case study on breech birth.docx

8/17/2019 CASE STUDY ON BREECH BIRTH.docx

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BREECH BIRTH

BACKGROUND

Pregnancy is an enjoyable and expected state for every mother as well as for entire family in our

society. Even though pregnancy is a natural outcome of a congenial marriage, it is biologically,

physiologically and psychologically stressful. Having borne this stress during the pregnancy, both

the mother and fetus are exposed to their greatest danger at childbirth. This may be fatal for either

or both or may lead to prolonged disability if any complication arises. To avert these potential

adverse outcomes, pre-natal, natal, and post-natal care are aimed at identification, assessment

and management of women whose pregnancies are at ris because of existing or potential

complication.

The !orld Health "rgani#ation $!H"% defines all pregnancies as &H'(H )'*+ due to the inherent

dangers the mother and the fetus are exposed to at the time of delivery in the absence of trained

help. Therefore, maternal and infant mortalities are high amongst those with poor access to trainedobstetrical help, as in the developing countries. 'n epal, on an average, twelve women die daily

either due to complication of pregnancy or childbirth. 'n order to standardi#e the documentation of

impact of health delivery system on maternal health, the !H" has introduced the aternal

ortality )ate $)%. aternal mortality has been defined by the !H" as &THE /E0TH "1 0

!"0 !H'2E P)E(0T ") !'TH' 1"3)T4-T!" /04* "1 TE)'0T'" "1

P)E(054, '))E*"E5T'6E "1 THE /3)0T'" 0/ *'TE "1 P)E(054,1)" 04

503*E )E20TE/ T" ") 'T* 00(E)ET 73T "T 1)' 055'/ET02 ") '5'/ET02

503*E*. aternal mortality rate measures the ris of a women dying from &puerperal causes

and is defined as the maternal mortality per 899,999 live births in a given area and year. The

ational survey conducted in :99;0/ estimated the aternal ortality as :9? occurs in rural area. 0ccording to the epal aternal ortality and

orbidity *tudy of 8>>


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INTRODUCTION

0 case study is an important learning techniAue with specific educational objectives. 0 case study

provides the chance to integrate theoretical nowledge with clinical practice with focus on a

specific or a set of problems. 0s the basic concept of case study can be applied to many situations

and is popular amongst many disciplines as a modality of imparting nowledge. 0s a student of

7achelor of ursing, we are reAuired to undertae a study on high ris pregnancy as an emphasis

on the national policy to improve the maternal and child health.

0bout fifty years ago it was not uncommon to now of someone who had died during child birth. 0t

that time, every young women about to become a mother was practically concerned about her

wellbeing. 0 healthy baby was considered an extra dividend. 1rom the obstetrical viewpoint,

maternal survival was of primary importance and in some instances, even the living fetus was

sometimes sacrificed for the mother safety.

The focus of obstetric care has changed during the past years because of advances in the

management of disorders that have an adverse effect on the pregnant women. However, there hasbeen a less significant reduction in perinatal mortality and morbidity. 'n many ways, morbidity

exerts a more profound economic effect than mortality.

*ince the fetus in any pregnancy is now at greater ris than the mother is, the concept of 0T )'*+

applies to both maternal and fetal outcome. 0 H'(H )'*+ pregnancy is one in which &THE

"THE) ") 1ET3* H0* 0 *'('1'50T24 '5)E0*E/ 5H05E "1 /E0TH ")

/'*07'2'T4 !HE 5"P0)E/ !'TH 0 2"! )'*+ P)E(054 ' !H'5H 0 "PT'02"3T5"E '* ECPE5TE/ 1") 7"TH.

The aim of obstetric care is to concentrate resources on improving peri-natal outcome. 't is thus

important to identify those at ris and then to provide the specific care reAuired to prevent death or

disability.


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OBJECTIVE OF HIGH RISK CASE STUDY

GENERAL OBJECTIVE

The purpose of high ris case study is to provide an exercise for the student to promote nowledge

and sill in obstetric care, so that she becomes aware of the ha#ards of supposedly &normal

pregnancies in the community. This will provide an impetus to detect pregnancies at ris once the

trained nurse returns to her community.

SPECIFIC OBJECTIVE

8. 'dentify high ris pregnancies.:. Elucidate the history and reveal the reason$s% why the pregnancy is high ris.D. 2earn to perform systemic and obstetrical examination methodically and correctly.@. 'dentify abnormalities, anticipate problems, plan and tae appropriate action during labour

and post-natal period to avoid mortality and morbidity.. Plan and implement comprehensive care of the client, using the nowledge gained from

basic science and nursing theory.;. 1ormulate nursing diagnosis and priorities nursing care plan according to patientFs needs.B. Provide holistic nursing care to the client and visitors using the nursing process.

. Help mother in establishing parent G infant relationship.89. "bserve and evaluate the care given to the baby by mother and provide comprehensive

guidance.88. 'dentify needs and post-natal complication in mother and infant by interview and physical

examination.8:. 0lleviate pain and discomfort in the patient by applying nursing measures and

administering analgesics as per prescription.8D. Teach mother and family about hygiene, self care and baby care for promotion of health

and prevention of disease.8@. !or together with client, family members and other health worer to plan the discharge

and follow up care of the mother and the baby.8. 0cAuaint one-self with the eAuipments, procedures and facilities used in the management

of high ris pregnancies.8;. To study, document and present a high ris pregnancy case report.

HIGH RISK PREGNANCY: IMPLICATIONS

High ris pregnancy is defined as a pregnancy in which the result is found to be poor for the

mother and the foetus before, during and after delivery. Thus in High ris Pregnancy the mother and the foetus are at a higher ris for morbidity and mortality due to problems that arise during

pregnancy either due to conception or due to other health problems which are pre existent or


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newly acAuired during the pregnancy. Having mentioned the definition of high ris pregnancy, we

should not eAually forget that every pregnancy is potentially at ris.

The incidence of high ris pregnancies in the developed countries is :? while in the developing

countries the value is about @?. This group of patients is responsible for B9?-


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The ris approach implies identification of high ris case at an ealy stage and maes available

silled care from the point of identification. The main aim of ris approach is to improve the

efficiency and objectiveness of the maternal and child health services through maximum utili#ation

of available resources including nursing care.

CATEGORIES OF “HIGH RISK“ PREGNANCY

MATERNAL AND PARIETY FACTORS:

i. aternal age of sixteen years and under.ii. ullipara at thirty-five years or over.iii. ultipara at forty years or over.iv. 'nterval of eight years of more since last pregnancy.v. High parity $five or more children%.

vi. Pregnancy occurring three years or less since last delivery.vii. on-marital pregnancy.

PREGNANCY INDUCED HYPERTENSION, KIDNEY DISEASE:

a% Pre-eclampsia with hospitali#ation before labour.b% Eclampsia.c% +idney diseaseI Pyelonephritis, ephrotic syndrome etc.d% *evere chronic hypertension $J8;9=899mmHg%.e% 7lood pressure of 8@9=899mmHg or more on two different occasions.

ANAEMIA AND HAEMORRHAGE:

a. Haematocrit $P56% of D9? or less in pregnancy.b. *evere hemorrhage in previous pregnancy reAuiring transfusion.c. Hemorrhage in the present pregnancy $ 0nte-partum hemorrhage%d. 0nemia $HbI J89gm ?% for which treatment other than iron supplement was

reAuired.

e. *icle cell disease and trait.f. History of bleeding or clotting disorder.

FOETAL FACTORS:


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a. Two or more previous premature deliveries. $/elivery of twins is considered a singledelivery.%

b. Two or more consecutive spontaneous abortions.c. "ne or more still-births at term.d. "ne or more births with gross congenital anomaly.

e. 07" or )H incompatibility or iso-immuni#ation.f. History of previous birth defects e.g. cerebral palsy, brain damage.g. History of large baby weighing more than nine pounds.

MOTHER’S SURGICAL CONDITION:

a.Pelvic floor restoration or any pelvic surgery.b.Previous surgery of uterus $e.g.myomectomy%

c. *urgery of ectopic pregnancy.

CEPHALO-PELVIC DISPROPORTION & DYSTOCIA:

a. 5ephalo-pelvic disproportionb. Two or more deliveries

c. ultiple pregnancies in the present pregnancy $twins, triplets etc.%d. Previous operative deliveries $caesarean section, mid-cavity forceps delivery etc.%e. History of prolonged labour $K 8< hours for primigravida L K 8: hours for multi-

gravida%f. Previously diagnosed abnormality of the maternal pelvis and genital tractg. *hort stature of the mother $HeightIJ8@9cm%.h. Mal!"#$#!% a%d Mal&e"e%$a$#!% 'B&eec( &e"e%$a$#!%)

CONCURRENT ILLNESS IN THE MOTHER:

a. /iabetes ellitus. (estational /iabetes

b. Hyper emesis gravidarumc. Thyroid dysfunctionI Hypothyroidism=Hyperthyroidismd. alnutrition or extreme obesitye. "rganic heart diseasef. *yphilis L T")5H infectionsg. Tuberculosis or other pulmonary pathologiesh. alignant, pre-malignant L locally invasive tumors $including H.ole%i. 0lcoholism L drug addiction j. Psychiatric disease or epilepsy. ental retardation

MISCELLANEOUS:a. Those with history of late registrationb Those with poor clinical attendance


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c. Those with wea family support

FACTORS THAT PLACE THE PREGNANCY AND FOETUS IN

HIGH RISK

FIRST TRIMESTER

CATEGORY RISK FACTOR

1. PHYSIOLOGIC Gross foetal chromosomal abnormality

Hydatidiform mole

Poor trophoblast

Multiple prenancies

2. PSYCHOLOGIC!L Psycholoical shoc"

Hyperemesisra#idarum

. $H%&!P%'$IC !bortion

(ru therapy

&adiotherapy ) *+ ray

!. I,-%C$IO,

iral infection

". G%,%$IC Sporadic Mutation/ Se0+ lin"ed recessi#e

chromosomal disorders

#. %,I&O,M%,$ Po#erty

Malnourishment

$obacco/ !lcohol/ (ru abuse

SECOND TRIMESTER


1. !,!$OMIC Maternal uterine abnormality

Incompetent cer#ical os

Gross foetal abnormality

!cute hydraminous

Multiple prenancies

Poor implantation

2. M!$%&,!L-!C$O&S

&h incompatibility

Hypertension


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&enal disease

'rinary tract infection

Heart disease

!ccidents

!no0ia of eclampsia or epilepsy

. I,-%C$IO, Polio/ Syphilis/ Hepatitis 1esp. H%2/

HI)!I(S/ other #iral infection!. I,%S$IG!$I%

P&OC%('&% !mniocentesis

". %,I&O,M%,$!L Po#erty/ Malnourishment/ $obacco/ !lcohol/

(ru abuse etc.#. I(IOP!$HIC

+

THIRD TRIMESTER


1. !,!$OMIC Mal+presentation

Cord complications

Placenta pre#ia

2. M!$%&,!L &h incompatibility

Hypertensi#e disease

(iabetes

$hyroto0icosis

. I,-%C$IO, iral infection

Pneumonia

Other inter+current infection!. (&'GS

!nti+thyroid drus

Steroids

!nti+con#ulsants

!nti+coaulants

". ,'$&I$IO,!L Protein+%nery Malnutrition

Iron de3ciency#. -O%$!L

COMPLIC!$IO,S Premature rupture of membrane

Preterm labour

Post+maturity

Hydramnious or oliohydramnious

Multiple estations

$. %,I&O,M%,$!L Po#erty/ $obacco/ !lcohol/ (ru abuse

Inade4uate nutrition

NURSE*S ROLE IN MANAGEMENT OF HIGH RISK

PREGNANCY


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8. /etect, categori#e and place the patient in the high ris category during antenatal period:. 'dentify the ris factor$s% early in the antenatal period and report them promptly to the

treating obstetrician.

D. Educate the patient and family members regarding the ris factor$s%, the need for regular antenatal chec-ups and the necessity for hospital delivery rather than home delivery.

@. 7e vigilante and anticipate complications during labour tae necessary precautionary stepsand report them to the treating obstetrician.

. otivate the parents to adopt suitable family planning method, or adopt puerperalsterili#ation if the family is complete.

BIOGRAPHICAL DATA : MOTHER

0E I ANITA GURUNG

0(E I T!ET4 *E6E $:B 4E0)*%

E/350T'" I TE $89 520**%

0//)E** I 640* G 8, /0032'

ETH'5 ()"3P I (3)3(

)E2'('" I H'/3

"553P0T'" I H"3*E!'1E

/3)0T'" "1 0))'0(E I E'(HT $< 4E0)*%

HUSBAND*S NAME : *H40 /H"M (3)3(


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0(E I TH')T4 *'C $D; 4E0)*%

E/350T'" I *25

"553P0T'" I 07)"0/

0E "1 H"*P'T02 I !E*TE) )E('"02 H"*P'T02

!0)/ I 0TE)'T4 !0)/

7E/ 37E) I 89 $05%

' P0T'ET 37E) I 898;@


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History taing is a very important component in the treatment of a patient. Histories regarding the

main complaints direct the care giver to the site of the pathology=altered anatomy L help to reach a

diagnosis. History taing also starts the patient-caregiver rapport, which is essential for effective

care L patient satisfaction.

rs. (3)3( was booed case of !estern regional hospital. *he had total five 05 visit. Her

last 05 visit was at approximatelyDBO: wee. *he came for admission on :8 th of 0ahar at >ID9am.

*he felt leaing of amniotic fluid since :9;% months.

• 2eaing of amniotic fluid since :9;


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rs. 0nita (urung got married at the age of nineteen years $8> yrs.%. Her marriage is within same

cast. *he and her husband have a delightful married life, with a loving husband-wife relationship.

They have been using mechanical method $condom% as the contraceptive for family planning.

Fa+#l H#"$!&:

Mrs. !nita Gurun li#es in a 5oint family 6ith her husband. Her husband is third child in

his family amon three siblins. Her sister+in+la6s are already married and settled

else6here. Mrs. !nita herself is elder child amon the t6o siblins. ,o any sini3cant

history in her family. 7ithin her husband8s family/ her father9in+la6 is a chronic

alcoholic and smo"er and her mother+in+la6 is under the medication of !sthma. Out of

this/ there is no any other sini3cant history in her family.

Fa+#l T&ee

0nitaFs

HusbandFs 0nitaFs

1amily


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Pe&"!%al (#"$!&:

Ke

Male

female

Patient’s

husband

Patient

Newbor

n


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rs. (urung is an educated housewife. *he is a non-vegetarian and her diet consists of rice,

pulses, beans, green vegetables, meat and fish. Her diet consists of rice with ghee, jaulo, juano-

o-jhol, meat and soup after she delivers. *he has a good appetite. Her bowel and bladder habit is

normal.

There is no any significant history of drug allergy. *he has good personal hygiene. *he neithersmoe nor drin alcohol.

S!c#!ec!%!+#c S$a$-":

rs. 0nita (urungFs family belongs to middle class epali family. Her family depends on pension

and her husbandFs job$abroad%. *he herself is unemployed.

Pa"$ Med#cal H#"$!&:

The past medical history provides an idea regarding the general wellbeing of the patient. There are

certain medical and surgical conditions, when present, can affect the mother and fetus.

she has no history ofI

Heart disease

Hypertension

)enal disease

'nfectionI Hepatitis, H'6=0'/*, 2eprosy etc.

/iabetes

/rug allergies

*ei#ure disorders

'njury=deformity of the pelvis.

Pa"$ !b"$e$c H#"$!&:


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*he has a seven $B% years old son. *he had antenatal chec up at the health post of

/amauli but for the delivery she came to !estern )egional Hospital. *he delivered a male baby

weighing :.g on :9;8=9D=9;. *he had a normal vaginal delivery and there were no any

significant problem to her as well as her baby during delivery and during the post natal period.

P&e"e%$ Ob"$e$c H#"$!&:

2ast enstrual Period $2P% I :9;B=9;=:@

Expected /ate of /elivery $E//% I :9;


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D a $ e

/$.

'K0)

Pall!&1

Oede+a

U%e:

Alb10l-

Bl!!d

P&e""-&e

P.O.G.

'/ee2")

F-%dal

He#0($

F.H.S

R e + a & 2 "

9 ; B = 9 < = 8 D

: -=- nil >9=B9 BO: - -

3*( to

detect

blighted

ovum

9 ; B = 8 9 = 8 9

D -=- nil >9=;9 8;O: 8@ -

T.T8st

dose,contin

ue iron

calcium

9 ; B = 8 8 = 8 ;

@ -=- nil >9=B9 :8O: :9 O)7* report,

3*(

9 ; 9=B9 D@O:

D 8@9

5onfirm

breech

presentati-on by 3*(,

f=u D wees

9 ; < = 9 D = 9 ;

< -=- nil >9=B9 DBO: T* 8D@

f=u after D

wees or

*"*

OTHER IN3ESTIGATIONS:


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Hb I 88.; gm?

)andom blood sugar I >9 mg=dl

Platelet I 8@-:9 wees.

• Presentation is breech

• o gross congenital anomaly is detected.

• The liAuor volume is adeAuate.

/ate of 3*(I :9;8=98=8:


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• *ingle life fetus in the uterine cavity, with regular cardiac activity and normal fetal activity

• The placenta is situated at the anterior and upper uterine clear of internal os

• The gestational age by the 7P/.1' and H5 corresponds to D@ wees.

• Presentation is breech• o gross congenital anomaly is detected.

• The liAuor volume is adeAuate 01' B

PHYSICAL E4AMINATION

Physical examination follows history taing, and is done in a systemic manner with special

emphasis on the site of pathology. The physical examination data correlated with subjective data of

history taing aids to reach a woring diagnosis direct the investigation and formulate a treatment.

The following are the steps of physical examinationI

• 'nspection

• Palpation

• Percussion

• 0uscultation

Her general physical examination carried out on the day of admission revealedI

Pallor I o any

'cterus I o any

5lubbing I o any

"edema I o any

M6/ I o any

2ymph nodes I o any

3#$al S#0%":


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• 7lood pressure I >9=;9 mm of Hg

• Pulse I B:=min regular, good volume

• )espiratory rate I 8


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*pine L ExtremitiesI

• o spinal deformity evident on physical examination.

• The extremities are symmetrical and functionally normal.

Ob"$e$cal E5a+#%a$#!%:

The obstetrical examination consists of abdominal and pelvic examinations. The obstetrical

examination is continuous process of assessment, especially around the time of labour when the

status of both the mother and the fetus are changing dynamically.

The purpose of the pre-natal examination is toI

• /etermine the si#e of the uterus L correlate with the gestational age. This helps to

anticipate complications if any e.g. twins, *(0 babies, polyhydramnious, oligihydramiousetc.

• 0ssess the state of previous caesarean scar if present.

• /etermine the lie L presentation of the fetus. 0ssess the progression of labour.

• /etect any maternal or fetal abnormality and tae corrective steps to prevent any

complication.

Abd!+#%al E5a+#%a$#!%:

'F#%d#%0 a$ $(e $#+e !f ad+#""#!% a$ 6:78a+):

• 'nspection

+ The abdomen was uniformly distended and ovoid in shape.+ *triae gravidera L linea nigra were present.

• PalpationI+ 1undal heightI D< wees of gestation. $chronological age of gestationI D


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• Percussion

+ ot applicable

Pelvic examinationI

• o swelling or varicose vein of the external genitalia

• ot any discharge

Pe& 3a0#%al 'P13) E5a+#%a$#!%

"s I @ cm

Effacement I D9?

embrane I 0bsent

Presenting partI High up

Cl#%#cal #+&e""#!%: G9P;8 D<;


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't is the commonest malpresentation.in breech presentation the lie is

longitudinal, podalic pole present in pelvic brim, presenting diameter is bitrochantric and the

denominator is sacrum.

0 breech birth is the birth of a baby from a breech presentation. 'n the breech presentation the

baby enters the birth canal with the buttoc or feet first as opposed to the normal head firstpresentation.

INCIDENCE:

The incidence is about 8 in at :< th wee and drops to ? at D@th wee and toD? in term. Thus in D out of @ spontaneous correction into vertex presentation occurs by D@ th wee

because the greater proportion of amniotic fluid facilitate free movement of fetus. The incidence is

expected to be low in hospital where high parity birth are minimal and routine external cephalic

version is done in antenatal period.

TYPES:

• 5omplete

• 'ncomplete

C!+le$e

The normal attitude of full flexion is maintained. The thigh are flexed at the hips and

the legs at the nee. The presentating part consists of two buttoc, external genitalia and two feet.

't commonly present in multipara $89?%.

I%c!+le$e

This is due to varying degree of extension of thighs or legs at the podalic pole. Three

varieties are possible $:?%.

Breech with extended legs(frank breech)

'n this condition, the thigh are flexed on the trun and legs are extended nee joint. The

presenting part consists of the two buttocs and external genitalia only. 't is commonly present in

primigravida, about B9?. The increase prevalence in primi gravida is due to a tight uterine tone

and early engagement of breech that inhibits flexion of the legs and free turning of the fetus.

Footling Breech


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7oth the thigh and the legs are partially extended bringing the legs to present at the brim.

This is rare condition.

Knee presentation

Thighs are extended but the nee are flexed, bringing the nees down to present at the

brim. This is very rare.

'n addition to the above, breech births in which the sacrum is the fetal denominator can be

classified by the position of a fetus. Thus sacro-anterior, sacro-transverse and sacro-posteriorpositions all exist, of which sacro-anterior indicates an easier delivery.


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Cl#%#cal =ae$#e":

'n an attempt to find out the dangers inherent to breech, breech presentstion is clinically

classified asI

Uncomplicated :

't is defined as one where there is no other associated obstetric apart from the breech,

prenaturity being exeluded.

Complicated:

!hen the presentation is associated with condition which adversely influence the

prognosis such as prematurity, twins, contracted pelvis, placenta previa etc. it is called complicatedbreech. Extended legs extended arms, cord prolapse or difficulty encountered during breech

delivery should no be called complicated breech but are called complicated or abnormal breech.

E#de+#!l!0:

F&e>-e%c

United States

Incidence is correlated to gestational age (see Table 1 below). However the overall

fre!uenc" is #$%& at deliver".

Table 8I (estational age and freAuency of breech birth

Ge"$a$#!%al A0e, /ee2" B&eec(, ?

:8-:@ DD

:-:< :<

:>-D: 8@

DD-D; >

DB-@9 B

ortality=orbidityI

• any complications can result from breech presentation. They are generally related to

complications of the fetal abnormalities that may be the primary reason for the breechpresentation and those related to umbilical cord compression resultant from abnormalprogression through the maternal pelvis.


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• 'ncreased birth traumaI 0s the duration of umbilical cord compression increases, the

practitioner tries to deliver the infant more rapidly than advisable, thus increasing theincidence of birth trauma.

• 'ncidence of prolapsed umbilical cord depends on type of breech presentation.

o 1ootling, 8B? incidence

o 5omplete, ? incidence

o 1ran, 9.? incidence

• 3mbilical cord abnormalitiesI 5ord length may be reduced, and, in footlings, there is an

increased ris of the cord coiling around the legs of the fetus.

E$#!l!0:

8.PrematurityI it is the commonest cause of breech

:.1actors preventing spontaneous versionI

• 7reech with extended legs

• Twins

• "ligohydraminos

• 5ongenital malformation of the uterus such as septste or bicorunated

•

*hort cord ,relative or absolute• 'ntrauterine death of the fetus

D.1avorable adaptationI

• Hydrocephalus- big head can be well accommodated in the wide fundus

• Placenta previa

• 5ontrcted pelvis

• 5ornufundal attachment of the placenta- minimi#es the space of the fudus where the

smaller head can placed comfortably

• 3ndue mobility of fetusI

• Hydraminos

• ultipara with lax abdominal [email protected] abnormalityI

• Trisomies 8D, 8< :8 and myotonicdystrophy due to alteration of fetal muscular tone and

mobility.)ecuurent or habitualI

• "n occasion, the breech presentation recurs in successive pregnancies. !hen it recurs in

three or more consecutive pregnancy, it is called habitual or recurrent breech. The probablecauses are congenital malformation of the uterus or bicorunated, and repeated cornufundalattachment of the placenta.

D#a0%!"#"


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Ultrasonography: 't is most informative

8. 't confirm the clinical diagnosis- especially in primigravida with engaged fran breech or with tense abdominal wall and irritable uterus.

:. 't can detect fetal congenital abnormality and also congenital anomalies of the uterus.D. 't measure biparietal diameter, gestational age and approximate weight of the fetus.@. 't also locali#ed the placenta.. 0ssessment of liAuor volume $important for E56%;. 0ttitude of the head- flexion or hypertension.

adiology: 0 straight C-ray rarely done

8. To confirm the clinical diagnosis:. To exclude bony congenital malformation $hydrocephalus%D. To note the si#e of the baby@. To note the position of the limbs and the head

Clinical I the diagnostic feature of a complete breech and a fran breech are given below in the

tabulated form.

5linical /iagnosis of 7reech Presentation

5omplete breech 1ran breech

!er abdomen

1undal grip

2ateral grip

Pelvic grip

Head G suggested by hard

globular mass

Head is ballottable

1etal bac is to one side and the

irregular limbs to the other

7reech G suggested by soft,

broad and irregular mass

7reech is usually not engaged

during pregnancy

3sually located at a higher level

round about the umbilicus

Head- irregular small pars of the

feet may be felt by head the side

of the head.

Head is non ballottable due to

splinting action of the legs on the

trun

'rregular parts are less felt on the

side

*mall hard conical mass is felt.

The breech is usually engaged

2ocated at a lower level in the

midline due to early engagement

of the breech


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1etal heart sound

!er "agina

/uring pregnancy

/uring labour

*oft and irregular parts are felt

through the fronix

Palpation of ischial tuberosities,

sacrum and the feet by the side

of buttocs.

The foot is identified by theprominence of the heel and

lesser mobility or the great toe

Hard feel of the sacrumis felt, often

mistaen for the head.

Palpation of ischial tuberosities,

anal opening and sacrum only

P!"#$#!%: The sacrum is the denominator of the breech and there are four positions. 'n anterior

position, the sacrum is directed towards the iliopubic eminences and in posterior position, the

sacrum is directed to the sacro iliac joints. The positions are

2eft sacro anterior $2*0%

)ight sacro anterior $)*0%

2eft sacro posterior $2*P%

)ight sacro posterior $)*P%

A%$e%a$al +a%a0e+e%$

• 'dentification of the complicating factors related with breech presentation

• External cephalic version

External version is a non-surgical method in which a doctor can help move the babywithin the uterus. 0 medication to help relax the uterus might be given as well as anultrasound exam, to better chec the position of the baby, the location of theplacenta, and the amount of amniotic fluid in the uterus. (entle pushing on thelower abdomen can turn the baby into the head-down position. Throughout theexternal version, the babyQs heartbeat will be checed closely so that if anyproblems should occur, the health care provider will stop turning immediately. ostattempts at external version are successful however, as the due date gets closerthis procedure is more difficult.


28/58

Time of versionI D-DB wees but can be attempted at any time there after up to early

stage of labour.

C!%$&a#%d#ca$#!% !f e5$e&%al ce(al#c =e&"#!%:

8. 0ntepartum haemorrhage $placenta previa or abription% Rris of placenta separation:. 1etal causes- congenital anomalies$major%, dead fetus, hyperextentionof the head, fetal

compromise$'3()%D. ultiple pregnancy@. )upture membrane- with drainage of liAuor . +nown congenital malformation of the uterus;. 5ontracted pelvis

B. Previous cesarean delivery G ris of scar rupture.


29/58

3a0#%al B&eec( del#=e&

6aginal breech delivery is considered in cases with adeAuate pelvis, average fetal weight$between

8. and D.g%, flexed head and without any other complication. 1ran breech is preferred. 'n all

such cases one must ensure close monitering of labour and facilities for immediate cesarean

delivery should necessity arises.

Ma%a0e+e%$ !f 3a0#%al B&eec( Del#=e&

'irst stage of labour

The management protocol is similar to that mentioned in normal labour. The fallowing are theimportant consideration. *pontaneous onset labour increases the chance of successful vaginal

delivery.

8. 6aginal examination is indicated:. 0t the onset of labour D. *oon after rupture of membrane to exclude cord porolapse@. 0n intravenous line is sited with ringer,s solution, oral intae is avoided, blood is sent for

group and crossmatching $considering the chance of cesarean section%. 0deAuate analgesic is given, epidural is preferred;. 1etal status and progress of labour are moniteredB. "xytocin infusion may be used for augumentation of labour

econd stage of labour I there are three method of vaginal delivery

8. *pontaneousI expulsion of the fetus occurs with very little assistance. This is not preffered.:. 0ssisted breechI the delivery of the fetus is by assistance from the beginning to the end.

This method is employed in all casesD. 7reech extractionI when the entire body of the fetus is extracted by the obstetrician. 't is

rarely done these days as it produces trauma to the fetus and the mother. 'ndications areI

• /elivery of the second twins after internal podalic version

• 5ord prolapse

•

Extended legs arrested at the cavity or at the outlet

Mec(a%#"+ !f lab!-&

Sac&! a%$e!& !"#$#!% 'be#%0 $(e c!++!%e"$)

7uttocs

• The diameter of engagement of the buttocs is one of the obliAue diameters of the inlet.

The engaging diameter is bitrochantric $89cm% with the sacrum directed towards the iliopubic eminence. !hen the diameter passes through the pelvic brim, the breech is engaged

• /escent of the buttocs occurs until the anterior buttocs touches the pelvic floor.


30/58

• 'nternal rotation of the anterior buttoc occurs through 8=< th of a circle placing it behind the

symphasis pubis.

• 1urther descent with lateral flexion of the trun occurs until the anterior hip hinges under

the symphasis pubis which is released first fallowed by the posterior hip

• /elivery of the trun and lower limb fallow

• )estitution occurs so that the buttocs occupy the original position as during engagementin obliAue diameter.

*houlder

• 7isacromial diameter $8:cm% engages in the same obliAue diameter as that occupied by

the buttocs at the brim soon after the delivery of the breech.

• /escent occurs with the internal rotation of the shoulder bringing the shoulders to lie in the

antero- posterior diameter of the pelvic outlet. The trun simultaneously rotates externallythrough 8=


31/58

corrected $excluding fetal abnormality% perinatal mortality ranges from -Dper 8999 birth. The

overall perinatal mortality in breech still remains >-:? compared with 8-:? for non breech

delivery. Perinatal death is D to times higher than the non breech presentation. The fetal mortality

is least in fran breech and maximum in footling presentation, where the chance of cord prolapse

is more. (ynaecoid and anthropoid pelvis are favorable for the aftercoming head. The fetal ris in

multipara is no less than that of primigravida. Thos is because of increased chance of cordprolapsed associated with flexed breech. The factorswhich significantly influences the fetal ris

areI

• *ill of the obstetrician

• !eight of the baby

• Position of the legs

• The type of the pelvis

T(e fe$al da%0e&

The fetal dangers in vaginal delivery are as fallowI

• 'ntracranial hemorrhageI-compression fallowed by decompression during delivery of the

unmoulded aftercoming head results in tear of the tentorium cerebelli and haemorrhage inthe subaracnoid space. The ris is more with preterm babies.

• 0sphyxiaI it is due to

• 5ord compressions soon after the buttocs are delivered and also when the head enters

into the pelvis. 0 period of more than 89 minutes will produce asphyxia of varying degree

• )etraction of the placental site

• Premature attempt at respiration while the head is still inside

• /elay delivery of the head• 5ord prolapse

• 'njuriesI the fallowing injuries are inflicted during manipulative deliveries

Haematoma- over the sternomastoid or over the thighs.

1racture- the commonest sites are femur, humerus, clavical, odontoid process.

There may be dislocation of the hip joint, mandible or th and ;th cervical vertebraeand epiphyseal separation.

6isceral injuries include rupture of liver, idneys, suprarenal glands, lungs and

haemorrhage in the testicles. erve- medullary coining, spinal cord injury, starching of the brachial plexus to

cause either ErbFs palasy or lumpe palasy

*ome of the injuries may prove fatal and contribute to perinatal mortality. 2ong term$neurological%mobidity of the surviving infants should not be underestimated.


32/58

SCHEME FOR MANAGEMENT OF BREECH DELI3ERY

ANTENATAL ASSESSMENT

1etal wellbeing, weight, attitude

aternal health$obstetric and medical%

aternal pelvis

Exte&%al ce(al#c =e&"#!%

Elec$#=e ce"a&ea% "ec$#!%

'@7ee2")

• Estimated fetal weight

• Hyperextended head

• 0ssociated complication

$obstetric and medical%Pelvic inadeAuancy

0round D; wees or

after 'n the labour suite

!ith tocolytic if needed

1etal monitering

$5T(%before and after

procedure

1ail*uccessful

/elivery as

vertex

6aginal breech

delivery

Elective cesarean delivery

• 0verage fetal

weight

• 1ran breech

• 1lexed head

• 0deAuate

5esarean section

0rrest of progress 0ssisted breechdelivery


33/58

Lea2#%0 !f A+%#!$#c Fl-#d

A+%#!$#c Fl-#d is the watery liAuid that surrounds the baby = fetus within the uterus. This 0mniotic

1luid allows the baby = fetus to move about freely without the hindrance caused by the uterus walls

being too tight around it. 0t the same time, this fluid helps provide a cushioning within the uterus

and gives the fetus buoyancy.

This 0mniotic 1luid begins to fill up the 0mniotic *ac from about : wees of fertili#ation. 0nother 89

wees later, the fluid contains different proteins, carbohydrates, electrolytes, lipids, phospholipids

and even urea, which provide nutrition to the fetus. Towards the later stages of pregnancy, the

amniotic fluid also begins to contain fetal urine. 't has also been recently discovered that the

amniotic fluid also contains non-embryonic stem cells.

Lea2#%0 !f A+%#!$#c Fl-#d

ormally, when the pregnancy completes the full term, the membranes of the amniotic sac burst

and the amniotic fluid begins to lea out via the vagina. This is called SS!%$a%e!-" R-$-&e Of

Me+b&a%e"F or SROM. 'n common parlance, this is also termed as the time when a womanFs

S!ater 7reasF.

However, there are times, when the amniotic sac may develop a tear or may rupture causing the

amniotic fluid to lea before term. !hen this occurs DB G D< wees before term, it is referred to as

SP&e+a$-&e R-$-&e Of Me+b&a%eF or PROM.

!hen either of these cases occurs, the fluid may just gush out or may just lea out in a continuoustricle lie a discharge.

!hen the premature rupture of amniotic sac occurs, it is necessary to determine the cause of the

leaing amniotic fluid. ormally, the leaing is caused by a bacterial infection or by a defect in the

structure of the amniotic sac or the uterus or the cervix. The mother-to-be is advised not to douche

or have intercourse when the water breas.

This leaage may lead to further c!+l#ca$#!%" for the growth of the fetus, as it may hamper the

growth of the fetus and may cause bacterial infection to spread from the vagina to the uterus and

conseAuently to the fetus.

*ometimes when there is a small tear in the amniotic sac, it may heal itself over a period of time

and the leaing may simply stop of its own accord.

However, if the leaing amniotic fluid is a result of a severe rupture of the membranes of the

amniotic sac, then labor may begin within @< hours. !hen this happens, the mother-to-be must

receive treatment in order to avoid causing an infection to the fetus.

"ften what is thought of as leaing amniotic fluid can just turn out to be the urine. Therefore, in

such cases, the mother-to-be must ascertain if the fluid is urine or not. 't is advised to wear a

sanitary napin and observe the color of the liAuid. The amniotic fluid is colorless. The mother-to-

be must never use a tampon during pregnancy.


34/58

'f the leaing amniotic fluid is brownish-yellow, green, or any other color, the mother-to-be is

advised show it to her physician and go to the hospital right away. The mother-to-be is also

advised to note down the color of the fluid and the time when the leaing began and tell her doctor

about these details.

'n such cases, most physicians will usually deliver the baby within :@ hours in order to avoid

infection ris.

owadays, many over the counter products are available to test whether the fluid is urine or

amniotic fluid. 't is always recommended that one avail of these tests to ensure the health of the

baby.

COURSE OF E3ENTS AT THE HOSPITAL

M!$(e& "e%$ $! lab!& &!!+ 'f#&"$ "$a0e) f&!+ ad+#""#!% &!!+ f!& N!&+al 3a0#%al Del#=e&

Ma%a0e+e%$ #% $(e f#&"$ "$a0e !f lab!&:

other was ept in the comfortable position.

0ssessment of physical and mental statusI a complete physical examination was

done to find out any abnormalities including general condition of the patient, 6italsigns, 1H*.

Psychological preparationI Emotional support was given to the patient and

explained about the procedure. "rdered investigations were sent lie )7*, 575 and 3rine )=E and reports were

also collected. Half hourly monitoring of 1etal Heart *ound and correct recording and reporting

was done. 0ugmentation with injection oxitocin was started according to doctorFs order.

Pa&$!0&a( was filled to monitor the progress of labour.

'ntae and output was monitored.

other was encouraged for adeAuate fluid intae lie blac tea, hot soups etc. to

prevent dehydration. 5ervix was fully dilated at BID9 pm and mother was taen to second stage of labour.

EAuipments= materials reAuired for the normal vaginal vaginal delivery was ept

ready.

Ma%a0e+e%$ #% $(e "ec!%d "$a0e !f lab!&:

other was shifted to the second stage $delivery room% and ept comfortably on the

delivery bed with the head elevated @9. otherFs 6ital signs and 1etal Heart *ound was also monitored and recorded.


35/58

*he was encouraged to push during strong contraction.

*trict aseptic techniAue was maintained during delivery.

S(e del#=e&ed a l#=e fe+ale bab a$ 8:88 + e#0(#%0 998 0+.

+angaroo mother care was provided to the baby.

7abyFs sex was shown to the mother.

Ma%a0e+e%$ !f $(e $(#&d "$a0e !f lab!-&:

0s soon as the baby was delivered injection *yntocin 89 units '= was given.

Post delivery 6ital signs were taen and recorded.

Placenta was delivered using 5ontrol 5ord Traction and placenta was observed

which was complete and normal.

6agina was carefully observed and cleaned. !et dress of the mother was changed.

*he was encouraged to massage the uterus every 8 minutes for minutes.

Teaching about breast feeding, perineal hygine, cord care was given.

other was transferred to the post natal ward.

MANAGEMENT OF THE NE/BORN BABY

• 'mmediately after the baby was born, she was received in dry, clean wrapper and

transferred to the warmer, which had already been prepared to receive the baby.

• 0fter placing the baby under the warmer, the nose and oral cavities were suctioned free of

secretions with sterile ET suction catheter. The babyFs 0P(0) was scored.

• The heel of the baby was fliced to stimulate him to cry=breath.

• 3mbilical cord was clamped with sterile thread and its redundant length trimmed.

• The baby was cleaned around the eyes, mouth and nose with clean paraffin soaed

gau#e. The baby was then cleaned from head to toe.

• The baby was weighedI 998 0+

• The baby was checed for maturity and presence of any obvious congenital birth defect.

• 0P(0)I )apid assessment tool to assess cardio-respiratory and neurological status of thenewborn. 't is determined by the level of oxygenation.

8. 0I 0ppearance I Pin or blue:. PI Pulse I Heart rateD. (I (rimace I )eflex immutability@. 0I 0ctivity I uscle toneI ormal or flaccid.. )I )espiration I ormal, laboured, shallow or apnoeic


36/58

APGAR "c!&e !f $(e bab b!&% $! $(e a$#e%$ -%de& "$-d:

Pa&a+e$e&" APGAR * +#%-$e APGAR * +#%-$e"

Heart )ate : :

)espiratory )ate : :

uscle Tone 8 8

)eflex 'mmutability 8 8

5olour 8 :

Total B <

IMMEDIATE NURSING CARE OF THE NEONATE

The newborn is in complete dependence of it caretaers. The nurse has to ensure the baby does

not aspirate the amniotic fluid and that the baby maintains hoemeostatis. Thus the main objectives

of taing care of newborn are toI

Establish and maintain a patent airway

aintain normal body temperature

Promote mother infant bonding

Provide optimal nutrition

Protection from infection and injury

aintain a patent airwayI

The oropharynx and nostrils are suctioned with bulb-suction once the head is delivered. The

mouth is suctioned first to avoid amniotic fluid or mucous aspiration. "nce the baby is delivered, the baby is placed in a lateral decubitus, 8 head down position

to facilitate drainage of secretions under a radiant warmer or on the motherFs abdomen. The oropharynx and nostrils are suctioned to ensure clearance of secretions.

aintain stable body temperatureI

/ry the baby with a soft warm towel

!rap the baby in a pre warmed blanet

Place the baby under a radiant warmer

0void unnecessary exposure 5hec the babyFs temperature every 8 min for the first hour if reAuired

Promote mother infant bondingI


37/58

*how the baby to the mother= parents as soon as is possible, and reveal the sex of the baby.

Place the baby close to the face of the parents so that bonding=attachment can be initiated.

'nitiation of breast feedingI

Put the baby to the motherFs breast as soon as it is feasible.

Teach the mother about &on demand feeding.

Teach the mother to &burp the baby after every feed to prevent regurgitation= vomiting. Protection from 'nfection and 'njuryI

!ash hands or use sterile gloves when handling newborns.

/ivide the umbilical cord with sterile scissors and apply sterile disposable umbilical cord

clamp to the babyFs end of to umbilical cord stump. !ipe the eyes of the baby with sponge towel wet with pre-boiled water.

*ponges bathe the baby with warm water.

other must be taught to maintain good personal hygiene. *he must eep her nail short to

prevent injury to the newborn 0void unnecessary handling of the baby

ASSESSMENT OF THE NEONATE

OBECTI3E:

!e all expect our newborn to be normal, ie us, not reali#ing that there are others for no fault of

theirs are born with horrendous defects which could snuff the existence or worse still, leave a

person maimed forever. Thus, the objective of assessing the newborn is to detect any congenital

anomalies, injury, infection that could reAuire intervention in any way. The other main objective is to

help the baby maintain homeostasis in the face of adverse environment. To list the objectiveI

/etect congenital anomalies and plan out treatment where relevant.

/etect birth injury any other acAuired illness.

)ecord the vital statistics of the baby.

aintain homeostasis.

Mea"-&e+e%$:

Pa&a+e$e&": Mea"-&ed =al-e Refe&e%ce =al-e

Head circumference D8.: cm D8-D cm

5hest circumference D9.@ cm [email protected] cm

6ertex to heel length @B.; cm @


38/58

3#$al "#0%"

Te+e&a$-&e P-l"e Re"#&a$!& Ra$e

>


39/58

N!"e

o deformity involving the nose.o discharge from the nostrils.

M!-$( a%d $(&!a$:*ucing and rooting reflexes present.o cleft or palate.o oral thrush or dribbling of saliva.

Nec2

There was short L thic sin fold around the nec.o webbing of the nec or masses.

C(e"$

ormal in shape and appearance. 0ntero-posterior and lateral diameters were eAual.7ilateral nipples were present and symmetrical.

Re"#&a$!& ""$e+

)espiratory rate was @@=min. The pattern was abdominal-thoracic.o cough reflex.

Hea&$

Heart rateI 8@;=min, regular *8 *: heard. o murmur.

Abd!+e%

)ounded, soft.o infection or bleeding at the umbilical cord stump.

E5$e&%al Ge%#$al#a a%d e%e-+:

!ell developed female external genitalia.The labia majora was covered by the labia minora.The hymen and clitoris were disproportionately large.

• T(e bac2I

The spine was flexed, the spinous processes were complete.o pit, tuft of hair, melanoma or mass at the lower spine.

E5$&e+#$#e":The neonate had two upper and two lower extremities, w hich were well developed.o missing extra or fused digits


40/58

ail bedsI pinormal range of motion at all extremities."rtolaniFs and 7arlowFs tests were negative.

Ne-&!+-"c-la& ""$e+:

ormal tone of muscles on passive flexion and extension.The extremities were held in flexion.The baby was able to turn the head from side to side when placed in prone position.The baby was able to hold the head hori#ontal with the bac when held hori#ontal.

Ne!%a$al &efle5e":

0ll neonatal reflexes appropriate for his developmental age were present i.e.I sucing, rooting,swallowing, oroFs and grasp reflex.

• C&I

The baby and a very strong and healthy cry.

Slee#%0 a$$e&%:

ormal.

ESTABLISHMENT OF MOTHERINFANT BONDING

7onding is a psychological state of belonging and reciprocation. other-infant bonding is essential

for proper nurture of the newborn. The bonding starts even before the birth of the child, but needs

to be reinforced at birth because of the &trauma of birth the mother undergoes. Thus, the crucial

period of bonding is during the first few hours after birth. 't is noted that the close physical contact

between the mother and the child sets into motion and intricate set of reciprocal actions, whereby

each stimulates and rewards the other. 't is postulated that hormonal stimulations may contribute

to the attachment, but social and cultural components play a very influential role.

7onding is strengthened by the babyFs interaction with the parents. The passive infant probably

receives less attention and stimulation than an active alert tone.

"ne of the ey components to strengthening the mother-infant bonding is breast-feeding. 1or my

patient, ' initiated breast feeding once the mother was shifted to the post natal room. /uring that

time, ' discussed about the expectations of the mother and reiterated the measures to strengthen

the mother-child bonding.

' also discussed aboutI


41/58

• Eye contact whenever possible and specially during breast feeding

• Process of attachment and its importance in parent-infant bonding.

• 'mportance of physical contact lie touching, picing up the child and holding, hugging.

• 5orrect position of the infant during breast-feeds.

• 'mportance of &burping the child after each feed.

• *leeping the child with the mother versus sleeping the child on the cot.

rs (urung has a healthy newborn baby. 't was not difficult to educate her about mother-infant

relation and breast feeding. 1or my patient, mother-infant bonding was easy to establish and

maintain. *he was avid learner and was ready to adopt measures reAuired for good infant nursing.

POSTNATAL CARE AND HEALTH EDUCATION

T(e P-e&e-+:

The puerperium covers the period from the expulsion of the placenta till six wees of postpartum.

/uring this time the intra-abdominal reproductive organ return to the non-pregnant state while a

number of physiological and psychological changes occur.

Obec$#=e !f !"$%a$al ca&e:

• To provide care for rapid restoration to optimum health of the mother.

• To prevent complication in the postnatal period.

• To ensure adeAuate nourishment of the neonate through breast feeding.

•

To teach about family planning methods and mae available family planning services.• To provide basic health education to mother and rest of family.

• To ensure good communication between the mother, rest of family and health worers.

Ma%a0e+e%$ !bec$#=e:

'mmediate attention and care to the newborn and mother.

)est and ambulation of the mother.

0deAuate sleep.

0deAuate and nourishing diet.

5are of bladder and bowl.

5are of breast and breast feeding.

Examination of mother and baby.

Heal$( ed-ca$#!%:

Ee ca&e:

The eyes were cleaned with boiled cotton and mother was advised to clean the

eyes of the baby with boiled cotton. The mother was advised not to get the mil into babyFs eyes while breast feeding.

C!&d ca&e:

The umbilical cord stump was cleaned with boiled cotton and dried with dry sterile

gau#e swab.


42/58

The mother was advised to clean the babyFs umbilical stump with boiled cotton,

even at home. The mother was instructed not to apply anything on the umbilical cord stump and to

eep it clean. 'nform the mother that the cord stump falls off in -89 days.

'nstruct the mother to watch for any discharge, bleeding or infection.

N!"e +!-$( ca&e:

The mother was advised to eep the nose and mouth clean with soft tissue paper.

S2#% ca&e

*ponge bath the baby after :@ hours of birth.

+eep the baby clean. 7athe the child every :-D days once the cord falls off.

/o not use the soap on the babyFs face.

0pply oil all over the body everyday.

Rec!=e& f&!+ $(e ("#!l!0#cal a-%d#ce

Exclusive breast feeding.

+eep the baby in the morning sunlight.

'f jaundice should prolong, then obtain medical chec up.

Na2#% ca&e:

Teach the mother the correct method of putting on the napin.

0s the mother to change the napin as soon as it is wet.

DAILY ASSESSMENT OF POSTNATAL MOTHER:

rs. (urung delivered a healthy baby on :9;


43/58

;. 0ppetite ormal, no nausea and vomiting

B. *leep /isturbed sleep


44/58

:% +nowledge

deficit L fear

related to

breechpregnancy and

leaing.

*he will

now about

the breech

pregnancyand leaing.

Explain the

process of breech

delivery and

management ofleaing.

0ssist L teach her

how to maintain

position during

delivery.

Encourage her to

maintain patienceduring delivery.

The process of

breech delivery and

management of

leaing wasexplained.

*he was assisted L

taught to maintain

position during

delivery.

*he was

encouraged tomaintain patience

during delivery.

S.

N!

N-&"#%0

D#a0%!"#"

N-&"#%0

G!al

Pla% !f Ac$#!% I+le+e%$a$#!%

D% 0ltered fluid

Lelectrolyte

balance related

to loss of body

fluids during

delivery as

evidenced by

dry lips.

aintain fluid

L electrolyte

balance

during Lafter

delivery.

0ssess the fluid

and electrolyte

status. onitor vitals,

'ntae=output.

onitor dryness of

mucous

membrane.

)eplace '=6 fluidas needed.

1luid and electrolyte

status was

assessed. 6itals and

intae=output were

monitored. /ryness of mucous

membrane were

monitored.

'=6 fluid wasadministered as


45/58

Provide oral fluids

lie water, blac

tea, soups etc.

needed.

"ral fluids lie

water, blac tea and

hot soups were

provided.

S.

N!

N-&"#%0

D#a0%!"#"

N-&"#%0

G!al

Pla% !f Ac$#!% I+le+e%$a$#!%

@% 0ltered

sleeping

pattern related

to new

environmentand

hospitali#ation

as evidenced

by freAuent

awaening.

Patient will

be able to

sleep

properly.

To assess the

sleep and rest

pattern. To provide Auiet

and peacefulenvironment.

To encourage

patient to sleep in

regular time daily.

Encourage patient

to drin warm mil

at bed time. To encourage the

patient to tal and

ventilate her

feeling at bed

time. To provide

comfortable

bedding and

pillow.

*leep and rest

pattern was

assessed. Uuiet and peaceful

environment wasprovided.

Patient was

encouraged to

sleep in regular

time.

Patient was

encouraged to drin

warm mil. Patient was

encouraged to

express her

feelings and

concern. 5omfortable

bedding and pillow

were provided.


46/58

S.

N!

N-&"#%0

D#a0%!"#"

N-&"#%0

G!al

Pla% !f Ac$#!% I+le+e

% )is of infection

related to leaing

of the amniotic

fluid and altered

primary

defenses in the

post-partum

period.

Prevent

infection to

mother and

child during

the hospital

stay

aintain standard

precautions and

hand washing

techniAue while

providing care. aintain aseptic

techniAue while

doing P=6

examination and

conducting delivery. 0dvice to maintain

perineal hygieneafter each urination

and stool. onitor vital signs.

onitor malaise,

chills, loss of

appetite, fatigue L

pallor. (ive antibiotics as

prescribed.

*tandard precaution

and proper hand

washing techniAue

was maintained whi

providing care. 0septic techniAue

was maintained

during P=6

examination and

delivery. 0dviced to maintain

perineal hygiene afteach urination and

stool. 6ital signs were

monitored.

alaise, chills, loss

appetite, fatigue and

pallor were

monitored. Prescribed antibiotic

$cefotaxime 8gm%

intravenous stat wa

given.

CARE PLAN FOR BABY

S.

N!

N-&"#%0

D#a0%!"#"

N-&"#%0

G!al

Pla% !f Ac$#!% I+le+e%$a$#!%

8% 'neffective

airway clearance

due to excessive

oropharyngeal

secretion.

5lear the

babyFs airway

so that the

baby can

breathe

comfortably.

!ipe the babyFs

mouth and nose

with soft gau#e as

soon as the head is

delivered. +eep the head

slightly lower than

7abyFs mouth and

nose was wiped as

soon as the head was

delivered.

The head was ept

slightly lower than


47/58

body L turned

laterally. (entle suction as

necessary. /emonstrate

routine care L havemother L family

members return the

demonstration.

5all the pediatrician

before delivery.

body and turned

laterally. (entle suctioning was

done. )outine care was

demonstrated andreturn demonstration

was also done by

mother L family

members too. Pediatrician was

called before delivery.

S.

N

!

N-&"#%0

D#a0%!"#"

N-&"#%0

G!al

Pla% !f Ac$#!% I+le+e%$a$#!%

:% 'neffective

thermoregulatio

n due to

exposure to the

environment

immediately

after birth.

The

newbornFs

body

temperature

will be

maintained

at normal

body

temperature.

!rap the baby in

warm= dry blanet

and place

beneath a radiant

warmer. /ry the baby

immediately.

)emove the wet

sheet and

monitor the

temperature.

aintain the

temperature of

the room.

The baby was

wrapped in a warm

and dry blanet

and beneath a

radiant warmer. The baby was dried

immediately.

!et sheet was

removed and

temperature was

monitored.

Temperature of the

room was

maintained.


48/58

S.N!

N-&"#%0D#a0%!"#"

N-&"#%0G!al

Pla% !f Ac$#!% I+le+e%$a$#!%

D% )is of

developing

hypoglycemia

due to

ineffective

breast feeding.

The newborn

will not

develop

hypoglycemia

.

7reast feed the

baby immediate

after delivery and

every : hours or

when baby

demands.

Encourage

mother to breast

feed the baby as

demanded by

baby L teach her

importance of

breast mil.

The baby was

breast feed

immediately after

and every : hours

or when baby

demands.

The mother was

encouraged to

breast feed the

baby as demanded

by baby and taught

her the importance

of breast mil.


49/58


50/58

MEDICINE USED IN MY PATIENT

The following medications were administered to rs. 0nita (urung during her admissionI

'njection *yntocin

'njection 5efotaxime

I%ec$#!% O5$!c#% 'S%$!c#%) :

"xytocin is a peptide hormone secreted by the posterior pituitary that elicits mil injection in

lactating women. 'n pharmacologic doses, "xytocin can be used to induce uterine contractions

in a gravid uterus and maintain labour.

3sesI

o/iagnostic usesI "xytocin challenge test near term provides information on

adeAuacy of placental reserve and the need for intervention in the presence of an abnormaltest.

oTherapeutic usesI "xytocin is used to induce labour and augument dysfunctionallabour.

'ndicationI

o'nduction of labour

o3terine inertia

o'ncomplete abortion

oPost partum haemorrhage

/osageI

o'nduction of 2abourI "xytocin is administered via micro-drip, infusion or syringe

pumps at a rate of 8m3=min and gradually increased every 8-D9 minutes to -:9m3=mintill a physiologic contraction pattern is established.oPost partum haemorrhageI -:9 units is added to 99 ml ? dextrose, 0nd the dose

is titrated to control uterine atony.oProphylaxisI *ingle intramuscular dose of units is given to prevent postpartum

haemorrhage and augument uterine contraction after delivery of the baby.PrecautionI

5ontraindicationsI

o(rand multipara

o5ontracted pelvis with 5P/, obstructed labour

o

Previous history of caesarean section or hysterotomyoalpresentation

o'nco-ordinated uterine contraction

oHypovolemic state

o5ardiac disease

/angersI

o3terine rupture

oHypotension


51/58

o 0nti-diuretic effect

oPituitary shocI yocardial infarction due to coronary spasm caused by non-purified

preparation of posterior pituitary is now seen only with very high doses of "xytocin.o1oetal distress=deathI Encountered in presence of already compromised foetus, and

is due to diminished placental circulation brought on by strong and sustained uterinecontraction

I%ec$#!% Cef!$a5#+e :

5efotaxime is a third-generation cephalosporin antibiotic. 2ie other third-generation

cephalosporins, it has broad spectrum activity against (ram positive and (ram negative

bacteria. 'n most cases, it is considered to be eAuivalent to ceftriaxone in terms of safety and

efficacy.

Mec(a%#"+ !f ac$#!%

'nhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins

$P7Ps% which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in

bacterial cell walls, thus inhibiting cell wall biosynthesis. 7acteria eventually lyse due to ongoing

activity of cell wall autolytic en#ymes $autolysins and murein hydrolases% while cell wall

assembly is arrested.

5efotaxime, lie other V-lactam antibiotics does not only bloc the division of bacteria,

including cyanobacteria, but also the division of cyanelles, the photosynthetic organelles of

the (laucophytes, and the division of chloroplasts of bryophytes. 'n contrast, it has no effect on

the plastids of the highly developed vascular plants. This is supporting the endosymbiotic

theory and indicates an evolution of plastid division in land plants

Cl#%#cal -"e

5efotaxime is used for infections of the respiratory tract, sin, bones, joints, urogenital

system, meningitis, and septicemia. 't generally has good coverage against most (ram-

negative bacteria, with the notable exception of Pseudomonas. 't is also effective against

most (ram-positive cocci except for Enterococcus. 't is active against penicillin-resistant strains

of *treptococcus pneumoniae. 't has modest activity against the anaerobic 7acterides fragilis.

C(e+#"$&

The s"n-configuration of the methoxyimino moiety confers stability to V-lactamase en#ymes

produced by many (ram-negative bacteria. *uch stability to V-lactamases increases the activity

of cefotaxime against otherwise resistant (ram-negative organisms.

D!"a0e

http://en.wikipedia.org/wiki/Beta-lactamhttp://en.wikipedia.org/wiki/Beta-lactamhttp://en.wikipedia.org/wiki/Beta_lactamasehttp://en.wikipedia.org/wiki/Beta_lactamasehttp://en.wikipedia.org/wiki/Beta-lactam


52/58

0dultI 8-: gm 7/

5hild 8month-8: yearsI 9-8


53/58


54/58

DISCHARGE TEACHING

Health teaching is an important part of holistic patient care. 't begins from the time of admission

till the patient is discharged and is reinforced in the subseAuent follow ups at the "P/. Health

teaching tries to ensure that appropriate care is given to the patient even after discharge. This is

especially relevant to the context of care for new born babies and post partum mothers, wherecultural and traditional practices form an integral part, but do not always have a rational base.

Health teaching tries to integrate the traditional with the rational.

The following topics were covered during the health teachingI

8. utrition for baby L mother :. 7reast care and breast feedingD. Personal hygiene including pericare@. )est and resumption of activities. 5are of the baby;. "il massage

B. 'mmuni#ation. 1amily planning89. 1ollow up visits88. edications

. N-$$#!%:

Post natal mothers reAuire a balanced diet to recuperate from the stress of parturition, meet the

caloric reAuirements of breast feeding and return to normal daily activities.

The diet of the post natal mother should contain green leafy vegetables, plenty of liAuids,cereals, pulses and meat. 0 post natal mother should tae at least four meals a day. 5ulturally

influenced diet high on calorie lie ghee, 5hau, sweets etc are allowed. This ensures that the

baby acAuires adeAuate calories through the motherFs mil.

9. B&ea"$ ca&e a%d B&ea"$ feed#%0:

5are of the breast commences from the ante-natal period. This not only ensures that the nipple

is not retracted when the breast feeding commences, but also raises the awareness of the

advantages of the breast feeding as opposed to commercial preparation. 3nnecessary

manipulation of the breast is avoided during late pregnancy, as this may precipitate early labour.

The mother is encouraged to feed the baby soon after birth.

The mother is taught the proper techniAue of breast feeding the baby. This includes the

followingI

"n demand feeds

Proper positioning of the baby during feeds

7urping the baby after feeds

aintenance of personal hygiene.


55/58

7. Re"$ a%d ac$#=#$#e":

The mother needs rest during the puerperium to recuperate from the stress of labour and

immediate post natal period. The mother reAuires about > hours of sleep a day, and she needs

about : months of period to recover from pregnant state to non-pregnant state after delivery.

The above statement does not mean that the mother is bed bound, but that she is gradually

helped to return to normal daily activities. The mother is not allowed to undertae heavy or

labourious tass during the puerperium, as it predisposes to uterine prolapse.

The mother is taught about the pelvic floor exercises to tone up the musculature.


56/58

Encourage the mother to bathe and change clothes daily.

Pericare must be done after every urination and defecation.

The mother is educated about the types of lochia, its odour and character. The mother is

advised to obtain consultation or any abnormality in lochia, especially if she develops fever.

6. Med#c#%e":

y patient was prescribed antibiotics, analgesics and she was further prescribed hematinics

and calcium supplements by the doctor.

' explained the justification for taing the prescribed medications for the mentioned durations.

8. F!ll! - 3#"#$":

The parents were advised to return with the baby after a wee from the date of discharge.

The parents were advised to visit the Pediatrician at the next visit for the babyFs firstimmuni#ation shot of 75(.

They were further advised to see consultation in case of any difficulty.

FOLLO/ UP CARE

1ollow up care and home visits are modalities to mae certain that the patient who had reAuired

in hospital treatment in recuperating well in the domestic environment. 't is to ensure that the

patient is compliant with the prescribed therapy and has not developed any complication that

would reAuire immediate medical attention. Thus in case of new born, community base follow up

is essential for early detection of congenital illness and infection or complication in the mother.

The follow-up fulfils the following detailsI

• Evaluation of health status of baby and mother.

• /etection of deviation from normal, the health of the baby and mother at home.

• /etection of complications early

• 0ssessment of uterine involution

• *olve problems faced by the mother or baby.

"n the follow up visit, the baby and the mother were well and did not suffer from any

complication. 'n epal there is no facility of home visiting doctors=nurses for follow-up after

discharge from the hospital. The patients are therefore encouraged to attend at the "P/ of the

local hospital which is certainly stressful for the recuperating patient but on the other hand

solves the difficulty of shortage of physicians and community nurses available in our country.


57/58

CONCLUSION

5ase studies are a modality of learning patient management in a clinical setting. The patient is

followed through from the time of admission till discharge and the first follow up. The case study

provides a holistic approach to patient care and updates the nowledge of the nurse regarding

the disease process, possible complication and how to handle this situation as a team player.o pregnancy is simple and the uneventful second stage can suddenly turn critical at the next

stage or an apparently healthy baby may suddenly be fighting for its life. Thus high ris

pregnancy case study brings home the message that every pregnancy is a potential at ris

pregnancy and the only way to ensure safety for the mother and child is to provide a thorough

care.

y patient had already delivered one male baby in normal mode of delivery however she had

anxiety because of breech pregnancy with leaing. Her anxiety level was decrease because of

continuous reassurance. *he was discharged from hospital without any complication.she washappy on discharge day due to continuous contact with care provider$me%.

I /ISH GOOD HEALTH OF THE MOTHER AND HER BABY AND /ISH

HER A /ONDERFUL LIFE AHEAD


58/58

Refe&e%ce"

/icason, *ilverman L *chult. $8>>@%. aternal 'nfant ursing 5are, :nd

edition.

/utta /.5. $:998%. Text boo of "bstetrics, th

edition, @99 G @8;.

1raser /iare ., 5ooper argaret 0. $:99D%. yles Textboo for idwives, 8@ th

edition, *ydney, ;@ G B

(ovoni 2aura E., ayers Manice E. /rugs and ursing 'mplications, @ th edition,

8;>

(ulanic L yers. $:99D%. osbyFs ursing care plans, ursing diagnosis L

intervention, th edition

Howins and 7ourne. $8>>>%. *hawFs textboo of (ynecology, 8: th Edition

Moshi ohan P., 0dhiari )amesh +umar. $8>>;%. anual of /rugs and

Therapeutics, 8st edition, Health 2earning aterial center, DB9, @9;.

ayes. $8>%. 0 textboo for idwives, D@@ G D8.

*ubedi /urga, (autam *araswoti. $:989%. idwifery ursing Part '', 8st edition,

edhavi Publication, +athmandu, ::8 G ::>.

*ubedi /urga, (autam *araswoti. $:988%. idwifery ursing Part ''', 8 st

edition, edhavi Publication, +athmandu, 89@ - 88.

httpI==emedicine.medscape.com=article=B>B;>9-overview

httpI==www.americanpregnancy.org=labornbirth=breechpresentation.html

httpI==www.bu##le.com=articles=leaing-amniotic-fluid.html

http:))en.6i"ipedia.or)6i"i)@reechAbirth
http://emedicine.medscape.com/article/797690-overviewhttp://www.americanpregnancy.org/labornbirth/breechpresentation.htmlhttp://www.buzzle.com/articles/leaking-amniotic-fluid.htmlhttp://en.wikipedia.org/wiki/Breech_birthhttp://emedicine.medscape.com/article/797690-overviewhttp://www.americanpregnancy.org/labornbirth/breechpresentation.htmlhttp://www.buzzle.com/articles/leaking-amniotic-fluid.htmlhttp://en.wikipedia.org/wiki/Breech_birth

case study on breech birth.docx

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