A CASE STUDY ON ANTEPARTUM HAEMORRHAGE (PLACENTA PREVIA

PURBANCHAL UNIVERSITY
ASIAN COLLEGE FOR ADVANCE STUDIES
    SATDOBATO,LALITPUR




                                                     A

CASE STUDY ON

ANTEPARTUM HAEMORRHAGE
                    (PLACENTA  PREVIA)












SUBMITTED TO                                     SUBMITTED BY:
MRS. PARBATI PANDEY                                                SMRITI  MANANDHAR
MR. RATNA GURAGAIN
MRS. MAIYA SHOVA MANANDHAR
MRS.BHAGWATI

ACKNOWLEDGEMENT

                        I am thankful to Asian college of Advanced Studies for providing me an opportunity to carryout this case study as practical fulfillment of First year curriculum of post basic bachelor of midwifery nursing.

I would like to thank all the respected Madams, hospital staffs and my friends and also to my subject teachers who have contributed their valuable time, knowledge and guidance to prepare this small case study about Antepartum haemorrhage.

I want to express my deep gratitude to MEENA TAMANG (my case), her family and her visitors. This case study would have never been success without her and her family’s co-operation.

At last I would like to express my profound appreciation to all my colleagues for their help and support.

Yours Sincerely

 SMRITI MANANDHAR

B. N. First Year

Roll No: 37

BACKGROUND

High risk pregnancy is defined as one in which mother, fetus and newborn is or will be at increased risk for mortality and morbidity due to problems and complication during pregnancy.

All pregnancies and deliveries are potentially at risk. However, there are certain categories of pregnancies where the mother, the fetus or the neonate is in a state of increased risk.

Incidence: - 45% in developing countries and 25% in developed countries.

The high risk case study gives us the knowledge about high risk condition in pregnancy; labour and puerperium like prolong labour, PIH, Post term pregnancy, APH, PPH, RH Negative, Maternal and Fetal distress, obstructed labour etc.

In this case study I got chance to get some knowledge about how to manage maternal and fetal health, how to minimize maternal and fetal risk factor to minimize maternal and fetal mortality and morbidity.

Globally, 585,000 women died from the complication of pregnancy and labour (WHO 1996). More than 99% of deaths occurred in developing countries and the MMR is at 100 times higher in Nepal than in other developed countries. The MMR of Nepal is 539/100000 (1996, DHS) live births in one of the highest in the South East Asia Region and the world.

It is due to lack of knowledge, poor health service, poor transportation, lack of awareness, low socio-economic condition, cultural factors which determines the status of women and their health seeking practices. If we detect these risks in time we can minimize the complication and risk in Anti-natal, Intra-natal and Post-natal. Nowadays these services are included in Safe Motherhood Program.

Objectives of high risk case study:

                          

This case study was done during my 3rd week of Midwifery practicum on Emergency in Paropakar Maternity & Women’s Hospital, Thapathali. The objectives of this case study are to provide holistic approach of care to patient, applying nursing theory and gain detail knowledge about a particular disease or case. The case that I have chosen for my case study was Antepartum haemorrhage(placenta previa).

The specific objectives of this case study are as follows:-

1.      To upgrade knowledge about Antepartum haemorrhage(placenta previa), it’s diagnosis, treatment and management including nursing management.

2.      To develop harmonious relationship among the patient & visitors.

3.      To provide holistic nursing care to my patient by using nursing process and nursing theories.

4.       To gain the detail knowledge about one specific case and it’s nursing management.

5.      To identify the causes, pathophysiology, clinical features and diagnostic investigation of Antepartum haemorrhage(placenta previa).To obtain detail history & perform physical examination of my patient.

6.      To compare the causes, clinical features, diagnostic investigation & treatment of  Antepartum haemorrhage(placenta previa)., between the patient & book.

7.      To identify and compare normal developmental task of my patient.

8.      To apply knowledge from the basic science, nursing theory, nursing care plan, pharmacy and pharmacology and other related courses to plan and implement nursing care.

9.      To prevent the patient from further complication of disease.

10.  To provide the health education and preventive measures to client and his family about betterment of health to maintain and promote health and prevent other common illness and infection.

11.  To minimize the stress of the patient and his family by using appropriate diversional therapy.

12.  To involve the patient, his family members and health team workers in discharge planning and follow up.

13.  To precede information and knowledge about Antepartum haemorrhage(placenta previa) through case presentation.

 

PART I

Biographic data of the patient

Name:                                    MEENA TAMANG

Age:                                       40yrs

Address:                               Makwanpur

Occupation:                         Housewife

Education:                           Illiterate

Blood group:                       O +ve

Married for:                          16 year

Religion:                            Hindu

Socioeconomic status:    Low socioeconomic status

Attended doctor:                Group ‘F’

Unit Incharge:                    DR.Madhu Shrestha

Husband  name:                 Rajendra Tamang

Occupation:                         Agriculture

I. P. No:                                  18255

Diagnosis:                            G6 P5 L4 at 29+2 WOG with APH(Placenta Previa)

Date of Admission:            2068-11-15 at 7.30 A.M

Ward:                                     EMERGENCY

Hospital:                               Thapathali Maternity Hospital

 

History taking

   History taking is a type of interview that is used to collect relevant data from patient. About 80% of the information is obtained by history taking. History should be taken in systematic way without any omissions & should be complete & accurate to develop a diagnosis & effective care plan. The information obtained from history taking is included in subjective data in the sense that it is given from the patient’s or relatives own point of view.

      I also collected subjective data of my patient from thorough history. The result of data collected was as follows:

History of present Illness:  

40 yrs pregnant female of  29 weeks and 2 days gestation presents to the emergency room because of vaginal bleeding since 1 month;spotty during early days but significant over the last 5 days.  The patient also reports some contractions, but denies any continuing abdominal pain.  She denies any recent trauma.

Early treatment was done on reional hetauda Hospital.then the patient war referred to the center hospital,Paropakar Maternity and Women’s Hospital,Thapathali.

Past Obsetrical History:
-G6 P5l4 (6 gestations, 5parity, 1 pre-term,  4 currently living)
-5 previous SVD’s (spontaneous vaginal delivery)

-4 female child birth in full term gestation and weight consequently 15yrs,12yrs,7yrs,and6 yrs ago
-Second male child birth 13years ago,weighed 2000grams,premature at 32 weeks of gestation;but died at 6months with unknown reason
- previous obstetrical complications during pregnancies : All SVD’s with precipitated labour of about  4-5 hours and a child birth premature delivery with mortality of unknown cause at 6 months.

Menstrual History:

Menarche at the age of 15 years with regular  menstrual cycle of 28 -30days.

Minimal blood loss about 50 -100 ml in 4-6 days with occasional dysmenorrhage. 

Past Medical History:

None(no any history of tuberculosis, diabetes,hypertension,anemia,heart disease,

childhood disease,jaundice ,allergy to food and drugs and STD )

Past Surgical History:None

Family History:  Unremarkable, no history of twins or multiple gestations

Including no any  remarkable medical history of illness in family.

Social History:  Patient lives with her husband and daughters in rural region of Makwanpur district.  Denies any smoking, alcohol or other drug use during her pregnancy.  Denies any spousal abuse.  Illiterate, currently works as a housewife.  Low economic status.

Current Gestational History:
- G6 P5l4

-Date of Last Menstration:  20/04/068
-Estimated Date of Delivery:  27/1/068
-Estimated Gestational Age (based on dates):  29weeks 2 days
- Antenatal  visit at the nearer health post at hetauda twice ant 1^st dose of Inj.T.T. 0.5ml I/M taken

Contraceptive history:

Depo-provera was used.

Health seeking practice:

She belongs to an uneducated family. Although,she and her family have belief in traditional method like “Dhami” and “Jhakri”, they were aware about the essentiality of the health services.If somebody is sick,they  perfer visiting the health post nearby for treatment.

Environmental factor:

Habituated in 2 stroyed resident with 7 rooms separate kitchen and sanitary laterine within local rural environment of adequate electricity,water, transportation, local health and education facilities.

Nutritional History:

Casual dietary pattern of nepalese khana, roti and non vegeterian meals;usual 5/6 times during pregnancy.No denial to food and appetite.

Developmental History:

Normal  developmental history from infancy to young adult.

Habits/Psychosocial History:

-sleeping pattern of around 8 hours at night and 2 hours a day if possible.

-interested in household works  and performing daily activities

-normal micturation and regular bowel habits

-cope and understand the situation well

-good relation with family,parents ,peer groups and relatives

-Attitude of male dominant society persist so,the family crisis of present health prblem and sex determinance of the child was issued.

Physical examination of my case

Objective Data :-

A physical examination is the evaluation of a body to determine its state of health. A complete health assessment also includes gathering information about a person’s medical history and lifestyle, conducting laboratory tests, and screening for disease. These elements constitute the data on which a diagnosis is made and a plan of treatment is developed.

     I also performed the physical examination of Mrs.Meena Tamang to determine her health status. The techniques used for physical examination are:

·         Inspection

·         Palpation

·         Auscultation

·           Percussion

Physical Exam during admission:
Vital Signs:  Stable (BP – 100/60, P – 86 b/min)
General Appearance:  No apparent distress, appeared clinically stable,pallor present
Skin :Elastic, capillary reflex < 2 seconds

Weight :42kg

Height:  5feet

Uterine Height:  30 cm

Per vaginal bleeding:clots present with placental tissue seen and

Fetal Lie: Longitudinal

Presentation:Cephalic

Enagement of Presenting part:Free
Contractions:  Present
Fetal Heart Tones:  138 x minute

Cervical Exam:  Deferred but cervical OS opened

Brief Differential Diagnosis:
- Placenta Previa
- Placental Abruption
- Displacement of Cervical Mucous Plug
- Premature Rupture of Membranes
- Cervicitis, Vaginitis/Vulvovaginitis

Diagnostic Tests: Transabdominal Ultrasound (see below)
Number of Gestations:  1
Lie:  Longitudinal
Position/Presentation: Right /Cephalic
Fetal Heart Tones:  144 x minute
Fetal Movements:  Present
Placenta:  Partial  occlusion of internal cervical os

a)    General Appearance

Well oriented to time, place and person. Well conscious, co-operative, slightly anxiety and fear, no pallor and anemic.

b)   Vital Sign

            Pulse:                         86/m

            Respiration:              22/m

            Temperature:            97 degree F

           BP:                               100/60

          Weight:-                     42kg

          Height:-                     5feet

c)    Nutritional status

The mother has gain average weight with respect to height.

d)   Mental state

Alert response appreciably

e)    Personal Hygiene

Seems clear and wear clean cloths

f)     Head

Clean, dry and smooth hair, no lice, no extra growth

g)   Ears

Normal shape, no swollen glands, no valve discharge

h)   Eyes

No discharge, no swollen, normal vision, normal eye movement

i)     Lips

Normal lips, moist, no cracks

j)     Tongue

Pink, no dehydration, moist

k)    Gums

No swelling and no bleeding

l)     Skin

          Slightly pale, no redness, not any liaison

m)  Lymph node

Not visible and palpable

n)   Chest

Symmetric shape and size of the chest, no shortness of breadth, no any abnormal sound, heart beat regular and normal

o)   Breast

Both breasts are symmetrical in shape and size. No lump found

p)   Arms & legs

Shape and size normal, full range of motion, Edema + in ankle

q)   Abdomen

1)    Inspection

Ovoid shape, normal size, no any scar, linea nigra present, no any visible dilated veins

2)    Palpation

·         Fundal palpation: There is normal growth of fetus and fundal height term size

·         Pelvic palpation:On pelvic palpation head is engaged

·         Pelvic grip palpation: The head is fixed and engaged

           

3)    Auscultation

On auscultation FHS is heard regular and 138/min

r)     Genitalia

No swelling, no redness, no any infection.

s)    Reflexes:

§  Motor and sensory reflex-good

§  Corneal reflex-positive

§  Biceps reflex-positive

§  Triceps reflex-present

§  Brachio-radial reflex-both forearm flex

§  Knee-jerk reflex-present

§  Planter reflex-present

§  Ankle reflex-present.

Summary of History Taking and Physical Examination

History taking and physical examination helps to reveal information about the patient. They are the tool in obtaining subjective and objective data and thus helps to assemble information about patient.

About 80% of the information in the assessment is obtained by history taking. It is therefore essential to take history in systematic manner. About 15% of the information is revealed by physical examination. It helps to identify the health status of the patient. Physical examination is performed to gather objective data and to correlate them with subjective data. It also reveals additional problems that the patient have not recognized. When doing physical examination, cephalo-caudal approach is followed, that is head to toe approach.

After performing history taking and physical examination following things were found:

·         Patient was anxious, but cooperative.

·         Patient belonged to middle class family.

·         No history of alcoholism and smoking.

·         She is anxious and restless too.

·         Vitals are stable

·         Nutritional status-satisfactory

·         No any abnormalities found in other regions

·         Appetite-slightly decreased

         

                                                              

PART II

 

Antepartum Haemorrhage

Any bleeding that occurs from the genital tract after the 24 weeks of viability/gestation till before the birth of the baby

Classification of antepartum haemorrhage

1.Placental site Bleeding:

A.accidental haemorrhage or Abruptio placenta:

A condition characterized by separation of a normally implanted placenta

B.Placenta previa:

Placental implantation in the lower uterine segment near or at internal cervical OS.

C.Vasa previa:

It is the rupture of marginal sinuses,most probably the rare cause of APH.

2.Extra placental bleeding:

·         Local cause:

vulvular vein varicosities,cervical erosions,cervical polyps,cervical carcinomas,and trauma

·         Other causes:

Excessive show

Coagulopathies

Uterine rupture

Idiopathies bleeding

·         Unclassified (bleeding of unknown origin)

PLANCENTA PREVIA:

The implantation of placenta in the lower uterine segment near or at internal cervical OS.

Based on this patient’s clinical presentation, placenta previa was suspected and further confirmed by transvaginal ultrasound.  Placenta previa is defined as the presence of placental tissue over or adjacent to the cervical os.

Risk Factors:

Below is a list of several risk factors that are associated with placenta previa.  Our patient had several, including increased parity, increased maternal age, and residence in higher altitude.

List of associated risk factors for placenta previa. From "Bates Obstetrics."

 Epidemiology :

·         1:300livebirths

·         0.3-5% of total APH cases

·         1.5-5% of cases with pervious ceaserean section

·         Complete placenta previa prevalence rate :20-45%

·         Partial placenta previa prevalence rate:30%

·         Marginal placenta previa prevalence rate:25-50%

Classification of placenta previa:

              I.        Type I Placenta previa(Low lying placenta previa):

Only the lower margin of placenta reaches into upper portion of uterine segment .vvaginal delivery is possible. There is th e low risk of antepartum haemorrhage and maternal and fetal condition is good.

            II.        Type II Placenta previa(Low lying Marginal placenta previa):

Marginal placenta extends upto lower uterine segment neat the internal Os of the cervix. Vaginal delivery is possible particularly if placenta is anterior .Blood loss is usually moderate although maternal and fetal condition vary;fetal hypoxia is more likely to be present than maternal shock.

           III.        Type III placenta previa(incomplete central placenta previa/partial placenta previa):

Placenta is located over the internal Os but not centrally.Bleeding is likely to be severe,particularly when lower uterine segment stretch and cervix begin to efface and dilate in late pregnancy. Vaginal delivery is inappropriate because placenta preceeds the fetus.

          IV.        Type IV placenta previa(complete central placenta previa/ total placenta previa )

Placenta is centrally located over the internal Os and torrential haemorrhage is more likely. Caesearean section is essential in order to sae the lives of both mother and fetus.

Diagram showing different categorizations of placenta previa.

Classically, the clinical presentation of placenta previa is painless vaginal bleeding in the second or third trimester.  In contrast, placental abruption, classically presents with painful vaginal bleeding.

Pathophysiolgy:

Placental implantation is intiated by the embryo (embryonic plate) adhering in the lower (caudal)uterus.With the placental attachment and growth ,the developing placenta may cover the cervical os.However it is thought that a defective decidual devascularization occurs over the cerix,possibly secondary to inflammatory or atrophic changes. As such of the placenta haing undergone atrophic changes could persist as a vasa previa.

A leading cause of third trimester bleeding/haemorrhage,placenta previa present classically,a painless bleeding.Bleeding is though to occur in association with the development of the lower uterine segment in third trimester.placental attachment is disrupted at this area gradually in the preparation of the onset of labour.When  this occur at implantation site as the uterus is unable to contract adequately and stop thw flow of blood from the open vessels.

Thrombin release from the bleeding site promotes uterine contraction and a vicious circle of bleeding,uterine contraction placental separation and bleeding persists.

Aetiology:

The exact cause is generally unknown. The predisposing factors includes

Predisposing factors includes

S.n	According to book	According to patient
1	Grand multiparity	She is also Grand multiparous mother.
2.	Multiple pregnancies	Not present.
3	Infertility treatment	Not present
4.	Previous uterine surgery/ caeseran section	Not present
5.	Fetal Malpresentation	Not present
6.	Uterine anomalies	Not present
7.	Short interpregnancy interval	Interpregnancy interal is about 1 ½ years
8.	Smoking	Patient is non smoker
9.	Cocaine	Not any

Sign and symptoms:

Signs:

S.n	According to book	According to patient
1	Patient general condition is pale and anaemic are proportionate to visible blood loss	Patient general condition is pale and anaemic
2.	On abdominal examination; ·         The size of uterus reveals proportion to period of gestation ·         The uterus feels relaxed, soft and elastic without any localized area of tenderness ·         Persistence of malpresentation(breech transverse or unstable lies is more frequent) ·         Head floating while palpation	On abdominal examination; ·         The size of uterus reveals proportion to period of gestation ·         The uterus feels relaxed, soft and elastic without any localized area of tenderness ·         Persistence of malpresentation(breech transverse or unstable lies is more frequent) ·         Head floating while palpation
3	If severe,signs of hypovolemic shock may present and fetal distress may  predispose.	At operation,mild meuconium stained was observed
4.	Blood  loss is often bright red	Bright red colored blood loss observed

Symptoms:

S.n	According to book	According to patient
1	Sudden onset	-bleeding present spontaneously 5 days back
2.	Painless bleeding	-Presence of painless bleeding
3	Apparently causeless and recurrent	No any history of trauma or injury or previous placenta previa

Diagnostics investigations:

Transabdominal (96-98% sensitivity) or transvaginal (almost 100% sensitivity) ultrasounds are the diagnostic methods of choice for confirming placenta previa.  Ultrasound can not only diagnose placenta previa, but further define it as complete, partial, or marginal, which can have implication in how to manage the patient. Placenta previa that is diagnosed before 24 weeks of gestation should be managed conservatively, and a repeat sonogrophy should be done between 28 and 32 weeks’ gestation.  Many cases of placenta previa that are diagnosed in the second trimester will resolve by the third trimester.

Textbook image of placenta previa from "William's Obstetrics." Transabdominal sonogram of the placenta (white arrowheads) behind the bladder covering the cervix (black arrowheads).

Textbook image of placenta previa from "William's Obstetrics." Transvaginal sonographic image of the placenta (arrows) completely covering the cervix adjacent to the fetal head.

Cervical Examination:

A cervical examination was deferred in our patient, as appropriate management.  Because of the risk of provoking life-threatening hemorrhage, a digital examination is absolutely contraindicated until placenta previa is excluded.  Such digital cervical examination is never permissible unless the woman is in an operating room with all the preparations for immediate cesarean delivery—even the gentlest digital examination can cause torrential hemorrhage.

Haematological reports:

·         Complete blood count

·         Haematocrit

·         Blood group and crossmatch

·         Bleeding time/clotting time

Investigation done to my case

Investigation	Normal value	Findings
		11/15	11/16	11/18	11/20
Blood Group		O positive	-	-
Hemoglobin	12 – 14 in female	7.3	9.1	4.6	9.7
WBC
Platelets		15000	-	-	-
Neutrophils		90	-	-	-
Lymphocytes		10%	-	-	-
Sugar (R)	80 – 100 mg	-	-	-	-
Urea	15 – 40 mg	18	-	-	-
Creatinine	0.4	0.7	-	-	-
Sodium	135 ­– 145 m.mol/l	138	-	-	-
Potassium	3.5 – 4.5 m.mol /l	4.2	-	-	-
Bilirubin T/D		T-0.9/D-0.3	-	-	-
PT		14sec	-	-	-
BT		12sec	-	-	-
SGPT		16	-	-	-
SGOT		24	-	-	-
VDRL		Non- reactive	-	-	-
HBSAG			-	-	-
HIV			-	-	-
Alkaline Phosphate		286	-	-	-
PCV		-	-	12	-
Reticulocyte		-	-	2.7	-

X-Ray Abdomen  Erect  and Supine:    Normal

Ultra Sonogram:                 Single live fetus with cephalic presentation              

                                                Anterior lying placenta

                                                            Normal AFI 12cm

                                                            Fetal weight approx 1.4kg

Treatment and management:

Women with a previa may be considered in one of the following categories:

§  The fetus is preterm and there are no other indications for delivery

§  The fetus is reasonably mature

§  Labor has ensured

§  Hemorrhage is so severe as to mandate delivery despite gestational age.

Although our patient was clinically stable, her bleeding could not be appropriately controlled.  It was also felt that her fetus was reasonably mature, and the decision was made to do an emergency cesarean section.

Furthermore, as part of management, large-bore intravenous access and baseline laboratory studies (hemoglobin, hematocrit, platelet count, blood type and screen, and coagulation studies) should be obtained. If the patient is less than 34 weeks’ gestation, administration of antenatal corticosteroids should be undertaken (as was done in our patient) as well as an assessment of the facility’s emergency resources for both the mother and the neonate.

According to Johnson and Macafee protocol:

The first step of management of these patients is hospitalization

Immediate treatment:

According to the book	In my patient
1.  Assessment
·   History taking for the conformation of diagnosis	Presence of signs and symtoms of placenta previa while history taking
·   Bleeding(fresh or clots)	Fresh bleeding
·   Uterus(contracted/relaxed)	Relaxed uterus
·      Maternal condition(stable /unstable) If patient is in shock; The initial treatment should be restorative consisting of  resucitation, rest,warmth ,sedation, and transfusion of blood to overcome shock and re estabilishment of blood circulation with minimal delay	Pale, anemic maternal state,prone to shock Patient was kept in complete bed rest. Blood arranged and transfused to maintain blood circuation Patient instructed well about the disease condition and encouraged to express feelings regarding the situation
2. Differential diagnosis via Investigations:
·      Ultrasonography(allocate the placenta)	USG done(low lying placenta previa identified)
·   Haematological reports (complete blood counts haematocrits,blood group and cross match,bleeding time ,clotting time)	All these haematological investigations done
3.Futher examination
·   Avoid vaginal examination	Vaginal examination avoided
·   Speculum examination to rule out local cause	Speculum examination not done

Subsequent management:

Subsequent management depends upon the duration of gestaion and severity of the condition.

1.    Expectant mangement:

The pre requisites for inclusion into expectant mangement are

§ Gestation age less than 37 weeks duration

§ Initial amount of bleeding less than 600 ml

§ Patient is not in labour

§ Maternal and fetal condition not in jeopardy

§ Should extend for more than 1 week in duration to call it successful

The expectant management consists of the following measures

Ø  Complete bed rest with beside toilet facilities.sedatives such as diazepam 5mg may be prescribed to improved compliance with bed rest

Ø  Blood should be grouped ,crossmatched and reserved for the patient at all times

Ø  Iron ,vitamin and calcium supplements are continued.Laxatives may be given to avoid straining at stools.Haemoglobin is estimated at regular intervals

Ø  Vital signs and fetal heart sound stable

Ø  Approximately 3 days after all bleeding has ceased gentle speculum examination should be performed to rule out local cause of bleeding

Ø  Ultrasound examination is preferred for placental localization ,it confirms the diagnosis and judges the severity

Ø  Minimal ambulation

The expectant management is continued until

Ø  37 weeks of pregnancy are completed

Ø  Severe bout of bleeding occurs

Ø  The patient goes into labour

Ø  Maternal and fetal jeopardy

Definitive mangement:

It comprises prompt delivery.This is consider whenever

Ø  The patient has her first bout of bleeding after 37 completed weeks

Ø  Sucessful conservative treatment brings the patient upto 37 weeks

Ø  If the initial or subsequent bout of bleeding is very severe

Ø  Patient is in labour

Ø  Evidence of maternal or fetal jeopardy

Ø  Intrauterine fetal death

USG is done for determining placental site –If likelihood for safe vaginal delivery .Vaginal examination is done .ARM and oxytocin induction is done

If placenta previa of grade II, III and central variety,serious loss of blood or vaginal delivery adds possibility for considerable blood loss; Lower Segment ceaserean Section is the treatment of choice  in both before  and after 37 weeks of gestation.

 In case of profuse bleeding,after restorative management , Lower Segment ceaserean Section is done.

In my patient ,emergency Lower Segment ceaserean Section is done after restorative management.

Mangement before 37 weeks of pregnancy for LSCS for Fetus:

In the book	In  my patient:
Assessment of lung maturity by aminocentesis	Aminocentesis not done
Steroid therapy(betamethasone/Dexamethasone)	Dexamethasone 12 mg I/V two dose given to the mother before LSCS

Complications:

According to book:

1.          Maternal complications:

    i.          During pregnancy :

·         Antepartum haemorrhage with varying degree of shock is an inevitable complication

·         Malpresentation

·         Premature labour

ii.      During labour:

·      Premature rupture of membrane

·   Cord prolapsed

·   Slow dilation of cevix

·      Intrapartum haemorrhage

·      High incidence of operative interference

·   Pastpartum haemorrhage due to imperfect retraction of lower uterine segment on   the site where placenta is implanted,atonic uterus)

·      Occasionally associated (15%)of morbidity adherent placenta on lower segment

·   Trauma to cervix and lower uterine segment because of extreme softness and vascularity

·      Patient may be in shock in relatively small amount of blood loss

·   Retained placenta due to increase placental implant area in uterine segment and mordbid adherent placenta

 iii.    Pueperium:

·         Increase rate for sepsis(due to high incidence of operative interference,placenta near vagina and anemia devitalisation of the patient)

·         Subinvolution of the uterus

·         Embolism

2.      Fetal complications:

      i.  Low birth weight

    ii.Asphyxia

   iii.  Intra uterine death

   iv.  Birth injuries

      v.Congenital malformation

According to the patient:

1.Maternal complication:

·      Antepartum haemorrhage

·      Preterm delivery

·      Post partum haemorhage

2.Fetal complication:

·         Low birth weight

Nursing process

Nursing process is defined as a systematic way of assessing the patient’s needs, planning care, implementing and evaluating the outcome of care given. It is a scientific and problem solving approach in nursing. In this caring science, our concern is the patient and his/her family, prevention of disease and promotion of health.

In my case study, I have provided care on the base of nursing process. I have address the patient by collecting subjective and objective data analysis and valid them. Then I detect some nursing diagnosis such as she was anxiety due to knowledge deficiency about labour, poor personal hygiene due to health condition (labour pain etc.)

So keeping those conditions of the patient I applied Orem’s self care theory while caring my patient.

Dorothea E. Orem: Self care theory

According to Dorothea E. Orem self care is the ability of individuals to initiate and perform activities on their own behalf in order to maintain life, health and well being.

Orem’s general theory of nursing is composed of three inter-related theories, self care theory, self deficit theory and nursing system theory.

·         Self care theory: Identifies universal developmental and health deviation self care requisites.

·         Self care deficit theory: Which specifies when nursing care is needed, provides the central focus of Orem’s general theory of nursing. When the therapeutic self care demand is greater than a patient’s self care agency, a self care deficit exists and nursing care is required.

·         Nursing systems theory comprise three systems – Wholly compensatory, partly compensatory and supportive educative.

The nurse uses one or more nursing systems to promote a patient self care.        

Nursing Diagnosis done in my patient

·         Deficient Fluid Volume related to fluid shift from intravascular to extravascular space secondary to vasospasm.

·         Ineffective airway clearance related to the anesthetic effects.

·         Anxiety related to diagnosis and concern for self and fetus.

·         Deficient Diversional Activity related to prolonged bed rest.

·         Risk for urinary tract infection due to indwelling catheter.

·         Acute pain related to operative procedure.

Nursing Interventions during hospitalization

Maintaining Fluid Balance

·         Control I.V. fluid intake using a continuous infusion pump.

·         Monitor intake and output strictly; notify health care provider if urine output is less than 30 mL/hour.

·         Monitor hematocrit levels to evaluate intravascular fluid status.

·         Monitor vital signs every hour.

·         Auscultate breath sounds every 2 hours, and report signs of pulmonary edema (wheezing, crackles, shortness of breath, increased pulse rate, increased respiratory rate).

Promoting Adequate Tissue Perfusion

·         Increase protein intake to replace protein lost through kidneys

.

Decreasing Anxiety and Increasing Knowledge

• Explain the disease process and treatment plan including signs and symptoms of the disease process.
• Allow time to ask questions and discuss feelings regarding the diagnosis and treatment plan.

Promoting Diversional Activities

• Explain the need for bed rest to the woman and her support persons.
• Explore woman's hobbies/diversional activities.
• Instruct family to arrange for easy access to TV, phone, computer, and stereo to limit woman getting out of bed.
• Instruct family to arrange for community support (eg, church, women's groups).

Maintaining Cardiac Output

I. Control I.V. fluid intake using a continuous infusion pump.

ii. Monitor intake and output strictly; notify primary care provider if urine output is less than 30 mL per hour.

iii. Monitor maternal vital signs, especially mean BP and respirations.

iv.Monitor oxygenation saturation levels with pulse oximetry. Report oxygenation saturation rate of less than 90% to primary care provider.

Nursing Management During the Postpartal Period.

Because the woman with antepartum haemorrhage is hypovolemic, even normal blood loss can be serious. Assess the amount of vaginal bleeding and observe the woman for signs of shock. Monitor blood pressure and pulse every 2 hours for 48 hours. Check hematocrit daily. Measure  intake and output.Postpartum depression can develop after such a difficult pregnancy. To help prevent it, provide opportunities for frequent maternal-infant contact and encourage family members to visit. The couple may have many questions, so be available for discussion. Give the required information; information of caring of the children and immunization.

Date	S.N	Nursing Diagnosis	Goal of Action	Plan of Action	Rationale	Implementation	Evaluation
11/15	1	Impaired fetal gas exchange related to altered blood flow and decreased surface area of gas exchange at the site of pla	After 8 hours of nursing intervention ,the patient will verbalise understanding of causative factors and appropriate treatment	-to asses vital sign -to maintain rest -to monitor amount and type of bleeding -to maintain the position of mother on left Side -restrict vaginal examination -monitor uterine contraction and FHS -maintain positive attitude about fetal outcome	-provide baseline data for maternal blood loss -systemic rest is mandatory and important throughout all phases of disease to reduce fatiue and improve strength -provide objective evidence of bleeding -to promote placental perfusion -prevent tearing of placenta if placenta previa is cause of bleeding -asses whether labor is present and fetal status and external system avoids cervical trauma -support mother and child bonding	-asses vital sign -maintain rest -monitor amount and type of bleeding by saving the pads -position mather on left lateral position -restrict vaginal examination -monitor uterine contraction and FHS -maintain positive attitude about fetal outcome	After 8 hours of nursing intervention the patient was able to verbalise understanding of causative factors and appropriate intervention.My goal was met.
11/15	2	Fluid volume deficit related to excessive blood loss	Client’s vital signs and lab values remain normal	-to monitor vital signs -to observe skin color,Oxygen saturation,skin temperature and loss of conciousness -evaluate the amount of vaginal bleeding -to replace the fluid by blood transfusion	- provide baseline data for maternal blood loss -assess the general condition of patient -provide objective evidence of bleeding -helps in fluid replacement	-monitor vital signs -observe skin color,Oxygen saturation,skin temperature and loss of conciousness - evaluate the amount of vaginal bleeding by counting pads, presence of clots and pooling of  blood -fluid replacement by II pint blood transfusion	Client’s vital signs and lab values was normal in following day investigations
11/16	3	Fluid volume deficit related to excessive blood loss	Client’s vital signs and lab values remain normal	-to monitor vital signs -to observe skin color,Oxygen saturation,skin temperature and loss of conciousness -evaluate the amount of vaginal bleeding -to replace the fluid by blood transfusion	- provide baseline data for maternal blood loss -assess the general condition of patient -provide objective evidence of  bleeding -helps in fluid replacement	-monitor vital signs -observe skin color,Oxygen saturation,skin temperature and loss of conciousness - evaluate the amount of vaginal bleeding by counting pads, presence of clots and pooling of  blood -fluid replacement by I pint blood transfusion	Client’s vital signs and lab values was normal in following day investigations
2068/11/17	4	Post-operative pain and discomfort related to excessive cough.	Pain will be reduced within 2 hours.	- To keep the patient in comfortable position. -To give analgesics as prescribed. - To provide psychological support. -To give cough expectorant as prescribed. -To support the incision site while coughing. -To explain the patient about pain and ask to notify the duty staff if pain is severe. -To encourage for deep breathing and coughing exercise.	-It helps to promote rest and sleep. -It relieves from postoperative pain. -This reduces anxiety. -This helps in easy cough expectoration. - Prevents stress on the wound. - To treat accordingly. -This promotes ventilation in lungs	-Kept the patient in comfortable position. -Gave analgesics as prescribed. -Gave psychological support. -Gave cough expectorant as prescribed. -Support the incision site with both hands while coughing. -Explained the patient to notify the duty staff about the pain if severe. -Encouraged her to take deep breathing and coughing exercises.	Goal was achieved as patient felt comfortable from pain and cough was also reduced.
11/18	5	Fluid volume deficit related to excessive blood loss	Client’s vital signs and lab values remain normal	-to monitor vital signs -to observe skin color,Oxygen saturation,skin temperature and loss of conciousness -evaluate the amount of vaginal bleeding -to replace the fluid by blood transfusion	- provide baseline data for maternal blood loss -assess the general condition of patient -provide objective evidence of bleeding -helps in fluid replacement	-monitor vital signs -observe skin color,Oxygen saturation,skin temperature and loss of conciousness - evaluate the amount of vaginal bleeding by counting pads, presence of clots and pooling of  blood -fluid replacement by II pint blood transfusion	Client’s vital signs and lab values was normal in following day investigations
11/19	6	Potential risk of infection related to poor  hygiene.	Infection will be reduced during hospitalization.	-To maintain good personal and perineal hygiene. -To keep the operative site clean and dry. -To monitor vital signs regularly. -To watch wound for pain, swelling, soakage and discharge. -To control the number of visitors.	-Prevents the organisms to enter the incision area. -Prevents the growth of organisms. -Elevated temperature indicates the signs of infection. -This helps to detect the wound infection. -Helps in preventing the entry of infection that are carried from outside by the visitors.	-Maintained good personal and perineal hygiene. -Kept the operation site clean and dry. -Monitored vital signs regularly. -Watched the wound for pain, redness, swelling, soakage and discharge. -Controlled the number of visitors.	Goal was achieved as patient did not develop infection during hospitalization.
11/19	7	Knowledge deficit related to breast feeding (baby in PBU)	Patient’s knowledge will be increased at the time of discharge.	-To instruct the patient to visit the baby at PBU and breast feed according to instructed time. -Teach the patient to feed colostrums. -To encourage her to squeeze the breast and apply breast binder. -To encourage her to feed the baby 2 hourly and as demanded.	-It helps her to learn in real situation. -Because it is very nutritious for the baby it also prevents from the diseases. -To reduce the breast engorgement -This prevents the baby from hypoglycemia.	-Take her to the PBU and handle the baby for breast feeding. - Taught her to feed the colostrums -Encouraged her to squeeze the breast and apply breast binder. -Encouraged her to feed the baby 2 hourly and as demanded.	Goal was achieved as patient can feed baby properly without any difficulty after 5 days.
11/20	8	Alteration in body temperature (100 F) related to cough on the 4th day of LSCS.	Temperature will be reduced to 98 degree F within 1 hour.	-To monitor the temperature. -To open the windows to make the room well ventilated. -To remove the blankets. -To give paracetamol 2 tabs as prescribed. -To encourage to drink plenty of fluid.	-To reassess the fever. -In order to promote cross ventilation. -This decreases the temperature by evaporation. -It directly acts on hypothalamus and decrease the temperature -It maintains fluid and electrolyte balance.	-Moniterd the temperature. -Opened the windows to make the room well ventilated. -Removed the blankets. -Gave paracetamol 2 tabs as prescribed. -Encouraged to drink plenty of fluid.	Goal was achieved as patient’s temperature was reduced to 98 F within 1 hour.
11/21	9	Risk of altered parenting related to infection and interference with bonding	Client will resumes bonding with neonate	- to encourage baby care by the mother -to continue breastfeeding -to involve father also in baby care	-it upgrades the maternal child bonding	-encourage baby care by the mother -continue breastfeeding -involve partner also in baby care	Goal was achieved.The baby was being care by the mother andfather affectionately.
11/22	10	Need for health education	To assist her in self care by upgrade knowlede	-to provide teaching about the importance of rest and exercise, nutrition diet, breast feeding and medications and regular follow up. -to provide knowledge about Immunization of baby, avoid lifting heavy and weighty. Sign and symptoms of high risk of mother and baby etc.	-upgrade knowledge awareness of  health and provide self care and self dependence.It helps to self satisfaction.	-teach about the importance of rest and exercise, nutrition diet, breast feeding. continuous with medicines and regular follow up. -Immunization of baby, avoid lifting heavy and weighty. Sign and symptoms of high risk of mother and baby etc.	She can state about the importance of different topics of the health care.She has positive response of health teaching so my goal was fulfilled

NURSING CARE PLANS FOR BABY

Date	S.N	Nursing Diagnosis	Goal of Action	Plan of Action	Rationale	Implementation	Evaluation
2068/11/22	1	Development of pustules related to poor personal hygiene.	Pustules will be treated within the hospitalization period.	-To assess the pustules. -To give savlon solution bath and apply betadine on pustules as ordered. -Teach the family not to do oil massagetill pusules present. -To give psychological support. -To keep the baby clean and dry.	-For prompt treatment -This prevents the pustules from being spread. -Oily skin becomes dirty easily and there is a chance of increasing pustules. -This reduces anxiety of the patient. -This prevents from further infection.	-Assessed the pustules and informed paediatrician -Gave savlon bath and applied betadine on pustules as ordered. -Taught the family not to do oil massage till pustules present. -Gave psychological support to the patient and the family. -Kept baby clean and dry.	Goal was achieved as pustules were treated.
11/22	3	Potential to develop hypothermia regarding continuous exposure to external environment.	Baby will not develop hypothermia.	-To wrap the baby with warm clothes and change the wet napkins frequently. -To maintain the room temperature. -To encourage the mother to feed the baby according to baby’s demand. -To monitor body temperature.	-This prevents the heat loss due to exposure to cool environment. -To provide optimal environmental temperature. -This prevents from hypoglycemia and to stabilize the baby’s temperature. -It provides information as to source of changes in temperature and to Detect hypothermia.	-Wrapped the baby with warm clothes and changed wet napkins frequently. -Maintained the room temperature. -Encouraged mother to feed the baby according to baby’s demand. -Monitored body temperature.	Goal was achieved as the baby did not develop any signs of hypothermia.

 

Drugs used in my case

1)    Inj.Ampicillin:

Group: Broad spectrum antibiotics

Mechanism:

-it inhibits the bacterial cell wall synthesis in binary fission which ultimately leads to cell lysis.

Uses:

-prophylaxis(to reduce infection)

            Dose:

-1 gm  I/V 6 hourly   

           Side effect:

-diarrhoea, nausea,vomitting,skin rashes,hypersensitivity reaction perioral oedema

            Contra-indication:

- allergic reaction of this drug.     

            Nursing management

·         Ask whether the patient has allergry to penicillin

·         Give I/V intermittently toprevent the vein irritation

·         Dilute medicine is stable only for 1 hour,so give after dilution.

2)    Inj.Dexona:

Group: Corticosteriods

Mechanism:

-   crossess the placental brarrier and stimulates the production of surfactant in the lungs of the fetus

Uses:

-   to accelerate fetal lung maturity prior to preterm delivery

            Dose:

-12 gm I/V twice a day     

           Side effect:

-Hypertension, Decrease in urine output, Increase heart rate uterus, pre-matured birth, fetal distress, fetal death etc.

            Contra-indication:

-hypersentitivity.     

Nursing management

·         Observe carefully for the side effects of overdose.

3)    Oxytocin (Syntocine)

Group: Hormonal drugs

Mechanism:

-Increase calcium level in the cell, selective stimulation of uterine muscle and increase construction of the uterus.

            -It expels milk from smaller to larger amount.

Uses:

-Induce labour

-uterine inertia

-to induce uterine contraction

-pain with breast engorgement

            Dose:

-to induce labour 2 to 5 units in 500ml of R/L IV drip

-post delivery 10 unit IM

                  

           Side effect:

-Hypertension, Decrease in urine output, Increase heart rate uterus, pre-matured birth, fetal distress, fetal death etc.

            Contra-indication:

-Feto pelvic disproportion, fetal distress, abnormal presentation. It is not used if cervix is not dilated, allergic reaction of this drug.           

            Nursing management

·         Blood pressure and fetal heart rate taken every ½ hourly. If increase stops call the doctor.

·         If oxytocine infusion slowly the rate can be increased, if this is no response.

·         Observe carefully if uterus is contracted or not.

4)    Inj.Cifran:

Group: antibacterial

Mechanism:

-inhibits bacterial DNA gyrase

Uses:

-enteric fever

-septicemia

-prophylaxis(post operatively)

            Dose:

-200mg I/V BD

-50mg orally BD

                  

           Side effect:

- nausea ,vomitting, diarrhoea, joint pain, headache, dizziness, vertigo,jaundice,renal failure.

            Contra-indication:

-hypersentivity.       

            Nursing management

·         Donot chew before swallowing.This medicine may be taken on an empty stomach or with food.Drink plenty of water or other fluids

·         Continue taking medicine for the full course of treatment

5)    Metronidazole:

Group: anti protozoal drugs

Mechanism:

-not known,but nitrogroup is reduced to intermidiate compounds which cause cyto toxicity,probably by damagin DNA          

Uses:

-post operatively to reduce infection

            Dose:

-400 mg TDS                   

           Side effect:

-nausea ,vomitting, diarrhoea, metallic taste, abdominal pain, headache, dizziness, vertigo.ataxia,urticaria, priritus, flushing 

            Nursing management

·         Give after meals,on full stomach.

·         Encourage the patient to finish full course of medicine even though side effect may be unpleasent

·         I/V form should be administered by slowly infusion don’t by I/V bolus

·         Inform patient may cause metallic taste

6)    Aciloc:

Group: H2 receptor antagonist

Mechanism:

-it inhibits the action of histamine on the H2 receptors of parietal cells reducing artric acid output and concentration under basal condition and also when stimulated by food , insulin,histamine and caffeine

Uses:

-postoperatively to avoid GI irritation

            Dose:

-injection.Aciloc 50 mg TDS I/V

-Tab.Aciloc 150 mg TDS orally             

           Side effect:

-dizziness,headache,fatigue,confusion,skin rashes,rarely liver dysfunction and blood disorders,bradycardia after rapid I/V injection,hypersensitivity.

            Contra-indication and precaution:

-pregnancy,lactation,renal and hepatic dysfunction,gastric cancer 

            Nursing management

·         Administer I/V push slowly

·         Instruct patient to take drug as directed

·         Tell patient to swallow oral form whole with water;don’t chew..

7)    Diclofenac:

Group: anti inflammatory,analgesic and anti pyretic

Mechanism:

-analgesics:it blocks the pain center in thalamus,it inhibits the synthesis of prostaglandin and prevent sensitization of pain receptor to histamine,bradykinin and 5 HT agent,mediators of pain and inflammatory

            -anti inflammatory

            -antipyretic:reduces the temperature by resetting the temperature regulating center to normal.

Uses: Postoperatively to reduce pain

            Dose:

-75mg I/M TDS

-50 mg orally SOS          

           Side effect:

-nausea,dyspepsia,GI bleeding,hypersensitivity reaction,tinnitus,mental confusion,vertigo,thrombocytopenia.

            Contra-indication:

-peptic ulcer,bleeding disorders,severe hepatic and renal insufficiency    

            Nursing management

·         Always administer after meal or with food to decrease GI upset

·         Injection should be iven deep I/M in luteal muscle;injection site should be rotate because it is painful

·         Instruct patient to immediately report GI problems

8)    Tranxemic acid:

Group: Anti fibrinolytic

Mechanism:

-       It inhibits activation of plasminogen to plasmin

Uses:

-to prevent or reduce bleeding

            Dose:

-1 gm I/V TDS                  

           Side effect:

                        -dizziness,diarrhoea,unexpected pain,eyesight problems,itchy,red or swollen skin,thrombosis

Contra-indication:

-allergy to tranexemic acid,severe kidney problems,thrombosis,severe brusing,patient who have presence of blood clots in their blood vessels

            Nursing management

·         Take the oral medicine with a glass of water .Swallow the whole tablet ,donot crush or chew

9)    Calcium:

Calcium is essential nutrient for our body.

Function:

o   Help to formation bone and teeth.

o   Help to coagulation of blood.

o   Help in contraction of muscle.

o   Relay to electric and chemical massage.

o   Milk production.

Dose:

o   500 mg/day for adult. Expectant and lactating mother’s required 1000mg/day.

o   Adverse reaction.

o   Bradycardia, arrhythmia etc.

Contra – indication:

Hypercalcaemia, Hypercalciuria, severe renal failure, renal calculi.

10) Iron (Fe++)

Iron is very essential mineral for our body. It is involved in oxygen transport.

                 Dose:

o   Male and female adult 20-30 mg/day.

o   Children 15-20 mg/day.

o   Pregnant woman 20-40 mg/day.

o   Lactating mother 20w-30 mg/day.

            Function:

o   Involved formation of hemoglobin.

o   Help in brain development and regulation body function.

o   Help in immuno system.

Uses:

Iron deficiency anemia ferrous fumarate 400 – 600 mg daily.

Pregnant and lactating mother: to prevent iron deficiency prophylaxis close 200mg daily.

Side effect:

- Myalgia, arthralgia, fever, Urtiearia, skin pigmentation anaphylaxis.

11) Ringer’s lactate solution (Rehydration therapy/ parenteral composition of Ringer’s lactate)

 Three types of chlorides (sodium chloride, potassium chloride, calcium chloride) and sodium lactate. This solution is very important for our body because it provides fluid, calories (lactate) and maintains metabolic acidosis in our body.

Side effect: 

-Pulmonary edema, cardiac failure, hypothermia electrolyte imbalance, metabolic acidosis, local irritation, conclusion in infant.

Contra –indication:

     - Renal failure, pulmonary edema, proteiniemic.

Nursing intervention:

                 - Watch for sign of fluid overload

                                                                                                                                           

  

      PATIENT AND FAMILY TEACHING DURING HOSPITALIZATION

Health education is a vital part of nursing care of patient during hospitalization. It is a basis for providing preventive, promotive, curative as well as rehabilitative services to the patient including the visitors. As an approach of providing health education to my patient & visitors, I have included the following points.

About the hospital rules & regulations.

       I had explained the patient about the hospital policy, visiting hours, medication system etc.

About the disease

       I gave detail information to the patient about the disease including causes, signs & symptoms, treatment, prevention & health maintenance.

About investigations done in patient

      During hospitalization the patient had undergone various diagnostic investigation including blood test & ultra sono graphy

About Treatment

       I gave health teaching to the patient about the progress of disease & the purposeof treatment,blodd transfusion done and its requirement .

About possible complications

       As the patient had cesearean section, complication is possible for her. As the mother is so worried about her condition, the possible complications were explained to her.

 

 

 

Daily progress and management of my case

Date:  2068-11-15 at 7.30 A.M.

Meena Tamang arrived in emergency complaining of per vaginal bleeding,.Her general condition was afebrile,pallor present.

Vitals:

Temperature:           97degree Fahrenheit

BP:                              100/60

Respiration:              22/minute

Pulse:                         86/min

FHS:                           138/minute

Presentation:                       Cephalic

Position:                    LOA   

Lie:                             Longitudinal

Head:                         4/5th

Cervical Exam:  Deferred

Investigation send for USG,haemoglobin,complete blood count,liver function test,PT Alkaline phospate.

Management:

-save pads

-arrange IV pints of blood and II pint transfused

-Maintain left lateral position

-catheterization done

-patient admitted and transferred to ANC “B”

Medications:

Inj ampicillin 1gm QID

Inj dexona 12mg BD

Date:  2068-11-16

Vitals:

Temperature:           97degree Fahrenheit

BP:                              100/60

Respiration:              22/minute

Pulse:                         86/min

FHS:                           138/minute

Presentation:                       Cephalic

Position:                    LOA   

Lie:                             Longitudinal

Head:                         4/5th

Cervical Exam:  Deferred

Investigation send for haemoglobin

Management:

-continue observation

-save pads

-I pint blood transfused

-Maintain left lateral position

-catheterization continue

-bed rest

Date:  2068-11-17.

She was transferred to OT as P/V bleeding preceeds and Emergency LSCS with BTL(Bilateral Tube Ligation)done.Alive female baby of 1700 gm was delivered at 068/11/17 at 12:45 pm with APGAR 5/10 in 1 minute,9/10 in 5 minutes.

Delivery Report:

Alive female baby delivered at 068/11/17 at 12:45 pm with APGAR 5/10 in 1 minute,9/10 in 5 minutes

Complete out of placenta and membrane after 10 minute of baby delivered

Inj .syntocin has been given I/M after baby born

Type of delivery was Emergency LSCS with BTL(Bilateral Tube Ligation)

While delivery  700ml, blood loss monitored and slightly meuconium stained liquor was observed .

Placenta weight 300 gm

Baby was send to PBU due to premature delivery with low birth weight.

Post operative interventions:

-patient tranferred to post operative ward.

-Monitored vital signs ½ hourly

Vitals:

Temperature:           97degree Fahrenheit

BP:                              90/60

Respiration:              24/minute

Pulse:                         90min

-NPO for the day

-I/O charting done

-Obsevation for p/v bleeding,abdominal distension and wound soakage

Medications:

-Inj.cifran IV BD

-Inj Metron IV 400mg TDS

-Inj Aciloc IV 50mg TDS

-Inj Tranxemic Acid 1gm TDS

-inj Pethidine 50mg+Inj phenargan 25mg IM SOS

-Inj Voveran 75mg stat

Date:2068-11-18

She was transferred to Annex 12,Bed no.202.

Investiagtion send:

Hb:4.6gm%

PCV:12

Reticulocytes:2.7

Physical Exam(postnatal examination):
Vital Signs:  Stable (BP – 90/60, P – 102)
General Appearance:  No apparent distress, appeared clinically stable,pallor present,no oedema and icterus
Skin:  Elastic, capillary reflex < 2 seconds

Uterine Height:  24 cm
per abdaomen examination:no abdomen distension and soakage

Lochia:rubra(discharge 3-4pads a day)

Management :

-II pint whole blood transfused

-Monitored vital signs ½ hourly

-sips to liquid diet

-I/O charting done(intake:2900ml;output:1050ml)

-Obsevation for p/v bleeding,abdominal distension and wound soakage

-Catheter continue

Medications:

-Tab.cifran 500m BD

-Tab Metron IV 400mg TDS

-Tab Aciloc IV 50mg TDS

-Tab Voveran 50mg SOS

Date:2068-11-19

Management :

-I pint whole blood transfused

-Monitored vital signs

- liquid diet

-I/O charting done(intake:2800ml;output:1550ml)

-Obsevation for p/v bleeding,abdominal distension and wound soakage

-Catheter continue

Medications:

-Tab.cifran 500m BD

-Tab Metron IV 400mg TDS

-Tab Aciloc IV 50mg TDS

-Tab Voveran 50mg SOS

Date:2068-11-20

Physical Exam(postnatal examination):

Vital Signs:  Stable (BP – 90/60, P – 102)
General Appearance:  No apparent distress, appeared clinically stable,pallor present,no oedema and icterus
Skin:  Elastic, capillary reflex < 2 seconds

Uterine Height:  22 cm
per abdaomen examination:no abdomen distension and soakage

Lochia:rubra(discharge 3pads a day)

Breast:engorged

Management :

-sips to liquid diet

-I/O charting done

-Obsevation for p/v bleeding,abdominal distension and wound soakage

-Catheter out

-Expressed breast milk

Medications:

-Tab.cifran 500m BD

-Tab Metron IV 400mg TDS

-Tab Aciloc IV 50mg TDS

-Tab Voveran 50mg SOS

           

Her general condition was improving than the day before. She looked clean and tidy but she complained abdominal distention and pain. So I advised her to ambulate.

Date:  2068-11-20 to 2068-11-23(discharge date)

Her general condition was fair. Lochia rubra pesent at the normal blood loss and I advised her to ambulate and to do pericare. And I also taught her about pelvic floor exercise, family planning, hygiene diet, personal hygiene ,breast care etc. During these days her vital signs are stable suture area also healing.

           

Baby’s physical examination

Vital signs

Respiration:              32/m

            Pulse:                         130/m

            Temperature:            97^oc    

            Weight:                      3 kg

            Length:                      45 cm

Sex:                         Male

General condition: Baby seems small. His movement of limbs, trunk, head and neck are normal.

Skin:   No cynosis, no jaundice, no rash, color is normal and lymph nodes normal.

Skull:  Shape and size normal, no caput and haematoma, no any injury in head and both fontanels are normal.

Eyes:  Shape, size and position are normal, no discharge from eyes. No redness and swelling of any part of eyes.

Ears:   Shape, size and position are normal, no discharge from both ears.

Nose:  Shape, size and position are normal. No discharge. No swelling.

Mouth:  Lips are moist. No cracks, no swelling, no cleft plate and hair lips. Color of lips is pink. Shape and size of tongue is normal.       

Neck:  No congenital goiter and any abnormal presentation.

Chest:              Shape and size normal, bell – shaped with equal anterior, poster and lateral diameter.

Abdomen:  Abdomen is cylindrical shape and slightly distention. Prominent vein is not dilated, No cord bleeding, Bowel sound are present. No rashes present in skin.

Genitalia:  Shape, size and position is normal. No discharge. Position of testes is also normal. No phymosis No scrotal swelling.

Limbs:  Position of upper and lower limbs is normal. No any congenital deformity found. No rashes. No clubbing and extra fingers. Joint movement is also normal.

Spinal cord:  Normal, no spinal bifida present, no abnormalities found.

Anus:  Anus is also normal. He passed stool.

Rooting reflex:  Present

Sucking reflex: Good

Swallowing reflex: Good

Gagging reflex:  It is not seen or observed

Move reflex:  Present

Grasping, Dancing (stepping), Tonic neck reflexes:Present

 

DIVERSIONAL THERAPY USED IN MY PATIENT TO MINIMIZE THE STRESS

Everyone experiences stress and accompanying anxiety; this anxiety is increased during illness and the recovery process. Illness and stress are interwoven to such a degree it is difficult to

determine which precedes the other. When a person’s adaptive attempts are unsuccessful, illness occurs. Also, a person who is ill has fewer adaptive resources available to cope with stressors. Even though some stressors may not directly cause illness, stress is a significant component in the onset and progression of many diseases.

Being in an unfamiliar environment, losing control over one’s schedule, and being dependent on others for care are all issues with which hospitalized clients must cope. Each of these issues is a stressor that requires adaptation in order to maintain a steady state. Most clients do not have the energy to cope with the numerous changes simultaneously.

       

My patient is a multiparous mother with diagnosis of antepartun haemorrhage. She is in a state of stressful situation that she is so much worried about herself, her baby & her husband. She continuously asked us whether she & her baby is alright or not? So being hospitalized her level of stress has increased. So as a nurse it is my duty to help my patient minimize her stress. Here are some of the ways that I tried to minimize stress of my patient.

 

Meeting Basic Needs

There is a close relationship between basic physiological needs and stress. Anything that interferes with the satisfaction of basic needs evokes the stress response and attendant anxiety. Clients who are cold, hungry, or in pain have higher anxiety levels than those who are comfortable.

During the period of hospitalization my patient had NPO for caesarean section for two days. So her basic needs are interrupted .So in order to fulfill her basic needs I provided Intravenous fluid to her. Likewise I also helped her to fulfill her elimination needs by helping her to go to the toilet,

also assisted her to maintain personal hygiene .In this way I tried my best to meet her basic needs as a way of minimizing her stress.

Environmental Strategies

Because an individual’s immediate environment can influence stress levels, it is important for the nurse to decrease environmental stimuli that may contribute to anxiety.

I tried my best to make the hospital environment clean, quite & familiar in order to reduce stress of the patient.

Verbalization

Encouraging clients to express their feelings is especially valuable in stress reduction. Freud (1959) used the term catharsis to describe the process of talking out one’s feelings. People instinctively know the value of “getting things off their chest” through verbalization.  Verbalization promotes relaxation primarily in two ways.  First, when a feeling is described it becomes real. Once the problem is identified, the person can begin to deal effectively with it. Also, the actual activity of talking uses energy and, therefore, reduces anxiety.

I encouraged the patient to verbalize her feelings about disease process, family background, economical status & the care provided to her. She explained her feelings to me & experienced that her stress was minimized. She was happy to talk with me.

Involvement of Family and Significant Others

The client’s developmental stage influences the type of intervention for stress management. Children and adolescents have varying coping skills; children of all ages rely on their parents to a varying degree for security and support. It is important to include the entire family in the care of the client whenever possible.

As families provide essential support for clients I allowed the client’s visitors to involve in caring the patient, as an approach of decreasing client,s anxiety. Her husband was involved in her care during hospitalization.

Stress Management Techniques

There are a variety of stress management techniques that can easily be taught to clients, families, and significant others. Many of these techniques are considered to be complementary modalities

as they are used in conjunction with traditional medical treatment methods (i.e., medication, radiation therapy). Some of the most common approaches for managing stress are discussed below.

Exercise

Physical exercise is a powerful way to reduce anxiety and can be used by clients of all ages and with varying physical abilities; it must be done on regular basis.

I encouraged the patient to perform regular physical exercise as tolerated by her in order to reduce stress & be healthy.

Relaxation Techniques

There are several approaches that help individuals relax.  (Such as aromatherapy, herbals, music, and humor) that promote relaxation.

The patient used to listen soft music which is also one of the approach of relaxation technique.

Progressive Muscle Relaxation

Progressive muscle relaxation (PMR) is a method of inducing relaxation by tensing and releasing various muscle groups. For example, the individual tightens her hands into a fist, holds the tension for a few seconds, and then slowly relaxes her fingers and hands, paying particular attention to the different sensations of tension and relaxation.

I encouraged the patient to perform yoga which is helpful in inducing muscle relaxation.

Guided Imagery

                                                   

Another technique for helping clients manage stress successfully is guided imagery, a process in which the person uses all the senses to experience the sensation of relaxation. During guided imagery, the client is directed to concentrate on a pleasant scene or image in order to become more relaxed. In many situations, music is a helpful adjunct to guided imagery.

I instructed the client to concentrate on a pleasant sound or image to experience the sensation of relaxation.

Autogenic training

It is the method of replacing painful and unpleasant event or situation with pleasant over through self readiness and action. It helps to relieve pain and induce sleep which can minimize the stress easily. So I taught my patient about this method and provided her sufficient rest & adequate sleep.

 

Health teaching

Health teaching plays an important role to prevent disease, promote health as well as to cure disease more rapidly with out any complications. One of the most important roles of the nurse is to provide health education. So I, being a nurse, I had also given health education to patient and family.

·         To promote the health

·         To motivate for early diagnosis and treatment

·         To help limit the disability

·         To keep in relationship

Keeping above objectives in mind I had given health education to the patient (since admission to the discharge date at 068/11/23)about following topics.

Topics

Nutrition-Pregnant and postnatal mother needs balance diet which should have adequate protein, carbohydrate, vitamins, calcium, iron etc. Balance diet helps to pregnant and postnatal mother to regain her health and her baby’s health add to promote health and lactation. She must eat four times per day which is required for lactation.

Most of the mothers are anemic so, the iron containing diet is also encouraged.

Baby needs good nutrition so mother has to breast feed the child regularly till 4-5 month without water also. This is the only one source of good nutrition for the baby. She has to take care about this

Rest and activities- Rest and sleep is very important during pregnant and postnatal mother. So she has to rest in a day also. Sleep pattern should be good. Light exercise can be done. Lifting heavy things should be avoided.

Personal hygiene-This should be done to prevent infection. Inner clothes should be cleaned, dry and changed frequently.

Sexual intercourse and family planning-We discussed about sexual intercourse and family planning method. As,she has done permanent family planning,counselling is done and the client opinions positively towards the operation done.

Care of the baby-Gently handling of baby, daily care of eyes, ears and groins with warm cloth, periodic bath and oil massage, frequently change of napkin, check frequently urine and stool pass.

Breast feeding of the baby-I advice to teach her about demand feeding, exclusive breast feeding. Breast milk secretion high in amount in night than day so breast feed in night as well as day. Exclusive breast feeding help to temporary family planning method (LAM).

Medicine-Doctor has prescribed the following medicines

Tab ferrous sulphate 1 tab OD for 45 days                                                                              Tab calcium 1 tab OD for 45 days

I explained about its usefulness.

Immunization-I explained her about the importance of immunization for the baby.

Follow Up-I told her about the importance of routine check up and health for follow up purpose.

Others-Immediate check up if any signs of infection, fever, severe headache, pain, swelling, foul discharge, convulsion etc.

If baby has any problem such as dyspnoea fever, not sucking breast milk, increase respiration etc. to visit the doctor as soon as possible.

 

What I learn from case study

   

Case study is a very good approach for the students to learn about the disease & nursing practice in depth. It gives us comprehensive knowledge about a specific disease& relate with real situation. It is the suitable way of applying theory in practice in real situation. Here are some points which I learned from this case study.

1)            About the disease

               I studied about this disease in depth by the resources available in, literatures, research, internet and some journals. I also obtained information from doctor, sisters. I know about the disease, it’s causes , predisposing factors, pathophysiology, signs & symptoms, diagnosis, therapeutic management, conservative management, nursing management, complications & get a chance to compare all these with  real case.

2)  About the patient

                Through this case study I got the opportunity to know the history of patient, his personal, family,social ,occupational ,educational as well as present & past health history, his habit, way of living, ways of thinking and its influence on health and illness. I also got chance to  compare normal developmental task with the patient.

3) About the family and environment

                 I also got the information about my patient’s family background, socio-cultural and education background, concept about health and illness, nutrition, economic status, religion, traditional beliefs and general attitude of family toward the disease and treatment

4) About the nursing care

               I applied holistic approach while proceeding nursing care to the patient, I also applied Orem’s theory of nursing while caring my patient I also used The NANDA’s diagnosis technique while using the nursing process. I gain a lot of knowledge about the care plan.

5)  About documentation

                 Documentation is also the most  important and useful skill. So through this case study my skill of documenting was tremendously improved. I could formulate the case study systematically and deeply.

6)      About the hospital policy

                      During my case study , I involved in every sector of activities like from admission to discharge procedures. I learnt about the routine care performed in Maternal Intensive Care Unit , investigation procedures, medication policy like supplies ,different units, available resources as well as the process of  reporting , recording & reporting.  , So I could know lots of rules and policy about the  Paropakar Maternity & women’s Hospital, which is really very useful for me.

 Summarization

During our clinical practice of major midwifery, our posting was in thapathali maternity hospital there I have selected a case for detail study which is in high risk group. In the Emergency The briefing about the case study given below:

Meena Tamang ,40 years multi parous woman diagnosed with 29+2 WOG with APH(Placenta Previa) She was came from Makwanpur to this hospital with the complain of P/V bleeding since last 5 days. First we had done her physical examination then other all investigations were conducted.  The findings were low lying placenta with patient in anemic state. After she was admitted transferred in ANC”B “at 2068 /11/15.

On the 2068-11-17 she had delivered female baby of 1700 gm. at 12:45 pm Emergency LSCS with bilateral tube ligation.

During the hospitalization of the mother and baby, I had provided holistic care to them considering physical, mental, social, spiritual and economic aspect. I had provided care on the base of Orem’s Self care theory.

Patient totally hospitalization was 8 days. At the time of discharge their (the mother and the baby) condition was improved, looking happy and cheerful. I gave health teaching to the patient and her family about nutrition, family planning, immunization, personal hygiene, rest and exercise, care of baby, medicines; follow up visit, breast feeding and high risk condition of baby and mother.

Conclusion

When I found this case ‘for the high risk case study’ to be very important for me, gaining new knowledge, experience about Antepartum haemorrhage(Placenta previa), physiology changes, complication and management and up grading confidence in such types of patient care.

My case study was APH(Placenta Previa). This case study helped me a lot of obtaining comprehensive practical experience in nursing, management of APHcase.

I had provided total care of this patient by applying Orem’s self care theory in planning and implementation of patient’s care health education gives to patient and her family members about the care of baby and mother.

Thus the case study was completed on the base of my plan. I learnt various new experiences. E.g.: theory application, high risk management, knowledge into predical setting etc.

At last I am satisfied with this case study because the goals (Objectives) are met.

~ THE END ~

 

 Bibliography:-

1).John T. Queenan, John C. Hobbins, Catherine Y.2005.  Protocols for high-risk pregnancies Spong.4th edition.

2) Dutta D.C,Text book of Obstretics,2004,page 256-278

3) Daftery Shirish N.,Chakrevarty Sudip,assisted by Daftery.S.:2007,Manual of Obstretics,2^nd edition,page no 230-235

4) www.patient.co.uk.

5)www.sogc.org

6)www.emedicine.com

7) http://www.drugbank.ca/