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BACKGROUND

As a practical requirement of post basic nursing (bachelor in


nursing) curriculum under practicum of midwifery nursing major,
its our requirement to do two months of practical training at
Paropakar maternity and womens hospital and to complete the
study and of present two cases. The case study of the each case
in depth and report the detail of the management in total. This
kind of the research work as well as scientific paper writing and
presentation in front of the learned audience is a part and partial
of the course.

During this period I took the case of delivery with ceaserean


section and primary PPH (post partum hemorrhage) of the MICU
bed H1. This case study presentation report is designed so as to
gain comprehensive knowledge of the complication of the third
stage of labor and its management to provide holistic care to the
patient.

SELECTION OF THE CASE

PPH (postpartum hemorrhage) is one of the most alarming and


serious emergencies, a midwife may face during the practice. It is
specially terrifying complication of 3 rd stage of labor. PPH is still
ranked among the top three major causes of maternal death
globally. The majority (99%) of deaths due to PPH are reported in
the developing countries. To facilitate a safe and healthy outcome
for the mother elective management of the PPH is very important
if occur. The midwife is often the first and may be the only
professional person presented when a hemorrhage occurs, so her
prompt, competent action will be crucial in controlling blood loss

and reducing the risk of maternal morbidity or even death. The


reasons behind the selecting these cases are: -

One of the most alarming and serious emergencies.


Top three major causes of maternal death globally.
Approximately 30% of direct maternal death worldwide is
due to hemorrhage.

Timely diagnosis, management, and the prompt treatment


prevent the likelihood complications.
So I was very much interested to study in depth of this case. I
took great privilege for me to gain the detail about the PPH so
that we could be able to manage any PPH cases. Thats why I had
selected this case and made a report too.

Objectives
General objectives:
General objectives:-General objectives of case study is to provide
holistic care through nursing process by applying economic, sociocultural background and traditional belief and practice with the
help of knowledge from basic science and fundamental nursing
knowledge.

Specific objectives;1) To identify high risk cases & select the appropriate
them.
2) To collect relevant health history of patient & family in
order to identify need & problem.
3) To gain & upgrade knowledge about disease.

4) To do complete physical examination & identify


problem.
5) To Learn to perform systemic and obstetrical
examination methodically & correctly.
6) To observe & evaluate the case given to the baby by
mother & provide comprehensive guidance.
7) To compile and perceived knowledge gaps which limit
the prevention, recognition and management of PPH.
8) To compile and perceived knowledge gaps which limit
the prevention, recognition and management of PPH.
9) To prevent patient from further complication.
10)
To minimize the stress of the patient by giving
psychological and emotional reassurance.
11)
To help to decrease MMR & IMR.
12)
To fulfil the objectives of curriculum.

BIOGRAPHICAL DATA OF THE PATIENT

Name

Bimala Bhujel

Husbands name

Hari Bhujel

Age

26 yrs/ female

Ward

MICU and old post operative ward

Bed no

H1

Inpatient number
Address
Occupation

:
:

17777

Nuwakot- 6
:

Housewife + Agriculture

Education

Illiterate

Date of admission

2067/11/9 at 3pm

Date of discharge

2066/12/15

Provisional diagnosis
: G2P1 at 39+ wop in LPOL with Low
fetal movement with previous CS
with CPD
Final diagnosis
:
condom tamponade

Emergency LSCS with BTL with PPH with

LMP

2067/02/09

EDD

2067/11/16

Delivery date

2067/11/09

Delivered by

LSCS done by Dr. Bhaba

ABOUT THE BABY


Baby born at 08:15 pm on 067/11/09
Cord round the neck once tightly,
Occipito- posterior position.
Weight: - 2750 gm male alive baby
APGAR score with 1 minute: -6/10, with in 5 minute:-8/10

COMPLETE HISTORY OF THE PATIENT


Chief complain: She has complain of low fetal movement
with labour pain and backache since yesterday night,

Character of pain is off and on.

Menstrual history: She had menarche at the age of 13 years.


Her menstrual cycle was regular varies from 25 to 30 days,
menstrual flow about 4-5 days. There was normal blood loss
during menstruation. Her last date of menstruation was
2067/02/09.

Present obstetrical history: She is second gravida, married for


6 year. She has history of amenorrhoea for 9 month with regular
antenatal visits (4 times) and complete T.T injection. There was no
history of vomiting, fever during her pregnancy period. Her LMP
was 2067/02/09. And EDD was on 2067/11/16.

History of past illness: No significant past illness


Past surgical history: She has history of previous LSCS on first
baby.
Drugs history: No any drug allergies.
Family history: No any history of heredity illness and disease.
Personal history : She has normal bowel and bladder habit,
sleep and rest habit also regular and normal. No any personal
history of smoking and alcoholism.

Present health history: She had delivered by LSCS. Following


the suegery she started having vaginal bleeding.

Personal health history: Mrs. Bimala Bhujel. There is no history


of smoking alcoholism. She is housewife. She has normal dietary
habit taking meats one times a week. Her Sleep and rest habit is
normal with normal bowel and bladder habit. She takes bath
twice in a week
History of newborn baby: - Alive male baby of2750 gm, weight.
Baby was born with Occipito-posterior position; Apgar score was
5/10, and 8/10. The baby was born at 08.15 pm. There was no
congenital abnormality. The baby had grunting so he was
admitted on NICU for observation.

FAMILY PEDIGREE
Now she lives in a joint family with mother in law, father in law, one brother in law
and one sister in law and her husband. She has got fully love and affection from her
family.

Fathers Side

Mothers Side

Female :

M
ale :

Patient :

PHYSICAL EXAMINATION OF MOTHER


PATIENT CONDITION DURING ADMISSION
Mrs. Bimala Bhujel was admitted with the chief complain of pain
abdomen since yesterday night, backache and character of pain is
on and off during the admission.

Temperature
Pulse

: 98.4.F
: 140/min

Respiration

: 22/min

Blood pressure : 70/30 mm of Hg

PHYSICAL EXAMINATION
General appearance

lethargic

Height

5feet 2 inch

Weight

48 kg

Urine for sugar and protein

nil

General appearance of the mother


and slightly pale.

: Seems tired, lethargic,

SYSTEMIC EXAMINATION (from head to toe)

Head: no dandruff, lice, clean hair, and well distribution of hair.


Eyes: both eyes are symmetrical in size and shape, no swelling of
eyelids, slightly pale in color of conjunctiva due to blood loss.
Ear: not any discharge from both ear and both are symmetrical
in size and shape, no hearing problem.
Nose: normal patency, no discharge, and normal sinuses.
Mouth: no crack lip, no stomatitis, and tongue is normal. No
tooth decay.
Neck; no enlargement of the lymph node.
Hands: no cyanosis, and no any clubbing.
Chest; The chest is symmetrical in shape and size. There was
no respiratory problem, with normal chest sound present.
Auxiliary lymph node is normal.
Breast: Breasts are symmetrical in size, no breast lump, no
crack, flat and inverted nipple, breasts are clean. There was no
breast engorgement,
Abdomen: There are no enlargement of liver and spleen. There
is previous LSCS scar on abdomen. The funded height was
normal with well contracted uterus. No abdominal distention and
presence of normal bowel sound. There was normal involution as
the fundus was found 1.25 cm below the umbilical, no palpable of
urinary bladder. Breast no problem in breast feeding, normal milk
secretion, normal size and shape (symmetrical), no breast
engorgement.

Lower extremities: slightly edema in leg, no sign of deep vein


thrombosis, varicose vein and no any tenderness.
Genital organs: The condition of the wound was well; there is
no sign of infection, no any gap between the suture lines.
Episiotomy wound was dry and clean. There was no swelling or
varicose vein of vulva.
Lochia: lochia rubra (red) slightly stains in pad. No abnormal
bleeding, and no hemorrhoid.
Back: pain in sitting position. Complain of backache.
About appetite: she has good appetite and have desire to eat
no problem in diet.
Rest and sleep: sleeping pattern is normal and regular.

PHYSICAL ASSESSMENT OF NEONATE


Through detail head to toe physical examination, we can identify
normal characteristics and no existing abnormalities of newborn

GENERAL MEASUREMENT

Measurement

According
book

to According
neonate

Head circumference 31-35 cm

34 cm

Chest
circumference

30.5 cm-33 cm

32 cm

48-53 cm

51 cm

Head to heel length

to

Body weight

2700-4000 gm

2750 gm

VITAL SIGN
Respiration

38/m

Pulse

130/m

Temperature

98.6 f

General appearance: Normal


Posture: flexion of head and extremities, which rest on chest
and abdomen.
Skin
At birth: pink red, puffy, smooth
Edema around the eye, face, legs
Head
Anterior fontanels: diamond shape
Posterior fontanel: triangular shape
Eyes
Slightly edematous lids
Closed eyes
No jaundice present
Ears
Position: top of the pinna is horizontal to the outer canthus of
eye
No discharge
Pinna flexible, cartilage present

Nose
No nasal discharge
Nasal patency
Mouth and throats
Sucking, rooting and gag reflex present
No presence of precocious teeth, cleft lips and palate
No oral thrush
Neck
Short, thick, skin fold around the neck
Chest
Both chests are symmetrical
Neuro-muscular system
Extremities maintain 60 degree of flexion
Extension of extremities followed by previous position of flexion
Moro reflex present.

NURSING CARE AND HEALTH EDUCATION

I. Eye care
Eye care was done with boiled cotton and advised to mother to
clean babys eyes
Advised the mother to avoid milk getting into eye
II. Cord care
Cleaned the cord with betadine with sterile cotton
Avoid tight napkin
Watch for any discharge bleeding and infection

III. Nose and mouth care


Mother was advised to clean nose and mouth.
IV. Skin and napkin care
Mother was encouraged to apply oil daily and massage gently.
Give bath once a week, apply massage oil daily
Advised mother to change the napkin whenever needed
DEVELOPMENTAL TASK OF YOUNG ADULTHOOD
S
N

ACCORDING TO BOOK

ACCORDING TO PATIENT

Accepting self and stabilizing self- Accepting self and stabilizing


concept and body image.
self-concept and body image.

Establishing independence from Establishing independence from


parental home and financial aid.
parental home and financial aid
because she is married.

Becoming
established
in
a
vocation or profession these
provides personal satisfaction,
economic
independence
and
felling of making a worth while
contribution to society.

Learning to appraise and express Learning to appraise and express


love responsibility through more love responsibility through more
than sexual contacts.
than sexual contacts

Establishing an intimate bond Establishing an intimate bond


with another, either through with another, either through
marriage or with close friend.
marriage or with close friend.

Establishing and managing a Establishing and managing a


home and managing a time home and managing a time
schedule and life stress.
schedule and life stress.

Becoming
established
in
a
vocation or profession these
provides personal satisfaction,
economic
independence
and
felling of making a worth while
contribution to society.

Finding a congenial, social and Finding a congenial, social and


friendship group.
friendship group

Deciding whether or not to have a Deciding whether or not to have


family and carry out task of a family and carry out task of
parenting.
parenting

Formulating
a
meaningful Formulating
a
meaningful
philosophy of life and reassessing philosophy
of
life
and
priorities and values.
reassessing priorities and values.

1
0

Becoming involved as a citizen in Becoming involved as a citizen in


the community.
the community

Part II
Disease Profile:WHAT IS PPH?

Clinical definition of PPH:


PPH is defined as excessive bleeding (more than 500 ml) from
the genital tract at any time following the babys birth up to six
weeks after delivery and which adversely affects the general
condition of the mother evidenced by rise in pulse rate and falling
blood pressure.
Quantative definition of PPH:
It is defined as the amount of blood loss in excess of 500 ml
following birth of baby. But the effect of blood loss in anemic
patient is also called PPH.

Types
I. Primary PPH
II. Secondary PPH
Primary PPH: Hemorrhage occurs within 24 hours following birth
of baby. These are of two types third stage hemorrhage:
bleeding occurs before the expulsion of the placenta. And true
PPH is bleeding occurs subsequent to expulsion of placenta. In
majority PPH occurs within 2 hours following delivery.
Secondary PPH: If bleeding occurs subsequent to the first 24
hours following birth up until the 6 weeks of postpartum is called
secondary PPH. It is most likely occurs between 10 and 14 days
after delivery.
The patient
that I took for the
presentation has got primary PPH.

case

study

and

Incidence:
The incidence is about 1 % amongst hospital deliveries in
developing countries. In Nepal it is the second cause of high MMR
in PPH.

Causes:
The main cause of primary PPH are:1. Tone (atonic uterus) 70%
Failure of sustained uterine contraction following partial or
complete placental separation may result in massive
haemorrhage from the placental vascular bed. Prolonged

labour, uterine overdistension, grand multiparity, retained


placental tissue or haematometria (abruption) may
contribute to inadequate myometrial contraction. Uterine
inversion is a rare but dramatic cause of uterine atony and
haemorrhage.

2. Tissue 10%
Trauma from the delivery may tear tissue and vessels
leading to significant postpartum bleeding
3. Trauma 20%
Haemorrhage may result from vulval, perineal, vaginal or
cervical tears. Rupture into the clitoral venous plexus may
cause remarkable loss. Occult bleeding into the para vaginal
space, ischiorectal fossa and broad ligaments may follow
vaginal laceration. Occasionally, uterine rupture presents as
a PPH.
4. Thrombin (blood coagulation defects as in hypofibrin
anaemia)
Clotting dysfunction and disturbance of platelet function are
unusual but important causes of PPH. In the majority of
cases, the clotting disorder is secondary to pre-eclampsia,
abruption or massive blood loss. Almost all maternal
mortalities attributable to PPH are associated with
coagulopathy and, in most cases, the bleeding dysfunction is
recognised late and inadequately treated. Failure to control
PPH quickly with standard measures behoves exclusion of
coagulopathy and full specialist support.
5. Combination of atonic and traumatic causes

Causes of secondary PPH:1. Retained piece of placenta and membrane

2. Subinvolution of placental site due to delayed healing.


3. Secondary haemorrhage for C/S wound usually occurs between
10-14 days.
4. Withdrawl bleeding following estrogen therapy.
5. Other carcinoma of cervix or polyps.
6. Separation of slough over a devenous cervico vaginal
laceration following infection.
Risk factors
1. Factors relating to pregnancy
Antepartum haemorrhage in this pregnancy
Placenta praevia
Multiple pregnancy
Pre-eclampsia or pregnancy induced hypertension
Previous PPH
Maternal obesity
2. Factors relating to delivery
Emergency C/S 9%
Elective C/S 4%
Retained placenta 5%
Mediolateral episiotomy 5%
Operative vaginal delivery 2%
Labour of more than 12 hour 2%
Babys weight more than 4 kg
3. Pre existing maternal haemorrhagic condition
Factors 8th deficiency haemophilia A carries
Factors 9th deficiency haemophilia B carries
Von will brands disease

PATHOPHYSIOLOGY OF PPPH

Over the course of pregnancy, maternal blood volume


increases by approximately 50% (from 4 L to 6 L). The plasma
volume increases some what more than the total RBC volume,
leading to a fall in the hemoglobin concentration and
hematocrit value. The increase in blood volume serves to fulfill
the perfusion of the low resistance utero placental unit and to
provide a reserve for blood loss that occurs at delivery.
At term, the estimated blood flow to the uterus is 500-800
ml/min, which constitutes 10-155 of cardiac output. Most of
this flow traverses the low resistance placental bed. The
uterine blood vessels that supply the placental site traverse a
weave of myometrial fibers. As these fibers contract following
delivery, myometrial reactraction occurs. Retraction is the
unique characteristic of the uterine muscle to maintain its
shortened length following each successive contraction. The
blood vessels are compressed and kinked by crisscross
latticework, and normally blood flow is quickly occluded. This
arrangement of muscle bundles has been referred to as living
ligatures or physiologic sutures of the uterus.
Uterine atony is a failure of the uterine myometrium fibers to
contract and retract. This is the most important cause of PPH
and usually occurs immediately following delivery of the baby,
up to 4 hours after the delivery trauma to the genital tract (i.e
uterus, uterine cervix, vagina, labia, clitoris) in pregnancy
results in significant more bleeding than would occur in yhe
non pregent state because of increased blood supply to these
tissues. The trauma specifically related to the delivery of the
baby, either vaginally in a spontaneous or assisted manner or
by cesarean delivery, can also be substantial and can lead to
significant disruption of soft tissue and tearing of blood vessels.

FLOW CHART
Due to of various etiological factors

Maternal blood vessels increase

Plasma volume 50% rises, Hb concentration falls

Reservation of blood in uteroplacental unit

Blood supply tranverse via myometrial fibre

Myometrial fibre contract and myometrial rentraction occurs


(blood vessels occulded)
Uterine atony- failure of myometrium fibers to contract and retract

Bleeding occurs

CLINICAL MANIFESTATION
According to book
Visible bleeding
Enlarge uterus, feels boggy

According to patient
Present
present

Sign of shock
Present
I. Pallor,
cold
and
I. Present
clammy skin
II. Present
II. Increased pulse rate
III. Present
III. Falling blood pressure
hg.)
IV. Tachypnoea
IV. Present
V. Decreased urine output V. Present
VI. Altered
level
of VI. Present
consciousness
may
become restless or
drowsy
VII. Absent
VII. Maternal collapse
VIII. Present
VIII. Decreased Hb%

(140/minutes)
(70/30 mm of
(32/minutes)
(200 ml)
she is drowsy

(6.2 gm/dl)

DIAGNOSTIC EVALUATION

According to book
History
Physical examination
Estimation of blood loss
Palpation of uterus size
Vaginal examination
USG to detect any retentined
products and clots in the
uterus
Swab for vaginal discharge for
M/E

According to patient
Not
taken
due
to
operative procedure
Done
Done (800ml)
Done (feel boggy and
around umbilicus)
Done (no trauma)
Not done
Not done

Laboratory investigation and its normal value


Investigation

Book value

Patients

Remark

value
-B+ve
Blood
grouping
Hemoglobin Male-13 to 18
gm/ dl
Female
11.5
9.7 gm/dl
to 16.5 gm/ dl
Not done

Low

Blood CBC
HIV, HBsAg

negative

12 sec
Blood
coagulatioin
profile (PT)
150000
Platelet
function
-450000
studies
Platelets
antibodies

Negative
12sec

normal

175000

normal

Not done

Management
Principle of management
1.
2.

3.

Call for extra help


Stop the bleeding
Rub up a contraction
Give an oxytocin
Empty the uterus
Resuscitate the mother
or

To diagnose the cause of bleeding.


To take prompt and effective measures to control bleeding.
To correct hypovolaemia

Management of primary PPH


HAEMOSTASIS algorithm

H Call for helps


A Assess (vital signs, blood loss) and resuscitate
The golden first hour
E Establish etiology, embolic, ensure availability of blood
M Massaging the uterus
O Oxytocin infusion, prostaglandins
S Shift to operating theatre (anti-shock garment, especially if
transfer is required and bimanual compression)
T Tissue and trauma to be excluded and proceed to tamponade
with balloon or uterine packing
A Applying the compression sutures
S Systematic pelvic revascularization
I Interventional radiology and uterine artery embolisation
S Subtotal or total abdominal hysterectomy
Accoeding to the Book

According to the
patient
the
placenta:1. Remove the placenta :- If the 2. Removed
Placenta removed after the
placenta
has
not
been
delivery of the baby through
removed from the uterus and
surgical procedure.
the patient's cardiovascular
condition is worrying, remove

the placenta. Do not wait for


the anaesthetist because if
you wait the patient may be
dead by the time the
anaesthetist arrives. In less
acute cases or where the
placenta has been delivered,
insert
a
wide
gauge
intravenous
cannula
and
infuse colloid and crystalloid
solutions and red blood cells
if available. As soon as
anaesthesia
is
available
deliver the placenta, check
the uterine cavity and the
lower
genital
tract.
Meanwhile, unless bleeding is
major, proceed with the
following steps.
Step I
2. Make the uterus contract:
i - massage the uterus
ii - Inj. Methargin 0.2 mg IV
iIi- Inj. Syntocin 10 unit IV drip
with 500 ml R/L
iv- empty the bladder
v- examine the placenta
vi- Inj. Morphine 15 Mg IV may
be given
Step II
3. uterus is to be
explored
under GA:
Simultaneous inspection of the

- Not done due to operative


wound
- Given
- Given
- Kept folys catheter
- Done and is complete.
- Not given

- Not done

cervix, vagina specially the


paraurethral region is to be
done to exclude co-existent
bleeding sites from the injured
area.
Step III
4. Bimanual compression and uterine
massage
:Bimanual
compression of the uterus
prevents an increase in the
radius of the uterus due to
bleeding in the uterus and
atony. Simultaneously, the
uterus is pushed cephalad,
which
puts
the
uterine
arteries under tension and
reduces blood flow to the
uterus. Catheterise bladder.
Step IV
5. If bleeding persists and the
uterus
is
not
firmly
contracted (indicating that at
least part of the bleeding is
due to uterine atony rather
than trauma) administer the
prostaglandin drug that is
part of the hospital's routine.
Inj 15 methyl PGF2 250g
IM in the deltoid muscle
every 15 minutes (upto
maximum of 2 mg) or
Misoprostol (PGE1) 1000g
per rectum is effective.

Not done

Tab Misoprostol 800g per


rectum given.

Step V
6.Uterine tamponade:1.
Tight
intrauterine
packing done uniformly under
general
anaesthesia.
Intrauterine packing is useful in
case of uncontrolled postpartum
haemorrhage
where
other
methods have failed and the
patient is being prepared for
transport to a tertiary care
centre.
2.
Balloon
tamponade:Tamponade using various types
of hydrostatic balloon catheter
has mostly replaced uterine
packing. Mechanism of action is
similar to uterine packing. Foley
catheter, Barki balloon, Condom
catheter
or
SengstakenBlakemore tube is inserted into
the uterine cavity and the
balloon is inflated with normal
saline(200-500 ml). It is kept for
4-6 hours. It is successful in
atonic PPH. This can avoid
hysterectomy in 78% cases.
7.Aortic
compression:
Transabdominal compression of
the
aorta
against
the
promontorium
is
done
in
preparation for laparotomy if
required. In all cases the uterus

Not done

Condom tamponade done

Not done

must be closely supervised i.e.,


a midwife must be with the
patient with her hand on the
patient's uterus and ensuring
that the uterus does not relax
and fill with blood.
8. Treat anaemia, coagulopathy,
thrombocytopenia
Step VI
9. Operative procedures:a. Ligation
of
uterine
arteries- the ascending
branch of the uterine
artery is ligated at the
lateral border between
upper and lower uterine
segment. The suture(No 1
chromic) is passed into the
myometrium 2 cm medial
to the artery. In atonic
haemorrhage
bilateral
ligation is effective in
about 75% of cases.
b. Ligation of the ovarian
and
uterine
artery
anastomosis if bleeding
continues,, is done just
below
the
ovarian
ligament.
Rarely
temporary occlusion of the
ovarian vessels at the
infundibulopelvic ligament
may be done by rubber
sleeved clamps.

Blood transfusion done (2


pint whole blood)

Not done

Not done

Not done

c. Ligation
of
anterior
division of internal iliac
artery
(unilateral
or
bilateral) reduces the
distal blood flow. It helps
stable clot formation by
reducing
the
pulse
pressure up to 85%. Due
to
extensive
collateral
circulation, there is no
pelvic
tissue
necrosis.
Bilateral ligation can avoid
hysterectomy
in
about
50% cases.
d. B-lynch
compression
suture
and
multiple
square
sutures:-Both
these surgical methods
work by tamponade (like
bimanual compression) of
the uterus. S uccess rate is
about 80% and it can
avoid hysterectomy.
e. Angiographic
arterial
embolisation
(bleeding
vessels) under fluoroscopy
can be done using gel
foam. Success rate is more
than 90 % and it avoids
hysterectomy.
Step VII
10.
Hysterectomy:rarely
uterus fails to contract and
bleeding continues in spite of

B-lynch compression suture


done

Not done

Not done

the
above
measures.
Hysterectomy has to be
considered
involving
a
second consultant. Decision
of hysterectomy should be
taken earlier in a parous
women. Depending on the
cases it may be subtotal or
total.
SHEME OF MANAGEMENT OF TRUE PPH
Immediate measures
Cell for extea help
Commence I\V line with a wide
bare cannula
Send blood for cross- matching and
ask For 2unit of blood(at least)
Rapidly
infuse
normal
saline
haemaccel and litters till blood in is
available.
To feel the uterus by abdominal palpation

UTERUS ATONIC

UTERUS HARDS AND


CONTRACTED(TRAUMICE)

Massage the uterus to make lt hand


Injection methergin 0.2mg I\V
To add oxytocin 10 units in 500ml of
N/S the rate of 40d/min
To examine the expelled placenta
To Catheterise the bladder

EXPLORATION

UTERUS REMINE ATIONIC


HAEMOSTATIC SUTURE ON
Exploration of the uterus
TEAER SITES
Blood transfusion
To continue oxytocin
UTERUS ATONIC
15 methyl PGF2 250mg per I/M is intramyometrial
Misoprostal 100mg per rectum

UTERINE TAMPONDE
Bimanual compression
Tight intrauterine packing under anesthesia
Insertion of sengstaken blak more tube and inflation
SURGICAL METHOD
Stepwise uterine devascularisation procedure
Ligation of uterine artery and utero-ovarine anastomosic
vessels
Unilateral or bilateral
Ligation of another division of internal iliac artery
B-lynch branch sutures
Angiographic aterial embolisation with gelatin sponge
HYSTERECTOMY (REARELY)
Nursing Management
1) Reassure the women and her support person
2) Rub up a contraction by massaging the uterus if it is still
palpable

TH

3) Express any clots


4) Encourage the mother to empty her bladder
5) Give an uterotonic drug such as ergometrine
6) Keep all pads and linen to cases the volume of blood lost
7) If bleeding persists, discuss a range of treatment options with
the women and , if appropriate ,prepare the women for theatre.

COMPLICATION
Shock / Pulmonary embolism
Encephalopathy
Acute renal failure
Puerperial sepsis
Coma
Death

PREVENTION
Postpartum hemorrhage cannot always be prevent. However the
incidence and specially its magnitude can be reduced
substantially if the following guideline are as fallowed

ANTENATAL Improve of health status (HB% is normal)


High risk patient are to be screened and delivered in a well
equipped hospital
Blood grouping should be done
INTRANATAL Slow delivery the baby
Expert obstetric anesthetist is needed when the delivery
conducted under general
anesthesia(in forceps, ventous and
breech delivery)
During C/S spontaneous separation and delivery of placenta
reduce blood loss
Active management of 3rd stage specially of at risk
Temptation of finding
Examination of the placenta and membrane after delivered
In all cases of the induced by labour by oxytocin the infusion
should be continued for a last one hour after delivery

POSTPARUM-

Exploration of the utero-vaginal cannel for evidence of trauma


To observe the patient for about two hours of the delivery and if
uterus remind hard and contracted

Prognosis
90% of cases treated with antibiotics improve within 48-72 hours.
If this is not the case, the patient should be re-evaluated.
Associated diseases
Haemolysis, Elevated Liver enzymes and Low Platelets (HELLP).
DRUGS USED IN MY PATIENT:
1) Injection RL II pint
2) Injection DNS II pint
3) Injection 5% Dextrose
4) Injection syntocin 10 unit
5) Injection Taxim 1gm IV BD
6) Injection Metron 500 mg IV TDS
7) Injection Aciloc 150mg IV BD
8) Injection Gentamycin 1 gm IV BD
9) Injection Voveronn75 mg IM sos
10)

Injection Phenargan 25 mg IM BD sos

11)

Ferrous sulphate

Nursing care provided to the patient during hospitalization.


Assessment.
Detailed history taking and physical examination was done.
Along with them patients different laboratory test were

performed which are also already discussed. Besides this, daily


assessment about the client and babies health status was done
focusing on their physical, psychological, emotional, sociological
and spiritual functioning.
Nursing Diagnosis of mother:
Anxiety related to operative procedure (ceaserean section)
Altered comfort,pain related to surgery.
Altered nutritional status less than body requirement related to
blood loss.
Risk of infection related to ascending of microorganism from
perineum.
Sleep pattern disturbance related to unfavorable hospital
environment.
Self care deficit to therapeutic bed rest following surgery
Nursing diagnosis of babies:
As baby was not brought to hospital, so could not provide care to
baby but information on baby care was given.
Planning, Nursing intervention and Evaluation:
The expected outcomes, overall interventions provided to the
patient and evaluation are discussed in the nursing care plan
below in the order of priority set according to Maslows hierarchy.
Nursing Care Plan of Mother in Priority Order:
S.
N
1

Nursing
diagnosis
High risk for
haemorrha
gic
and
hypovolemi
c
shock
related
to
postpartum
haemorrha
ge.

Goal

Intervention

Rational

To prevent
from shock
during
hospitalizati
on.

- Assessment - Helps to
fo the patient know
the
condition.
condition of
the patient.
Moniter - Helps to
vital
sign evaluate the
every hour.
patient's
deteroriate
condition.
- Helps to

Evaluation
No
any
complicatio
n
arise
during
hospitalizat
ion so my
goal
was
achieved.

Provide
patient with
complete bed
rest.
IV
replacement
as ordered in
the cardex.

Altered
comfort;
pain related
to surgical
procedure(
ceaserean
section)

Patient will
report relief
from
pain
within
30
minutes

Arranged
and
cross
matching the
blood
grouping.
Assess pain
location,
characteristic
s
and
severity
Assess
vital signs.

Review
intraoperativ
e
room
record
for
medicines
previously
administered.
Reposition
the client to
comfortable
position.
Encourage

prevent from
further
complication
.
- Helps to
maintain
fluid
and
electrolyte
balance.
Help
to
manage
in
emergency
situation.
Provides
basis
for
selection
of
proper
intervention
Signifies the
physiologic
effect of pain
and give clue
for
intervention.
Helps
in
identifying
the type of
analgesics
given.
Relieves
discomfort
from
pressure.

Goal was
met , as
patient
verbalized
about pain
relief and
involved in
her
activities.

use
of
relaxation
technique
and diversion
therapy e.g.
muscle
relaxation,
imagery,
visualization,
autogenic
training,
meditation,
music etc.

Helps
to
divert
her
mind
from
pain to other
pleasant
stimuli.
Induces
relaxation

Administer
analgesics as
prescribed.
It helps to
relief pain by
chemical
effect.
S.
N

Nursing
Diagnosis

Nursing
Goal

Plan of Action

Rationale

Evaluation

Sleep
pattern
disturbance
related
to
unfavorable
hospital
environmen
t

Client will
have sound
sleep
tonight
after
applying
nursing
measures

Determine
normal sleep
habits
and
changes that
are occurring
Obtain
comfortable
bedding.
Establish
sleep routine
suitable to old
pattern
and
new
environment.
Encourage
light physical
work/exercise
during
daytime,
stop activity
several hours
before
bedtime.
Provide warm
massage,
warm milk, at
bed time.

Assess need
for
and
identifies
correct
intervention
increases
comfort
for
sleep.
Related
stress
and
anxiety may
be reduced.
Daytime
activity can
help expend
energy
and
be ready for
night
time
sleep.
Activity
close
to
bedtime may
stimulate
delay
sleeping.
Promotes
relaxing
soothing
effect.

Instruct
relaxation
measures.
Reduce noise Helps
to
and light
induce sleep.
Provide
comfortable

Provides
atmosphere
conductive to

Goal was
met.
Patient
reported
that
her
sleep was
improved
than
last
night

position
for
sleep.
Avoid
interruptions;
postpone
nursing
activities that
fall
at
bedtime.
Consult
physician for
further
management
e.g.
sedatives,
analgesics,
hypnotics etc.

Fear
and To reduce
anxiety
patient fear
related
to and anxiety
PPH.
and provide
comfort.

- Provide fully
psychological
support to the
patient.
- Control the
visitors
and
crowd
to
provide quite
environment.

sleep.
Prevents
pressure,
promotes
rest.
May
be
unable
to
sleep
after
interruption

May require
medicines if
nursing
measures fail
to
induce
sleep.
- Helps to
reduce
the
patient's fear
and anxiety.

Goal was
achieved
as
patients
anxiety
- Helps to was
maintain
reduced
very
clam that
environment verbalized
which allows by patient.
patient
to
have
rest
Ventilate comfortable.
patient's
- Helps to
feeling
and divert
emotion.
patient's
mind
and
help
to
reduce

Need
for
discharge
teaching
related
to
knowledge
deficit.

Potential of
hypothermi
a related to
exposure to
cold
environmen
t.

Maintain emotional
good IPR.
feelings.
- Helps to
Allow develop good
relatives
to trusting
stay close to support.
the patient.
Helps
patient
to
feel
very
secure
and
comfortable.
To provide Explain - It helps to
discharge
about
the prepare
teaching.
discharge
patient
procedure.
mentally .
- Explain the - It help to
patient about maintain
the
dose
maintaining
accurately.
the right dose
of medicine.
- Explain the - It help to
patient about maintain the
the nutritional nutritional
diet.(Iron
status.
containing
diet)
- It help in
- Explain the regulation of
importance of self care.
personal
hygiene.
Temperatur -Temperature -To find out
e will be of body was the
bodys
maintained assessed
temperature
normal
regularly.
accurately.
during
-The window -To make the
hospitalizat and door are room warmth
ion.
closed
but with
ventilation
ventilation.

Discharge
teaching
has given
on
prescribed
time.

Hypotherm
ia
was
prevented
during
hospitaliza
tion.

was
maintained.
-Baby
was
wrapped
properly

-To maintain
body warmth
by
prevent
loss of body
temperature
-Babys
-Kangaroo
temperature
mother care is rise due to
was done
temperature
of mother.
-Wet napkin
-Breast
decreased
feeding
was body
done
temperature
frequently.
by
conduction
Application of Nursing Theory in Nursing Management:
The Nursing practice is the basic purpose of the discipline. As a
profession nursing has the responsibility to assess individual,
groups, families and communities to retain, obtain and maintain a
state of health. In order to assume such a responsibility nursing
must have a foundation of theoretical knowledge which is based
on research findings. It is not good enough to practice based on a
intuition, habit or traditional as a basis for making nursing
decision. Nursing theories identify and define inter related
concept important in nursing and state the relationship between
and among these concepts. Theories describe relationship that
are developed logically and consistently with their basic
assumption. Nursing theory also increase the nursing profession
body of knowledge by generating research to guide and improve
practice. Nursing theory guides nurses by providing guideline for
practice and identifying nursing care goals.
While caring the patient during hospitalization, we have to use
nursing theory so that the care become more effective and helpful
to move the patient toward recovery. I had applied Orems
Nursing theory while giving nursing care to patient. According to

Orems Nursing has as its special concern the individuals needs


for self care action and provision and management of it on a
continues basis in order to sustain life and health recover from
disease or injury and cope with their effects.
Orems develops her general theory of nursing in three related
parts.
1. Self care
2. Self care deficit
3. Nursing System
The Nursing system designed by the nurse is based on the self
care need and abilities of the patient to perform self care
activities.
Orem has identified these classification of nursing system to
meet the
Self- care requisites of the patient, these are:
Wholly compensatory system
Partly compensatory system
Supportive- educative system
According to Orem, Nursing had its special concern to the
individual need for self care action and basic in order to sustain
life are health recover from disease and injury and coping with
effects.
Orems develops her general theory of nursing in three related
parts.
1. Self care: Practices of activities that individuals initial and
perform on their own behalf in maintaining life health and well
beings.
2. Self care deficit: Constitutes is the care of Orems general
theory nursing because it delivers why nursing care is needed.
The self care deficits is the condition when the individual is
incapable or limited in the provision of contineus.
3. Nursing System: designed by the nursing is based on the self
care needs and abilities of the patient to project self care
activities. Orem has identified three classification of nursing
system to meet the self requisities of patient, these are:
Wholly

compensatory As my patient was fully conscious

system

and able to perform her maximum


activities of living herself. No need to
give her wholly compensatory.
Partly
compensatory As my patient was week because of
system
blood loos, so she need help. So I
assisted her in many activities like
Assist in nutrition.
Assist while taking medicines.
Assist while going toilet.
Maintain safety environment and
prevent from infection.
Pericare
Supportiveeducative Encourage to do self care teach
system
importance of personal hygiene.
Educate about diet maintenance,
drink plenty of fluid and take
nutrition diet.
Encourage about care of babies.
Encourage personal hygiene and
pericare twice a day
Regular perineal exercise.
No smoking.
No alcohol.
Regular health checks up.
Educate about immunization.
Educate about Family Planning.
STRESS MANAGEMENT:
Stress is a change in environment or unpleasant experience
of, life that is prescribed as a threat, challenge or harm to the
personal dynamic equilibrium. When stress is more severe or
more prolonged than usual, however a person may need a nurses
help in coping she was on stress due to strange environment and
feeling of tension because baby condition and also due to painful
medical procedure. I tried to minimize her stress byBuilding good rapport with patient, her parents and other family
members.

Giving a complete orientation of ward, routine of ward, its rules


and regulation e.g. visiting time, diet, doctors round, available
facilities etc.
Giving clear information of disease.
Parents are allowed and encouraged to express their feelings and
concerns and cleared them whenever possible.
Advice her to feed the baby alternatively, on alternate breast site
so that she will not be on hurry.
Developing a trustful relationship with patient and her family.
Giving clear information of baby care and immunization.
Giving clear information about Family Planning.
Giving clear information of perinal care and exercise.
Respecting them, their culture, belief and practice..
By applying different diversion therapy to the patient to divert
their mind from the stress of pain.
DIVERSIONAL THERAPY:
I tried to divert patients mind by discussing her village her family
herhusbands then advise how to maintain care of a baby eg.
about feeding ,intake fluid more than before. Also talked about
her previous baby;s general condition and how to prevent both
baby from specific disease. I realized that this talk reduced her
anxiety to some extent.
Talk therapy
Distraction
Imaginary
Relaxation therapy
Individual psychotherapy
Supportive psychotherapy
Group therapy
Recreational therapy
Others therapy
1) Talk Therapy:
I provided him and his family the opportunity to ventilate their
feeling by every aspects of psychological, social and cultural view.
I made frequent conversation with my patient and his family
which definitely gave them chance to feel that there are people
who are there to help them and they also ventilate that.
2) Distraction:

This is the method of diverting mind in another pleasant situation.


I suggested him to distract his mind by listening radio, music like
VAGAN, talk with other patients and visitors around him.
3) Imaginary:
It is the imagination and concentration to take a mental vocation.
I advised him to imagine peaceful, pleasant scene which might
help him in forgetting stressful situation.
4) Autogenic training:
It is the method of replacing painful and unpleasant event of
situation with pleasant ones through self readiness and action. It
helps to relieve pain and induce sleep which can minimize the
stress. So I taught my patient about this method and provided
him sufficient rest.

Day to Day Progress Report:


2067\12\10
Today is the first post operative day. So patient is conscious and
she is in sips of fluid. Continue catheterization and fluid intake
and output is good. Dressing done by doctor and the wound is
clean and no sign of infections. Encourage for ambulation and she
can mobilize with support. So her condition is going better. No
more per vaginal bleeding, lochia rubra present. Baby is with her
husband and the condition is good.
Temperature-97.70 F.
Pulse 110min.
Respiration 24/min
Blood pressure 140/90 mm hg
2067/12/11
Temperature 970 F
Pulse 116/min
Respiration 20/min
Blood pressure 110/80 mm hg
Lochia Rubra

Today is second post operative day and the condition of patient is


fair. The vital signs are stable. Oral fluid started and continued IV
antibiotics. Ambulate the patient and provided pericare. Dressing
done by doctor and removed the condom tamponade because the
bleeding was controlled.
2067/12/12
Temperature 96.80 F
Pulse 110/min
Respiration 20/min
Blood pressure 110/80 mm hg
Lochia Rubra
Today is third day of post operative day and the condition of
patient is going to improve. Soft diet started and oral antibiotics
converted and catheter removed. Dressing done and provided
pericare. Breast feeding done and patient shifted to old post
operative ward.
2067/12/13
Temperature 96.70 F
Pulse 110/min
Respiration 20/min
Blood pressure 110/80 mm hg
Lochia alba
Today is fourth post operative day and patient looks better and
fresh. Continued oral antibiotics. Vital signs are stable and normal.
Pericare provided on demand breast feeding done and the babys
condition is good. Patient can go toilet without support and
normal diet started from today.
2066/12/14
Temperature 98.60 F
Pulse 80/min
Respiration 20/min
Blood pressure 110/70 mm hg

Lochia - alba.
Patients general condition improved than before Vaginal
bleeding at small amount. No complain of pain and weakness.
Patient had developed heavy bleeding so highly notorious diet
advised for her better health management. Urine passed and
Stool. Dressing done and the wound is getting better and
removed sutures so patient was discharged today. I provided
discharge teaching and told about medicine. Patient was
discharged on following medication.
DRUGS ON DISCHARGE:
1) Tablet cefixime 200 mg BD for 6 days
2) Tablet metron 400 mg TDS for 4 days
3) Iron fe++ for 1 month
Follow up after 7 days.

1. Injection Cefixine
Pharmacologic class: Third generation cephalosporin
Therapeutic class: Antibiotic
Action: High activity against gram negative bacteria &a variety
of
batalactamaseproducing
organism.
Active
against
pseudomonas & anaerobic bacteria &spirochetes.
Indication: Septicaemia, bacteraemia, RTI including pneumon
a, UTI & gynaecological obstetrical infections including pelvic
cellulites, endometritis, intra- abdominal infections including
peritonitis, meningitis etc.
Dosage:
Adult=1-2gm once a day, not more than 4gm.

Child= 50-75mg/kg/day in 2 divided doses not more than 2gm in


a day.
Contraindication: Hypersensitivity to cephalosporins, severe
renal dysfunction,
Infants less than 1 month,
Special Precaution: Cross sensitivity in penicillin hypersensitive
patients impaired renal function, pregnancy and lactation.
Side effect: Anaphylatic reaction, others pain at injection site,
hypersensitivity
reactions, GI disturbances, candidiasis,
eosinophilia, neutropenia, leucopenia and thrombocytopenia.
Nursing implication:
- Properly dissolve the solute by shaking the vial well.
- Reconstituted solution is stable for 24 hour at room temperature,
for 90 hour under refrigeration thereafter it should be discarded.
-For IV injection the injection should be adequately diluted.
-Don't inject more than 1gm into a single dose IM site to prevent
pain and tissue reaction.
-Ask the patient about any drug allergy.
-Watch the side effect of the drug.
- Monitor patient's hydration status if adverse GI reactions
occur.
-Monitor blood count frequently.
-Always check the manufacture and expire date of the drug.
Don't mix Aminoglycosides or sodium bicarbonate with
cephalosporin
2. Injection Metronidazole:
Pregnancy Category B
Drug classes
Antibiotic, Antibacterial, Amebicide, Antiprotozoal

Therapeutic actions
Bactericidal: Inhibits DNA synthesis in specific (obligate)
anaerobes, causing cell death; antiprotozoal-trichomonacidal,
amebicidal: Biochemical mechanism of action is not known.

Indications and Dosages


ADULTS
Oral:
Amebiasis: 750 mg/tid PO for 510 days. (In amebic dysentery,
combine with iodoquinol 650 mg PO tid for 20 days.)
Antibiotic-associated pseudo membranous colitis: 12 g/day PO
for 710 days.
Gardnerella vaginalis: 500 mg bid PO for 7 days.
Giardiasis: 250 mg tid PO for 7 days.
Trichomoniasis: 2 g PO in 1 day (1-day treatment) or 250 mg tid
PO for 7 days.
IV :Anaerobic bacterial infection: 15 mg/kg IV infused over 1 hr; then
7.5 mg/kg infused over 1 hr q 6 hr for 710 days, not to exceed 4
g/day.
Prophylaxis: 15 mg/kg infused IV over 3060 min and
completed about 1 hr before surgery. Then 7.5 mg/kg infused over
3060 min at 6- to 12-hr intervals after initial dose during the day
of surgery only.
Topical :Treatment of inflammatory papules, pustules, and erythema of
rosacea: Apply and rub in a thin film twice daily, morning and
evening, to entire affected areas after washing; results should be
seen within 3 wk; treatment through 9 wk has been effective.
In non-pregnant women: 1 applicatorful intravaginally one to
two times per day for 5 days.
PEDIATRIC PATIENTS
Anaerobic bacterial infection: Not recommended.
Amebiasis: 3550 mg/kg/day PO in three doses for 10 days.
Contraindications and cautions
Contraindicated
with
hypersensitivity
to
metronidazole;
pregnancy (do not use for trichomoniasis in first trimester).
Use cautiously with CNS diseases, hepatic disease, candidiasis
(moniliasis), blood dyscrasias, lactation.
Pharmacokinetics
Route Onset
Oral
Varies

Peak
12 hr

IV
Topic
al

Rapid
Generally
systemic
absorption

12 hr
no

Metabolism: Hepatic; T1/2: 68 hr


Distribution: Crosses placenta; enters breast milk
Excretion: Urine and feces
Adverse effects
CNS: Headache, dizziness, ataxia, vertigo, incoordination,
insomnia, seizures, peripheral neuropathy, fatigue
GI: Unpleasant metallic taste, anorexia, nausea, vomiting,
diarrhea, GI upset, cramps
GU: Dysuria, incontinence, darkening of the urine
Local: Thrombophlebitis (IV); redness, burning, dryness, and skin
irritation (topical)
Other: Severe, disulfiram-like interaction with alcohol, candidiasis
(superinfection)
Drug Interactions
Decreased effectiveness with barbiturates
Disulfiram-like reaction (flushing, tachycardia, nausea, vomiting)
with alcohol
Psychosis if taken with disulfiram
Increased bleeding tendencies with oral anticoagulants
Nursing considerations
Assessment
History: CNS or hepatic disease; candidiasis (moniliasis); blood
dyscrasias; pregnancy; lactation
Physical: Reflexes, affect; skin lesions, color (with topical
application); abdominal examination, liver palpation; urinalysis,
CBC, liver function tests
Interventions
Avoid use unless necessary. Metronidazole is carcinogenic in
some rodents.
Administer oral doses with food.
Apply topically after cleansing the area. Advise patient that
cosmetics may be used over the area after application.
Reduce dosage in hepatic disease.

Preparation: Reconstitute by adding 4.4 mL of sterile water for


injection, 0.9% sodium chloride injection to the vial and mix
thoroughly. Resultant volume is 5 mL with a concentration of
100 mg/mL. Do not use if cloudy or if containing precipitates; use
within 24 hr; protect from light. Add reconstituted solution to
glass or plastic container containing 0.9% sodium chloride
injection, 5% dextrose injection or lactated Ringer's; discontinue
other solutions while running metronidazole.
Infusion: Before administration, add 5 mEq sodium bicarbonate
injection for each 500 mg used, mix thoroughly. Do not refrigerate
neutralized solution. Do not administer solution that has not been
neutralized. Infuse over 1 hr
Teaching points
Take full course of drug therapy; take the drug with food if GI
upset occurs.
Do not drink alcohol (beverages or preparations containing
alcohol, cough syrups), severe reactions may occur.
Your urine may appear dark; this is expected.
Refrain
from
sexual
intercourse
during
treatment
for
trichomoniasis unless partner wears a condom.
Apply the topical preparation by cleansing the area and then
rubbing a thin film into the affected area. Avoid contact with the
eyes. Cosmetics may be applied to the area after application.
You may experience these side effects: Dry mouth with strange
metallic taste (frequent mouth care, sucking sugarless candies
may help); nausea, vomiting, diarrhea (eat frequent small meals).
Report severe GI upset, dizziness, unusual fatigue or weakness,
fever, chills.

DISCHARGE TEACHING

Health teaching is an important part while providing care to


the mother, baby, as well as family members. It is an integral part
of the nursing process too. It begins from the time of admission till
the discharge time including follow up visit/care. So, it is our
responsibility to plan and suggest the parents and family
members for continuity of care at home and motivate them to
implement the suggested plan at home.
Therefore, I had given health teaching on different topics which
are as follows:
Nutrition
Breast care
Personal hygiene
Rest and activities
Oil massage
Sexual intercourse
Medication
Follow up visit
1. Nutrition
Postnatal mother need more balance diet including adequate
protein, carbohydrate, vitamins and minerals more than other
mother for health maintenance and early healing of wound.
Postnatal diet should contain green leafy vegetables, plenty of
fluid, cereals and pulses, meat etc. and should take food at least 4
times a day. Culturally influenced food also should prefer like
ghee, chaku etc.
2. Breast care
Breast care should begin from antenatal period and should
continue to postnatal period. In new concept, we should not
manipulate nipple during pregnancy because it can be precipitate
premature contraction and may be chance of abortion. But
whatever it is said we should always keep breast as well as nipple
clean.
3. Rest and activities
Rest and activities as well as sleep is very important in this period
for the recovery. She need at least 9 hours sleep .Ambulation is
necessary at this period to prevent from other compilation and
early recovery. She can do minor activities such as care of self,

minor homework etc. But heavy lifting and working in field should
be avoided.
4. Oil massage
Oil massage is not only our traditional practice but also it is
scientific practice for good circulation on the body. If she prefer oil
massage she can carryout in daily basic.
5. Personal hygiene
It prevents infection and helps for health promotion. Inner cloth
should be well cleaned and dry and changed frequently. She
should take bath and hair wash twice a week is recommended.
6. Sexual intercourse
Girja devi Thakur had got delivery episiotomy with tear so sexual
intercourse should be delayed.
7. Medicine
I gave teaching about regular medication time, duration and
certain side effects of medicine. On discharge Dr. ordered
following medicine
Cap. Ferofolic 1 cap. /day for 6 weeks
Tab. Calvit 1 tab/day for 6 weeks
I explained her about why these medicines are needed. It is
necessary to prevent infection and promote health. These
medicines should take after meal and seek medical facilities if nay
side effects occur.
9. Follow up visit
She should have follow up after 6 weeks. Advised her any time
follow up visit if any complication raised .I explained about
importance of follow up visit and come this hospital if possible
otherwise visit other facilities near to her village.
Health teaching
Health teaching plays an important role to prevent disease,
promote health as well as to cure disease more rapidly with out
any complications. One of the most important roles of the nurse is
to provide health education. So I, being a nurse, I had also given
health education to patient and family.
To promote the health
To motivate for early diagnosis and treatment
To help limit the disability
To keep in relationship

Keeping above objectives in mind I had given health education to


the patient about following topics.
NutritionPregnant and postnatal mother needs balance diet which should
have adequate protein, carbohydrate, vitamins, calcium, iron etc.
Balance diet helps to pregnant and postnatal mother to regain her
health and her babys health add to promote health and lactation.
She must eat four times per day which is required for lactation.
Baby needs good nutrition so mother has to breast feed the child
regularly till 4-5 month without water also. This is the only one
source of good nutrition for the baby. She has to take care about
this
Rest and activitiesRest and sleep is very important during pregnant and postnatal
mother. So she has to rest in a day also. Sleep pattern should be
good. Light exercise can be done. Lifting heavy things should be
avoided.
Personal hygieneThis should be done to prevent infection. Inner clothes should be
cleaned, dry and changed frequently.
Sexual intercourse and family planningWe discussed about sexual intercourse and family planning
method. I advised her to use permanent family planning method
after 45 days because she has twobaby now.
Care of the babyGently handling of baby, daily care of eyes, ears and groins with
warm cloth, periodic bath and oil massage, frequently change of
napkin, check frequently urine and stool pass.
Breast feeding of the babiesI advice to teach her about demand feeding, exclusive breast
feeding. Breast milk secretion high in amount in night than day so
breast feed in night as well as day. Exclusive breast feeding help
to temporary family planning method (LAM).
MedicineDoctor has prescribed the following medicines
Tab
ferrous
sulphate
1
tab
OD
for
45
days
Tab calcium 1 tab OD for 45 days
I explained about its usefulness.
Follow Up-

I told her about the importance of routine check up and health for
follow up purpose.
OthersImmediate check up if any signs of infection, fever, pain, swelling,
foul discharge, bleeding etc.
If babies have any problem such as dyspnoea fever, not sucking
breast milk, increase respiration etc. to visit the doctor as soon as
possible.
SUMMARY OF THE CASE STUDY
During my 8 weeks posting in Thapathali Maternity hospital, for
practicum, I found a patient with heavy bleeding in emergency
ward and and I selected that case for the case study. The case
was secondary post partum haemorrhage.s
Mr Kamala Rai, 33 yrswas came in emergency on 2066/12/04
because of heavy vaginal bleeding. She has two childrens and
both is home delivery. This is her 1st experience of being
admitted in hospital. Before this occurance to her, she has no any
significant diseases beforehand.
During hospitalization, I provided her a holistic nursing care by
considering her physical, mental, spiritual and socio cultural and
economic aspects. I provided nursing care based on Orem's
nursing system theory. I provided her needed health teaching
regarding health promotion, maintenance, prevention from
complication and discharge teaching. During her hospitalization
she and her family were very co operative and it was not so
difficult for providing care and collecting information.
WHAT I LEARN FROM THIS CASE STUDY
Case study is one of the good source of learning about the
nursing practice as well as the related disease in depth. It gave us
comprehensive study of one selected patient and comparative
with book in real situation.
During my case study, what I learned are listed below:
1)ABOUT THE DISEASE
I gained the knowledge of pneumonia in depth by case study by
using available resources from library, literatures, researches and
internet which I compared to the clinical presentation of patient

which gives clear information. I also obtained information from


doctors and seniors.

2) ABOUT THE PATIENT:


I got opportunity to know the history of patient, his health habits,
ways of living and his cultural background and it's influence on
health and illness.
3)ABOUT THE FAMILY AND ENVIRONMENT:
I got the information about my patient's family background, socio
cultural and educational background, concept about health and
illness and economic status, religion, traditional beliefs and
disease and treatment.
5)ABOUT THE NURSING CARE
I applied holistic approach while providing nursing care to my
patient. I applied Orem's nursing theory during caring of my
patient by using NANDA'S diagnosis technique while planning,
implementing the nursing care plan. I gained the detailed
knowledge about nursing diagnosis and how to develop care plan.
ABOUT STRESS AND IT'S MANAGEMENT
My patient had got heavy bleeding and anxiety which was related
to her disease condition. I got the chance to solve her problem by
providing different techniques of stress management and
diversional therapy. I also provided emotional or psychological
reassurance to the patient.
ABOUT THE DOCUMENTATION
Documentation is also important and useful skill so I developed it
by this case study. I could formulate the case study systematically
and deeply.
7) ABOUT HOSPITAL POLICY
During my case study, I involved in different sectors of activities
such as reporting, recording, admission, discharge procedures. So
I could know lots of rules and policy of Thapathali hospital.
CONCLUSION
During our 4 weeks posting Thapathali hospital everyone should
take case study, document and present in comprehensive and
systematic way including disease, it's cause, pathophysiology,
treatment and management in comparative way with the real
situation to patient. By this way I gained knowledge in depth by
comparing the case with patient and my topic of case study is
secondary post partum haemorrhage.. I collected information

from library, internet, from patient and compared it with patient in


real situation.
During my case study, I provided holistic nursing care to my
patient. I gained the knowledge about the nursing theory and it's
application in real situation. So the case study not only give the
opportunity to develop cognitive domain but also provides us the
opportunity to develop psychomotor domain, which is very
important in nursing field. The patient the main source of
converting knowledge in practice
Case study is the appropriate method to gain knowledge and
practice. I always appreciate this type of method.