6 found rs. C.S. breast feeding the baby.

S +7e$ti*e data6 mother said she was still breast feeding the baby. She also said she was feeling pain from the incision area. She said the sanitary pad was wet and she had changed it and there were no clots of blood. O+7e$ti*e data6 vital signs were< body temperature was :=.* degrees Celsius" respirations were *- breaths per minute" pulse rate was =. beats per minute and blood pressure was )).,-.mmHg. There was no bleeding observed from the incision dressing. The sanitary pad was slightly wet and lochia was still moderate and there were no blood clots. other was still breast feeding the baby. I'(ression6 high risk post caesarean mother" : hours )9 minutes post natally and adapting well. Assess'ent6 altered comfort pain. Plan6 refer to care plan. I'(le'entation6 the prescribed narcotic analgesic" pethidine )..mg was administered intramuscularly in#order to reduce pain. rs. C.S. was advised to continue with the deep breathing exercise in#order to relax muscles hence reducing the pain. She was also advised on the other probable cause of the pain which was the contraction of the uterus /sub#involution0. She was also advised to assuming positions that were comfortable to her in#order to reduce pain from the wound. She was advised to still continue breast feeding the baby.

))

E*al ation o, t%e +a+# S +7e$ti*e data6 mother said the baby was fine and was still breast feeding. She said there was no bleeding from the umbilical cord. O+7e$ti*e data6 body temperature was :=.+ degrees Celsius heart rate was ):= beats per minute and respirations were 8+ breaths per minute. The baby>s body was warm to touch and pink. He was awake and active. He was breast feeding well. There was no nasal flaring. There was no bleeding from the umbilical cord and the cord ligature was still in situ. His nappies were dry. I'(ression6 low risk post natal baby" : hours and )9 minutes post natally and adapting well to extra uterine life. Assess'ent6 as per care plan Plan6 to continue with plan of care. I'(le'entation6 mother was praised and encouraged to continue breast feeding the baby. E*al ation6 49622(' E*al ation o, t%e 'ot%er ?ound mother still breast feeding baby they were both awake. S +7e$ti*e data6 mother said she was feeling much better and the pain was gone. She said she was feeling sleepy. O+7e$ti*e data6 vital signs were< body temperature was :=.* degrees Celsius" respirations were *- breaths per minute" pulse rate was == beats per minute and blood pressure was )).,-.mmHg. There was no bleeding observed from the incision dressing. The sanitary pad was slightly wet and lochia was still moderate and there were no blood clots. other was still breast feeding the baby. 7 liter of normal saline had finished. I'(ression6 high risk post caesarean mother" : hours :. minutes post natally and adapting well. Assess'ent6 as per care plan Plan6 to continue with the care plan. I'(le'entation6 rs. C.S. was advised to take a nap when the baby stops breast feeding in#order for her to rest and relax her body. )...mls of urine was drained and recorded on the output chart. 7nother liter of ringer>s lactate )...mls was commenced and was left to be dropping at a rate of =. drops per minute.

)*

E*al ation ,or +a+#6 ?ound baby breast feeding. S +7e$ti*e data6 mother said the baby was fine and breast feeding. She said there was no bleeding from the umbilical cord. O+7e$ti*e data6 body temperature was :=.= degrees Celsius" heart rate was )8* beats per minute and respirations were 8: breaths per minute. The baby>s body was warm to touch and pink. He was awake and active. He was breast feeding well. There was no nasal flaring. There was no bleeding from the umbilical cord and the cord ligature was still in situ. His nappies were dry. I'(ression6 low risk post natal baby" : hours :. minutes post natally and adapting well to extra uterine life. Assess'ent6 as per care plan Plan6 to continue with plan of care. E*al ation6 49652(' E*al ation o, t%e 'ot%er S +7e$ti*e data6 mother said that she was fine and nothing was wrong with her. She said she was still breast feeding the baby and breast milk was coming. O+7e$ti*e data6 vital signs were< body temperature was :=.9 degrees Celsius" respirations were *- breaths per minute" pulse rate was +- beats per minute and blood pressure was )*.,-.mmHg. There was no bleeding observed from the incision dressing. The sanitary pad was slightly wet and lochia was still moderate and there were no blood clots. other was still breast feeding the baby. I'(ression6 high risk post caesarean mother" 8 hours post natally and adapting well. Assess'ent6 as per care plan Plan6 to continue with plan of care. E*al ation o, +a+# S +7e$ti*e data6 mother said the baby was fine and he was still breast feeding. O+7e$ti*e data6 body temperature was :=.+ degrees Celsius" heart rate was ):- beats per minute and respirations were 8+ breaths per minute.

):

The baby>s body was warm to touch and pink. He was awake and active. He was breast feeding well. There was no nasal flaring. There was no bleeding from the umbilical cord and the cord ligature was still in situ. His nappies were dry. I'(ression6 low risk post natal baby" 8 hours post natally and adapting well to extra uterine life. Assess'ent6 as per care plan Plan6 continue with care plan E*al ation6 48652(' ?ound mother and baby sleeping and they were left to rest in#order to relax the muscles. E*al ation6 4:652(' E*al ation o, 'ot%er6 S +7e$ti*e data6 some time. rs. C.S. said she was fine and feeling much better after resting for

O+7e$ti*e data6 body temperature was :=.9 degrees Celsius" respirations were *= breaths per minute" pulse rate was +8 beats per minute and blood pressure was )).,-.mmHg. There was no bleeding observed from the incision dressing. The sanitary pad was slightly wet and lochia was still moderate and there were no blood clots. I'(ression6 high risk post caesarean mother" = hours post natally and adapting well. Assess'ent6 as per care plan Plan6 to continue with plan of care. I'(le'entation6 *9.mls of urine was drained and recorded. other was explained to that the baby needs to be assessed fully in#order to check if there was any abnormality or problem since he was not assessed whilst in labor ward. E*al ation o, +a+# S +7e$ti*e data6 mother said that the baby was fine and that he was awake. She said she had changed the nappy since it was wet with urine.

)8

Initial assess'ent o, t%e neonate O+7e$ti*e data General a((earan$e The baby looked active and the whole body was pink in color. He was in a well flexed position Vital si"ns6 body temperature was :=.D degrees Celsius" heart rate was ):8 beats per minute and respirations were 8+ breaths per minute. Bod# ;ei"%t6 :... grams and was within the normal range of *9.. grams to 8... grams . 0ead $ir$ ',eren$e6 :8cm Cro;n to %eel6 8-cm 0ead 'n inspection the head was proportional to the body" hair was well distributed" no haematoma or caput. 'n palpation the fontanells were flat and open. The sutures were not over riding. E#e $o eye discharges seen" no sub#conjunctiva bleeding" the sclera was white" and the pupils were reacting to light. Nose $o nasal congestion" no nasal flaring" inside the nose was moist and the nasal septum was centrally located. Mo t% The lips were soft" not cracked" mucus membranes were pink and there was no drooling of saliva. There was no cleft palate" no tongue tie" or false teeth. Ears There was no ear discharge. The upper pinna ear was in line with the outer canthus of the eye. Ne$< and s%o lder $eck was not webbed" no neck rigidity and no distended jugular veins. There was a full range of motion. $o indication of fractures of the shoulder. U((er e)tre'ities They were symmetrical" no extra digits and not webbed. There was no palmer pallor and there was a full range of motion.

)9

C%est Symmetrical movements of the chest with respirations and barrel shaped chest. There was no chest in#drawing. 'n auscultation no whee5es or rales were heard. Ba$< $o pigmentations" spina bifida was not detected as well as the mylomeningocele. A+do'en oving with respirations and was not distended. There was no bleeding on the umbilicus. The three blood vessels were present and the cord was short about :cm. There was no organomegally. 'n auscultation bowel sounds were present. Genitalia Ct was a male child" no dyspadia and the urethra was patent. An s Ct was patent and baby had passed meconium. Lo;er e)tre'ities %egs were well flexed" symmetrical" no talipes" and there was full range of motion. Ne rolo"i$al assess'ent Moro re,le) 4aby was able to react normally when the arms were left to fall. Rootin" re,le) 4aby was able to follow when touched on the cheeks. S $<lin" re,le) The baby was able to breastfeed when properly positioned and attached. Gras(in" re,le) 4aby was able to grasp the hand Wal<in" re,le) When the baby was lifted up to stand by toes he was able to imitate walking. I'(ression6 low risk post natal baby" = hours post natally and adapting well to extra uterine life. Assess'ent6 as per care plan Plan6 to continue with plan of care

)=

I'(le'entation6 mother was explained to that the baby was fine and that there was nothing wrong with him. She was encouraged to continue breast feeding the baby and keeping him warm. She was advised to sleep with the baby in a treated mos;uito net that was hanging above her bed to avoid mos;uito bits. She was also advised to continue doing what she was advised to do. E*al ation6 4:682(' ?ound rs. C.S. breast feeding the baby and she said she was fine. 4id farewell to her after giving handover to the night duty midwives. DA- ONE POST CAESAREAN SECTION 3T0 AUGUST 1223 /652a' Beceived handover from night duty midwives who said that the mother received all her medication and she had spent the night fairly well. 3652 a' S +7e$ti*e dataE rs. C.S. said she was fine and that she had slept well. She said she had received medication during the night and early morning. She said she was waking up during the night to breast feed the baby. She also said that she had started passing flatus. She said she had changed the sanitary pad twice and there was mild lochia as compared to the past day. She said she was not having any pain and that there was no bleeding from the incision area. She said she had been given a bed bath by her mother early morning. She said she was breast feeding well with no problems. She also said that the baby had slept well and was only crying when he wanted to breast feed or when the nappy was wet. P%#si$al e)a'ination o, 'ot%er =o+7e$ti*e data> General o+ser*ations rs. C.S. looked stable not in pain and well relaxed. She was well kempt in body and clothes. Vital si"ns6 body temperature was := degrees Celsius" !ulse rate was =8 beats per minute" respirations were :* breaths per minute and blood pressure was )*.,+. mmHg. 0ead to toe e)a'ination 0ead Ct was proportional to the body" and there were no scars on the face. Hair was well distributed with no signs of alopecia and hair was treated. E#es Had pink conjunctiva" estimated hemoglobin level was )..9gm,dl. $o discharge was seen" had normal visual field and able to roll the eyes.

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Nose $o nasal congestion" nasal septum was centrally located and no lesions in the nose. Cilia were well distributed and the nostrils were moist. Mo t% %ips were slightly dry. The tongue was pink and no dental carries. There was no oral thrush. Ne$< Centrally positioned" not webbed" no lesions or scars were seen on the neck. There was no goiter and was able to swallow. $o distended veins and carotid arteries were pulsating. U((er e)tre'ities The arms were symmetrical" no pigmentations" and no lesions. Capillary refill time was two seconds. $o limited range of motion. C%est 'n inspection the chest was not barrel" no lesions or bruises" no scars were seen and chest movements were symmetrical. 'n auscultation there was normal air entry" no whee5es or rales. Breast $o lesions" bruises or sores on the breast. $ipples were not inverted. 'n palpation" no mass was detected and colostrum was expressed. Ba$< There were no sores" pigmentation or scars. 'n auscultation there was normal air entry. A+do'en 'n inspection" there was an incision wound" no lesions or bruises. 'n auscultation bowel sounds were absent. 'n palpation there was no organomegaly and it was tender to touch. The incision wound was not bleeding and was covered with a dressing. @terus was firm and well contracted. The bladder was empty. Lo;er e)tre'ities They were symmetrical. Some scars on the legs. There were no varicosities or edema of the feet. She was able to move the limbs. Genitalia 'n inspection" there were no warts" lesions or edema. %ochia was rubra" moderate with no clots. I'(ression 7 high risk post caesarean section mother" ** hours post natally and adapting well.

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Plan6 to continue with care plan. I'(le'entation6 mother was reminded to continue breast feeding the baby and she was also advised to be changing the sanitary pad when wet. She was also advised to keep the baby warm and to be changing the nappy when wet. She was also advised to be monitoring for any danger signs such as bleeding from the incision area" heart palpitations and excessive bleeding from the vagina. She was also advised to start ambulating in#order to promote blood circulation. O+7e$ti*e data ,or +a+#6 vital signs were< temperature was :=.D degrees Celsius" heart rate was ):= beats per minute and respirations were 88 breaths per minute. The baby was awake and active. His body was pink and was in a well flexed position. $o scratches" no pustules or lesions were seen on the baby>s skin. There were no eye discharges. The were no chest in#drawings or whee5es heard. The umbilical cord was dry and clean and there was no bleeding. I'(ression6 low risk post natal baby" ** hours post natally and adapting well. 7ssessmentE as per care plan !lanE to continue with plan of care. I'(le'entation6 mother was shown and educated on cord care and the umbilical cord was cleaned with spirit and clean cotton swabs. E*al ation6 ).E:.am S +7e$ti*e data6 mother said that she was fine and the baby was also fine and breast feeding well. O+7e$ti*e data6 vital signs wereE temperature :=.: degrees Celsius" respirations were )-" pulse rate was +8 beats per minute and blood pressure was )).,-.mmHg. Conjunctiva was pink and there was bleeding from the incision dressing. %ochia was mild and there were no blood clots seen. I'(ression6 high risk post caesarean mother" *8 hours post natally and adapting well. Assess'ent6 as per care plan Plan6 to continue with plan of care. I'(le'entation6 :..mls of urine was drained and recorded. @rinary catheter was removed following doctors orders. Cntravenous fluids were stopped and mother was advised to start taking sips of water and other fluids such as fruit juice. She was advised

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to be urinating fre;uently at#least after every * to : hours to promote contraction of the uterus. O+7e$ti*e data +a+#6 vital signs were< temperature was :=.+ degrees Celsius" heart rate was ):*beats per minute and respirations were 8+breaths per minute. The baby was awake and active. His body was pink and was in a well flexed position. There was no chest in#drawing or whee5es. The umbilical cord was dry and clean and there was no bleeding. 4aby was breast feeding. I'(ression6 low risk post natal baby" *8 hours post natally and adapting well. Assess'ent6 as per care plan. Plan6 to continue with plan of care. E*al ation 41652(' S +7e$ti*e data6 mother said that she was fine and she had taken orange sobo. She said baby was fine and nothing was wrong with him. O+7e$ti*e data6 vital signs wereE temperature :=.+ degrees Celsius" respirations were *." pulse rate was +. beats per minute and blood pressure was )).,-.mmHg. Conjunctiva was pink and there was bleeding from the incision dressing. %ochia was mild and there were no blood clots seen. I'(ression6 high risk post caesarean mother" ) day and * hours post natally and adapting well. Assess'ent6 as per care plan Plan6 to continue with plan of care. I'(le'entation6 prescribed antibiotics flagyl 9..mg and ampicillin 9..mg were given intravenously as prophylaxis for bacteria. O+7e$ti*e data ,or +a+#6 vital signs were< temperature was :=.D degrees Celsius" heart rate was )*- beats per minute and respirations were 8: breaths per minute. The baby was sleeping. His body was pink and was in a well flexed position. There was no chest in# drawing or whee5es. The umbilical cord was dry and clean and there was no bleeding. I'(ression6 low risk post natal baby" ) day and * hours post natally and adapting well. Assess'ent6 as per care plan. Plan6 to continue with plan of care.

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E*al ation 4:652(' S +7e$ti*e data6 rs. C.S. said she was fine and there was nothing wrong with either herself or the baby. She said the baby was breast feeding well and she had changed twice the napkins. O+7e$ti*e data6 vital signs wereE temperature :=.+ degrees Celsius" respirations were )D" pulse rate was +- beats per minute and blood pressure was )*.,-.mmHg. Conjunctiva was pink and there was bleeding from the incision dressing. %ochia was mild and there were no blood clots seen. I'(ression6 high risk post caesarean mother" ) day and = hours post natally and adapting well. Assess'ent6 as per care plan Plan6 to continue with plan of care. I'(le'entation6 mother was advised to continue taking good care of the baby and breast feeding him. She was also reminded to be urinating fre;uently to promote contraction of the uterus. She was also advised to continue ambulating to promote blood circulation. O+7e$ti*e data o, +a+#6 vital signs were< temperature was :+ degrees Celsius" heart rate was ):* beats per minute and respirations were 8= breaths per minute. The baby was breast feeding. His body was pink and was in a well flexed position. There was no chest in#drawing or whee5es. The umbilical cord was dry and clean and there was no bleeding. I'(ression6 low risk post natal baby" ) day and = hours post natally and adapting well. Assess'ent6 as per care plan. Plan6 to continue with plan of care. E*al ation 4:682(' ?ound mother chatting with her mother and sister since it was visiting hour. 4id farewell to mother after giving handover to night duty midwives. other was advised to report any changes to the midwives and was assured of continuity of care.

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DA- TWO POST CAESAREAN SECTION ?T0 AUGUST 1223 /652a' Beceived hand over from night duty midwives who said that the mother had received all her medication and there was no complaint raised during the night and early morning. S +7e$ti*e data6 rs. C.S said that she had no problems except slight pain from the incision. She said that she was taking fluids and she took soft porridge that morning. She also said that she had been urinating well during the night without problems and had not yet passed stools. She said that she was having mild discharge / lochia0 compared to the previous day. She was able to breast feed well without any discomfort or breast pain. O+7e$ti*e data6 She was well kempt in body and in clothes. She looked well relaxed" happy and calm. Aital signsE blood pressure was )*.,+. mmHg" temperature was :=.9 degrees Celsius" pulse rate was -.beats,minute and respiratory rate was *8breaths,minute. Conjunctiva was pink#estimated hemoglobin was )..9g,dl. ucus membranes were pink in color. $o masses palpated" no breast engorgement" nipples were clean and not cracked. The dressing on the incision wound was dry. @terus was well contracted and firm and Dcm below the umbilicus. The bladder was empty. %ochia was 7lba and it was mild. I'(ression6 high risk post caesarean section mother" ) day and *) hours post natally and adapting well. Assess'ent6 altered comfort pain. Plan6 refer to care plan I'(le'entation6 3692 AM !aracetamol 9.. mg was already given in the morning =E.. am and recorded on the chart. 7dvised the patient on breast care and perineal care /self hygiene0. She was advised to be taking a bath at least two times a day and to be changing sanitary pads as soon as they are wet and whenever necessary. She was also advised to be using clean" dry sanitary pads and also to be cleaning her perineum from front to back after defecating or urinating. 7dvised the patient to empty her bladder fre;uently every * hours. 7dvised the patient to wash her hands soon after using the toilet and before breastfeeding the baby. 6ducated rs. C. S on good nutrition. This included the information on the six food groups / meat" legumes" vegetables" fats" fruits and carbohydrates0 7dvised the patient to be taking a lot of fluids and to be eating food that has fibers to reduce the incidences of constipation.

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6ncouraged the patient to continue ambulating to promote blood circulation and wound healing. The wound dressing was removed and the wound was cleaned with spirit and it was clean

42622 a' The patient said that she had reduced pain Aital signs wereE blood pressure was )*.,+. mmHg" temperature was :=.degrees Celsius" pulse rate was += beats per minute and respiratory rate was )= breaths per minute. %ochia was alba and mild" and was not smelling 41622 noon Aital signs wereE blood pressure was )*.,-. mmHg" temperature was :=.+ degrees Celsius" pulse rate was +-beats,minute and respiratory rate was *.breaths,minute. %ochia was alba and mild" and was not smelling The patient said that she had passed urine 49622(' Aital signs wereE blood pressure was )*.,-. mmHg" temperature was :=.= degrees Celsius" pulse rate was -.beats,minute and respiratory rate was *.breaths,minute. %ochia was mild. !rescribed medications were administered flagyl 8..mg and amoxyl 9..mg orally. 4:652(' Aital signs wereE blood pressure was )*.,-. mmHg" temperature was :=.8 degrees Celsius" pulse rate was +*beats,minute and respiratory rate was )-breaths,minute. %ochia was mild. other was advised to continue breast feeding the baby. Handover was given to night duty midwives and mother was advised to report of any changes to the midwives. 4:682(' 4id farewell to the mother E*al ation rs. C.S demonstrated understanding of the information that was given to her because she was able to pass urine. She was also able to ambulate to promote circulation and wound healing. She continued breast feeding the baby on demand through out the day.

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SUBSE@UENT ASSESSMENT O& T0E BABS +7e$ti*e data6 mother said that the baby had no problems and slept well during the night. He was able to breast feed" to pass urine and had passed stools three times since the previous night. O+7e$ti*e data6 The baby was pink and was sleeping. Temperature was :=.* degrees Celsius" pulse rate was ))-beats,minute" and respiratory rate was 88breaths,minute. Conjunctiva was pink. @mbilical cord was dry and clean. I'(ression6 low risk post natal baby" ) day and *) hours post natally and adapting well. Assess'ent6 as per care plan. Plan6 to continue with plan of care. 48698 (' The baby was active and pink in colour Temperature was :=.- degrees Celsius" pulse rate was )*. beats,minute and respiratory rate was :*breaths,minute. Conjunctiva was pink 6yes Gno discharge was seen $ose Gno nasal flaring Chest# no chest in#drawing @mbilicus# the cord was drying" clamp was tight and not bleeding !erineum# nappy was dry I'(le'entation6 other was advised to continue breast feeding the baby and be changing nappies when wet. She was also told to be monitoring the baby>s condition and report any changes. Continued encouraging the mother to keep the baby warm by covering him with clean" warm and dry linen Taught the mother on how to clean the umbilical cord and demonstrated on the procedure. $o signs of infection seen 6ncouraged and advised the mother to keep the umbilicus clean and not put anything on it 6ducated the mother on the danger signs on the baby and when to come to the hospital with the baby. 6ducated the mother on the immuni5ations of the baby and the importance of getting the baby immuni5ed.

E*al ation *8

The mother demonstrated understanding on how to take care of the baby by keeping him warm and by demonstrating on how to clean the umbilical cord.

DA- 5 POST CAESARIAN SECTION 44T0 AUGUST 1223 ?622a' S +7e$ti*e dataE rs. C.S said that she had no problems" and she slept well during the night. (uring the night she woke up to breastfeed to baby. She said that the pain on the incision wound had subsided. She said that she was still taking the prescribed oral medications. She also said that she had started taking solid food and was able to pass stools and urine. She said that she was having mild lochia. She said that the doctor review her and she was discharged and to be reviewed on )9th 7ugust *..-. General a((earan$e =o+7e$ti*e data> She was well kempt in body and in clothes. She looked well relaxed" happy and calm Vital si"ns6 blood pressure was )*.,-. mm Hg" temperature was :=.- degrees Celsius" pulse rate was --b,min and respiratory rate was *.b,min. E#es# Conjunctiva was pink. Mo t% Gmucus membranes were pink in colour Breast G no masses palpated" no breast engorgement" nipples were clean and not cracked ilk was expressed. U((er e)tre'ities G palms were pink" capillary refill took * seconds" no edema of hands A+do'en G the wound was dry @terus was well contracted and firm and +cm below the umbilicus The bladder was empty %ochia was 7lba and it was mild Lo;er e)tre'ities Gno edema" no varicose veins" no deep vein thrombosis I'(ression6 High risk post natal mother day 8 post caesarian section adapting well postnataly PLANE 7s in discharge plan INTERVETIONS rs. C.S was discharged on !aracetamol )g - hourly orally for : days. 7moxyl 9..mg hourly orally for : days and ?lagyl 8..mg - hourly orally for : days 6ducated rs. C.S on danger signs such as severe headache" di55iness" severe abdominal pains" severe bleeding" offensive lochia 7lba and serous" severe leg pains and advised her

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to come to the hospital if such danger signs occur. (emonstrated self breast examination to the patient and she demonstrated back. 7dvised the mother to be examining her breast * to : days after the end of menstruation. Counseled the patient on family planning its importance and the methods available. 7dvised her on the changes that occur post#natally such as lochia rubra" alba and serosa and also on involution of the uterus. Beminded rs. C.S on the importance of rest and sleep. Beminded her to be urinating fre;uently at least every * hours even when there is no urge. 7dvised her on the importance of post natal check at ) week and six weeks. She was also advised to come for post natal check up on )9th 7ugust *..EVALUATION other explained on how she would be taking the drugs and self care. She demonstrated on breast examination and showed understanding of the information that had been discussed with her by answering ;uestions. ASSESSMENT O& T0E BABThe mother said that the baby had no any other problem. He was able to breastfeed" pass urine and able to pass stools. General A((earan$e The baby was pink and was sleeping Temperature was :=.D degrees Celsius" pulse rate was ).=b,min" and respiratory rate was :-b,min Conjunctiva was pink E#es G no discharge seen Nose# no nose flaring C%est# no in drawing U'+ili$ s G was drying normally" clamp was tight and not bleeding. Perine ' G nappy was dry and no rashes were seen I'(ressionE $ormal baby 8 days post natally adapting well PLAN6 Befer to care plan IMPLEMENTATION 6mphasi5ed to the mother on the care of the baby such as bathing and cord careA 6ncouraged the mother on exclusive breastfeedingA Beminded the mother on the danger signs of the baby such as body feeling hot to touch" baby refusing to breastfeed" discharging pus from the eyes and to come to hospital if she sees any change in the baby>s condition. EVALUATION rs. C.S. was able to position and attach baby properly to breastfeed. She demonstrated and understanding on the information given to her by answering ;uestions.

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DISC0ARGE CRITERIA
MOT0ER rs. C. S will be discharged based on the following criteriaE Aital signs should be within normal range i.e. body temperature should be within the range of :=#:+.*oc" blood pressure around the average normal reading of )*.,-. mmHg" respirations within the range of )=#*. breaths per minute and pulse rate within the range of =.#-. beats per minute. %actation should be well established and the baby should be suckling well. Cncision wound should be clean and dry with no active bleeding and no signs of infection such as development of pus and inflammation. The uterus should be well contracted and non#tender. She should experience mild flow of non#offensive lochia rubra which should not contain any debris of retained products of conception. She should be physically and psychologically stable. She should not have signs of anaemia and jaundice i.e. pale and yellow conjunctiva respectively. She should also be able to pass stool and urine with no difficulties. She should have knowledge and skills in caring for the neonate and ensuring safety of the neonate e.g. bathing and keeping the neonate warm. She should have knowledge of danger signs in of baby and post#natal mother e.g. bulging fontanels and active vaginal bleeding. She should have knowledge on exclusive breastfeeding" family planning" incision wound care" umbilical cord care" mixed diet and vaccination.

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BAB Aital signs should be within the normal ranges thus< temperatureE :=.)#:+.*oc" heart rate )*.#)=. beats per minute and respiration :.#=. breaths per minute. 4aby should be able to suckle breast milk well. 4aby should not manifest signs of anaemia and infection such as pale conjunctiva and bulging fontanel respectively. 4aby should be able to pass meconeum and urine. 4aby should be active with all reflexes established. The umbilical cord should be dry with no signs of infections. 4aby should generally be pink with no cyanosis or jaundice. 4aby should not have ophthalmic neonatorum or oral thrush. DISC0ARGE PLAN Breast ,eedin"B +reast $are and %and ;as%in"A rs. C.S. will be taught the advantages of breast feeding" to the baby" mother and family that includes providing the necessary nutrients to the baby" uterus involution" and saving money respectively. She will be taught on exclusive breast feeding with emphasis on breastfeeding on demand or at least eight times a day. She will further be taught to breast feed on demand and to allow the baby to empty both breasts at a time to ensure that the baby gets enough milk" production of more milk and prevent breast engorgement. She will also be taught on proper position and attachment of the baby to the breast which ensures that the baby is suckling enough milk and it also prevents development of cracks and sores. She will also be advised to clean her breast at least three times a day with a clean piece of cloth and clean water to reduce chances of infecting the baby.

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She will also be taught on the importance of washing hands before breast feeding baby and after changing baby>s nappy or visiting the toilet to prevent cross infection. Wo nd Care rs. C.S. will be taught how to care for the wound and to be cleaning it once a day with clean cotton swabs and spirit to prevent infection. She will be advised to avoid touching the incision area with hands to prevent introducing microorganisms. She will be advised to hold the abdomen when coughing or snee5ing to reduce intra# abdominal pressure thereby minimi5ing pain and chances of incision gaping. She will be advised to be waking up from a lying position in side ways to reduce pressure on the incision are and hence minimi5e chances of gaping. Dan"er si"ns rs. C.S will be taught on danger signs she is to look out for in her body and the baby>s that should prompt medical help should there be an occurrence. These danger signs areE Mot%er6 fever" jaundice" post#partum hemorrhage" offensive lochia" severe headache" di55iness" deep vein thrombosis" pus or oo5ing from the incision area" gaping of the incision wound and sub#involution of the uterus. Ba+#6 bulging fontanel" sunken fontanel" fever" jaundice" eye discharge" nasal flaring" chest in drawing" swelling" redness and pus exudates from umbilical root or stem Diet rs. C.S will be taught on the six food groups such as animal and plant proteins" fruits" vegetables" fat and oils and carbohydrates. She will also be taught the importance of each group which is body building and repair of worn out tissues" protection from diseases and energy giving. She will also be advised that at every meal at least four groups should be available. She will further be given a practical example of affordable and locally found foods that form the re;uired food groups to reinforce her understanding. She will be advised to take at least : meals in a day with snacks in between such as oranges" mangoes depending on which type is in season. She will also be advised to be taking lots of fluids not less than - tumblers in a day to help form soft stool for easy elimination.

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Perineal and +o;el $are She will be advised to change sanitary pads each time they are wet and not less than four times a day to ensure dry perineum and prevention of growth of microorganisms. She will also be taught to clean the perineum from front to back each time she passes stools or urinate to prevent introduction of microorganisms to the genitalia. Bladder $are She will be advised to be passing urine fre;uently at least every *#: hours to help in easy uterine involution and prevent post partum hemorrhage. Ba+# $are rs. C.S. will be taught how to bath the baby and that she should be bathing the baby once a day with luke#warm water in a room. She will also be taught to be changing the nappies when they are wet to avoid causing nappy rush. She will be advised to be cleaning and washing baby>s utensils and clothes to remove micro#organisms. She will also be taught how to care for the umbilical cord that she should be cleaning it with spirit or plain water and a clean cotton swab once a day or whenever necessary.

A'+ lation rs. C.S. will be taught that ambulation aids in removal of blood and blood clots from the uterus by the way of gravity hence preventing post# partum hemorrhage. 7mbulation also reduces chances of development of thrombo#embolism. E)er$ises rs. C.S. will be taught the importance of exercises which help in early regain of pre# pregnancy state. She will also be taught keggels exercises which help in regaining vaginal wall>s pre#pregnancy tonicity. She will be discouraged from doing strenuous exercises as her pelvic structures will take time before regaining their normal pre# pregnancy state. Slee( and rest rs. C.S. will be advised to have enough time for sleep and rest which are vital in regaining of one>s pre#pregnancy state. She will further be taught to group activities together to find time to rest and sleep when the baby is also sleeping.

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I'' niCations rs. C.S. will be advised to complete TTA doses and will be encouraged to help baby complete his doses. Types of vaccines the baby is expected to receive and time intervals for each dose will be taught to her. &a'il# (lannin" rs. C.S. will be taught on the importance of family planning and the available methods. She will also be advised to seek further and specific counseling in family planning at family planning clinic when she goes back to the hospital for six weeks post#natal check. Se) alit# rs. C.S. will be taught that hospital policies recommend resumption of sexual intercourse six weeks post#nataly. 4y six weeks mother will have regained most of her pre#pregnancy form. !rolonging the period of sexual inactivity can lead to unfaithfulness on the part of the partner and hence risking HCA infection and other sexually transmitted infections. &ollo; ( $are rs. C.S will be taught the importance of one week post#natal visit and Six weeks post#natal visit and she will be given appointment days i.e. )8th 7ugust *..for the one week postnatal check and )-th September *..- for six weeks postnatal check. C0ALLENGES AND LIMITATIONS %imited availability of resources for example we did not have the followingE midwife>s pack" sterile packs" sterile sanitary pads etc. ?ailure to counsel mother together with her husband due to lack of space and privacy in the ward. ?ailure to conduct one week postnatal check due to failure of rs. C.S. to report to the hospital. ?ailure to make a home visit due to lack of time and transport. ?ailure to conduct six weeks post#natal assessment because we will have shifted to a different ward.

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LESSONS LEARNT 7ll post#natal women including multiparas need to be taught on child care as not all of them are updated with ever changing policies based on research findings. ultiparas despite having undergone labor and delivery still need to be reminded of child care. Couple counseling is very vital because decisions about woman>s and baby>s health might not be sorely woman>s business. ONE WEEK POST NATAL C0ECK 'ne week post natal check was not conducted because rs. C.S. did not report to the hospital on )8th 7ugust *..- despite being given appointment date.

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