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 risk because of existing or potential complication. The World Health Organization (WHO) defines all pregnancies as HIGH RISK 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 trained obstetrical help, as in the developing countries. In Nepal, on an average, twelve women die daily either due to complication of pregnancy or childbirth. In order to standardize the documentation of impact of health delivery system on maternal health, the WHO has introduced the Maternal Mortality Rate (MMR). Maternal mortality has been defined by the WHO as THE DEATH OF A WOMAN WHILE PREGNANT OR WITHIN FOURTY-TWO DAYS OF TERMINATION OF PREGNANCY, IRRESOECTIVE OF THE DURATION AND SITE OF PREGNANCY,FROM ANY CAUSE RELATED TO OR ITS MANAGEMRENT BUT NOT FRIM ACCIDENTAL OR INCIDENTAL CAUSES. Maternal mortality rate measures the risk of a women dying from puerperal causes and is defined as the maternal mortality per 100,000 live births in a given area and year. The National survey conducted in 2006AD estimated the Maternal Mortality as 281/100,000 live births that means everyday 6 and every year approximately 2066 mother die of pregnancy. Among total maternal mortality 90% occurs in rural area. According to the Nepal Maternal Mortality and Morbidity Study of 1998AD, 62% mother die after the birth of the baby, 28% die during pregnancy, 10% die during labour. According to the Nepal Family Health Survey of 1996AD, approximately 40% of all pregnancies fall into the high risk category, emphasizing the necessity of accessible trained obstetrical care in the community. The determinants of maternal mortality are categorized into direct, indirect and contributory causes, to understand and locate resources to address the prevalence of high maternal mortality. A direct obstetric death result from complication of pregnancy, labor or puerperium, and is closely equated to true maternal death. The important causes of direct maternal death are ante and postpartum hemorrhage, obstructed labor, eclampsia, puerperal sepsis and complication of abortion. These, collectively account for more than 70% of maternal deaths. Indirect obstetric death occurs because of pregnancy, in presence of pre-existing disease state (e.g. heart valve disease, collagen vascular disorder etc.) or due to development of a new disease in presence, pregnancy (e.g. hepatitis, anemia etc.). Contributory causes to maternal mortality include socio-economic status, maternal illiteracy, traditional factors and unavailable health services.

INTRODUCTION

A case study is an important learning technique with specific educational objectives. A case study provides the chance to integrate theoretical knowledge with clinical practice with focus on a specific or a set of problems. As the basic concept of case study can be applied to many situations and is popular amongst many disciplines as a modality of imparting knowledge. As a student of Bachelor of Nursing, we are required to undertake a study on high risk pregnancy as an emphasis on the national policy to improve the maternal and child health.

About fifty years ago it was not uncommon to know of someone who had died during child birth. At that time, every young women about to become a mother was practically concerned about her wellbeing. A healthy baby was considered an extra dividend. From 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 has been a less significant reduction in perinatal mortality and morbidity. In many ways, morbidity exerts a more profound economic effect than mortality.

Since the fetus in any pregnancy is now at greater risk than the mother is, the concept of AT RISK applies to both maternal and fetal outcome. A HIGH RISK pregnancy is one in which THE MOTHER OR FETUS HAS A SIGNIFICANTLY INCREASED CHANCE OF DEATH OR DISABILITY WHEN COMPARED WITH A LOW RISK PREGNANCY IN WHICH AN OPTIMAL OUTCOME IS EXPECTED FOR BOTH.

The aim of obstetric care is to concentrate resources on improving peri-natal outcome. It is thus important to identify those at risk and then to provide the specific care required to prevent death or disability.

OBJECTIVE OF HIGH RISK CASE STUDY

GENERAL OBJECTIVE

The purpose of high risk case study is to provide an exercise for the student to promote knowledge and skill in obstetric care, so that she becomes aware of the hazards of supposedly normal pregnancies in the community. This will provide an impetus to detect pregnancies at risk once the trained nurse returns to her community.

SPECIFIC OBJECTIVE

1. 2. 3. 4.

Identify high risk pregnancies. Elucidate the history and reveal the reason(s) why the pregnancy is high risk. Learn to perform systemic and obstetrical examination methodically and correctly. Identify abnormalities, anticipate problems, plan and take appropriate action during labour and post-natal period to avoid mortality and morbidity. 5. Plan and implement comprehensive care of the client, using the knowledge gained from basic science and nursing theory. 6. Formulate nursing diagnosis and priorities nursing care plan according to patients needs. 7. Provide holistic nursing care to the client and visitors using the nursing process. 8. Provide emotional and physical support to mother during the conduct of delivery and in the peri-natal period. 9. Help mother in establishing parent infant relationship. 10. Observe and evaluate the care given to the baby by mother and provide comprehensive guidance. 11. Identify needs and post-natal complication in mother and infant by interview and physical examination. 12. Alleviate pain and discomfort in the patient by applying nursing measures and administering analgesics as per prescription. 13. Teach mother and family about hygiene, self care and baby care for promotion of health and prevention of disease. 14. Work together with client, family members and other health worker to plan the discharge and follow up care of the mother and the baby. 15. Acquaint one-self with the equipments, procedures and facilities used in the management of high risk pregnancies. 16. To study, document and present a high risk pregnancy case report.

HIGH RISK PREGNANCY: IMPLICATIONS

High risk 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 risk Pregnancy the mother and the foetus are at a higher risk 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 newly acquired during the pregnancy. Having mentioned the definition of high risk pregnancy, we should not equally forget that every pregnancy is potentially at risk.

The incidence of high risk pregnancies in the developed countries is 25% while in the developing countries the value is about 45%. This group of patients is responsible for 70%-80% of perinatal morbidity and mortality. Thus in order to reduce the maternal and perinatal mortality rate and improve on the obstetrical result, we must identify this group and provide appropriate supervision and facility for successful delivery.

DEFINITIONS & CONCEPTS

RISK FACTORS:

A risk factor is a link in a chain of associations leading to an illness. The risk factor may itself be an indicator of disease. Thus in pregnancy, parity, age, height, Birth canal condition, birth interval and presence of disease become some of the determinants of health of the mother and the newborn around childbirth. Thus, the risk factor may be already present or introduced early in pregnancy or be introduced early in the pregnancy or be introduced late during the process of labour.

RISK RATIO:

Risk ratio is the ratio between the prevalence of disease condition among exposed population to that among the unexposed. This index is used in the assessing the likelihood that an association represents a casual relationship.

RISK APPROACH:

This concept is promoted by the WHO to identify the group at risk or the target group e.g. at the risk mothers, infants, families; chronically ill; handicapped; elderly etc. in a defined population as per certain distinctive criteria and then direct appropriate resources to them first. This management concept is known as the Risk Approach. This is summed up as something for all, but more for those in need in proportion to the need. The risk approach is a managerial device for increasing the efficacy of health care services within the limits of existing resources.

The risk approach implies identification of high risk case at an ealy stage and makes available skilled care from the point of identification. The main aim of risk approach is to improve the

efficiency and objectiveness of the maternal and child health services through maximum utilization of available resources including nursing care.

CATEGORIES OF HIGH RISK PREGNANCY

MATERNAL AND PARIETY FACTORS:

i. Maternal age of sixteen years and under. ii. Nullipara at thirty-five years or over. iii.Multipara at forty years or over. iv.Interval 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.Non-marital pregnancy.

PREGNANCY INDUCED HYPERTENSION, KIDNEY DISEASE: a) b) c) d) e) Pre-eclampsia with hospitalization before labour. Eclampsia. Kidney disease: Pyelonephritis, Nephrotic syndrome etc. Severe chronic hypertension (160/100mmHg). Blood pressure of 140/100mmHg or more on two different occasions.

ANAEMIA AND HAEMORRHAGE:

a. b. c. d.

Haematocrit (PCV) of 30% or less in pregnancy. Severe hemorrhage in previous pregnancy requiring transfusion. Hemorrhage in the present pregnancy ( Ante-partum hemorrhage) Anemia (Hb: 10gm %) for which treatment other than iron supplement was required. e. Sickle cell disease and trait. f. History of bleeding or clotting disorder. FOETAL FACTORS:

a.Two or more previous premature deliveries. (Delivery of twins is considered a single delivery.)

b.Two or more consecutive spontaneous abortions. c. One or more still-births at term. d.One or more births with gross congenital anomaly. e.ABO or RH incompatibility or iso-immunization. f. History of previous birth defects e.g. cerebral palsy, brain damage. g.History of large baby weighing more than nine pounds.

MOTHERS SURGICAL CONDITION:

a.Pelvic floor restoration or any pelvic surgery. b.Previous surgery of uterus (e.g.myomectomy) c. Surgery of ectopic pregnancy.

CEPHALO-PELVIC DISPROPORTION & DYSTOCIA:

a. b. c. d. e.

Cephalo-pelvic disproportion Two or more deliveries Multiple pregnancies in the present pregnancy (twins, triplets etc.) Previous operative deliveries (caesarean section, mid-cavity forceps delivery etc.) History of prolonged labour (> 18 hours for primigravida & > 12 hours for multigravida) f. Previously diagnosed abnormality of the maternal pelvis and genital tract g. Short stature of the mother (Height:140cm). h. Malposition and Malpresentation (Breech presentation)

a. b. c. d. e. f. g. h. i. j. k.

CONCURRENT ILLNESS IN THE MOTHER: Diabetes Mellitus. Gestational Diabetes Hyper emesis gravidarum Thyroid dysfunction: Hypothyroidism/Hyperthyroidism Malnutrition or extreme obesity Organic heart disease Syphilis & TORCH infections Tuberculosis or other pulmonary pathologies Malignant, pre-malignant & locally invasive tumors (including H.Mole) Alcoholism & drug addiction Psychiatric disease or epilepsy Mental retardation

MISCELLANEOUS: a. Those with history of late registration b. Those with poor clinical attendance c. Those with weak family support

FACTORS THAT PLACE THE PREGNANCY AND FOETUS IN HIGH RISK

FIRST TRIMESTER

CATEGORY 1. PHYSIOLOGIC 2. PSYCHOLOGICAL 3. THERAPEUTIC

RISK FACTOR Gross foetal chromosomal abnormality Hydatidiform mole Poor trophoblast Multiple pregnancies Psychological shock Hyperemesisgravidarum Abortion Drug therapy Radiotherapy / X- ray Viral infection Sporadic Mutation, Sex- linked recessive chromosomal disorders Poverty Malnourishment Tobacco, Alcohol, Drug abuse

4. INFECTION 5. GENETIC 6. ENVIRONMENT

SECOND TRIMESTER

CATEGORY 1. ANATOMIC

RISK FACTOR Maternal uterine abnormality Incompetent cervical os Gross foetal abnormality Acute hydraminous Multiple pregnancies Poor implantation Rh incompatibility Hypertension Renal disease Urinary tract infection Heart disease Accidents

1. MATERNAL FACTORS

 1. INFECTION 1. INVESTIGATIVE PROCEDURE 1. ENVIRONMENTAL 1. IDIOPATHIC THIRD TRIMESTER CATEGORY 1. ANATOMIC

Anoxia of eclampsia or epilepsy Polio, Syphilis, Hepatitis (esp. HEV), HIV/AIDS, other viral infection Amniocentesis Poverty, Malnourishment, Tobacco, Alcohol, Drug abuse etc. -

RISK FACTOR Mal-presentation Cord complications Placenta previa Rh incompatibility Hypertensive disease Diabetes Thyrotoxicosis Viral infection Pneumonia Other inter-current infection Anti-thyroid drugs Steroids Anti-convulsants Anti-coagulants Protein-Energy Malnutrition Iron deficiency Premature rupture of membrane Preterm labour Post-maturity Hydramnious or oligohydramnious Multiple gestations Poverty, Tobacco, Alcohol, Drug abuse Inadequate nutrition

1. MATERNAL

1. INFECTION 1. DRUGS

1. NUTRITIONAL 1. FOETAL COMPLICATIONS

1. ENVIRONMENTAL

NURSES ROLE IN MANAGEMENT OF HIGH RISK PREGNANCY

1. Detect, categorize and place the patient in the high risk category during antenatal period

2. Identify the risk factor(s) early in the antenatal period and report them promptly to the treating obstetrician. 3. Educate the patient and family members regarding the risk factor(s), the need for regular antenatal check-ups and the necessity for hospital delivery rather than home delivery. 4. Be vigilante and anticipate complications during labour; take necessary precautionary steps and report them to the treating obstetrician. 5. Motivate the parents to adopt suitable family planning method, or adopt puerperal sterilization if the family is complete.

BIOGRAPHICAL DATA : MOTHER

NAME

: ANITA GURUNG

AGE

: TWENTY SEVEN (27 YEARS)

EDUCATION

: TEN (10 CLASS)

ADDRESS

: VYAS 1, DAMAULI

ETHNIC GROUP

: GURUNG

RELIGION

: HINDU

OCCUPATION

: HOUSEWIFE

DURATION OF MARRIAGE

: EIGHT (8 YEARS)

HUSBANDS NAME

: SHYAM DHOJ GURUNG

AGE

: THIRTY SIX (36 YEARS)

EDUCATION

: SLC

OCCUPATION

: ABROAD

NAME OF HOSPITAL

: WESTERN REGIONAL HOSPITAL

WARD

: MATERNITY WARD

BED NUMBER

: 10 (ANC)

IN PATIENT NUMBER

: 1016482

BLOOD GROUP OF MOTHER

: A POSITIVE

DATE OF ADMISSION

: 2068/03/21

DATE OF DISCHARGE

: 2068/03/22

DURATION OF STAY IN HOSPITA

: ONE (1 DAY)

PROVISIONAL DIAGNOSIS

: G2P1 @ 38+4 WEEKS OF PREGNANCY WITH BREECH PRESENTATION WITH LEAKING

ATTENDING DOCTOR

: DELLA SINGH JOSHI

HISTORY TAKING

History taking 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 & help to reach a diagnosis. History taking also starts the patient-caregiver rapport, which is essential for effective care & patient satisfaction.

Mrs. GURUNG was booked case of Western regional hospital. She had total five ANC visit. Her last ANC visit was at approximately37+2 week. She came for admission on 21th of Aahar at 9:30am. She felt leaking of amniotic fluid since 2068/03/20 at 4am.

Chief complaint:
Amenorrhea since nine (9) months. Leaking of amniotic fluid since 2068/03/20 at 4am

History of Present illness:

History of amenorrhea since nine months. Feeling of quickening at 16+ weeks of pregnancy. Normal fetal movement at the time of admission. On regular antenatal check-up at the department of obstetrics, since tenth weeks of amenorrhea. No history of fever, drug/medication use, trauma bleeding per vagina, hypertension etc. History of mild morning sickness for first four month. Mild edema present in lower limbs

Menstrual History:
Age at menarche Menstrual cycle Duration of menses Interval in between menstruation Amount of flow History of mild dysmenorrheal : Twelve years (12 yrs) : Regular : Five-six days (5-6 days) : Twenty-eight to thirty days (28-30 days) : Normal

Marital History:

Duration of marriage : Eight years Mrs. Anita Gurung got married at the age of nineteen years (19 yrs.). Her marriage is within same cast. She 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.

Family History:

Mrs. Anita Gurung lives in a joint family with her husband. Her husband is third child in his family among three siblings. Her sister-in-laws are already married and settled elsewhere. Mrs. Anita herself is elder child among the two siblings. No any significant history in her family. Within her husbands family, her fatherin-law is a chronic alcoholic and smoker and her mother-in-law is under the medication of Asthma. Out of this, there is no any other significant history in her family.

Family Tree
Anitas Family Anitas Husbands Family

Key
Male

female

Patients husband Patient Newbor n

Personal history:

Mrs. Gurung is an educated housewife. She 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, juanoko-jhol, meat and soup after she delivers. She has a good appetite. Her bowel and bladder habit is normal.

There is no any significant history of drug allergy. She has good personal hygiene. She neither smoke nor drink alcohol.

Socio-economic Status:

Mrs. Anita Gurungs family belongs to middle class Nepali family. Her family depends on pension and her husbands job(abroad). She herself is unemployed.

Past Medical History:

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 of: Heart disease Hypertension Renal disease Infection: Hepatitis, HIV/AIDS, Leprosy etc. Diabetes Drug allergies Seizure disorders Injury/deformity of the pelvis.

Past obstetric History:

She has a seven (7) years old son. She had antenatal check up at the health post of Damauli but for the delivery she came to Western Regional Hospital. She delivered a male baby weighing 2.5kg on 2061/03/06. She 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.

 Present Obstetric History:

Last Menstrual Period (LMP) Expected Date of Delivery (EDD) Gravid Parity Gestational Age : 2067/06/24 : 2068/03/31 : G2 : P1+0 : 38+4 weeks

Mrs. Gurung confirmed her pregnancy by doing urine for pregnancy test in Western Regional Hospital as doctors advice. She had done the test three weeks after missing her regular cycle. She had only mild degree of morning sickness and did not need to take any medications. Her trimesters were eventful with regular ANCs at the department of OBG, Western Regional Hospital. The antenatal record is given below:

ANTENATAL RECORD

D a t e

Wt. (Kg)

Pallor/ Oedema

Urine: Alb/glu

Blood Pressure

P.O.G. (Weeks)

Fundal Height

F.H.S

Remarks

0 6 7 / 0 8 0 6 7 / 1 0 0 / 6 7 / 1 1 / 0 6 8 / 0 2 / 1 0 6 8 / 0 3 / 0 6

52

-/-

nil

90/70

7+2

USG to detect blighted ovum T.T1st dose,contin ue iron calcium

53

-/-

nil

90/60

16+2

14

54

-/-

nil

90/70

21+2

20

RBS report, USG

57

-/-

nil

90/70

34+2

35

140

Confirm breech presentation by USG, f/u 3 weeks

58

-/-

nil

90/70

37+2

TS

134

f/u after 3 weeks or SOS

OTHER INVESTIGATIONS:

Hb

: 11.6 gm%

Random blood sugar

: 90 mg/dl

Platelet

: 148,000

VDRL

: Non reactive

HBsAg

: Negative

HIV

: Negative

Blood group

: O positive

Ultrasound: Obstetric Scan:

Date of USG: 2067/11/16

Single live fetus in the uterine cavity, with regular cardiac activity and normal fetal activity The placenta is situated at the anterior and upper uterine The gestational age by the BPD.FI and HC corresponds to 19-20 weeks. Presentation is breech No gross congenital anomaly is detected. The liquor volume is adequate.

Date of USG: 2061/01/12

Single 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 BPD.FI and HC corresponds to 34 weeks. Presentation is breech No gross congenital anomaly is detected. The liquor volume is adequate AFI 7

PHYSICAL EXAMINATION

Physical examination follows history taking, 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 taking aids to reach a working diagnosis direct the investigation and formulate a treatment.

The following are the steps of physical examination: Inspection Palpation Percussion Auscultation

Her general physical examination carried out on the day of admission revealed:

Pallor Icterus Clubbing Oedema JVD Lymph nodes

: No any : No any : No any : No any : No any : No any

Vital Signs: Blood pressure : 90/60 mm of Hg Pulse : 72/min regular, good volume Respiratory rate : 18/min Temperature : 98.6F Weight : 51 Kg Height : 150cm

General Physical Examination: General physical examination is done in cephalo-caudal approach that is head to toe.

General Appearance: Her general condition is good, though she looked a bit apprehensive. She had a slightly uncomfortable gait due to the gravid uterus and leaking. Her personal hygiene was maintained.

Head & neck:

Chest:

Examination of the head revealed well groomed black hair, healthy scalp without infestation or infection. Her ears are symmetrical with well formed auricles. There were no signs of infection and her hearing was good. Her eyes are symmetrical; the pupils are bilaterally equal and reacting to light. The extraocular muscle movements are coordinated. There are no sign of infection. Her nose is normally shaped and without deformity. The examination of the mouth and the oral cavity revealed adequate oral hygiene. The examination of the neck did not reveal any mass or gland enlargement.

No obvious deformity of the chest evident. Examination of the respiratory system revealed adequate air entry bilaterally with clear lung fields. Examination of the cardiac area revealed the apex to be at left fifth intercostals space in the mid-clavicular line. The first and second heart sounds heard in all four cardiac auscultatory areas were normal. Examination of breasts revealed well-developed, symmetrical breasts with central, normal, hyperpigmentated nipple surrounded by the areola. No obvious mass was palpable in the breast matrix. No cracks on the nipple are evident.

Spine & Extremities:

No spinal deformity evident on physical examination. The extremities are symmetrical and functionally normal.

Obstetrical Examination:

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 to:

Determine the size of the uterus & correlate with the gestational age. This helps to anticipate complications if any e.g. twins, SGA babies, polyhydramnious, oligihydramious etc. Assess the state of previous caesarean scar if present. Determine the lie & presentation of the fetus. Assess the progression of labour. Detect any maternal or fetal abnormality and take corrective steps to prevent any complication.

Abdominal Examination: (Finding at the time of admission at 9:30am):

Inspection The abdomen was uniformly distended and ovoid in shape. Striae gravidera & linea nigra were present. Palpation: Fundal height: 38 weeks of gestation. (chronological age of gestation: 38+4 weeks ) Fetal movement appreciated. Lie : Longitudinal Presentation : Breech Presenting part : Not engaged. Uterine contraction is present Auscultation: Fetal Heart Sound (FHS) heard on the right side of the abdomen, at the umbilicus level. Fetal Heart Rate : 130/minute regular Percussion Not applicable

Pelvic examination:

No swelling or varicose vein of the external genitalia Not any discharge Per Vaginal (P/V) Examination Os : 4 cm Effacement : 30%

Membrane Presenting part

: Absent : High up

Clinical impression: G2P1+0 38+4 weeks with breech presentation with Leaking in active stage of labor.

Plan: VAGINAL DELIVERY

BREECH PRESENTATION

INTRODUCTION:
It 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. A breech birth is the birth of a baby from a breech presentation. In the breech presentation the baby enters the birth canal with the buttock or feet first as opposed to the normal head first presentation.

INCIDENCE:

The incidence is about 1 in 5 at 28th week and drops to 5% at 34th week and to 3% in term. Thus in 3 out of 4 spontaneous correction into vertex presentation occurs by 34th week 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:
Complete Incomplete

Complete
The normal attitude of full flexion is maintained. The thigh are flexed at the hips and the legs at the knee. The presentating part consists of two buttock, external genitalia and two feet. It commonly present in multipara (10%).

Incomplete
This is due to varying degree of extension of thighs or legs at the podalic pole. Three varieties are possible (25%).

Breech with extended legs(frank breech)

In this condition, the thigh are flexed on the trunk and legs are extended knee joint. The presenting part consists of the two buttocks and external genitalia only. It is commonly present in primigravida, about 70%. 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
Both 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 knee are flexed, bringing the knees down to present at the brim. This is very rare.

In 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-posterior positions all exist, of which sacro-anterior indicates an easier delivery.

Clinical varieties:
In an attempt to find out the dangers inherent to breech, breech presentstion is clinically classified as:

Uncomplicated:

It is defined as one where there is no other associated obstetric apart from the breech, prenaturity being exeluded.

Complicated: When the presentation is associated with condition which adversely influence the prognosis such as prematurity, twins, contracted pelvis, placenta previa etc. it is called complicated breech. 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.

Epidemiology:
Frequency

United States Incidence is correlated to gestational age (see Table 1 below). However, the overall frequency is 3-4% at delivery.

Table 1: Gestational age and frequency of breech birth

Gestational Age, Weeks Breech, % 21-24 25-28 29-32 33-36 37-40 33 28 14 9 7

Mortality/Morbidity:
Many complications can result from breech presentation. They are generally related to complications of the fetal abnormalities that may be the primary reason for the breech presentation and those related to umbilical cord compression resultant from abnormal progression through the maternal pelvis. Increased birth trauma: As the duration of umbilical cord compression increases, the practitioner tries to deliver the infant more rapidly than advisable, thus increasing the incidence of birth trauma. Incidence of prolapsed umbilical cord depends on type of breech presentation. Footling, 17% incidence Complete, 5% incidence Frank, 0.5% incidence

Umbilical cord abnormalities: Cord length may be reduced, and, in footlings, there is an increased risk of the cord coiling around the legs of the fetus.

Etiology:

1.Prematurity: it is the commonest cause of breech 2.Factors preventing spontaneous version: Breech with extended legs Twins Oligohydraminos Congenital malformation of the uterus such as septste or bicorunated Short cord ,relative or absolute Intrauterine death of the fetus 3.Favorable adaptation: Hydrocephalus- big head can be well accommodated in the wide fundus Placenta previa Contrcted pelvis Cornufundal attachment of the placenta- minimizes the space of the fudus where the smaller head can placed comfortably Undue mobility of fetus: Hydraminos Multipara with lax abdominal wall 4.Fetal abnormality: Trisomies 13, 18 21 and myotonicdystrophy due to alteration of fetal muscular tone and mobility 5.Recuurent or habitual: On occasion, the breech presentation recurs in successive pregnancies. When it recurs in three or more consecutive pregnancy, it is called habitual or recurrent breech. The probable causes are congenital malformation of the uterus or bicorunated, and repeated cornufundal attachment of the placenta.

Diagnosis

Ultrasonography: It is most informative 1. It confirm the clinical diagnosis- especially in primigravida with engaged frank breech or with tense abdominal wall and irritable uterus. 2. It can detect fetal congenital abnormality and also congenital anomalies of the uterus. 3. It measure biparietal diameter, gestational age and approximate weight of the fetus. 4. It also localized the placenta. 5. Assessment of liquor volume (important for ECV) 6. Attitude of the head- flexion or hypertension. Radiology: A straight X-ray rarely done 1. 2. 3. 4. To confirm the clinical diagnosis To exclude bony congenital malformation (hydrocephalus) To note the size of the baby To note the position of the limbs and the head

Clinical: the diagnostic feature of a complete breech and a frank breech are given below in the tabulated form.

Clinical Diagnosis of Breech Presentation Complete breech Per abdomen Fundal grip Head suggested globular mass Head is ballottable by hard 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 trunk Irregular parts are less felt on the side Lateral grip Fetal back is to one side and the irregular limbs to the other Small hard conical mass is felt. Breech suggested by soft, broad and irregular mass The breech is usually engaged Pelvic grip Breech is usually not engaged during pregnancy Located at a lower level in the Usually located at a higher level midline due to early engagement round about the umbilicus of the breech Frank breech

Fetal heart sound

Per vagina During pregnancy Soft and irregular parts are felt Hard feel of the sacrumis felt, often through the fronix mistaken for the head.

During labour Palpation of ischial tuberosities, Palpation of ischial tuberosities, sacrum and the feet by the side anal opening and sacrum only of buttocks. The foot is identified by the prominence of the heel and lesser mobility or the great toe

Position: The sacrum is the denominator of the breech and there are four positions. In 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 Left sacro anterior (LSA) Right sacro anterior (RSA) Left sacro posterior (LSP) Right sacro posterior (RSP)

Antenatal management

Identification 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 baby within the uterus. A medication to help relax the uterus might be given as well as an ultrasound exam, to better check the position of the baby, the location of the placenta, and the amount of amniotic fluid in the uterus. Gentle pushing on the lower abdomen can turn the baby into the head-down position. Throughout the external version, the baby's heartbeat will be checked closely so that if any problems should occur, the health care provider will stop turning immediately. Most attempts at external version are successful; however, as the due date gets closer this procedure is more difficult.

Time of version: 35-37 weeks but can be attempted at any time there after up to early stage of labour.

Contraindication of external cephalic version: 1. Antepartum haemorrhage (placenta previa or abription) _risk of placenta separation

2. Fetal causes- congenital anomalies(major), dead fetus, hyperextentionof the head, fetal compromise(IUGR) 3. Multiple pregnancy 4. Rupture membrane- with drainage of liquor 5. Known congenital malformation of the uterus 6. Contracted pelvis 7. Previous cesarean delivery risk of scar rupture. 8. Obstetric complication- severe pre- eclampsia, obesity, elderly primigravida, bad obesteric history. Danger of external cephalic version: 1. 2. 3. 4. Premature rupture of membrane Premature rupture of membrane Placental separation and bleeding Entanglemen of the cord rou8nd the fetal part or formation of a true knot leading to impairment of fetal circulation and fetal death 5. Increase the chance of feto-maternal bleed 6. Amniotic fluid embolism Management, if version fail or contraindicated: two method of delivery can be planned To perform an elective cesarean section To allow spontaneous labour to start and vaginal breech delivery to occur

Vaginal Breech delivery

Vaginal breech delivery is considered in cases with adequate pelvis, average fetal weight(between 1.5 and 3.5kg), flexed head and without any other complication. Frank breech is preferred. In all such cases one must ensure close monitering of labour and facilities for immediate cesarean delivery should necessity arises.

Management of Vaginal Breech Delivery

First stage of labour The management protocol is similar to that mentioned in normal labour. The fallowing are the important consideration. Spontaneous onset labour increases the chance of successful vaginal delivery. 1. Vaginal examination is indicated 2. At the onset of labour

3. Soon after rupture of membrane to exclude cord porolapse 4. An intravenous line is sited with ringer,s solution, oral intake is avoided, blood is sent for group and crossmatching (considering the chance of cesarean section) 5. Adequate analgesic is given, epidural is preferred 6. Fetal status and progress of labour are monitered 7. Oxytocin infusion may be used for augumentation of labour Second stage of labour: there are three method of vaginal delivery 1. Spontaneous: expulsion of the fetus occurs with very little assistance. This is not preffered. 2. Assisted breech: the delivery of the fetus is by assistance from the beginning to the end. This method is employed in all cases 3. Breech extraction: when the entire body of the fetus is extracted by the obstetrician. It is rarely done these days as it produces trauma to the fetus and the mother. Indications are: Delivery of the second twins after internal podalic version Cord prolapse Extended legs arrested at the cavity or at the outlet Mechanism of labour Sacro- anterior position (being the commonest)

Buttocks The diameter of engagement of the buttocks is one of the oblique diameters of the inlet. The engaging diameter is bitrochantric (10cm) with the sacrum directed towards the ilio pubic eminence. When the diameter passes through the pelvic brim, the breech is engaged Descent of the buttocks occurs until the anterior buttocks touches the pelvic floor. Internal rotation of the anterior buttock occurs through 1/8th of a circle placing it behind the symphasis pubis. Further descent with lateral flexion of the trunk occurs until the anterior hip hinges under the symphasis pubis which is released first fallowed by the posterior hip Delivery of the trunk and lower limb fallow Restitution occurs so that the buttocks occupy the original position as during engagement in oblique diameter. Shoulder Head Engagement occurs either through the opposite oblique diameter as that occupied by the buttocks or through the transverse diameter. The engaging diameter of the head is suboccipio- frontal (10cm) Descent with increasing flexion occurs. Bisacromial diameter (12cm) engages in the same oblique diameter as that occupied by the buttocks at the brim soon after the delivery of the breech. Descent occurs with the internal rotation of the shoulder bringing the shoulders to lie in the antero- posterior diameter of the pelvic outlet. The trunk simultaneously rotates externally through 1/8th of a circle. Delivery of the posterior shoulder fallowed by the anterior one is completed by anterior flexion of the delivered trunk. Restitution and external rotation: untwisting of the trunk occur putting the anterior shoulder towards the right thigh in LSA and left thigh in RSA. External rotation of the occiput through 1/8th of a circle anteriorly. The frank trunk is now posiioned as dorso anterior

Internal rotation of the occiput occurs anteriorly, through 1/8th or 2/8th of the circle placing the occiput behind the symphysis pubis. The head is born by flexion- the chin, mouth, nose,forehead, vertex and occiput appearing successively. The expulsion of the head from the pelvic depends entirely upon the bearing down efforts and not at all on uterine contraction.

Prognosis

Maternal: Labour is usually not prolonged but because of operative delivery including cesarean section, the morbidity is increased. The risk include trauma to the genital tract, operative vaginal delivery (episiotomy, forcep), cesarean section, sepsis and anesthetic complication. As a consequence maternal mobidity is a slightly raised.

Fetal: The fetal risk in term of perinatal mortality is considerable in vaginal breech delivery. It is difficult to assess the magnitude of the real risk, because the complicating factors such ad prematurity, birth trauma, congenital malformation of the fetus that contribute significantly to the fetal hazards. The corrected (excluding fetal abnormality) perinatal mortality ranges from 5-35per 1000 birth. The overall perinatal mortality in breech still remains 9-25% compared with 1-2% for non breech delivery. Perinatal death is 3 to 5 times higher than the non breech presentation. The fetal mortality is least in frank breech and maximum in footling presentation, where the chance of cord prolapse is more. Gynaecoid and anthropoid pelvis are favorable for the aftercoming head. The fetal risk in multipara is no less than that of primigravida. Thos is because of increased chance of cord prolapsed associated with flexed breech. The factorswhich significantly influences the fetal risk are: Skill of the obstetrician Weight of the baby Position of the legs The type of the pelvis

The fetal danger The fetal dangers in vaginal delivery are as fallow: Intracranial hemorrhage:-compression fallowed by decompression during delivery of the unmoulded aftercoming head results in tear of the tentorium cerebelli and haemorrhage in the subaracnoid space. The risk is more with preterm babies. Asphyxia: it is due to Cord compressions soon after the buttocks are delivered and also when the head enters into the pelvis. A period of more than 10 minutes will produce asphyxia of varying degree Retraction of the placental site Premature attempt at respiration while the head is still inside

Delay delivery of the head Cord prolapse Injuries: the fallowing injuries are inflicted during manipulative deliveries Haematoma- over the sternomastoid or over the thighs. Fracture- the commonest sites are femur, humerus, clavical, odontoid process. There may be dislocation of the hip joint, mandible or 5th and 6th cervical vertebrae and epiphyseal separation. Visceral injuries include rupture of liver, kidneys, suprarenal glands, lungs and haemorrhage in the testicles. Nerve- medullary coining, spinal cord injury, starching of the brachial plexus to cause either Erbs palasy or klumpke palasy Some of the injuries may prove fatal and contribute to perinatal mortality. Long term(neurological) mobidity of the surviving infants should not be underestimated.

SCHEME FOR MANAGEMENT OF BREECH DELIVERY

ANTENATAL ASSESSMENT

Fetal wellbeing, weight, attitude Maternal health(obstetric and medical) Maternal pelvis

External cephalic version Around 36 weeks or after In the labour suite With tocolytic if needed Fetal monitering (CTG)before and after procedure

Elective cesarean section (>38weeks) Estimated fetal weight Hyperextended head Associated complication (obstetric and medical) Pelvic inadequancy

Successful

Fail

Delivery as vertex Vaginal breech delivery Elective cesarean delivery Average fetal weight Frank breech Flexed head Adequate pelvis

Leaking of Amniotic Fluid

Cesarean section Assisted breech Amniotic Fluid is the watery liquid that surrounds the baby / fetus within the uterus. This Amniotic delivery Arrest of progress Fluid allows the baby / fetus to move about freely without the hindrance caused by the uterus walls Fetal cushioning within the uterus being too tight around it. At the same time, this fluid helps provide adistress (Non-reassuring FHR) and gives the fetus buoyancy. This Amniotic Fluid begins to fill up the Amniotic Sac from about 2 weeks of fertilization. Another 10 weeks 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. It has also been recently discovered that the amniotic fluid also contains non-embryonic stem cells. Leaking of Amniotic Fluid Normally, when the pregnancy completes the full term, the membranes of the amniotic sac burst and the amniotic fluid begins to leak out via the vagina. This is called Spontaneous Rupture Of Membranes or SROM. In common parlance, this is also termed as the time when a womans Water Breaks. However, there are times, when the amniotic sac may develop a tear or may rupture causing the amniotic fluid to leak before term. When this occurs 37 38 weeks before term, it is referred to as Premature Rupture Of Membrane or PROM. When either of these cases occurs, the fluid may just gush out or may just leak out in a continuous trickle like a discharge. When the premature rupture of amniotic sac occurs, it is necessary to determine the cause of the leaking amniotic fluid. Normally, the leaking 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 breaks. This leakage may lead to further complications 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 consequently to the fetus. Sometimes when there is a small tear in the amniotic sac, it may heal itself over a period of time and the leaking may simply stop of its own accord. However, if the leaking amniotic fluid is a result of a severe rupture of the membranes of the amniotic sac, then labor may begin within 48 hours. When this happens, the mother-to-be must receive treatment in order to avoid causing an infection to the fetus. Often what is thought of as leaking 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. It is advised to wear a sanitary napkin and observe the color of the liquid. The amniotic fluid is colorless. The mother-to-

be must never use a tampon during pregnancy. If the leaking 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 leaking began and tell her doctor about these details. In such cases, most physicians will usually deliver the baby within 24 hours in order to avoid infection risk. Nowadays, many over the counter products are available to test whether the fluid is urine or amniotic fluid. It is always recommended that one avail of these tests to ensure the health of the baby.

COURSE OF EVENTS AT THE HOSPITAL

Mother sent to labor room (first stage) from admission room for Normal Vaginal Delivery

Management in the first stage of labor:

Mother was kept in the comfortable position. Assessment of physical and mental status: a complete physical examination was done to find out any abnormalities including general condition of the patient, Vital signs, FHS. Psychological preparation: Emotional support was given to the patient and explained about the procedure. Ordered investigations were sent like RBS, CBC and Urine R/E and reports were also collected. Half hourly monitoring of Fetal Heart Sound and correct recording and reporting was done. Augmentation with injection oxitocin was started according to doctors order. Partograph was filled to monitor the progress of labour. Intake and output was monitored. Mother was encouraged for adequate fluid intake like black tea, hot soups etc. to prevent dehydration. Cervix was fully dilated at 7:30 pm and mother was taken to second stage of labour. Equipments/ materials required for the normal vaginal vaginal delivery was kept ready.
Management in the second stage of labor: Mother was shifted to the second stage (delivery room) and kept comfortably on the

delivery bed with the head elevated 450. Mothers Vital signs and Fetal Heart Sound was also monitored and recorded.

She was encouraged to push during strong contraction. Strict aseptic technique was maintained during delivery. She delivered a live female baby at 08:00 pm weighing 2250 gm. Kangaroo mother care was provided to the baby. Babys sex was shown to the mother.

Management of the third stage of labour:

As soon as the baby was delivered injection Syntocin 10 units I/M was given. Post delivery Vital signs were taken and recorded. Placenta was delivered using Control Cord Traction and placenta was observed; which was complete and normal. Vagina was carefully observed and cleaned. Wet dress of the mother was changed. She was encouraged to massage the uterus every 15 minutes for 5 minutes. Teaching about breast feeding, perineal hygine, cord care was given. Mother was transferred to the post natal ward.

MANAGEMENT OF THE NEWBORN BABY

Immediately 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. After placing the baby under the warmer, the nose and oral cavities were suctioned free of secretions with sterile ET suction catheter. The babys APGAR was scored. The heel of the baby was flicked to stimulate him to cry/breath. Umbilical cord was clamped with sterile thread and its redundant length trimmed. The baby was cleaned around the eyes, mouth and nose with clean paraffin soaked gauze. The baby was then cleaned from head to toe. The baby was weighed: 2250 gm The baby was checked for maturity and presence of any obvious congenital birth defect. APGAR: Rapid assessment tool to assess cardio-respiratory and neurological status of the newborn. It is determined by the level of oxygenation. 1. 2. 3. 4. 5. A: Appearance : Pink or blue P: Pulse : Heart rate G: Grimace : Reflex immutability A: Activity : Muscle tone: Normal or flaccid. R: Respiration : Normal, laboured, shallow or apnoeic

APGAR score of the baby born to the patient under study:

Parameters Heart Rate Respiratory Rate Muscle Tone Reflex Immutability Colour Total

APGAR 1 minute 2 2 1 1 1 7

APGAR 5 minutes 2 2 1 1 2 8

IMMEDIATE NURSING CARE OF THE NEONATE

The newborn is in complete dependence of it caretakers. The nurse has to ensure the baby does not aspirate the amniotic fluid and that the baby maintains hoemeostatis. Thus the main objectives of taking care of newborn are to: Establish and maintain a patent airway Maintain normal body temperature Promote mother infant bonding Provide optimal nutrition Protection from infection and injury

Maintain a patent airway: 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. Once the baby is delivered, the baby is placed in a lateral decubitus, 15 head down position to facilitate drainage of secretions under a radiant warmer or on the mothers abdomen. The oropharynx and nostrils are suctioned to ensure clearance of secretions. Maintain stable body temperature: Dry the baby with a soft warm towel Wrap the baby in a pre warmed blanket Place the baby under a radiant warmer Avoid unnecessary exposure Check the babys temperature every 15 min for the first hour if required Promote mother infant bonding: Show 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. Initiation of breast feeding: Put the baby to the mothers 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 Infection and Injury: Wash hands or use sterile gloves when handling newborns. Divide the umbilical cord with sterile scissors and apply sterile disposable umbilical cord clamp to the babys end of to umbilical cord stump. Wipe the eyes of the baby with sponge towel wet with pre-boiled water. Sponges bathe the baby with warm water. Mother must be taught to maintain good personal hygiene. She must keep her nail short to prevent injury to the newborn Avoid unnecessary handling of the baby

ASSESSMENT OF THE NEONATE

OBJECTIVE:

We all expect our newborn to be normal, kike us, not realizing 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 require intervention in any way. The other main objective is to help the baby maintain homeostasis in the face of adverse environment. To list the objective:

Detect congenital anomalies and plan out treatment where relevant. Detect birth injury any other acquired illness. Record the vital statistics of the baby. Maintain homeostasis.

Measurement:

Parameters: Head circumference Chest circumference Vertex to heel length Body weight

Measured value 31.2 cm 30.4 cm 47.6 cm 2250 gm

Reference value 31-35 cm 30.54-33.00 cm 48-53 cm 2700-4000 gm

Vital signs

Temperature 98.0 F

Pulse 146/min

Respiratory Rate 44/min

GENERAL PHYSICAL EXAMINATION OF THE NEONATE

Appearance:

General: The face, Chest, tongue & lips were pink. The extremities (hands & feet) were mildly cyanotic. The head was flexed and resting on the on the chest, the arms were flexed on the chest while the thighs were flexed up on the abdomen.

Skin: Skin was pinkish and slightly puffy and smooth. Vernix caseosa and lanugo hair were present. The face, legs, feet and dorsa of the hands were puffy. Head No caput present. Anterior fontanelle: diamond shaped Posterior fontanelle: triangular shaped No deformity present around the scalp. Eyes Closed eyes, Oedematous eyelids. Absence of tears. Ears The top 1/3 rd of the ear crosses the imaginary line joining the outer canthus of the eye to the external occipital protuberance. No deformity of the ear. No discharge. Nose No deformity involving the nose. No discharge from the nostrils. Mouth and throat:

Sucking and rooting reflexes present. No cleft or palate. No oral thrush or dribbling of saliva. Neck There was short & thick skin fold around the neck. No webbing of the neck or masses.

Chest Normal in shape and appearance. Antero-posterior and lateral diameters were equal. Bilateral nipples were present and symmetrical. Respiratory system Respiratory rate was 44/min. The pattern was abdominal-thoracic. No cough reflex. Heart Heart rate: 146/min, regular S1 S2 heard. No murmur. Abdomen Rounded, soft. No infection or bleeding at the umbilical cord stump.

External Genitalia and perineum: Well developed female external genitalia. The labia majora was covered by the labia minora. The hymen and clitoris were disproportionately large. The back: The spine was flexed, the spinous processes were complete. No pit, tuft of hair, melanoma or mass at the lower spine. Extremities: The neonate had two upper and two lower extremities, w hich were well developed. No missing, extra or fused digits. Nail beds: pink Normal range of motion at all extremities. Ortolanis and Barlows tests were negative. Neuro-muscular system: Normal 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 horizontal with the back when held horizontal.

Neonatal reflexes: All neonatal reflexes appropriate for his developmental age were present i.e.: sucking, rooting, swallowing, Moros and grasp reflex. Cry: The baby and a very strong and healthy cry. Sleeping pattern: Normal.

ESTABLISHMENT OF MOTHER-INFANT BONDING

Bonding is a psychological state of belonging and reciprocation. Mother-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. It 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. It is postulated that hormonal stimulations may contribute to the attachment, but social and cultural components play a very influential role.

Bonding is strengthened by the babys interaction with the parents. The passive infant probably receives less attention and stimulation than an active alert tone.

One of the key components to strengthening the mother-infant bonding is breast-feeding. For my patient, I initiated breast feeding once the mother was shifted to the post natal room. During that time, I discussed about the expectations of the mother and reiterated the measures to strengthen the mother-child bonding. I also discussed about: Eye contact whenever possible and specially during breast feeding Process of attachment and its importance in parent-infant bonding. Importance of physical contact like touching, picking up the child and holding, hugging. Correct position of the infant during breast-feeds. Importance of burping the child after each feed. Sleeping the child with the mother versus sleeping the child on the cot.

Mrs Gurung has a healthy newborn baby. It was not difficult to educate her about mother-infant relation and breast feeding. For my patient, mother-infant bonding was easy to establish and maintain. She was avid learner and was ready to adopt measures required for good infant nursing.

POST-NATAL CARE AND HEALTH EDUCATION

The Puerperium:

The puerperium covers the period from the expulsion of the placenta till six weeks of postpartum. During this time the intra-abdominal reproductive organ return to the non-pregnant state while a number of physiological and psychological changes occur. Objective of post-natal care: To provide care for rapid restoration to optimum health of the mother. To prevent complication in the postnatal period. To ensure adequate nourishment of the neonate through breast feeding. To teach about family planning methods and make 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 workers.

Management objective: Immediate attention and care to the newborn and mother. Rest and ambulation of the mother. Adequate sleep. Adequate and nourishing diet. Care of bladder and bowl. Care of breast and breast feeding. Examination of mother and baby.

Health education: Eye care: 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 milk into babys eyes while breast feeding. Cord care: The umbilical cord stump was cleaned with boiled cotton and dried with dry sterile gauze swab. The mother was advised to clean the babys umbilical stump with boiled cotton, even at home. The mother was instructed not to apply anything on the umbilical cord stump and to keep it clean. Inform the mother that the cord stump falls off in 5-10 days. Instruct the mother to watch for any discharge, bleeding or infection. Nose & mouth care: The mother was advised to keep the nose and mouth clean with soft tissue paper. Skin care Sponge bath the baby after 24 hours of birth. Keep the baby clean. Bathe the child every 2-3 days once the cord falls off. Do not use the soap on the babys face.

 Apply oil all over the body everyday. Recovery from the physiological jaundice Exclusive breast feeding. Keep the baby in the morning sunlight. If jaundice should prolong, then obtain medical check up. Napkin care: Teach the mother the correct method of putting on the napkin. Ask the mother to change the napkin as soon as it is wet.

DAILY ASSESSMENT OF POSTNATAL MOTHER:

Mrs. Gurung delivered a healthy baby on 2068/03/21 and she was discharged on 2068/03/22. So, her assessment on 2068/03/22 are as follows:

S.NO

Parameters

Findings

1.

Vital Signs: Temperature Pulse Blood Pressure Respiratory Rate 98.80 F 78 beats/minute 90/60 mm of Hg 16 breaths/minute

2.

Uterine height

14cm

3.

Lochia

Rubra (healthy)

4.

Abdomen

Mild tenderness

5.

Breast

Nipple everted, adequate milk flow

6.

Appetite

Normal, no nausea and vomiting

7.

Sleep

Disturbed sleep

S. No 1)

8. Nursing Diagnosis Anxiety &fear related to hospital environment as evidenced by perspiration.

Elimination Nursing Goal Minimizing anxiety of hospital admission

Plan of action

Passed urine, not stool. Nursing Intervention

Rational

Develop a therapeutic relationship with patient & family. Orient the patient to the hospital, its rules & facilities available. Reassure the patient that she is in safe, good hands & not alone. Assist in anxiety reducing maneuvers: relaxation, deep breathing and oral intake of warm fluids.

Therapeutic relationship with patient & family was developed. The patient was oriented to the hospital its rules & facilities available. The patient was reassured that she is in safe hands and not alone. Assisted in anxiety reducing maneuvers: relaxation, deep breathing and oral intake of warm fluids.

Compliance increases with trust.

Orientation & awareness of surroundings promotes comf and allays anxi Presence of trusted person helpful in reducing anxiet

Using anxiety reducing strategies enhances the patients sense personal maste & confidence.

Nursing Care Plan For Mother

S. No

Nursing Diagnosis

Nursing Goal

Plan Of Action

Implementation

2)

Knowledge deficit & fear related to breech pregnancy and leaking.

She will know about the breech pregnancy and leaking.

Explain the

process of breech delivery and management of leaking.

Assist & teach her

The process of breech delivery and management of leaking was explained. She was assisted & taught to maintain position during delivery.

how to maintain position during delivery.

Encourage her to maintain patience during delivery.

She was encouraged to maintain patience during delivery.

S. No 3)

Nursing Diagnosis

Nursing Goal

Plan of Action

Implementation

Altered fluid &electrolyte balance related to loss of body fluids during delivery as evidenced by dry lips.

Maintain fluid & electrolyte balance during &after delivery.

Assess the fluid and electrolyte status. Monitor vitals, Intake/output.

Monitor dryness of

mucous membrane. Replace I/V fluid as needed. Provide oral fluids like water, black tea, soups etc.

Fluid and electrolyte status was assessed. Vitals and intake/output were monitored. Dryness of mucous membrane were monitored.
I/V fluid was administered as needed.

Oral fluids like water, black tea and hot soups were provided.

S. No 4)

Nursing Diagnosis

Nursing Goal

Plan of Action

Implementation

Altered sleeping pattern related to new environment and hospitalization as evidenced by frequent awakening.

Patient will be able to sleep properly.

To assess the sleep and rest pattern. To provide quiet and peaceful environment. To encourage patient to sleep in regular time daily.

Sleep and rest pattern was assessed. Quiet and peaceful environment was provided. Patient was encouraged to sleep in regular time. Patient was encouraged to drink warm milk. Patient was encouraged to express her feelings and concern. Comfortable bedding and pillow were provided.

I b

Encourage patient

to drink warm milk at bed time. To encourage the patient to talk and ventilate her feeling at bed time. To provide comfortable bedding and pillow.

I u s p R r a s p M i

d t d p

S. No
5)

Nursing Diagnosis

Nursing Goal

Plan of Action

Implementation

Rational

Risk of infection related to leaking of the amniotic fluid and altered primary defenses in the postpartum period.

Prevent infection to mother and child during the hospital stay

Maintain standard precautions and hand washing technique while providing care. Maintain aseptic technique while doing P/V examination and conducting delivery. Advice to maintain perineal hygiene after each urination and stool. Monitor vital signs.

Standard precautions and proper hand washing technique was maintained while providing care. Aseptic technique was maintained during P/V examination and delivery. Adviced to maintain perineal hygiene after each urination and stool. Vital signs were monitored. Malaise, chills, loss of appetite, fatigue and pallor were monitored. Prescribed antibiotics (cefotaxime 1gm) intravenous stat was given.

To prevent infection wit ward.

To prevent infection.

It also helps prevent infe

Monitor malaise, chills, loss of appetite, fatigue & pallor. Give antibiotics as prescribed.

Increased T indicates on infection. Their prese indicate pos ongoing infe

Helps in red infection

CARE PLAN FOR BABY

S. No
1)

Nursing Diagnosis

Nursing Goal

Plan of Action

Implementation

Ineffective airway clearance due to excessive oropharyngeal secretion.

Clear the babys airway so that the baby can breathe comfortably.

Wipe the babys mouth and nose with soft gauze as soon as the head is delivered. Keep the head slightly lower than body & turned laterally. Gentle suction as necessary. Demonstrate routine care & have mother & family members return the demonstration. Call the pediatrician before delivery.

Babys mouth and nose was wiped as soon as the head was delivered. The head was kept slightly lower than body and turned laterally. Gentle suctioning was done. Routine care was demonstrated and return demonstration was also done by mother & family members too. Pediatrician was called before delivery.

S. No 2)

Nursing Diagnosis

Nursing Goal

Plan of Action

Implementation

Rational

Evaluation

Ineffective thermoregulation due to exposure to the environment immediately after birth.

The newborns body temperature will be maintained at normal body temperature.

Wrap the baby in

warm/ dry blanket and place beneath a radiant warmer. Dry the baby immediately.
Remove the wet

The baby was wrapped in a warm and dry blanket and beneath a radiant warmer. The baby was dried immediately. Wet sheet was removed and temperature was monitored. Temperature of the room was maintained.

Prevents heat loss & directly warm the baby.

The babys temperature was maintained to normal temperature.

sheet and monitor the temperature. Maintain the temperature of the room.

Minimize heat loss by evaporation. Prevent heat loss & early detection of hypothermia. To prevent the heat loss by convection.

S. No 3)

Nursing Diagnosis

Nursing Goal

Plan of Action

Implementation

Rational

Evaluation

Risk of

The newborn

Breast feed the

The baby was

Helps to

Baby did not

developing hypoglycemia due to ineffective breast feeding.

will not develop hypoglycemia.

baby immediate after delivery and every 2 hours or when baby demands. Encourage mother to breast feed the baby as demanded by baby & teach her importance of breast milk.

breast feed immediately after and every 2 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 milk.

maintain glucose level & prevent hypoglycemia.

develop hypoglycemia.

Brest milk contains many nutrients and protective factors.

S. No 4)

Nursing Diagnosis

Nursing Goal

Plan of Action

Implementation

Rational

Evaluation

Risk of infection related to low birth weight.

The baby will be prevented from infection.

Maintain standard precautions and hand washing technique while providing care. Immediately breast feed the colostrums milk. Expose the baby

Standard precautions and hand washing technique was maintained while providing care. Immediate breast feeding of the colostrums milk was done. The baby was

It helps to prevent from cross infection.

The baby was prevented from infection.

Colostrums milk contains natural immunity. Sunlight helps to

to the sunlight. Maintain the cord hygiene and teach the mother about its importance. Immunize the baby.

exposed to sunlight. Cord hygiene was maintained and the mother was taught about its importance. The baby was immunized.

prevent neonatal jaundice. It helps to prevent form infection.

It helps to prevent form infection.

MEDICINE USED IN MY PATIENT The following medications were administered to Mrs. Anita Gurung during her admission: Injection Syntocin Injection Cefotaxime

Injection Oxytocin (Syntocin) : Oxytocin is a peptide hormone secreted by the posterior pituitary that elicits milk injection in lactating women. In pharmacologic doses, Oxytocin can be used to induce uterine contractions in a gravid uterus and maintain labour. Uses: Diagnostic uses: Oxytocin challenge test near term provides information on adequacy of placental reserve and the need for intervention in the presence of an abnormal test. Therapeutic uses: Oxytocin is used to induce labour and augument dysfunctional labour. Indication: Induction of labour Uterine inertia Incomplete abortion Post partum haemorrhage Dosage: Induction of Labour: Oxytocin is administered via micro-drip, infusion or syringe pumps at a rate of 1mU/min and gradually increased every 15-30 minutes to 5-20mU/min till a physiologic contraction pattern is established. Post partum haemorrhage: 5-20 units is added to 500 ml 5% dextrose, And the dose is titrated to control uterine atony. Prophylaxis: Single intramuscular dose of 5 units is given to prevent postpartum haemorrhage and augument uterine contraction after delivery of the baby. Precaution: Contraindications: Grand multipara Contracted pelvis with CPD, obstructed labour Previous history of caesarean section or hysterotomy Malpresentation Inco-ordinated uterine contraction Hypovolemic state Cardiac disease Dangers: Uterine rupture Hypotension Anti-diuretic effect Pituitary shock: Myocardial infarction due to coronary spasm caused by non-purified preparation of posterior pituitary is now seen only with very high doses of Oxytocin.

 Foetal distress/death: Encountered in presence of already compromised foetus, and is due to diminished placental circulation brought on by strong and sustained uterine contraction Injection Cefotaxime : Cefotaxime is a third-generation cephalosporin antibiotic. Like other third-generation cephalosporins, it has broad spectrum activity against Gram positive and Gram negative bacteria. In most cases, it is considered to be equivalent to ceftriaxone in terms of safety and efficacy. Mechanism of action Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins (PBPs) which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis. Bacteria eventually lyse due to ongoing activity of cell wall autolytic enzymes (autolysins and murein hydrolases) while cell wall assembly is arrested. Cefotaxime, like other -lactam antibiotics does not only block the division of bacteria, including cyanobacteria, but also the division of cyanelles, the photosynthetic organelles of the Glaucophytes, and the division of chloroplasts of bryophytes. In 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 Clinical use Cefotaxime is used for infections of the respiratory tract, skin, bones, joints, urogenital system, meningitis, and septicemia. It generally has good coverage against most Gramnegative bacteria, with the notable exception of Pseudomonas. It is also effective against most Gram-positive cocci except for Enterococcus. It is active against penicillin-resistant strains of Streptococcus pneumoniae. It has modest activity against the anaerobic Bacterides fragilis. Chemistry The syn-configuration of the methoxyimino moiety confers stability to -lactamase enzymes produced by many Gram-negative bacteria. Such stability to -lactamases increases the activity of cefotaxime against otherwise resistant Gram-negative organisms. Dosage Adult: 1-2 gm BD Child 1month-12 years: 50-180mg/kg/day divided QID Severe infections

Adult: 2 gm q4hr, not to exceed 12 g/day Child1month-12 years: 50-180 mg/kg/day in 4-6 divided doses Side effects: CNS: Headache, dizziness, weakness, paresthesia, fever, chills, seizures, dyskinesia. CV: Heart failure, syncope GI: Nausea, vomiting, diarrhea, anorexia, pain, glossitis, bleeding increased AST, ALT, bilirubin, LDH, alk.phosphate, abdominal pain, pseudomembramous colitis; cholestasis. GU: Proteinuria, vaginitis, pruritis, candidiasis, increased BUN, nephrotoxicity, renal failure Haem: Leukopenia, thrombocytopenia, agranulocytosis,anaemia, neutropenia, lymphocytosis, eosinophilia, pancytopenia, haemolytic anaemia Integ: Rash, urtcaria, dermatitis Respiratory: Dyspnea Syst: Anaphylaxis, serum sickness, Steven-Johnson Syndrome, toxic epidermal necrolysis Contraindications:

Hypersensitivity to cephalosporins
Infants <1 month Precautions: Pregnancy, breast feeding, children, hypersensitivity to penicillins, GI/renal disease

WHY MY CASE IS A HIGH RISK PREGNANCY?

Any deviation from normal process in pregnancy is high risk. In my case Breech presentation is mal presentation and leaking is also present which increases risk of infection. In vaginal breech delivery many risk of baby being injured and asphyxia. Different data show asphyxia is a 2nd leading cause of neonatal death. In this way breech presentation is risk for both mother and baby. So it is high risk pregnancy.

DISCHARGE PLANNING & SUMMARY

The mother was discharged on 2068/03/22. There was no any complain of discomfort. The baby was well and breast feeding actively. The baby was active and had a good cry.

Patients name Husbands name: Age of patient : Inpatient number : Birth certificate number : Address : Date of admission : Date of delivery (time) : Date of discharge : Mothers blood group : Babys sex : Birth weight : Gestational age at delivery : Type of delivery : Puerperium : Medication :

Mrs. Anita Gurung Mr. Shyam Dhoj Gurung 27 years 1016482 58925 Vyas - 1, Damauli 2068/03/21 2068/03/21at 08:00 pm 2068/03/22 O positive Female 2.25 kg 38+4 weeks Vaginal breech delivery Uneventful 1. Cap. Calcium OD x 45 days 2. Tab. Iron OD x 45 days 3. Cap. Megapan 500mg QID x 5 days 4. Tab. Metron 1 tab TDS P/O x 5 days 5. Tab. Aciloc 150mg BD PO x 3 days 6. Tab. Flexon 500mg TDS x 3 days Dr. Della Singh Joshi One week after discharge(Sunday or Thursday) and SOS Discharge Note:

Consultant : Follow up :

DISCHARGE TEACHING

Health teaching is an important part of holistic patient care. It begins from the time of admission till the patient is discharged and is reinforced in the subsequent follow ups at the OPD. 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, where cultural 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 teaching: 1. Nutrition for baby & mother 2. Breast care and breast feeding 3. Personal hygiene including pericare 4. Rest and resumption of activities 5. Care of the baby 6. Oil massage 7. Immunization 8. Weaning 9. Family planning 10. Follow up visits 11. Medications 1. Nutrition:

Post natal mothers require a balanced diet to recuperate from the stress of parturition, meet the caloric requirements of breast feeding and return to normal daily activities. The diet of the post natal mother should contain green leafy vegetables, plenty of liquids, cereals, pulses and meat. A post natal mother should take at least four meals a day. Culturally influenced diet high on calorie like ghee, Chakku, sweets etc are allowed. This ensures that the baby acquires adequate calories through the mothers milk.

2. Breast care and Breast feeding:

Care 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. Unnecessary 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 technique of breast feeding the baby. This includes the following: On demand feeds Proper positioning of the baby during feeds Burping the baby after feeds Maintenance of personal hygiene.

1. Rest and activities:

The mother needs rest during the puerperium to recuperate from the stress of labour and immediate post natal period. The mother requires about 9 hours of sleep a day, and she needs about 2 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 undertake heavy or labourious tasks during the puerperium, as it predisposes to uterine prolapse. The mother is taught about the pelvic floor exercises to tone up the musculature.

2. Care of the baby:

The baby must be cleaned and cared daily. The eyes, face and body must be wiped with a clean cloth soaked with clean luke-warm water. The umbilical cord stump must be cleaned daily till it naturally drops off. The babys diapers must be checked and changed regularly. The perineum must be kept clean and dry to prevent rashes. 3. Oil massage: Massaging the baby ensures good skin circulation and prevention of pressure sores. The massage with stretching of the joints ensures suppleness and strengthens the muscle tone. Oil massage is a traditional practice amongst the Nepali community and is encourages both for the mother and the baby. 4. Immunizations: Active immunization against various bacterial and viral childhood diseases is part of the extended program for immunization in Nepal. The parents had a good knowledge of the immunization schedule.

5. Weaning food:
The baby requires dietary supplement from 6 months of age as the baby grows and the calories obtained from the breast milk becomes inadequate. The parents knowledge of weaning foods was reinforced when I discussed the weaning techniques. They had a good idea of home made preparations as well as proprietary products. 6. Personal hygiene and pericare: Good personal hygiene is a prerequisite for good health. 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. 7. Medicines: My patient was prescribed antibiotics, analgesics and she was further prescribed hematinics and calcium supplements by the doctor. I explained the justification for taking the prescribed medications for the mentioned durations.

8. Follow up Visits:
The parents were advised to return with the baby after a week from the date of discharge. The parents were advised to visit the Pediatrician at the next visit for the babys first immunization shot of BCG. They were further advised to seek consultation in case of any difficulty.

FOLLOW UP CARE
Follow up care and home visits are modalities to make certain that the patient who had required in hospital treatment in recuperating well in the domestic environment. It is to ensure that the patient is compliant with the prescribed therapy and has not developed any complication that would require 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 details: Evaluation of health status of baby and mother. Detection of deviation from normal, the health of the baby and mother at home. Detection of complications early Assessment of uterine involution Solve problems faced by the mother or baby.

On the follow up visit, the baby and the mother were well and did not suffer from any complication. In Nepal 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 OPD 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.

CONCLUSION
Case 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 knowledge of the nurse regarding the disease process, possible complication and how to handle this situation as a team player. No 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 risk pregnancy case study brings home the message that every pregnancy is a potential at risk pregnancy and the only way to ensure safety for the mother and child is to provide a thorough care.

My patient had already delivered one male baby in normal mode of delivery however she had anxiety because of breech pregnancy with leaking. Her anxiety level was decrease because of continuous reassurance. She was discharged from hospital without any complication.she was happy on discharge day due to continuous contact with care provider(me).

I WISH GOOD HEALTH OF THE MOTHER AND HER BABY AND WISH HER A WONDERFUL LIFE AHEAD

References
Dickason, Silverman & Schult. (1994). Maternal Infant Nursing Care, 2nd

edition.

 Dutta D.C. (2001). Text book of Obstetrics, 5th edition, 400 416. Fraser Diare M., Cooper Margaret A. (2003). Myles Textbook for Midwives,

14th edition, Sydney, 564 575

Govoni Laura E., Mayers Janice E. Drugs and Nursing Implications, 4th edition,

169
Gulanick & Myers. (2003). Mosbys Nursing care plans, Nursing diagnosis &

intervention, 5th edition

Howkins and Bourne. (1999). Shaws textbook of Gynecology, 12th Edition Joshi Mohan P., Adhikari Ramesh Kumar. (1996). Manual of Drugs and

Therapeutics, 1st edition, Health Learning Material center, 370, 406.

Mayes. (1989). A textbook for Midwives, 344 351.

Subedi Durga, Gautam Saraswoti. (2010). Midwifery Nursing Part II, 1st edition,

Medhavi Publication, Kathmandu, 221 229.

Subedi Durga, Gautam Saraswoti. (2011). Midwifery Nursing Part III, 1st

edition, Medhavi Publication, Kathmandu, 104 - 115.

http://emedicine.medscape.com/article/797690-overview http://www.americanpregnancy.org/labornbirth/breechpresentation.html http://www.buzzle.com/articles/leaking-amniotic-fluid.html

http://en.wikipedia.org/wiki/Breech_birth