Midwifery Case Study: Supporting Maternal and Fetal Health

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Kirinyaga University College**We aren't endorsed by this school

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NURSING SHS

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Nursing

Date

Dec 10, 2024

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James Karanja Midwifery CASE Study UPTO TerminationEndocrine Disorders - Medical Surgical Nursing (Kenya Medical Training College)Scan to open on StudocuStudocu is not sponsored or endorsed by any college or universityJames Karanja Midwifery CASE Study UPTO TerminationEndocrine Disorders - Medical Surgical Nursing (Kenya Medical Training College)Scan to open on StudocuStudocu is not sponsored or endorsed by any college or universityDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

STUDENT NAMES: JAMES KARANJA MAINADISGNATION: D/NURS/887/2022TITLE: MIDWIFERY CASE STUDYCOURSE: KENYA REGISTERED COMMUNITY HEALTH NURSINGSCHOOL: CONSOLATA SCHOOL OF NURSING NKUBUCLASS: MARCH 2022 Downloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

INTRODUCTION OF MIDWIFERY CASE STUDYIt is care given to an individual which is goal oriented where by a client whose gestation between 28 to 31 weeks is identified and followed antenatally till six weeks postnatallyAntenatally the client is followed to monitor progress of pregnancy in order to ensure good maternal health and fetal development.During labor the individual is observed for progress of labor and given psychological and emotional support to prevent damage to fetus.Postnatally the mother is followed to promote the physical wellbeing of the mother and the baby by advising the mother on nutrition, hygiene, immunization and family planning.OBJECTIVES OF FOLLOWUP ANTENATALLYTo support the mother physically, emotionally, Psychologically for labor, lactation and care of the new bornTo ensure healthy and mature infant is born at the end of the pregnancyDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

Assess the progress of pregnancy to detect any risk and act upon it very fast.To prepare the family psychologically for the awaiting of the new born in the familyTo ensure the wellbeing of the pregnant mother and growing fetusINTRAPARTUMTo monitor the progress of labor closely to ensure maternal and fetal wellbeingTo detect any deviation from normal for early managementTo prepare the mother physically and emotionally for deliveryTo educate the mother on what is expected from her during laborPOSTNATALLYTo teach the mother the physiological changes in pueperiumTo educate the mother on care of the baby through counseling in nutrition and hygieneTo promote breast feeding and lactationEducate the mother importance of clinic attendance, family planning, immunization and growth monitoring of infantsFIRST ENCOUNTER WITH MY CLIENTI first met my client on 22/march/2023 in maternal child health clinic at Consolata hospital Nkubu during her fourth visits at gestation of 30 weeks where I introduced myself to her and explained my interest in taking her to be my client. She accepted my request and she informed me that she lives in NkubuI attended to her, took her history and performed physical examination after obtaining consent from her. I then promised to inform her on Downloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

arrangement for the first home visit which she acknowledged and thanked her for the cooperation.BIODATA OF MY CLIENTNAME: Lucy KawiraSEX: FemaleAGE: 32MARITAL STATUS: MarriedOCCUPATION: FarmerEDUCATION: Secondary schoolRELIGION: ChristianRESIDENCE: NkubuTEL NUMBER: 0748392680NEXT OF KIN: Joses MajauRELATIONSHIP: SpouseOCCUPATION OF THE HUSBAND: FarmerCOUNTY: MeruVILLAGE: NkubuPARITY: 1+3GRAVIDITY: 5L.M.P:22/08/2022E.D.D:29/05/2023 Downloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

EXPECTED DATE OF DELIVERY+7-3+IWhere 7 is added to the days, 3 is subtracted from the month of the last menstrual period and 1 is added to the year22/08/22+7/-3/+1=29/05/23GESTATION PERIOD BY DATEMONTHWEEKDAYSAugust 1. 2September 4. 2October 4. 3November 4. 2December 4. 3January 4. 3February 4 0March 3 6TOTAL WEEKS: 31 WeekDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

HISTORY OF MY CLIENTPRESENT OBSTETRIC HISTORY My client’s parity is 1+3 and gravid 5. 30 weeks gestation, Expected date of delivery by date is 20/05/2023She was well with no queriesPAST MEDIACAL AND SURGICAL HISTORYLucy has a history of admission due to hyperemesis gravidarum at26 week’s gestation, no history of surgical operation, no history of blood transfusion, no history of any chronic illness and no history of drug and food allergy.FAMILY HISTORYLucy is second born in a family of four. All are alive and well. There is history of twins in her family (her parents) both her parent are alive and well.SOCIAL ECONOMIC HISTORYMy client lives with her husband in Nkubu with one child a girl five years old. Both my client and her husband neither smoke nor drink alcohol. Both are farmersGYNECOLOGICAL HISTORYDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

My client had her menarche at the age of twelve. Her menstrual cycle is twenty eight days and is regular. She has three histories of abortions at 2014, 2015, 2016 (all at 2/12) ANTENATAL PROFILEHemoglobin level: 11.5 g/dlVenereal disease research laboratory: Non-reactiveBlood group: ABRhesus factor: PositiveSerology: Non-reactiveTb screening: NegativeUrinalysis: NADBlood pressure: 123/68mmHg Pulse: 76b/mWeight: 70kgHeight: 170cmPHYSICAL EXAMINATIONOBJECTIVES OF PHYSICAL EXAMINATIONTo assess the client health and general wellbeingTo detect any abnormalities and manage it earlyTo assess fetal growth and maternal wellbeingDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

PRICIPLES USED IN PHYSICAL EXAMINATIONoInspectionoPalpationoPercussionoAuscultationSELF AND CLIENT PREPARATIONFirst I reviewed the anatomy and physiology of various systems. I then familiarized myself with the equipment used in the physical examination. I then washed and dried my hands.I explained the procedure to my client and informed her that I need her cooperation throughout the procedure and told her to empty her bladder. I then asked for her consent to do physical examination and she acceptedit.I ensured the privacy of my client by undertaking the procedure in a warm, private room with enough light. After ensuring my client is comfortable I started my examination systematically from head to toe and documented the findings as follows.HEADHair was well distributed, no scars, lice, or any fungal infection.EYESLucy was seeing well, no discharge from her eyes and there was movement of the eye ball, eyelid and eye balls. Pupils were reaction to light and were of equal size.EARSLucy was hearing well, there was neither discharge nor ear deformitiesDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

NOSENo epistaxis, no congenital abnormalities and no sores on the nostrilsMOUTHThere was no mouth sores, the lips were moist and there was fresh breath. There was no gum sores and bleeding, no dental carries and therewas no pallor on tongue inspection.NECKThere were no scars or swelling on inspection. There was no swollen lymph nodes and distended jugular vein on palpationUPPERLIMPOn inspection both lower limps were of equal size, there was no finger clubbing and pallor on finger nails. Capillary refill tool less than two second and the nails were short and clean.BREASTOn inspection both breast were of equal size, no scars or retracted nipples. On palpation there was no lump, no inflamed lymph node, and no discharge from the nipple and no tenderness on touchABDOMENOBJECTIVES OF THE ABDOMINAL EXAMINATIONTo observe and assess for enlargement of the liver and spleenTo assess fetal size and growthTo feel the position, presentation, fetal heart rate and fetal lieDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

To assess the size, shape, and fundal height of the abdomenoOn inspection the abdomen was distended and globular in shape, there was no scar, no contours and linear nigra was present.oOn palpation there was splenomegaly and no hepatomegaly. Fundal height was 34/40 weeks, lie was longitudinal, positionwas right occipital anterior and presentation was cephalicoThere was no tenderness on touchoOn auscultation fetal heart rate was present and regular at a rate of 140 beats per minute.GENITALIAThere was no swollen lymph node on the inguinal region. There were no warts on the external genitalia and there was no discharge.The mother’s genital hygiene was fantastic and I congratulated her for that.LOWER LIMBSNo deformities were present; both limbs were of equal length and size. There were no signs of varicose vein and deep vein thrombosis. No edema on the tibia, pedal and ankle regionSUMMARY OF THE PHYSICAL EXAMINATIONThe physical examination was done in a private room with enough light on a couch in antenatal clinic. After examination I informed the client that no abnormality detectedI advised her to wear flat shoes and educated her on importance of taking balanced diet for her wellbeing and that of the growing fetus. I advised her to take iron and folic acid supplement.I then taught her on danger signs in pregnancy like severe headache, edema on the face and limb, varicose vein and breast Downloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

lump and informed her to report to hospital if she experiences any. I thanked her for her cooperation and wished her the very best.NORMAL PREGNANCYMeans pregnancy or childbirth which is free of Complications of Pregnancy it means symptoms which normally accompany pregnancy which are of a minor and/or temporary nature (such as morning sickness and dizzy spells) and which do not represent a significant medical hazard to mother or baby;Signs of pregnancy:•Presumptive•Probable signs•Positive signsPresumptive signs and symptoms Are physical signs and symptoms that suggest but do not prove pregnancy 1.Abrupt cessation of menses if more than 10 days2.Breast changes- They enlarge, become tender, visible veins inthe breast, nipples become more pigmented, colostrum, a thin, milky fluid.3.Skin pigmentation changes (brownish pigmentation).4.Linea nigra- A dark vertical line on the abdomen from the sternum to the symphysis pubis.5.Striae gravidarum- Reddish linear marks appearing either on the breasts, abdomen buttocks and thighs.Downloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

6.Nausea and vomiting. - Morning sickness can also occur at any time of the day lasting for few hours.7.Frequency of micturition. - Caused by pressure of the expanding uterus on the bladder.8.Fatigue characterized by increase in hormonal levels.Probable signs and symptomsObjective findings within 12 to 16 weeksI.Enlargement of abdomen uterus changes from pear shaped to globular shape12 weeksii.Changes in size shape and consistency of the uterus. It appears globular in shape. iii.Hegar’s sign- softening of the lower uterine segment 6 to 8 weeks after onset of last menstrual periodsiv.Changes in the cervix- Chadwick’s sign bluish or purplish discoloration of the cervix and the vaginal wall.v.Goodell’s sign- softening of the cervix. May occur as early as4 weeksvi.There is increase in vaginal discharge.vii.Quickening sensation of the fetal movements.Positive signs and symptomsDiagnosis of pregnancy I.Fetal heart sounds- Usually heard between 16th and 20th weeks of gestation.ii.Fetal movement- Felt by the examiner after about 20 weeks of gestation.iii.Pregnancy test- This depends on the Human Chorionic Gonadotropin hormone secreted in the mother’s urine.Downloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

iv.Ultrasound- This is the scanner that enable you to see the fetus and its cardiac activity, particularly if performed by the 6th week of pregnancy. Investigations ordered for antenatal profile1 Hemoglobin levels- This is used to evaluate physical status and anemia.2 Blood grouping- It helps in knowing the blood group of the mother in case of emergency or transfusion needed3 Rhesus factor- The Rhesus factor may play a role in the baby’s health. It will also help to prevent hemolytic disease of the newborn. When one has a rhesus positive baby, the antibodies may cross the placenta causing hemolytic disease of newborns and when this is detected the mother is given anti D. It also prevents the mother from getting a miscarriage.4. HIV/ AIDS test and Syphilis. - This helps in reducing the number of babies born with HIV. If one is found to be infected, sheis offered treatment. It helps to improve their health and prevent passing the virus to the infant.5 Ultrasound- It helps to check the baby’s development and to help pick up any abnormalities such as Down’s syndrome. TREATMENT GIVEN DURING PREGANCYFerrous sulphateINDICATION; prevention of iron deficiency anemiaPrevention of neurotube defect in newborn.DOSAGE; one tablet, thrice a day for thirty daysFOLIC ACIDINDICATION; increase blood levelsDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

DOSAGE; one tablet, once, daily for thirty daysIMMUNISATIONFirst tetanus toxoid 0.5 milligram administered intramuscularly on the deltoid muscle in the left handHEALTH MESSAGE SHARED DURING THE FIRST ENCOUNTERTimeSpecificobjectivesContentTeaching methodLearning activityTeachingactivityTeaching aidevaluationIntroduction 3 MINIntroductionof self and the topic to be coveredI introduced myselfand the topic to be coveredlectureListening andansweringExplaining.Name tag.Topicand self-objective was well understoodLesson developmentphase one4MINAt the end ofthe session Lucy will have gainedknowledge on antenaProcess of providing care to pregnantwomen from conception to deliveryExplain and asking questionsListening andAnswering question.ExplainingComputer and televisionscreenLucy was able to define antenatal cliniccorrectlyDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

tal clinic and define it correctlyLesson developmentphase 2, 4MINBy theend of the session Lucy will beable tostate the importance of antenatal clinicoHelps in birth preparednessoMonitor the progress of pregnancyoEarly detections of complicIllustrated lectureExplaingListening and answering questionsComputerLucy was able to state the importance of antenatal clinicsDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

ationConclusion 3 MINSummarizingAsking questionson antenatalclinicsLectureAsking questions and clarifying ant doubtListening and answering questionsComputerLucy answered the question correctlyOBJECTIVES OF FIRST HOME VISIToTo introduce and familiarize myself with my client family.oTo assess home environment.oTo discuss danger signs in pregnancyoTo discuss what to do in case of danger signsFIRST HOMEVISIT REPORTIt was on 5/04/2023 when I visited my client at her home in Nkubuaccompanied by my friend. On arrival I found both my client and her husband waiting for us. We were warmly welcomed to their home; I began by introducing myself and my friend to the family members and their also introduced themselves. Thy then gave me go ahead to continue with the objectives of the home visit.HOME ASSESSMENTType of houseDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

They had a permanent house that was larger enough; it had bedrooms, sitting rooms and bathroom. They had a store and kitchen which was semi-permanent and separately built.In the kitchen the utensils were well arranged and cleanCleanliness of the houseThe house had good lighting and was well ventilated It was well cemented and the floor was not slipperyNumber of occupants My client and her husband and their five years’ daughterMEMBERS I METNAME;Lucy KawiraAGE;32 yearsSEX;femaleOCCUPATION;FarmerHer husbandNAME;Joses MajauAGE;38 yearsOCCUPATION; farmerSource of waterTheir main source of water was from the tap. They also had 10,000 liters’ tank for harvesting rain water which was fullDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

Source of foodThe main source of food was from their farm. They had plenty of bananas and vegetables like kales, spinachBasic dietThe basic diet for the family is mainly ugali and githeriThey had cows which provided them with milk for their teaThey had kept chicken for provision of meat and eggsDisposal of refuseThe family had not dug a compost pit for disposal of refuseThey used to throw the waste at the corner of homestead and burned themLatrinesThe family had one pit latrine which was cemented and was in good conditionAnimals keptThey had two cows which was the source of milkShe also kept chicken for provision of meat and eggsOccupation of the head of houseJose being the head of house he works as a large scale farmerThe main source of incomeThe main source of income is farmingHEALTH MESSAGE SHAREDLESSON PLAN FOR THE HOME VISITDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

Date: 5/04/20Venue: client’s home.Audience: client and her family.Presenter: James KaranjaBROAD OBJECTIVE: the end of the session Lucy will have gained knowledge on danger signs in pregnancy and birth preparednessTIMESPECIFIC OBJECTIVECONTENTTEACHING METHODTEACHING ACTIVITYTEACHING AIDLEARNED ACTIVITYEVALUATTIONIntroduction 3MINGreeting Lucy and the otherfamily memberGreatings,introduction of self and the topic to be coveredExplaing SayingNametag, handoutListeningand asking questionsLesson development phase one7MIBy the end of thesession patient oVaginal bleedingin pregnancyExplaining and interaction dialoAnswering questionsHandoutListeningand asking questionsListening andasking questionsDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

Nwill have gained knowledgeon danger signs in pregnancyoIncreased orreduced fetalmovementoSevere headacheoSevere edemaoFlushingof the faceoFits or convulsionsgueLesson develBy the end By avoidingLecture and Answering Handout and Listeningand Lucy answered the Downloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

opment phase 5MINof thesession Lucy will have gained knowledgeon how to prevent danger signs and what to do if they occurstrenuous activitiesBy attending ANC regularBy getting in touch withsome health personnelIn casetheyoccur explainingquestionsdemonstrationasking questionsquestions correctlyDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

to come to hospital immediatelyConclusion 3MINSummarizingThanking Lucy and the other family membersfor welcoming us warmlyAsking questions on danger signsin pregnancyLectureAsking questions and clarifying ant doubtListeningand answering questionsLucy showed signsof comprehension by asking answering questions correctlyProblems encountered during first home visitThere was no tap of water outside the pit latrine for one to wash hands after visiting the toiletNutrition was not well observed especially in the matter of balancediet especially for Lucy who was pregnantMeasures taken to solve the problems identifiedDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

I encouraged the family to construct a water tap using a small container outside the latrineI promised the family that next visit I will give them a health talk on dietary requirements and intake especially in pregnancyPLAN FOR SECOND HOME VISITOBJECTIVESTo know the progress of the clientTo identify any challenge or problem that may ariseTo share a relevant health message on individual birth planEXPECTATIONSTo meet my client having adhered to the measures given on the problem encounteredTo meet my client and the family in a good conditionSECOND HOMEVISIT REPORTIt was on 20/04/2023 when I visited my client at her home in Nkubu accompanied by my friend. On arrival I found both my client and her husband waiting for us. We were warmly welcomed to their home; I began by introducing my friend to the family members and their also introduced themselves. Thy then gave me go ahead to continue with the objectives of the home visit.HEALTH MESSAGE GIVEN ON FIRST VISITNAME OF THE CLIENT:Lucy KawiraNAME OF THE FACILITATOR:James KaranjaDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

TOPIC INDIVIDUAL BITH PLANTIME 15 MINUTESBROAD OBJECTIVE by the end of the lesson my client will have knowledge on components and importance of a birth plan.TIMESPECIFIC OBJECTIVECONTENTTEACHINGMETHODTEACHINGAIDTEACHERSACTIVITYLEARNERSACTIVITYEVALUATIONIntroduction2 minutesSelf-introduction and topic of studyI greeted the client introduced self and topic of coverageLectureWritten handoutExplainingListeningSelf-introduction and topic of coverage well coveredLesson planphase1 3 minutes By the end of the lesson my Lucy will have knowledge on Birth plan isthe preparednessby choosing a suitable hospitInteractive lectureWritten handoutExplaining and askingquestionsListening and answering questionsClient gained knowledge on what a birth plan isDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

what abirth plan isal facilityfor delivery with skilledattendant and havingacquired the necessary items required for the processLesson planphase 2 5 minutesBy the end of the lesson Lucy will have knowledge on components of individual ComponentsPlace of delivery /facilityBirth companionTransport funds Blood Interactive lectureWritten handoutExplaining and answering questionsListening and askingquestionsClient was able to list on components of a birth planDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

birth plandonorSavings moneyfor deliveryBirth attendantDue date ofdelivery Lesson planphase 3 4 minutesBy the end of the lesson my Lucy will have knowledge on importance of a birth planImportancePrevents delay in making decisionsEnhances safety of both mother and babyEnhances quick Interactive lectureWritten handoutExplainingListening and observingClient gained knowledge on importance of a birth planDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

access to health care and servicesLesson planphase 4 3 minutessummaryAppreciatingand thanking my client for heractive participationInteractive lectureWritten handoutexplainingListening aI thankedmy client for her cooperationPLAN FOR INTRAPARTUM PERIODOBJECTIVESoTo monitor the progress of labor closely to ensure maternal and fetal wellbeingoTo detect any deviation from normal for early managementoTo prepare the mother physically and emotionally for deliveryoTo educate the mother on what is expected from her during laborLABOURWARD HISTORY TAKINGNAME;Lucy KawiraDATE OF ADMISSION;04/05/2023Downloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

AGE;32yearsSEX;Female LOCATION;NkubuRELIGION;ChristianPERSONAL HISTORYShe started menstruation at the age of 12 years and flows regular for three days in a cycle of 28 days.There is no history of dysmenorrhea She is not on any method of family planningFAMILY HISTORYNo history of chronic illness in the familyOBSTETRIC HISTORYShe is a para1+3 gravida 5She has three history of abortion all at 2/12 months due to chromosomal abnormalities in the baby 2012, 2014and 2016.Downloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

PRESENTING HISTORYOn 04/05/2023 a para 1+3 gravida 5 at gestation 0f 36 +3 days presentedwith laps radiating to the back but not increasing in severity, no vaginal bleeding, no drainage of liquor nor dysuria, she reported to be perceivingnormal fetal movements. Examination findingsVitalsBlood pressure: 112/60mmHgPulse: 70b/mFetal heart rate: 140b/mTemperature: 36.3°CAbdominal examinationFundal Height: 36/40Presentation: CephalicLie: LongitudinalDescent: 5/5Vaginal examinationCervical os 1 cm, thick uneffaced and posterior located, no show on examining fingersDiagnosis: Threatened preterm labor: Latent phase of laborMANAGEMENTDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

To administer antenatal steroid (Dexamethasone 6mg twice a day for two days to aid in surfactant production to prevent respiratory distress syndrome)Four hourly maternal and fetal vitals monitoringFor obstetric Doppler ultrasound to evaluate cervical length, fetal Doppler gestation age.For full haemogramReview by the gynecologyDoppler was reassuring for normal delivery, cervical length 30mm, fetusgestation 36+2 days fetal weight 2546gHemoglobin level was 12.5 g/dlPlan: To administer sustain 400mg ODMaternal and fetal vitals monitoring 6 hourlyTo Induce on 8/5/2023On date 8/5/2023 morning patient had no lap’s vaginal examination doneto create a baseline before induction and was still 1 cm, thick uneffaced posterior located.VitalsBlood pressure: 111/78mmHgPulse: 86b/mFetal heart rate 140 b/mDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

She was started on induction at 6.00am with 2.5mls obtained cytotec (misoprostol) 200mg dissolved on water for injection using 20cc syringe. INTRAPARTUM PERIODAt 10:30 am she reported to be having laps radiating to the back increasing in intensity and severity. Patient reassessedOn vaginal examinationCervical Os 2 cm dilated, anterior thick and uneffacedArtificial rupture of membrane done to clear liquorCervical sweep donePost ARM fetal heartrate were 142b/mPlanFor augmentation of labor using sytocinon 2.5 IU in 500mls of normal salineIt was commenced at 10:50 AMAt 12:30 cervical os was 5cm dilated thin and partially effaced, she had three moderates’ contractions lasting for 10 minutes vitals were unremarkable next vaginal examination was to be done at 6:30pm. And partograph was started to monitor the progress of laborAt 6:30 pmCervical Os was 8 cm dilated effaced and show was present on examination fingersPelvis was adequate for spontaneous deliveryDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

Station was +1 no molding notedDescent 2/5. Plan was to continue monitoring for progress of labor via partographAt 7:30pmPatient developed an urge to push and I guided her to delivery couch, she lied on for cervix was fully dilated, fetal heart rate was 138b/m.I encouraged Lucy to Push when contractions peaks, and to rest in between contractions and take a deep breath to prevent her from been exhausted.At 7:40PM she delivered to alive male infant Apgar score 9 in I minute,10 in 5 minute and 10 in 10 minute weighing 3.1kgs, I.M oxytocin 10IU was administeredCord clamped, placenta delivered using controlled cord traction, all clotsand product of conception expelled, and no tear noted she was given a pad to monitor for amount of lochia loss.For the babyVitamin K was administered, tetracycline eye ointment instilled, weighed and breast feeding was iniated and monitored for 15 minutesFIRST EXAMINATION OF A NEWBORNAIMSTo establish gestational maturityTo exclude congenital abnormalitiesTo exclude birth injuriesGENERALDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

The general appearance was good since the skin was pink in color. The breathing was normal and the child had clear airway.HEADThere was no caput succedaneum on inspectionHead circumference was 33cmOn palpation all fontanels were presentThe head was of normal sizeEYESThere was no discharge from the eyesThe baby had blinking reflexNOSEThere was no nose bleedingThere was no nasal flaringThere was no polyps, no tumors that can lead to nasal blockagePresence of nasal septumMOUTHThe lips were hydratedNo bleeding gumsThere were no frenulumThere was presence of sucking reflex, rooting reflexEARSDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

The position of pinna in relation to canthus of the eyes was normalThere was no leakage of the cerebral spinal fluidThere was no webbing at the back of the neckUPPER LIMBS AND SHOULDERThere was no dislocation of the shoulderHe had grasping reflexThe hands were equalCHESTThere was normal respiratory patternNo discharge from the nippleRespiratory rate was normalABDOMENThere were presence of bowel sounds on auscultationOn examination of umbilical cord, there was no hernia, the stump was secureLOWER LIMBSThe legs was of the same sizeThere was crasp reflexThere was no swelling in the groin on palpationHIPSDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

Ortolanis test was done, by lying the baby on flat position, grasping the baby’s legs, knees flexed, hold the femur or both legs between the index finger, middle thumb and then rotate through the angle of 90 degrees towards the examining surface. There was no sounds that indicated dislocation.GENETELIAThe gene Talia was exposed, the scrotum present with the descending testesThere was no swelling or hematomas, position of the penis was at the centerThe baby had passed meconiumANUSThe anal canal was presentThe baby had passed meconiumSPINEThe baby was lagged on the abdomen and the finger run through the vertebrae column.There was no swelling, dimples, or hairy patch which could to spine defectsREFLEXSAll reflexes were present include rooting, sucking, grasping, Moro, sneezing, stepping, tonic neck reflexEXAMINATION OF THE PLACENTADownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

The weight of placenta was 46 grams and it was complete, it had no calcification, the cord had one vein and two arteries and was inserted centrally on the fetal surface. There was no knot and it was 48 centimeters in length. On the maternal side, the chorion peeled off at the edge of the placenta. It was thick, opaque, fliable, .the placenta lobes were left without gaps and edges forming uniform arele.NORMAL PUERPERIUMIt is the period that begins as soon as the placenta and membranes are expelled and last 6- 8 weeks characterized by; return to reproductive urgency to their non- pregnant state, initiation of lactationPHYSIOLOGY OF PEUPERIUMThe physiological changes include; involution of the uterus and other genital organs and initiation of lactationFACTORS RENSPONSIBLE FOR UTERINE INVOLUTIONAutolysis -self-digestion of uterine muscle which increases during pregnancy to the normal length and sometimes thickening by protecting the enzymes that break down the protoplasm in muscle fiber. Ischemia -brought by contraction and retraction of uterine muscles which compresses the blood vessels and reduce the uterine blood supply .breastfeeding ensures continuous production of oxytocin which ensure involution.Downloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

Reduction of uterus size- at the completion after birth the uterus is about 5cm, below the umbilicus or 20cm above the symphysis pubis, 24 hours later the fundus is 7.5 cm above the pubis symphysis.Lochia – Lochia rubra-this is the first discharge, composed of blood, shreds=ds of fetal membranes, decidua, vernix caseosa, lanugo and membranes. It is red in color because large amount of blood is contained here. It last 1-4 days after birthLochia serosa-it is termed as lochia that is pink in color. It last for 5-7 days afterbirthLochia Alba- it has whitish in color. It last 8 – 14 days after birthMANAGEMENT OF PUEPERIUMPRINCIPLESTo promote well-being of the mother and the child Encouraging the mother to breastfeed the babySupporting and strengthening the mother confidence in herself and enabling her to fulfill her mothering role within her culture and personal situation.ACTUAL MANADEMENT OF PUEPERIUMDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

ADMISSION TO POSTNATALMother and the baby is taken to postnatal ward for further management. She is advised to empty her bladder frequently, breastfeeding initiated immediately, the lochia loss is monitored via pad count. Vitals monitored4 hourlyPHYSICAL CARE TO THE MOTHERMother is encouraged to take birth, and on how to take a seat bath, she isadvised to change pad frequently.DIETDiet rich in protein are encouraged to enhance wound healing from placenta site, vegetables rich in iron are encouraged to increase blood loss in the body. Intake of warm fluids are encouraged to increase milk let down. They are encouraged to take balance diet.EXERCISESMother was encouraged to ambulate to prevent venous thrombosis and hypostasis. Which can led to increase in bleeding and blood clotting.DAILY EXAMINATION OF POST NATAL MOTHERSAIMSTo assess the general condition of the motherTo rule out the sign of anemiaTo assess involution of the uterusDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

To assess lochia lossTo detect early complications; like deep venous thrombosis, edemaTo share relevant health messagesHEAD TO TOE EXAMINATIONGENERAL APPEARANCEMother was clean and happy with no anxietyHEADHair was clean, soft, EYESThere was no dischargeNo jaundiceNo pallor that could indicate anemiaNOSENo tumors, no polyps’There was no discharge noted, no nose bleedingUPPER LIMBSThe hands were of the same size No finger clubbing’Capillary refill was present No paleness notedCHESTDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

Respiration were within the normal ranges 18 counts per minuteBREASTThey were engorged, lactation was fully established, the breast were active, the nipple was normalABDOMENThe bladder was empty, there was no tenderness and distension on palpation. Uterus was well contracted the fundal height was at the umbilicus which was normalPERINEUMOn inspection it was clean, no swelling, and no edema, lochia loss was red with no offensive smellLOWER LIMBSNo sighs of edema notedNo sighs of deep venous thrombosis notedCOMPLICATIONS OF PUERERIUMPuerperal hemorrhage due to retained products Puerperal sepsis due to poor personal hygieneDeep venous thrombosis due to immobilityAnemia due to excessive blood loss during or after deliveryBreast complications, like, flat nipplesSub- involution of the uterus due to retained products of conceptionPost-partum eclampsia following high blood pressureDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

NEEDS OF A NEONATEWarmth at which is maintained by avoiding exposure of the baby Nourishment – this involve exclusive breastfeeding for the baby was encouragedBonding the baby to stay with the motherPrevention of the infection by keeping the baby clean, mother is to bath her hands before and after during breastfeeding, cord care is done using hibitine to wipe the cord to prevent infectionAdequate sleep for the baby 18-22 hours for the first two monthsBaby needs a well ventilated room to enhance airway patencyExercise, the baby is left free kick and play by jerking the legs to improve muscle relaxation and circulationDaily examination was done to check the growth process and symptoms of infectionLITRATURE REVIEWSTAGES OF LABOURFirst stageBegins with uterine contractions which are regular and painful then detected clinically by effacement of the cervix followed by its dilatation.It has two phases namely:Downloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

Latent phase of laborDilatation of cervix from 0cm to 3 cm and normally last for 6 hoursThe active phase of laborBetween 3 cm to 10 cm cervical dilatation should dilate 1cm per hour in nulliparous and 1.5 multiparous women, contractions increases in severity gradually leading to severe pain towards the end which results to vomiting and reflex shivering.Second stage of laborIs diagnosed with a full dilatation of the cervix and the expulsion of the presenting part and finishes with complete delivery of the baby.Full dilatation of the cervix is accompanied by a bearing down sensationduring contractions and women encouraged to pushAs the contractions comes she is supposed to take a deep breath the holdit and subsequently bears down with all the force of her abdominal musclesThird stage of laborCommences immediately after the delivery of the baby and it includes delivery of the placenta, membranes and control of bleeding.Fourth stage of laborIs the period from delivery of placenta and membranes to the end of the first hour postpartum?The uterus ids firm at level of two fingers breath at the level of the umbilicus, myometrium contractions and retractions accompanied by Downloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

vessel thrombosis, operate effectively to control bleeding from placenta site,Mother is encouraged to urinated frequently to aid in involution of the uterusBreast feeding is iniated to create bondingPostnatal reportMother and the baby were shifted to postnatal word to continue with managementBreast were full active and the baby was breastfeeding wellPOSTNATAL FINDINGS ON EXAMINATION OF THE BABYHEAD:No sunken or bulging fontanelleEYES:The orbital ridges, eye brows, eye lashes were well formed. There was no pallor, no jaundice and no discharge from the eyes.EARS:Were on similar position on both sides, no discharge, upper margin of the pinna on the level of the eye.NOSE:There were no congenital abnormalities and the septum was wellformed. The nares were centrally placed and patent.MOUTH:There was no cleft of palate and lip. The mouth was normalNECK:No swollen lymph nodes and neck appears normalUPPER LIMBS:They are well formed with equal length and size. No extra or missing digits and there sign of pallor or jaundice.Downloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

CHEST:There was chest in drawing, chest walls were well formed there were no murmurs or abnormal sound on auscultation.ABDOMEN:It was not distended, cord was well ligated clean and dry and no abnormalities detected on the baby’s abdomen.LOWER LIMBS:They are well formed with equal length and size. No extra or missing digits. No abnormalities detected.BACK:There continuity of the spinal cord and no spinabifidaIMMUNIZATIONI administered the baby with BCG and birth polio vaccine recorded and gave a return date for the subsequent vaccine in the mother child booklet. Mosquito net was issued.DISCHARGE OF THE MOTHER AND THE BABY FROM THE WARDMy client was discharged on 10th may 2023 when her condition and thatof the baby was stable and I gave her health education on several parameters for her own good and that of the child. She was discharge with per oral paracetamol 1 gram three times a day for three days. I advised her to keep the drugs out of children in a cool dry place.I advised on how to care for the baby by taking good care of the cord to prevent infection. I emphasized on the importance of top tailing of the baby and taught her how to do it. I also told her to keep the baby warm and clean all the time and ensure that she feeds well.Downloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

I advised her on exclusive breastfeeding for six month for optimum growth and immune enhancement of the baby, good positioning for breastfeeding and sleep with the baby under an insecticide treated bed net to prevent mosquitoes causing malaria.I discussed with her the necessity of family planning and advised her to come with her husband after 6 weeks to choose the type of family planning they prefer. Explained to her importance of family planning and she understood.I reminded her to come back to the hospital immediately in case of heavy bleeding, fits and in case of engorged breast or foul smell from theabdomen, and if the child stops breastfeeding well, has difficult or fast breathing, feels hot or unusual cold, becomes less active and when the body becomes yellow especially on the eyes, palms and soles.She was given a birth notification for the baby and advised to collect birth certificate after one month from the office of registration.I finally thanked her for her total cooperation since the first day we met up to now she is discharged and planned with her our first postnatal visit.T.C.A 25th MAY 2023.FOR THE FIRST POST NATAL VISITOBJECTIVE:oTo educate mother about the cord care and its importanceoEducate mother on importance of exclusive breastfeedingoEducate mother on importance of child’s immunization and assess progress of mother and baby.Downloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

FIRST POSTNATAL VISIT REPORTIt was on a Saturday afternoon 20 /05/2023 when my colleague and I went to visit my client. On arrival we found her breastfeedingher baby. We greeted her and she welcomed us into the house. I explained the objectives of the visit. I then gained consent for examination of the baby.HEAD TO TOE EXAMINATION OF THE BABYGENERAL APPEARANCEThe general appearance of the baby was good. The skin was pink in color and it was moist. The baby had no pallor.HeadOn inspection the hair was black and well distributed. Both the posterior and anterior fontanels were accessible. On palpation the sutures had hardened and the fontanels had not closed.EyesThere was no pallor on mucus membrane or yellow coloration and indication of anemia and jaundice. No abnormal discharge observed, the eyes were open, alert and rolling from side to side.EarsOn inspection no discharge was noted, they were both equal in size. The ear pinna was on the same level with the eyes.NoseOn inspection no epistasis or nasal blockage due to polyps, mucus membrane was pink and moist. Mouth On inspection the mouth was clean no pallor, oral thrush or stomatitis. The mother reported of the baby breastfeeding well. Thelips were moist and pink in color. No paleness of the mucus Downloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

membrane thus ruled out anemia, inflammatory signs or bleeding of gums elicited. The tongue was moist and pink.NeckOn inspection the neck folds were clean and no presence of septic spots or pustules. There was no swelling observed on the neck and the cervical nodes. The thyroid gland were of normal size.Upper limbsBoth limbs were equal in size, no edema, with well manifested finger nails. No paleness on the nail beds ruling out anemia. No extra digits noted, the axillary glands were normal, no swelling noted.ChestNo abnormal chest movements on inspiration and expiration, no difficulties in breathing.Abdomen No distention of the abdomen noted. On palpation, no swelling wasnoted. No signs of bruising and the umbilical stump had healed.Lower limbsNo cyanosis detected, the extremities were not cold on touch. No extra digit or webbed feet noted and no swelling noted on the groins. The toe nails were clean and short.HipsNo abnormality was notedGenitalia The inguinal folds were clean. He is a boy and the genitalia was well developed. No abnormal discharge or rash was noted. No hypospadias or epispadias noted.Downloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

POSTNATAL EXAMINATION OF THE MOTHER AimsTo assess the general condition of the motherTo detect any complication or deviation from normal.General appearanceThe mother looked neat in clean clothes, well combed hair, healthyand in a happy mood.HeadThe head scalp was clean, hair well plaited with no parasitic infestation. There was no edema.EyesThere was no pallor on mucus membrane or yellow coloration and indication of anemia and jaundice. No discharge observed, conjunctiva hemorrhage or contact on inspection. No visual disturbance reported.EarsOn inspection no discharge was noted no pain reported, they were both equal in size no auditory problems reported.NoseOn inspection no epistasis or nasal blockage due to polyps, mucus membrane was pink and moist. Mouth The lips were moist and pink in color. Neither halitosis nor acetonebreathe present. No paleness of the mucus membrane thus ruled out anemia, inflammatory signs or bleeding of gums elicited. The tongue was moist and pink.Downloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

NeckThere was no swelling observed on the neck and the cervical nodes. The thyroid gland were of normal size. No dysphagia noted.Upper limbsBoth limbs were equal in size, no edema, with short and well maintained finger nails. No paleness on the nail beds ruling out anemia. No extra digits noted, the axillary glands were normal, no swelling noted.ChestNo abnormal chest movements on inspiration and expiration, no difficulties in breathing.BreastI explained to the mother on the importance of breast examination, and starting with the furthest divided into four quadrants and examined each through palpation. No lump was felt during the examination thus no benign or malignancy growth was suspected.AbdomenOn palpation the abdomen had not distended and the fundal height was not palpable since involution had taken place.GenitaliaShe reported of no abnormal discharge from the vagina.Lower limbs oNo signs of edema noted, no deep venous thrombosis or presence of varicose veins. The nails were short and clean and no sign of fungal infection.Downloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

HEALTH TALK DURING THE FIRST POSTNATAL HOMEVISITDate: 20/05/2023Venue: client’s home.Audience: client and her family.Presenter: James KaranjaBROAD OBJECTIVE: By the end of the session Lucy will have gained knowledge on importance of exclusive breastfeedingTIMESPECIFIC OBJECTIVECONTENTTEACHING METHODTEACHING ACTIVITYTEACHING AIDLEARNED ACTIVITYEVALUATTIONIntroduction 3MINGreeting Lucy and the otherfamily memberGreatings,introduction of self and the topic to be coveredExplaing SayingNametag, handoutListening and asking questionsLesson development By the end of thesessioThis is continuous Explaining andinteractioAnswering questionsHandoutListening and askiListening andasking questionsDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

phase one7MINn patient will have gained knowledgeon exclusive breastfeedingbreastfeeding for the first6 monthsof life without introduction ofother foods.n dialogueng questionsLesson development phase 5MINBy the end of thesession Lucy will have gained Contains the followingimportant components: oIronpreventLecture and explainingAnswering questionsHandout and demonstrationListening and asking questionsLucy answered the questions correctlyDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

knowledgeon importance of breast milks anemiaoLactoseenhance absorption of calciumoVitaminE prevents oxidation offatty acids.Conclusion 3MINSummarizingThanking Lucy and the other family membersAsking questions exclusive LectureAsking questions and clarifListening and answeriLucy showed signsof comprehensiDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

for welcoming us warmlybreastfeedingying ant doubtng questionson by asking answering questions correctlyPLAN FOR SECOND POSTNATAL VISIToTo assess the progress of mother and the babyoTo terminate my case studyoTo evaluate what I had taught during previous visits.SECOND POST NATAL VISIT (TERMINATION) REPORTIt was on a Saturday afternoon 10 /06/2023 when my colleague and I went to visit my client at 2 am. On arrival we found her baby had slept 15 minutes before. We greeted her and she welcomed us into the house. I explained the objectives of the visit.HEALTH MESSAGESSince it was my last visit, I summarized all the previous teaching on i.e. on knowledge on danger signs in pregnancy and birth preparedness, individual birth plan, and importance of exclusive breastfeeding. I asked a number of questions based on the discussed topics and the response towards each question was excellent since she could remember everything. Finally, I gave a short summary on the discussed topics and also I discussed with her minor complication to the baby during pueperium. This includes dehydration which can arise when the baby is not feeding well, napkin rash which happen when the napkin remains forDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

a long time without changing and fever if the cord care is not done well After which I appreciated her for welcoming me and allowing me to be his health care adviser and to be a frequent visitor to his home. I again thanked him for his co-operation and the support she gave me and even accommodating me for that short period. The family also appreciated us since she had benefited from us through the health talks that will forever help her during the subsequent pregnancies.SUMMARY OF THE CASE STUDY How I met my clientI first met my client on 22/march/2023 in maternal child health clinic at Consolata hospital Nkubu during her fourth visits at gestation of 30 weeks where I introduced myself to her and explained my interest in taking her to be my client. She accepted my request and she informed me that she lives in NkubuFirst home visitThe main aim was for;oTo introduce and familiarize myself with my client family.oTo assess home environment.oTo discuss danger signs in pregnancyoTo discuss what to do in case of danger signsSecond home visitThe main aim was;oTo know the progress of the clientoTo identify any challenge or problem that may ariseDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

oTo share a relevant health message on individual birth planINTRAPARTUM PERIOD OBJECTVESTo monitor the progress of labor closely to ensure maternal and fetal wellbeingTo detect any deviation from normal for early managementTo prepare the mother physically and emotionally for deliveryTo educate the mother on what is expected from her during laborINTRAPARTUM SUMMARYAt 10:30 am she reported to be having laps radiating to the back increasing in intensity and severity. Patient reassessedOn vaginal examinationCervical Os 2 cm dilated, anterior thick and uneffacedArtificial rupture of membrane done to clear liquorCervical sweep donePost ARM fetal heartrate were 142b/mPlanFor augmentation of labor using sytocinon 2.5 IU in 500mls of normal salineIt was commenced at 10:50 AMAt 12:30 cervical os was 5cm dilated thin and partially effaced, she had three moderates’ contractions lasting for 10 minutes vitals were unremarkable next vaginal examination was to be done at 6:30pm. And partograph was started to monitor the progress of laborDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

At 6:30 pmCervical Os was 8 cm dilated effaced and show was present on examination fingersPelvis was adequate for spontaneous deliveryStation was +1 no molding notedDescent 2/5. Plan was to continue monitoring for progress of labor via partographAt 7:30pmPatient developed an urge to push and I guided her to delivery couch, she lied on for cervix was fully dilated, fetal heart rate was 138b/m.I encouraged Lucy to Push when contractions peaks, and to rest in between contractions and take a deep breath to prevent her from been exhausted.At 7:40PM she delivered to alive male infant Apgar score 9 in I minute,10 in 5 minute and 10 in 10 minute weighing 3.1kgs, I.M oxytocin 10IU was administeredCord clamped, placenta delivered using controlled cord traction, all clotsand product of conception expelled, and no tear noted she was given a pad to monitor for amount of lochia loss.FIRST POSTNATAL VISIT OBECTIVESoTo monitor the progress of the baby and motheroTo share a health message on importance of exclusive breastfeedingoTo do a quick physical examination of the babyDownloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

PLAN FOR SECOND POSTNATAL VISIToTo assess the progress of mother and the babyoTo terminate my case studyoTo evaluate what I had taught during previous visitsEVALUATION OF THE CASE STUDYThroughout the case study I learnt a lot, I interacted with my client family and learnt a lot from themI am also convinced that my client learnt a lot throughout the case study and follow upPROBLEM ENCOUNTEREDTransport was the main problem encountered during my case study.FAMILY RESPONSE TO FOLLOW UPLucy and her familywerevery cooperative throughout the follow upWhenever I visited they appreciated me and welcomed me happily and showed a lot of interestThey benefited a lot from the health message sharedACHIEVEMENTSI managed to assess the progress of my client during the scheduled visit.I managed to identify the problems that were becoming an obstacle to Lucy and I guided him through health messages like, importance of Downloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

exclusive breastfeeding and the positioning of the baby after feeding newborn danger signs,TO CLIENT AND THE FAMILYLucy was well, breast were fully active and the baby was breastfeeding on the demand.She had great improvement after learning about importance of breastfeeding, and she took plenty of fluids to aid in breastmilk productionVOTE OF THANKSI sincere wish to thank my client, her husband and all the family members for positive attitude towards me and also willingness to be followedRECOMMENDATIONSWomen intending to get pregnant to go first and get pre-conceptioncare which will prepare them for the pregnancyMothers to start attending antenatal clinic immediately they notice they are pregnant so as to be able to get ferrous sulphate and folic which aid in development of fetus and prevent congenital abnormalities.All postnatal mothers to attend the postnatal clinic as per the targeted postnatal visit.Male involvement in the antenatal, intrapartum and postpartum to be emphasized.Downloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

BIBLIOGRAPHYMyles textbook for midwifes.Procedure manual for nurses from nursing councilMother and child health bookletACKNOWLEDGEMENTI would like to take this opportunity to thank the Almighty God for the strength he has given me to complete this case sturdy. I also want to thank my tutor Mrs. Kaburu for the guidance she gave in the cause of my case study.Special thanks to my client Lucy and her family for their support throughout the case study. I thank my colleagues who has been accompanying me the entire antenatal and postnatal visit to my client. The baby will be immunized at 6weeks on 12/06/2023.Downloaded by Tracy Disnah (tdisnah@gmail.com)lOMoARcPSD|32470484

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