MADER-E-MEHARBAN COLLEGE OF NURSING

SCINENCE AND RESEARCH, SKIMS SOURA SGR.

CASE STUDY ON

A CASE OF 30 YEARS MULTI GRAVIDA WITH PLACENTA PREVIA,

WITH 27 WEEKS OF GESTATION

SUBMITTED TO: DR. MUNEERA BASHIR (ASSOCIATE PROFESSOR MMINSR)

SUBMITTED BY: - MS. SAIMA HABEEB

SUBJECT: - OBSTETRIC AND GYNAECOLOGICAL NURSING.

CLASS: - MSc NURSING 2nd Year.

 BACKGROUND OF CASE STUDY
High risk pregnancy is defined as one in which mother, fetus and newborn is or will be at increased risk
for mortality and morbidity due to problems and complication during pregnancy.
The high risk case study gives us the knowledge about high risk condition in pregnancy; labour and
Puerperium like prolong labour, PIH, Post term pregnancy, APH, PPH, RH Negative, Maternal and Fetal
distress, obstructed labour etc.
In this case study I got chance to get some knowledge about how to manage maternal and fetal health,
how to minimize maternal and fetal risk factor to minimize maternal and fetal mortality and morbidity.
Globally, 585,000 women died from the complication of pregnancy and labour (WHO 1996). It is due
to lack of knowledge, poor health service, poor transportation, lack of awareness, low socio-economic
condition, cultural factors which determines the status of women and their health seeking practices. If we detect
these risks in time we can minimize the complication and risk in Anti-natal, Intra-natal and Post-natal.
Nowadays these services are included in Safe Motherhood Program.

Objectives of high risk case study:

This case study was done during my Ist week of Midwifery practicum in LD Hospital . The objectives of this
case study are to provide holistic approach of care to patient, applying nursing theory and gain detail knowledge
about a particular disease or case. The case that I have chosen for my case study is Antepartum haemorrhage
(i.e placenta previa).

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

1. To upgrade knowledge about Antepartum haemorrhage (placenta previa), it’s diagnosis, treatment and
management including nursing management.
2. To provide holistic nursing care to my patient by using nursing process and nursing theories.
3. To gain the detail knowledge about one specific case and it’s nursing management.
4. To identify the causes, pathophysiology, clinical features and diagnostic investigation of Antepartum
haemorrhage (placenta previa).
5. To compare the causes, clinical features, diagnostic investigation & treatment of Antepartum haemorrhage
(placenta previa), between the patient & book.
6. To prevent the patient from further complication of disease.
PART I

Biographic data of my case:

Informant : patient

Name: DILSHADA

Age: 35 years

Address: KULGAM

Occupation: Housewife

Education: Illiterate

Blood group: A +ve

Religion: Muslim

Husband’s name: GH. Hassan

Occupation: Business

Monthly income 10,000.

M.R.D No: 18255

Diagnosis: G3 P1 L 1 A 1 at 27 WOG with APH (Placenta Previa)

Date of Admission: 07-06-17 at 3.30 P.M

Hospital: LD Hospital

Ward: LABOUR ROOM

Date of beginning of study 08-06-17
Date of completion of study: 16-06-17
ADMISSION NOTE
35 years pregnant female of 27 weeks of gestation presents to the emergency room because of vaginal bleeding
since 1 month; spotty during early days but significant over the last 5 days. The patient also reports some
contractions, but denies any continuing abdominal pain. She denies any recent trauma.
Early treatment was done on regional district Hospital Kulgam, then the patient was referred to the LD Hospital.

1. SOCIO-ECONOMIC AND ENVIRONMENT STUTUS:-

Mrs. Dilshada belongs to a middle standard family from District Kulgam. Her husband is an illiterate
person. She herself is also literate and is a house wife. There are five members in their family and all are
staying together. There are two earning personals in her family.
2. EDUCATIONAL STATUS:-
As per information given by patient, they are all uneducated. Patient, her husband and all other family
members are illiterate, and hence belong to an uneducated family.
3. SOCIAL HISTORY:
Patient lives with her husband and in laws in rural region of district Kulgam. Denies any smoking,
alcohol or other drug use during her pregnancy. Denies any spousal abuse, currently works as a
housewife..
4. ENVIRONMENTAL HISTORY:
Habituated in 2 storied building with 7 rooms separate kitchen and sanitary latrine within local rural
environment of adequate electricity, water, transportation, local health and education facilities.
5. NUTRITIONAL HISTORY:
Casual dietary pattern of vegetarian and non vegetarian meals; usually 3 times during pregnancy. No
denial to food and appetite.
6. SOCIO-CULTURAL AND RECREATIONAL ACTIVITY:-
As per patient information she likes gardening and also watching TV. As she lives in rural area, there are
not many facilities for recreational activities, but occasions like marriage, any religious festival becomes
good source of recreation.
7. HEALTH FACILITIES:-
They have all health care facilities in vicinity and do not face any problem regarding any health issue.
8. SPRITUAL- ACTIVITIES:-
She has got full belief in Almighty Allah and usually prays five times daily. She and her whole family
fast during the whole month of Ramadan, they also have believed in Astan (holy place) and Peer Baba
 (any poise and religious person). During any disease they usually pray to Allah and sometimes go to
Astan and Peer Baba.
9. CUSTOMS AND BELIEFS:-
Patient told that she belongs to an uneducated family. They educate every girl child, even allow them to
perform the job and their girls go for higher education also. They follow the pardah system as Muslim
do. They do not celebrate birthdays or don’t practice early marriage system. They do not take bath for so
many days in post-partum period, and usually do not take bath in periods also. They usually avoid taking
sour things because they think abdomen will get blotted (bulge out). They believe in ghost and usually
wear their children Taiweez and keep knife with the pregnant lady. They think that wearing Taiweez and
keeping knife will protect them from ghosts and other evil souls).
10. MARITAL STATUS:-
Dilshada was married to Gh. Hassan five year back. They did not know each other before marriage, they
have good marital relations. Her husband who is unemployed takes good care of her. She got married at
the age of 30 years.
11. ATTITUDE TOWARDS PRESENT PREGNANCY:-
Patient was anxious because of her present illness.
12. ATTITUDE OF FAMILY TOWARDS MOTHER:-
They were anxious for their daughter in law and at the same time were praying for her good health. All
family members were taking extra care of her during pregnancy.

PERSONAL HISTORY:-

a. CHILD-HOOD HISTORY: - Patient was born by normal full term vaginal delivery, she has one brother
and two sisters, she was born in and has normal growth and development. She was fully immunised. She
used to play, chat and fun with the other girls of her age. She did not suffer from any serious disease during
her childhood, and she had respect for parents and other elders.
b. Adulthood: - She had a normal adolescent period. She started her periods (menarche) at the age of 16
years, had regular periods for 3-5 days, sometimes had dysmenorrhea and she use home-remedies. She has
no drug abuse, no history of smoking, huka etc.
FAMILY TREE:-

A +w A+W
Patient

Keys:-MALE,FEMALE,PATIENT,A+W Alive and well

c. FAMILY HISTORY:-

MATERNAL: - Her father and mother both are alive and there is no a significant medical history of medical
illness among both of the parents. Her father is 55years and her mother is 51 years old, she has one brother and
two sisters, all of them are married. Her father is a farmer and mother is house wife. All family members are
healthy and normal.

AT HER IN-LAWS:- She has one brother in law younger to her husband and is not married. He is a student.
There in her in-laws everyone is normal and active. Her father and mother in law both are alive.

PAST MEDICAL HISTORY:

None (no any history of tuberculosis, diabetes, hypertension, anemia, heart disease,
Childhood disease, jaundice, allergy to food and drugs and STD)

PAST SURGICAL HISTORY: History of cholesystectomy one year back.

PAST OBSTETRICAL HISTORY:
-G3 P 1A 1L1
- previous LSCs
-One male child birth in full term gestation weighed 2500 grams
-previous obstetrical complications during pregnancies : Abortion, severe fatal distress.

MENSTRUAL HISTORY:
Menarche at the age of 16 years with regular menstrual cycle of 28 -30days with occasional dysmenorrhia,
and managed at home. Knowledge regarding menarche was given to her by her mother and sister, although she
was herself aware and was having previous knowledge. Dysmenorrhea subsided after marriage.

CURRENT GESTATIONAL HISTORY:

- G3 P 1A 1L1
-Date of Last Menstruation: 25/11/16
-Estimated Date of Delivery: 02/9/17
-Estimated Gestational Age (based on dates): 27 weeks

CONTRACEPTIVE HISTORY:
MALA - D was used.

HEALTH SEEKING PRACTICE:

She belongs to an uneducated family. Although, she and her family have belief in traditional methods . They
were aware about the essentiality of the health services. If somebody is sick, they prefer visiting the health post
nearby for treatment.

HABITS/PSYCHOSOCIAL HISTORY:
-sleeping pattern of around 6 hours at night and 2 hours a day if possible.
-interested in household works and performing daily activities.
-normal micturation and regular bowel habits.
-cope and understand the situation well.
-good relation with family, parents ,peer groups and relatives.
-Attitude of male dominant society persist so, the family crisis of present health problem and sex determination
of the child was issued.
Part II: PHYSICAL EXAMINATION OF MY CASE

I also performed the physical examination of Mrs. DILSHADA to determine her health status. The
techniques used for physical examination are:
Inspection
Palpation
Auscultation
Percussion

Physical Exam during admission:

Vital Signs: Stable (BP – 100/60, P – 86 b/min)
General Appearance: No apparent distress, appeared clinically stable, but pallor.
Skin : capillary refill < 2 seconds
Weight: 42kg
Uterine Height: 30 cm
Per vaginal bleeding: clots present with placental tissue seen
Contractions: Present
Fetal Heart Tones: 138 beats / minute
Cervical Exam: Deferred but cervical OS opened
Diagnostic Tests: Transabdominal Ultrasound
Number of Gestations: 1
Lie: Longitudinal
Position/Presentation: Right /Cephalic
Fetal Heart Tones: 144 beats / minute
Fetal Movements: Present
Placenta: Partial occlusion of internal cervical os
 GENERAL APPEARANCE
Well oriented to time, place and person. Well conscious, co-operative, slightly anxiety and fear, no
pallor and anemic.
 VITAL SIGNs
Pulse: 86/m
Respiration: 22/m
Temperature: 97 degree F
BP: 100/60
  MENTAL STATE:- Alert response appreciably
 PERSONAL HYGIENE:- Seems clear and wear clean clothes
 HEAD:- Clean, dry and smooth hair, no lice, no complains of headache
 EYES: - no discharge, no infection, no jaundice. Eyes clean, conjunctiva pinkish.
 NOSE: - clear, no septal deformity, no crusts and discharge no cold.
 MOUTH:-tongue moist, lips dry, no artificial dentures, teeth clean and healthy, no congenital deformity
i.e. cleft lip or cleft palate.
 EARS:-Normal shape, no swollen glands, no valve discharge
 NECK:-no swelling, no palpable nodes, no deformity, no pain in the neck.
 CHEST:- Symmetric shape and size of the chest, breasts well developed, nipples normal, no scar, no
palpable lymph glands, Chlostrum present.
 UPPER-EXTREMITIES:-symmetrical and no deformity, no scar, no extra digits, nails pink and clean,
skin colour normal, extremities warm, edema not present.
 ABDOMEN
1) Inspection:-
Ovoid shape, normal size, scar of previous surgery present, linea nigra present, no any visible dilated
veins
2) Palpation:-There is normal growth of fetus and fundal height according to gestational age.

3) Auscultation: On auscultation FHS not found.

 LOWER EXTREMITIES:-symmetrical, no deformity, no varicose veins, no edema, no extra digits, no
pain in calf muscles, Homans sign absent.
 BACK:-no spinal or any deformity.
 Genito-urinary system:- frequency of micturition, having smell in urine

Summary of History Taking and Physical Examination

After performing history taking and physical examination following things were found:
Patient was anxious, but cooperative.
She is anxious and restless too.
Vitals are stable
Nutritional status-unsatisfactory
No any abnormalities found in other regions
Appetite-slightly decreased
PART III: DIAGNOSIS BASED ON HISTORY: 7 months Amenorrhea with placenta previa.

DETAILED STUDY OF THE DIAGNOSIS :-

PLANCENTA PREVIA:

It is defined as the implantation of placenta in the lower uterine segment near or at internal cervical OS.
Based on this patient’s clinical presentation, placenta previa was suspected and further confirmed by
Transabdominal ultrasound. Placenta previa is defined as the presence of placental tissue over or adjacent to the
cervical os.

Epidemiology :

1:300livebirths
0.3-5% of total APH cases
1.5-5% of cases with pervious ceaserean section
Complete placenta previa prevalence rate :20-45%
Partial placenta previa prevalence rate:30%
Marginal placenta previa prevalence rate:25-50%

Classification of placenta previa:

I. Type I Placenta previa (Low lying placenta previa): Only the lower margin of placenta reaches into upper
portion of uterine segment .vaginal delivery is possible. There is the low risk of antepartum haemorrhage and
maternal and fetal condition is good.

II. Type II Placenta previa (Low lying Marginal placenta previa): Marginal placenta extends upto lower uterine
segment neat the internal Os of the cervix. Vaginal delivery is possible particularly if placenta is anterior .Blood
loss is usually moderate although maternal and fetal condition vary; fetal hypoxia is more likely to be present
than maternal shock.
III. Type III placenta previa (incomplete central placenta previa/partial placenta previa): Placenta is located
over the internal Os but not centrally. Bleeding is likely to be severe, particularly when lower uterine segment
stretch and cervix begin to efface and dilate in late pregnancy. Vaginal delivery is inappropriate because
placenta precedes the fetus.

IV. Type IV placenta previa(complete central placenta previa/ total placenta previa ) Placenta is centrally
located over the internal Os and torrential haemorrhage is more likely. Caesarean section is essential in order to
save the lives of both mother and fetus.
Diagram showing different categorizations of placenta previa.

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

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

A leading cause of third trimester bleeding/haemorrhage, placenta previa present classically, a painless
bleeding. Bleeding is thought to occur in association with the development of the lower uterine segment in third
trimester. Placental attachment is disrupted at this area gradually in the preparation of the onset of labour.
When this occurs at implantation site as the uterus is unable to contract adequately and stop thw flow of blood
from the open vessels.
Thrombin release from the bleeding site promotes uterine contraction and a vicious circle of bleeding,uterine
contraction placental separation and bleeding persists.
ETIOLOGY:
The exact cause is generally unknown. The predisposing factors includes
Predisposing factors includes

S.n According to book According to patient

1 Grand multiparity Not present.
2. History of abortion Present .
3 Infertility treatment Not present
4. Previous uterine surgery/ caesarean Present
section
5. Fetal Malpresentation Not present
6. Uterine anomalies Not present
7. Short interpregnancy interval Interpregnancy interval is
about 1 year
8. Smoking Patient is non smoker

SIGNS AND SYMPTOMS:

Signs:

S.n According to book According to patient

1 General condition and anaemia are Patient general condition is pale
proportionate to the visible blood loss. and anaemic.
2. On abdominal examination; On abdominal examination;
-The size of uterus is proportionate - Present
to the period of gestation.
-The uterus feels relaxed, soft and - Present
elastic without any localized area of
tenderness - Not present
-Persistence of Malpresentation

3. -Blood loss is often bright red. -Present

SYMPTOMS:
S.n According to book According to patient
1 Sudden onset of vaginal bleeding. -bleeding present
spontaneously 5 days back
2. Painless bleeding -Presence of painless bleeding

3 Apparently causeless and recurrent No any history of trauma or

injury or previous placenta
previa

INVESTIGATIONS:-
IN BOOK:- IN PATIENT:-
1. USG and CTG 1. Done in patient.
2. Tests, such as blood group, HB level. 2. Done in patient.
3. VDRL 3. Done in patient.
4. CBC, BT CT 4. Done in patient.
5. HBSAG 5. Done in patient

COMPLICATIONS:

Book picture Patient condition.

 Antepartum haemorrhage Present

 Malpresentation Not present
 Premature labour Present
 Premature rupture of membrane Present.
 Cord prolapse Not Present
 Slow dilation of cervix Not present
 Intrapartum haemorrhage Not Present
 Increase rate for sepsis Not Present.
 Intra uterine death Not present
TREATMENT AND MANAGEMENT: According to Johnson and Macafee protocol:
The first step of management of these patients is hospitalization

Immediate treatment:

According to the book In my patient

1. Assessment Done
History taking for the conformation of Done
diagnosis

Maternal condition(stable /unstable) Pale, anaemic maternal state, prone to shock

If patient is in shock;
The initial treatment should be restorative
consisting of resuscitation,
rest, warmth ,sedation,
and transfusion of blood to overcome shock
and re establishment of blood circulation with
minimal delay.
Patient was kept in complete bed rest.
Blood arranged and transfused to maintain blood
circulation.
Patient instructed well about the disease condition
and encouraged to express feelings regarding the
situation.

Differential diagnosis via Investigations: USG done(low lying placenta previa identified)
Ultrasonography (allocate the placenta)

Haematological reports All these haematological investigations done

(complete blood counts haematocrits,blood
group and cross match,bleeding time ,clotting
time).

Further examination
Avoid vaginal examination. Vaginal examination avoided.

Speculum examination to rule out local Speculum examination not done.

cause.
 SUBSEQUENT MANAGEMENT:
Subsequent management depends upon the duration of gestaion and severity of the condition.
1. Expectant management:
The expectant management consists of the following measures
Complete bed rest with beside toilet facilities. Sedatives such as diazepam 5mg may be prescribed to improved
compliance with bed rest
Blood should be grouped, cross matched and reserved for the patient at all times
Iron, vitamin and calcium supplements are continued. Laxatives may be given to avoid straining at stools.
Haemoglobin is estimated at regular intervals
Vital signs and fetal heart sound stable
Minimal ambulation
The expectant management is continued until 37 weeks of pregnancy are completed

DEFINITIVE MANAGEMENT:
It comprises prompt delivery.
 USG is done for determining placental site –If likelihood for safe vaginal delivery .Vaginal examination
is done.
 ARM and oxytocin induction is done

If placenta previa of grade II, III and central variety, serious loss of blood or vaginal delivery adds possibility
for considerable blood loss; Lower Segment caesarean Section is the treatment of choice in both before and
after 37 weeks of gestation.
In my patient ,emergency Lower Segment caesarean Section was done after restorative management.

Management before 37 weeks of pregnancy for LSCS for Fetus:

In the book In my patient:

Assessment of lung maturity by Amniocentesis not done

amniocentesis
Steroid therapy Dexamethasone 12 mg I/V two dose given
(betamethasone/Dexamethasone) to the mother before LSCS
DRUG CHART:-

Name of the Indication Dosage and route Nursing considerations

Drug
Assess vital signs.
Tab Iron and Iron deficiency anaemia 100ug and oral Provides teaching regarding intake of
Folic Acid Prophylactically given in iron
pregnancy Encourages to take medications along
Megaloblastic anaemia with food rich in vitamin C
Advises not to take medicine with tea
or milk
Provides instructions regarding colour
change of stool and urine.

INJ 9 mg /day (IV) -Monitors intake output of patient.

Dexamethasone For fetal lung maturity. -assessed patients level of
consciousness and headache during the
therapy.
- educated to take missed doses as
soon as remembered.
Nursing management during hospitalization

Maintaining Fluid Balance

Control I.V. fluid intake using a continuous infusion pump.
Monitor intake and output strictly; notify health care provider if urine output is less than 30 mL/hour.
Monitor hematocrit levels to evaluate intravascular fluid status.
Monitor vital signs every hour.

Promoting Adequate Tissue Perfusion

Increase protein intake to replace protein lost through kidneys

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

Promoting Diversional Activities

Explain the need for bed rest to the woman and her support persons.
Explore woman's hobbies/ diversional activities.
Instruct family to arrange for easy access to TV, phone, computer to limit woman getting out of bed.

Maintaining Cardiac Output

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

ii. Monitor intake and output strictly; notify primary care provider if urine output is less than 30 mL per hour.
iii. Monitor maternal vital signs, especially mean BP and respirations.
PART IV:

NURSING MANAGEMENT USING MIDWIFERY CARE MODEL IN NURSING PROCESS:-

ASSESSMENT:

Assess for the following clinical manifestations:

1. Painless unexplained vaginal bleeding.

2. Intermittent gushes of blood.
3. Placental placement revealed by USG.
4. Maternal apprehension caused by the bleeding episodes.

Possible Nursing Diagnosis for Placenta Previa:

 Risk for Impaired Fetal Gas Exchange r/t Disruption of Placental Implantation.
 Fluid Volume Deficit r/t Active Blood Loss Secondary to Disrupted Placental Implantation.
 Active Blood Loss (Hemorrhage) r/t Disrupted Placental Implantation.
 Fear r/t Threat to Maternal and Fetal Survival Secondary to Excessive Blood Loss.
 Activity Intolerance r/t Enforced Bed Rest During Pregnancy Secondary to Potential for Hemorrhage.
 Altered Diversional Activity r/t Inability to Engage in Usual Activities Secondary to Enforced Bed Rest
and Inactivity During Pregnancy.
NURSING CARE PLAN
Nursing diagnosis
1.Fluid volume deficit
related to active blood loss.
2. Impaired fetal gas
exchange related to altered
blood flow and decreased
surface area of gas exchange
at the site of placental
implantation.
planning
-Demonstrate adequate
hydration as evidenced by
stable vital signs, palpable
pulse, skin turgor and
capillary refill well, urinary
output and electrolytes
within normal limits.
-Maintenance of fluid and
electrolyte balance
-Demonstrate adequate
fetal gas exchange and well
being as evidenced by
uterine contractions and
fetal heart sounds.
-Maintenance of rest
Intervention
-Monitor vital signs.
-Observe skin color,Oxygen saturation,skin
temperature and loss of consciousness.
- Evaluate the amount of vaginal bleeding by
counting pads, presence of clots and pooling of
blood.
-Fluid replacement by blood transfusion
-Administer parenteral fluids as prescribed
-Monitor intake, output and daily weight
-Assess state of hydration
-Provide diet instructions:
-Asses vital sign
-Maintain rest.
-Monitor amount and type of bleeding by
saving the pads.
-Position mother on left lateral position.
-Restrict vaginal examination.
-Monitor uterine contraction and FHS.
-Maintain positive attitude about fetal outcome.
Give insulin treatment regular as indicated.
Observe signs of infection and inflammation
Improve efforts to prevention by good hand
 washing for all people in contact with patients
themselves
Demonstrate techniques, Maintain aseptic techniques in invasive
life style changes to prevent procedures.
infection. Provide counselling and support
Assess health status and report to physician
Decreased anxiety and regarding
absence of complications Hydramnios.
4.Anxiety related to loss of Pre-eclampsia and eclampsia Assess knowledge
control, fear of inability to of the processes and actions, including the
manage diabetes, fear of relationship of the disease with diet, exercise,
diabetes complications. stress and insulin requirements

Gain knowledge regarding Provide information about the workings and

gestational diabetes the adverse effects of insulin and review the
reasons for avoiding oral hypoglycaemic drugs

Provide information on the effects on the

effects of pregnancy on diabetic conditions.
5. Knowledge deficit
regarding gestational
diabetes mellitus.
APPLICATION OF NURSING THEORY:

I have selected Myra Levine’s conservation theory for application of nursing process on my patient having
placenta previa. This theory involves series of actions that a nurse takes to conserve health of the patient . It is
composed of four components I,e. conservation of energy, conservation of structural integrity, conservation of
social, and conservation of personal integrity. I have rendered nursing care based on this theoretical frame work.

Advised patient to avoid difficult

physical work, importance of strict bed
rest, avoidance of stair riding.

Educated patient about

different health schemes,
avoid sensory deprivation
,promoted patient’s use of
T.v, radio etc. educated
attendants regarding care
of mother .
Advised patient to take more
fluids, balanced diet,
CONSERVATION maintenance of personal
hygiene.

Involved patient in decision making

regarding her health, encouraged her to
take care of herself and her fetal well
being

HEALTH EDUCATION:

The main objective of health education is to change human behaviour to prevent disease and to maintain health.
The people need to be educated about health practices; self care nutrition and any other subjects. so mother
should be educated about following things:

REST:
 Advised strict bed rest. Instructed family to arrange for easy access to TV, phone, computer to limit
woman getting out of bed.
 Encouraged patient to take position of comfort i.e left lateral position.
 Educated patient about importance of complete bed rest.
 Advice patient to perform only light exercises.
 Avoid heavy lifting
 DIET:
 Advised to avoid stress.
 Advised to take high calorie diet.
 Educated about source of proteins, iron etc.
 Educated mother to take balanced diet.
 Advised mother to take enough of fluids.

CARE OF GROWING FOETUS:

 Educated about fetal movements.
 Educated mother to inform doctor if fetal movements decrease.
 Regular follow up:
 Advised mother and her family to visit hospital as advised by doctor and educated about warning signs
when she has to report to doctor.
HYGIENE:
 Advised mother to maintain good personal hygiene to prevent infection.

PROGRESS NOTE:
Dilshada , 36 years old woman diagnosed with 27 weeks of gestation with APH (Placenta Previa). She was
came from Kulgam, referred to this hospital with the complain of P/V bleeding since last 5 days. First we had
done her physical examination then other all investigations were conducted. The findings were low lying
placenta with patient in anemic state. After that she was admitted transferred to labour room.
During the hospitalization of the mother , I had provided holistic care to her considering physical, mental,
social, spiritual and economic aspect. I had provided care on the base of Myra Levine’s conservation theory.
Patient totally hospitalization was 8 days. At the time of discharge, the mother condition was improved, looking
happy and cheerful. I gave health teaching to the patient and her family about nutrition, personal hygiene, rest
and exercise, medicines; follow up visit, and high risk condition of mother.
Bibliography:-

1).John T. Queenan, John C. Hobbins, Catherine Y.2005. Protocols for high-risk pregnancies Spong.4th
edition.
2) Dutta D.C,Text book of Obstretics,2007, new central books agency; page 246-250
3) Daftery Shirish N.,Chakrevarty Sudip,assisted by Daftery.S.:2007,Manual of Obstretics,2ndedition,page no
230-235
4)Maternal & Child Nursing Seventh Edition Vol.1 page 413.
5)Maternity nursing, Lowdermilk Perry, seventh edition, chapter 23, page 751.
6)Maternal Neonatial Nursing Lippincott manual of Nursing Practice
7)http://wikipedia.org