INTRODUCTION

During my clinical posting in TMC and Dr. BRAM Teaching Hospital in the
postnatal ward, I have selected a postnatal mother, Mrs. Ruma Deb , age 23
years with gestational age of 40 weeks and I have selected this case for my case
presentation.

HISTORY COLLECTION

IDENTIFICATION DATA

NAME OF THE HOSPITAL : TMC and Dr. BRAM Teaching Hospital

MOTHERS NAME : Mrs. Ruma Deb
AGE : 23 years.
I.P. NO. : 1762/21
WARD : Postnatal ward.
ADDRESS : Ranibazar, Tripura west
RELIGION : Hinduism
DATE OF ADMISSION : 30.8.2021
EDUCATION : Madhyamik pass.
OCCUPATION : Home maker
MONTHLY FAMILY INCOME : 15,000/-
OBSTETRICAL SCORE : G1P1A0 L1

LMP : 23.11.20

EDD : 30.08.21

GESTATIONAL AGE : 37 weeks

DIAGNOSIS :BREAST ENGORGEMENT

CHIEF COMPLAIN:

Mrs. Ruma Deb was admitted with the pain in the abdomen with leakage of water.

REASONS FOR HOSPITALIZATION

G1P1A0L1 with gestational age of 40 weeks got admitted to hospital for delivery .

OBSTETRICAL HISTORY

PAST OBSTETRICAL HISTORY

My patient is a primi gravida mother.She had no past history of gynecological disorders.

PRESENT OBSTETRICAL HISTORY

1st trimester:
She conceived spontaneously after 2 year of marriage. Pregnancy was confirmed by
pregnancy kit test at home after 1 month of amenorrhea. Blood and urine investigation was
done. Her hemoglobin level was 11.5 gm/dl. She had mild nausea and vomiting. She was
going for regular antenatal check ups.

2nd trimester:

Quickening felt at 18 weeks of pregnancy. There is gradual enlargement of uterus and

cessation of menstruation continued. No history of bleeding. She took 2 doses of injection
DT. Went for regular antenatal check up and continue iron and folic acid tablet.

3rd Trimester

There was gradual enlargement of uterus, fetal movement becomes more pronounce . she had
the complains of backache, frequency of micturition, she got admitted in the hospital for safe
confinement. She does not have any history of severe anemia, PIH and any bleeding per
vagina.

MEDICAL HISTORY

PAST MEDICAL HISTORY

There is no significant history of medical illness in the past.

 PRESENT MEDICAL HISTORY

There is no any medical illness like TB, Jaundice, Anemia etc.

SURGICAL HISTORY

PAST SURGICAL HISTORY

There is no history of surgical illness in the past.

PRESENT SURGICAL HISTORY

There is no history of surgical illness at present.

FAMILY HISTORY

a) Type of Family : Nuclear family.

b) No of Members in the family : 4 members.
c) History of consanguineous marriage : no consanguineous marriage in the family.
d) Hereditary illness : not present.
e) Family Composition and family tree :

Key

---Death
Lt. Moti lal Deb Mrs. Renu Deb
------Female

---- Male

------patient

Mr. Nihar Deb Mrs. Ruma Deb Mr. Bijoy Deb

NAME AGE SEX RELATION EDUCATION HEALTH

Mrs.Renu Deb 62 years F Mother-in-law - healthy

Mr.Nihar Deb 32years M Husband B.A pass healthy

Mrs.Ruma 23years F Patient XII pass Healthy

Deb
Mr.Bijoy Deb 28 years M Brother-in-law M.A student Healthy
 PERSONAL HISTORY

a) Diet : She in non vegetarian,

b) Appetite : Normal
c) Sleep :Sleeping pattern is regular 10 hours a day.
d) Bladder : frequency in micturition.
e) Bowel : constipation is present.
f) Personal hygiene : she maintains personal hygiene properly.

SOCIO – ECONOMIC HISTORY:

a) Housing : pucca house.
b) Rooms : 4 rooms.
c) Occupancy : own house.
d) Ventilation : well ventilated.
e) Light : electricity is present
f) Water Supply : tube well.
g) Rest and sleep : she used to sleep 10 hours per day.
h) Exercise : she does not performed any exercise.
i) Cultural history : they are following Bengali culture.

MENSTRUAL HISTORY
a) Age of menarche : 12 years.
b) Duration :5-6 days
c) Flow : normal
d) LMP : 23.11.20

MARITAL HISTORY-

Married for 2 year.

 Relationship with husband satisfactory.
 No consanguineous marriage

CONTRACEPTIVE HISTORY
She have not use any contraceptive method or device.
INTRANATAL HISTORY:
The duration of first stage was about 10 hours during the second stage the cervix was fully
dilated. Duration of second stage was about 2 hours. The placenta delivered about 15 minutes
after delivery.After that she was shifted to the recovery room.
LABOUR NOTES:
She shifted to labour room by 8:15 a.m. on 30.8 2021 with good uterine contraction and
maternal bearing down afford. She delivered a live term male baby of weight 3 kg at 10:10
a.m.
PHYSICAL EXAMINATION
GENERAL APPEARANCE
Body built: :moderately built.
Nourishment: moderately nourished.
Activity: Active.
Posture: Lordosis.
Pallor: not pale.
Consciousness: conscious and oriented.
Height - 157 cm
Weight – 66kg

VITAL SIGNS
Temperature - 98.70F.
Pulse – 74 b/m.
Respiration - 22b/m.
B.P 110/70 mm of Hg

SKIN
Colour -Brown.
Moisture - normal.
Texture - smooth.
Edema - absent.
-
HEAD
Hair - Equally distributed.
Scalp - clean, dandruff and lice are absent.
Colour -black

FACE
Chloasma is present on face.
Puffiness is absent.

EYES
Eye brows - normally distributed.
Eye lids -not edematous.
Eye lashes -no infection.
Eye balls - sunken.
Conjunctiva - pink.
Sclera -no discolouration.
Pupils - reacted to light.
Vision - normal.

EARS
External ear - No infection.
Gross hearing - Normal.
Pinna - No infection.
Discharge - absent.

NOSE
Nasal septum - no deviation.
Nostril - patent.
Placement - normal and symmetrical.

MOUTH
Lips -Dry.
Mucosa - no lesions, dry.
Gums -No bleeding.
Teeth - Aligned.
Tongue -pink in colour.
Throat -not enlarged.
Odour - no halitosis
NECK
Range of motion - possible.
Thyroid gland - no enlarged.
Lymph nodes – not palpable.
Distended neck veins- absent.
CHEST
Inspection
Shape -Normal.
Symmetry of expansion- symmetric.
Breast-
Inspection:
Size and shape -enlarged.

Primary and secondary areola -present.

Montgumery’s tubercle -present.

Nipple -erected,no nipple crack no ore present.

Palpation

- Palpation done by circular method, no lymph node or enlargement.

- Colostrum discharge is present.

- No tenderness present.

- Breast tightness present

ABDOMEN
Inspection-
- Size - decreased
- Linea nigra - present.
- Striaegravidarum- present.
- Contour -good.
- Scar\lesions -absent

Palpation:

Abdominal girth -15 cm.

Fundal height- 59 cm.

Auscultation:

Bowel sound: Heard

Percussion: no accumulation of fluid

GENITOURINARY SYSTEM

Episiotomy: Present
R- Redness is present.
E- Edema is absent.
E- Ecchymosis is absent.
D- discharge is absent
A-Approximation of suture is adequate.
EXTREMITIES:

UPPER EXTREMITIES

Carpel tunnel syndrome - absent.

Numbness - absent.

Range of motion - possible.

 Pallor - absent.

LOWER EXTREMITIES

Range of motion - possible.

Edema - absent.

Varicosity - absent.

Homan’s sign - negative.

INVESTIGATION

Sl Name of Patient’s value Normal Remarks

no. investigation value

1 Haemoglobin 11.9 gm/dl 12.1- 15.1 Normal

gm/dl

2 Blood group B+ve

3 HIV Negative

4 HBsAg Negative

5. VDRL Negative
 MEDICATION
N NAME DOS ROU FREQUE ACTION SIDE-EFFECTS NURSES
O. OF THE E TE NCY RESPONSIBILITY
DRUG
1. Tab. 200 Oral 1Tab  Iron combines with porphyrin and globin chains to form  indigestion, 1. Maintain 10
Ferrous mg OD rights of drug
hemoglobin, which is critical for oxygen delivery from the
sulphate.
lungs to other tissues.  Iron is transported by the divalent
 severe stomach administration
2. Check the side
pain
metal transporter 1 (DMT1) across the endolysosomal effects of the drug.
membrane to enter the macrophage.  vomiting 3. Check the expiry
date.

2. 200 Oral 1 tablet  Beta-lactam antibiotics, cefixime binds to specific 1. 4. Nurse should be
Tab. mg OD  Abdominal or
certain of the
penicillin-binding proteins (pbps) located inside the bacterial
Cefixime stomach pain patient's identity and
cell wall, causing the inhibition of the third and last stage of  agitation
confirm asking the
bacterial cell wall synthesis. Cell lysis is then mediated by  black, tarry stools
patient for their
 bleeding gums
bacterial cell wall autolytic enzymes such as autolysins; it is name.

possible that cefixime interferes with an autolysin inhibitor.

5. Nurse should
check the patient is
not
allergic to the drug.
 BREAST ENGORGEMENT

INTRODUCTION:

Breast engorgement means your breasts are painfully overfull of milk. This usually occurs
when a mother makes more milk than her baby uses. Your breasts may become firm and
swollen, which can make it hard for your baby to breastfeed.

DEFINITION:

 Breast engorgement occurs in the mammary glands due to expansion and pressure
exerted by the synthesis and storage of breastmilk .
 Breast engorgement is the swelling of the breast due to an increase in blood and
lymph supply as a precursor to lactation.

ANATOMY AND PHYSIOLOGY:

STRUCTURE OF THE LACTATING BREAST

Mammary glands are modified sweat glands. The non-pregnant and non-lactating female
breast is composed primarily of adipose and collagenous tissue, with mammary glands
making up a very minor proportion of breast volume. The mammary gland is composed of
milk-transporting lactiferous ducts, which expand and branch extensively during pregnancy
in response to estrogen, growth hormone, cortisol, and prolactin. Moreover, in response to
progesterone, clusters of breast alveoli bud from the ducts and expand outward toward the
chest wall. Breast alveoli are balloon-like structures lined with milk-secreting cuboidal cells,
or lactocytes, that are surrounded by a net of contractile myoepithelial cells. Milk is secreted
from the lactocytes, fills the alveoli, and is squeezed into the ducts. Clusters of alveoli that
drain to a common duct are called lobules; the lactating female has 12–20 lobules organized
radially around the nipple. Milk drains from lactiferous ducts into lactiferous sinuses that
meet at 4 to 18 perforations in the nipple, called nipple pores. The small bumps of the areola
(the darkened skin around the nipple) are called Montgomery glands. They secrete oil to
cleanse the nipple opening and prevent chapping and cracking of the nipple during
breastfeeding.

THE PROCESS OF LACTATION

The pituitary hormone prolactin is instrumental in the establishment and maintenance of
breast milk supply. It also is important for the mobilization of maternal micronutrients for
breast milk.

Near the fifth week of pregnancy, the level of circulating prolactin begins to increase,
eventually rising to approximately 10–20 times the pre-pregnancy concentration. We noted
earlier that, during pregnancy, prolactin and other hormones prepare the breasts anatomically
for the secretion of milk. The level of prolactin plateaus in late pregnancy, at a level high
enough to initiate milk production. However, estrogen, progesterone, and other placental
hormones inhibit prolactin-mediated milk synthesis during pregnancy. It is not until the
placenta is expelled that this inhibition is lifted and milk production commences.

After childbirth, the baseline prolactin level drops sharply, but it is restored for a 1-hour spike
during each feeding to stimulate the production of milk for the next feeding. With each
prolactin spike, estrogen and progesterone also increase slightly.

When the infant suckles, sensory nerve fibers in the areola trigger a neuroendocrine reflex
that results in milk secretion from lactocytes into the alveoli. The posterior pituitary releases
oxytocin, which stimulates myoepithelial cells to squeeze milk from the alveoli so it can
drain into the lactiferous ducts, collect in the lactiferous sinuses, and discharge through the
nipple pores. It takes less than 1 minute from the time when an infant begins suckling (the
latent period) until milk is secreted (the let-down). The image below summarizes the positive
feedback loop of the let-down reflex.
CAUSES:

BOOK PICTURE PATIENT PICTURE

Due to exaggerated normal venous. Absent
Lymphatic engorgement of the breast which Absent
precedes lactation .
The primiparous patient & the patient with Absent
inelastic breast are likely to be involved .
Starting breast feeding too late Absent

Not giving enough feed to baby or poor

removal of milk by the baby Not giving enough feed to baby or poor
removal of milk by the baby

ONSET:

BOOK PICTURE PATIENT PICTURE

It usually manifest after the milk secretion 3rd day started.
start (3 or 4 day postpartum )

BOOK PICTURE PATIENT PICTURE

1. Both breast are-
 Swollen Present
 Warm Present
 Tender Present
 Painful breast Present
2. Nipple becomes –
 Edematous Present
 Hard areola Present
 Flushed Absent
3. Vein over breast-
 Prominent present
 Engorged present
4. Low grade absent
5. fever(100F or 37.8 0 C). Generalized
malaise
6. Swollen &tender lymph nodes in
armpits
7. Pain on feeding to baby

 500g 1 weeks after birth

 300g 2 weeks after birth
  50g 6 weeks after birth
 The endometrial lining rapidly regenerates (16 days)
 The placental site undergoes a series of changes in the postpartum period.
(PATIENT PICTURE):

The weight changes of uterus:

1000g immediately after birth (excluding the fetus, placenta, membrane and amniotic
fluid

Subinvolution:

Subinvolution is the failure of the uterus to return to a nonpregnant state. -The most common
causes of sub involution are retained placenta fragments and infection.

(PATIENT PICTURE):

No Subinvolution occurred.

CERVIX:

Immediately after delivery, the cervix is extremely soft, flabby and floppy. It may be bruised
and edematous, especially anteriorly if there was an anterior lip during labor. It looks
congested and readily admits two to three fingers. The cervix contracts slowly, the external os
admits two fingers for a few days and by the end of first week, narrows down to admit the tip
of a finger only. The contour of the cervix takes longer time to regain (six weeks) and the
external os never reverts to the nulliparous state.

The broad and round ligaments, which accompanied the uterus during its increase in size, are
now lax because of the extreme stretching. This accounts for the easy displacement of the
uterus by the bladder. By the end of the puerperium the ligaments regain their non pregnant
length and tension.

(PATIENT PICTURE):

Cervix is extremely soft, flabby and floppy.

LOCHIA:

It is the vaginal discharge that occurs after birth. Lochia is discharge originates from the
uterine body, cervix and vagina.For the first 2 hours after birth the amount of lochia should
be about that of a heavy menstrual period, after that time the lochial flow should steadily
decrease.

LOCHIA-ODOUR AND REACTIONS :It has got a peculiar small and It reactions is
alkaline leading to become acid towards the end.

TYPES
 BOOK PICTURE PATIENT PICTURE
1. Lochia rubra-red color (1-4days) It Present
consists of blood, shreds of fetal
membranes and decidual ,vernix
caseosa,lanugo and meconium.

2. Lochia serosa-yellowish or pink or Absent

pale brownish colour(5-9 days) It
consists of old blood, less of RBC,
but more of leukocytes, and wound
exudates mucus from cervix and
micro organism (anaerobic
streptococci and staphylococci.

3. Lochia alba-pale white(10-15days) absent

Contains plenty of decidual
cells,leucocytes,mucus,cholestrin
crystals,fatty and granular epithelial
cells and micro organism.

AMOUNT The average amount of discharge for the first 5-6 days is estimated to be 250ml

CLINICAL IMPORTANCE OF LOCHIA

•Odour: If offensive indicates retained plus or cotton pieces inside the vagina should be kept
in mind

•Amount: Scanty or absent signifies infection or lochiametra If excessive also indicates

infection.

•Colour: Persistence of lochia rubra beyond normal limit signifies Subinvolution or retained
bits of conceptus

•Duration: Duration of the lochia alba beyond 3 weeks suggest local genital lesions.

Vagina and Perineum

The immediate postdelivery vagina remains quite stretched, may have some degree of edema
and bruising, and gapes open at the introitus. In a day or so it regains enough tone that the
gaping reduces and the edema subsides. It is now smooth-walled, larger than usual and lax.
Its size decreases with the return of the vaginal rugae by about the third post partal week. It
will always be a little larger than it was prior to the first childbirth. Perineal muscle tightening
exercises will restore its tone. This can be accomplished by the end of the puerperium with
daily practice.

GENERAL PHYSIOLOGICAL CHANGES

BOOK PICTURE PATIENT PICTURE
PULSE: After the initial tachycardia associated with labour and 60 beats/min
delivery, a bradycardia often develops in the early puerperium.
A woman’s pulse rate during the postpartal period is usually
slightly slower than normal. This increased stroke volume
reduces the pulse rate to between 60 and 70 beats per minute. As
diuresis diminishes the blood volume and causes blood pressure
to fall, the pulse rate increases accordingly. By the end of the
first week, the pulse rate will have returned to normal.

TEMPERATURE : A woman may show a slight increase in Temperature:

temperature during the first 24 hours after birth.Occasionally, 98.70F.
when a woman’s breasts fill with milk on the 3rd or 4th
postpartum day, her temperature rises for a period of hours
because of the increased vascular activity involved.Genito-
urinary tract infection should be excluded if there is rise of
temperature

URINARY TRACT :The bladder wall becomes oedematous Urine out put: 20ml
and hyperaemic and often shows evidences of sub mucous
extravasations of blood.Because of relative insensitivity to the
raised intravesical pressure due to trauma sustained to the nerve
plexus during delivery, the bladder may be over distended
without any desire to pass urine. Dilated ureters and renal pelvis
return to normal size within 8 weeks

GASTROINTESTINAL SYSTEM : Digestion and absorption Constipation present

begin to be active again soon after birth. Bowel sounds are
active, but passage of stool through the bowel may be slow
because of the still present effect of relaxin on the bowel. Bowel
evacuation may be difficult because of the pain of episiotomy
sutures or haemorrhoids. Increased thirst in early puerperium
and Slight intestinal paresis leads to constipation

WEIGHT LOSS: Rapid diuresis and diaphoresis during 2nd to Weight- 66kg reduced by
5th days after birth result in weight loss of 5 lb (2 to 4kg), in 3 kg
addition to approx. 12 lb (5.8 kg) lost at birth. Lochia flow- 2-3
lb(1kg) loss. Total weight loss- 19 lb. Additional weight loss
depend on amount of weight gain in pregnancy and active
measures to reduce weight.

FLUID LOSS: Net fluid loss of at least 2 liters during 1st 1 liter due to poor urine
week .Additional 1.5 liters during the next 5th weeks .The output.
amount depends on amount retained during pregnancy
,dehydration during labour and blood loss during delivery
BLOOD VALUES: Diuresis evident between 2nd to 5th day Absent
 after birth, as well as blood loss at birth, acts to reduce the added
volume accumulated during pregnancy.Rapid reduction occurs,
so that blood volume returns to its normal prepregnancy level by
2nd week after birth. Cardiac output rises soon after delivery to
about 60% above the pre labour value but gradually returns to
normal within one week.

RBC VOLUME AND HEMATOCRIT: It returns to normal by

the end of 1st week after the hydaemia disappears .Leukocytosis
to the extent of 30000 per cu mm occurs following delivery
probably in response to stress of labour .Platelet count decreases
soon after the separation of the placenta but secondary elevation Not done.
occurs with increase in platelet adhesiveness between 4-
10dyas .Fibrinogen level remains high upto the 2nd week of
puerperium resulting in persistent high level of esr in puerperium
as during pregnancy.A hypercoagulable state persist for 48hrs
postpartum and fibrolytic activity is enhanced in first 4 days.
MENSTRUATION AND OVULATION :
If the woman does not breast fed her baby, the menstruation
returns by 6th week following delivery in about 40% and by
12th week in 80% of cases. In non-lactating mothers, ovulation
may occur as early as 4 weeks and in lactating mothers about 10
weeks after delivery.A women who is exclusively breastfeeding,
the contraceptive protection is about 98% upto 6 months
postpartum. Thus, lactation provides a natural method of
contraception. However ovulation may precede the first
menstrual period in about one-third and it is possible for the
patient to become pregnant before she menstruates following her
confinement. Non-lactating mother should use contraceptive
measures after 3 weeks and the lactating mothers after 3 months
of delivery.

Absent.

LACTATION

DEFINITION:
Lactation is the process of milk secretion from the mammary glands of a mother soon after
childbirth. The milk, thus produced provides nutrition and immunity to the young one.
Galactopoiesis is the stage that maintains milk production and requires prolactin and oxytocin.
Breasts (BOOK PICTURE)

For the first two days following delivery, no further anatomic changes occur in the breasts. The
secretion from the breasts called colostrum, which starts during pregnancy, becomes more
abundant during this period.

Colostrum is a deep yellow, serous fluid that is alkaline in reaction. It has higher specific
gravity, protein, sodium, chloride and vitamin A content than breast milk. Carbohydrates, fat
and potassium content are lower than in the breast milk.

(PATIENT PICTURE):

Colostrum secreted.

Physiology of Lactation:

Lactation is initiated in all puerperal women normally and naturally unless effectively
prohibited by a lactation suppressant. Though some secretary activity is present (colostrum)
during pregnancy, it is accelerated following delivery and milk secretion actually starts on
third or fourth postpartum day. Around this time, the breasts become engorged, tense and
tender and feel warm. In spite of a high prolactin level during pregnancy, milk secretion is kept
in abeyance. The steroids estrogen and progesterone circulating during pregnancy are thought
to make the breast tissues unresponsive to prolactin. When estrogen and progesterone are
withdrawn following delivery of the placenta, prolactin begins its milk secretary activity in
previously fully developed mammary glands. The secretary activity (lactogenesis) is enhanced
by growth hormone, thyroxin, glucocorticoids and insulin.

Discharge of milk from the mammary glands (galactokinesis) depends on the suction exerted
by the baby during suckling and the contractile mechanism, which expresses the milk from the
alveoli into the ducts.

After initiation of lactation, its subsequent = continuation is dependent on the suckling

stimulus of the baby to the breast. During suckling, a conditioned reflex is set-up. The
ascending impulses from the nipples cause the posterior pituitary to liberate oxytocin, which
enters the circulating blood in the breasts and causes contraction of the myoepithelial cells -
surrounding the alveoli and ducts. The contraction of these cells expels the milk out of the
alveoli, through the ductile to the = lactiferous (storage) sinuses where it is readily = accessible
to the baby by compression of the sinuses as the baby sucks.

The milk ejection reflex is inhibited by factors such as pain, breast engorgement or adverse
psychic condition. The ejection reflex may be deficient for several days following e initiation
of milk secretion in some women and results in breast engorgement.

Maintenance of lactation (galactopoiesis) is achieved by the continued release of prolactin

from the anterior pituitary. For maintenance of effective and continuous lactation, sucking is
essential. It is not only essential for the S removal of milk from the glands, but also causes the
release of prolactin. Secretion of milk is is continuous process unless suppressed by
congestion, emotional disturbances or medication. Milk pressure reduces the rate of production
and hence periodic breastfeeding is necessary to relieve the pressure, which in turn maintains
the secretion.

The sucking propels the milk the final distance through the lactiferous ducts into the a baby's
mouth. The movement of milk from the lactiferous sinuses is called the "let-down" or "milk
ejection, and is felt by the woman as a specific event. Eventually the let-down can be triggered
without the actual sucking of the baby, by the mother's simply hearing the baby cry or thinking
about the baby. This is due to the influence of emotions on this mechanism. In such an event,
the milk may stream from the breasts and leak on to the mother's clothing. As the demand and
supply of milk stabilizes and lactation is well established, this profuse ejection of milk from
the breasts is less apt to happen.

Milk Production:

In the first postpartum week, the total amount of milk yield in 24 hours is calculated to be 60
multiplied by the number of postpartum days and is expressed in terms of milliliters. Thus, the
milk yield on the fourth day is about 60x4240 ml. A milk yield of 120-180 ml per feeding is
usual by the end of second week

Stimulation of Lactation

The methods that can be adopted during pregnancy include:

 Improving the maternal desire to breast feed the baby through education regarding
breastfeeding
 Care and preparation of the nipple.
Following delivery the mother should be encouraged to:

 Put the baby to breast as soon as possible after delivery.

 Nurse the baby every 2 to 3 hours without missing any feeding.
 Take plenty of oral fluids.
Suppression of Lactation:

Suppression becomes necessary if the baby is born dead or dies in the neonatal period or when
the woman does not want to breastfeed her baby or if breastfeeding is contraindicated. Either
hormones or mechanical means may be used to achieve suppression.

Drugs

1. Bromocriptine (parlodel) 2.5 mg orally twice daily for two weeks. This inhibits prolactin
secretion.

2. Ethynyl estradiol 0.05 mg twice daily for five days.

3. Combination of estrogen and testosterone preparation (mixogen), intramuscularly soon after

delivery.

Use of parlodel may be associated with early return of ovulation and hormonal preparations
carry the risk of thromboembolic complication.

Mechanical methods can be used effectively when lactation is to be suppressed after the
establishment of milk secretion. For this the woman should:

 Stop breastfeeding
 Not express or pump out milk from breasts Apply a tight compression bandage or
binder for 2 to 3 days.
 Analgesic tablets may be given to relieve pain

Care in Puerperium:

Immediate Care:

• Observed for minimum 2hours in labor ward : vital signs, bleeding, micturition.

• Uterus : well contracted. Bleeding: within normal limits

• Before shifting to ward:

>examine perineum, episiotomy site

>sterile dressing with antiseptic

• Relatives, food, fluids, good sleep

• Encourage early ambulation

Involution of Uterus:

• Assessed by noting height of fundus above symphysis pubis

• Day after delivery: 12 cm above symphysis

• 1cm decrease per day

• By end of 2nd week: no longer palpable

Care of Bladder

• Encouraged to void soon after delivery

• Doesn’t void within 6-8 hours : bladder atony

• Retention : common in early puerperium (esp. in epidural analgesia & traumatic delivery with
perineal lacerations) : vulvovaginal hematoma Uterine atony hemorrhage.

Urinary infection:- • Local analgesics• Catheterization (for 24 hours) till tone restoration

Care of bowels:

• Increase fluid intake & roughage

• Prescription of mild laxatives

Diet:

• Immediately start normal diet

• Plenty of fluids & milk daily : lactation

• Calorie & protein intake

• Additional daily requirement: 500kcal & 25g proteins

• Fresh fruits & green leafy veg : vitamins• Iron: continued for 3 months / whole lactating
period

Care of perineum:

• Regular antiseptic cleaning of episiotomy wound

• Wash with warm water & use sterile pads

• Analgesics
• Severe pain: hematoma

• Infection : antibiotics

• Episiotomy wound: healed by 3 weeks

Sleep and rest:

• Must be adequate,• Rooming in : baby on mother’s co

Early ambulation: • Venous thrombosis & embolism

Care of breast:

• Baby breast fed as soon as possible

• No frequent & early feeding engorged & painful

• Correct positioning &clean nipples

• Draw out retracted nipples

• Cracked nipples: painful : emollient creams after feeds.

Discomfort: • Episiotomy & perineal lacerations, breast engorgement & after pains ( uterine
contraction )• Caesarean section: pain at incision site, post spinal headache• Analgesics

Mood changes:• Common in early puerperium : postpartum blues• Reassurance & support.

Hospital stay

 Vaginal delivery: after 48hrs

 Caesarian section : 4-5 days

Advice to discharge:

1. Immunization of mother
 Anti-D IgG within 72hrs
 Rubella vaccine / MMR
2. Contraception
 Post partum sterilization
 Interval sterilization
 Counseling
3. Medications
 Adviced to avoid medications as far as possible
 Take only on medical advice
4. Infant advice
 Adequate follow up
 Rooming in
 BCG vaccine prior to going home
 Immunisation schedule
 Advice mother to feed on demand
5. Postnatal exercises
 Early in puerperium
 Move limbs, deep breathing exercises, abdominal muscle tightening exercises everyday
 Repeated 3-4 times a day
 Perineal muscle exercises: improve vaginal muscle tone, prevent vaginal laxity & stress
incontinence
 Back muscle toning

Postnatal check-up

• Scheduled at 6 weeks

• Maternal problems discussed

• Breast-feeding

• Lochia & menses

• Clinical examination, abdomen, breasts

• Local examination : episiotomy & discharge

• Pelvic examination

• PIH, GDM

• Any medical problems

• Advice on resuming job, coitus, other activities

Contraceptive advice: • Breast feeding alone won’t suffice as contraception• Various options
given, partner included• IUCD inserted if acceptable

• Other options which won’t reduce breast milk amount:-

 Progesterone only pill

 Injectable progestogens (depot medroxy progesterone acetate)
 Inform about possible side-effects
 Should avoid estrogen-pregesterone combination: affect quantity & quality of milk
 Permanent sterilizations: postpartum/ interval sterilization/

Infant:

• Seen by paediatrician

• Checked for any problems

• Weight , feeding problems

• Reinforce immunization schedule

Principles of puerperal care:

 Restoration of maternal health to prepregnant state
 Promotion of breast feeding
 Correction of any problems arisin Correction of any problems arising due to delivery
 Advice on baby care & immunization
 Contraceptive advices
NEWBORN ASSESSMENT

IDENTIFICATION DATA

Name of baby - B/O Ruma Deb

Age in days - 1day

Gender - male

Gestational age - 40 weeks

Type of delivery - NVD

Date and time of delivery- 8:15 am

Date of assessment - 31.8.21

APGAR SCORE

COMPONENT 0 1 2
HEART RATE 2
RESPIRATORY 2
RATE
MUSCLE 2
TONE
REFLEXES 2
COLOR 1
TOTAL 9/10
SCORE

Anthropometric measurement
Sl no Parameters Child value
1 Weight 3kg
2 Length 40cm
3 Head circumference 34cm
4 Chest circumference 32 cm

VITAL SIGNS

Characteristics Baby value

Temperature 37 0 C
Heart rate 140b/min
Respiration 36b/min
 General Assessment

 Appearance : good
 Body Built: good
 Sensorium: The sensorium of baby is good.
 Emotional state: The baby can feel any type of interest, distress or happiness.
 Posture: The baby lies in a “relaxed attitude” , limbs are extended.
 Foul Body Odour: The baby has no foul body odour.
 Foul Breath: The baby is not having any foul breath.

Skin condition

 Skin colour: The baby’s skin colour is pink and shiny.

 Temperature: The baby’s body temperature is 37 •c .
 Texture: The skin texture of baby is good.
 Turgor and elasticity: The baby’s skin turgor and elasticity is adequate.
 Edema / puffiness: The body of the baby is not edematous.

Hair

 Colour: The colour of the hair is black.

 Distribution: The hair is well distributed.

Nails

 Condition: The nail of the baby is short and soft.

 Angel Of Nail Beds: The angel of nail beds of the baby is good, there is absent of nail
deformity.

Nail bed colour : The colour of nail bed is pink.

b)HEAD AND FACE

 Skull: The baby had no caput succedaneum ,cephal hematoma & fontanelles are
opened.
 Cyanosis: Cyanosis is not present in baby’s body.

c)EYES

 Eye Brows: The eyebrows of the baby’s are symmetrical.

 Eye lashes: The eye lashes are developed.
 Eye lids: The eyelids are developed.
 Shape and appearance of eyes: The shape of the baby’s eye is symmetrical and the
appearance is good.
 Sclera: Sclera of the baby is white.
 Conjunctiva: pink in colour.
 Pupils: The baby’s pupils are reacting to light.
d)EARS

Appearance: Normal

Symmetry : symmetrical

Shape and size: normal

e)NOSE

The size of the baby’s nose is symmetrical. The shape of the baby’s nose is normal and in the
midline. The baby is having nasal flaring. No nasal discharge is present in the baby. The baby
is not having any nasal atresia and low nasal bridge.

f) MOUTH

LIPS

 Colour: The lip colour is pinkish

 Shape: The shape of the lip is normal.
 Condition: The baby’s lips is hydrated.
 Teeth: The baby is not having any natal teeth.
 Gums: The gums are well developed.
 Tongue: The baby’s tongue has no oral thrush.
 Oropharynx: The oropharynx is seen normal.
 Tonsils: The baby’s having no tonsillitis.
 Uvula: The uvula is present and also in midline.
 Parotid: The baby’s parotid gland is present.
 Submandibular: The baby’s submandibular gland is present.
 Sublingual: The baby’s sublingual gland is present.

g)NECK

The baby’s neck is symmetrical and also movable from side to side. There is absent of
fracture of clavicle, stiffness or rigidity, hyperextension , torticolis in the baby’s neck.

h)Thorax and Lungs

 Respiratory Rate: Found 36 breaths per minute.

 Rhythm: The rhythm is normal.
 Shape: The shape of the thorax and lungs is normal .
 Lung auscultation: normal breathing sound is heard.

Breast and Axilla

Witch milk is absent.

Distance between nipple 7.5 cm

Heart
  Heart rate: The heart rate of the baby is 140 beats per minute.
 Heart sound: Heart sound is normal. S1- s2 sound heard

i)Abdomen

i)Inspection

 Umbilicus: Normal
 Umbilical hernia: absent

ii)Palpation

 Liver: The shape of the baby’s liver is normal in shape.

 Spleen: The spleen size of the baby is normal.
 Tenderness: There is no tenderness.

iii) Percussion:

Ascities: There is absent of ascities.

iv) Auscultation:

Peristaltic movement: The peristaltic movement is good.

Bowel sound: heard

Percussion: No accumulation of fluid.

j)Genitalia

The scrotum of the baby is well pigmented and normal. Both testes are present in the scrotal
sac. There is absent of hypospadias, epispadias , phimosis, ambiguous genitalia , inguinal
hernia.

Rectum: The rectal opening is present in the baby’s body. There is no abnormality present in
rectum and anal canal such as anorectal malformation , Hirsprung disease etc.

k)Back:

The spinal curvature of the baby is normal. There is no defect present in spinal cord such as
tufts of hair, spina bifida cystic and spina bifida occulta.

Joints: The joints of the baby is movable.

l)EXTREMITIES

Upper extremities

The upper extremities of the baby is proportional length, there was no deformities seen in
upper extremities. The range of motion is normal. The baby is not having any fused or
webbed fingers. The baby is not having any extra fingers. There is absent of webbing fingers
in baby’s body.There is absent of clubbing of finger’s.

ii) Lower extremities

The baby has symmetry in both legs .The baby’s range of motion of lower extremities is
normal.

Barlow’s Sign: The baby has not having any type of barlow’s sign.

Ortolani’s sign: The baby has not having any type of ortolani’s sign.

REFLEXES:

Sl Book picture Patient Picture

no
 REFLEXES
Reflexes are involuntary movements or
actions that help to identify normal brain and
nerve activity. Some reflexes occure only in
specific period of development .The
following are some of the reflexes seen in
newborns.
ROOTING REFLEX
1. Present at birth
Dissappears by about 4 month after birth The baby’s rooting reflex present.
Begins when the corner of the baby’s mouth
is stroked or touched.
The baby turns the head and opens the
mouth to follow and “root” in the direction
of the stroking. This helps the baby to find
the breast or bottole to begin feeding.If this
reflex doesn’t vanish in 3-4 months, the CNS
may be malfunctioning.

2. SUCKING REFLEX
Begins about the 32nd week of pregnancy. The baby’s sucking present and can suck
Is not fully developed until about 36 weeks . properly
Disappears by 4 months after birth
Premature babies may have weak or
immature sucking ability.
A finger or nipple placed in baby’s mouth
will elicit rhythmical sucking.
Depressed sucking may be due to medication
given during childbirth.

Sl Book picture Patient Picture

no
3. MORO REFLEX The baby’s moro’s reflex present.
Present at birth
Disappears by about 4-5 months after
birth
 Often called a startle reflex because it
usually occurs when the baby is
startled by loud sound or movement.
In responsze to the sound , the baby
throws back the head ,extends the
arms and legs, cries, and then pulls the
arms and legs back in.
Or
Baby is held horizontally ,then
swiftly ;lowered a few inches, or the
head may be lowered a few inches, or
a loud sudden noise will make baby’s
arms fling out and then come together
as hands open the clutch.
Absence or weakness of this reflex
may suggest a severely disturbed
CNS.

4. TONIC NECK REFLEX

Appears about 2 months after birth The baby’s Tonic neck reflex is present and
Disappears by about 6-7 months after active.
birth
When the baby’s head is turned to one
side , the arm on that side stretches out
and the opposite arm bends up at the
elbow
Often called the fencing position

5. PALMER GRASP REFLEX

Present at birth The baby’s palmer grasp reflex is present and
Disappers by about 2-3 months active.
Stroking the palm of a baby’s hand
causes the baby to close the fingers in
a garsp
Reflex is stronger in premature babies
OR
By pressing just one of baby’s palms,
fingers should grasp the object.
Absence or weakness of this reflex
could reflect an injured spinal cord or
depressed CNS

Sl Book picture Patient Picture

no
6. BABINSKI REFLEX The baby’s babinski reflex is present.
Baby’s foot is stroked from heel
toward the toes. The big toe should lift
up, while the others fan out.
Absence of reflex may suggest
 immaturity of the CNS, defective
spinal cord, or other problems.
Reflex may be seen up to age one,
andthen reaction will be reversed with
the toes curling downward.
7. DOLL’S EYE REFLEX
While manually turning baby’s head, The baby’s Doll’s eye reflexed is present and
his eyes will stay fixed, instead of active.
moving with the head.
While normally vanishing around one
month of age ,if it reappears later,
there may be damage to the CNS.’
8. GALANT REFLEX:
While stroking baby’s back to one The baby’s Galant reflex is present and
side, her spine and trunk will arch active.
toward that side.
Absence may indicate spinal injury or
depression of the CNS.

9. PEREZ REFLEX:
Firmly stroking baby’s spine from tail The baby’s perez reflex is present
to head ,will make her cry out and
head will rise.
If this reflex does not vanish in 4-6
months, baby’s CNS may be severely
depressed.
10. PLANTER’S GRASP: The baby’s Planter grasp reflex is active. I
Pressing thumbs against the balls of placed the thumb in baby’s finger and baby
baby’s feet will make his toes flex. can flex the toe .
Absence of this reflex may indicate
damage to the spinal cord.

11. WITHDRAWAL REFLEX: The baby’s withdraw reflex is active

A Pinprick to the sole of baby’s foot
will make baby’s knee and foot reflex.
Absence of this reflex could indicate a
damage sciatic nerve.

X. GROWTH AND DVELOPMENT

Stages Book picture Patient picture

a) Physical Physical development:
developme  Weight: Average birth weight of newborn is
nt: 2.5 kg.It decreases by 10% in first 10 days of  Baby’s weight is
3kg.
1.Gross life and then increases at the rate of 500-600
motor
 2.Fine
gm per month during first 6 month.
motor

 Length: At birth, the length of newborn is 45-

 Lenght of the
50 cm. It increases approximately 2- 2.5 cm
baby is 40 cm.
per month during first 6 months.

 Head circumference : At birth , it is

 Head
approximately 33-35 cm and increases at the
circumference of
rate of 1.5 cm per month during first 6 month . the baby is 34 cm.

 Chest circumference: It is about 31-33 cm.

 The chest
circumference is
 Heart rate is 130+ 20 beats / minute
32 cm.
 Heart rate is 140
 Respiration is 35 + 10 breaths / minute. beats/minute.

 Blood pressure 80/50 + 20/10 mm Hg.  Respiration of the

baby is 36 breaths/
min.
Gross motor
 Flexed posture with elevated
The baby lies in relaxed
pelvis, but knees not under
attitude with limbs
abdomen unlike at birth. extended.
 Head lag presents when pulled
from supine to sitting position.

Stages Book picture Patient picture

  The baby lifts head
 Lifts head momentarily momentarily when held
when held upright. upright.
 Turns head from side to side  Turns head from side to
in prone position. side in prone position.
 Head sags when held in  The baby’s head sags when
sitting position. held in sitting position.
Fine motor  Hands tightly fisted.
 Hands tightly fisted.  The baby can grasps object
 Grasps object with strong strongly

palmer grasp, but drop

immediately.

b) Psychoso Stage 1: Trust vs. Mistrust

cial
 The baby developed trust
developm The first stage of Erikson's theory of
ent utterly on caregivers.
psychosocial development occurs
between birth and 1 year of age and
is the most fundamental stage in
life. Because an infant is utterly
dependent, developing trust is based
on the dependability and quality of
the child's caregivers. At this point
in development, the child is utterly
dependent upon adult caregivers for
everything they need to survive
including food, love, warmth,
safety, and nurturing. If a caregiver
fails to provide adequate care and
love, the child will come.

DELIVERY NOTES
Date and time of delivery- 30/06/21 at 8:15 am

Duration

First stage- 10 hours

Second stage- 2 hours

Third stage- 15mins

On PV

 Os fully dilated at 7:00 am 30/06/21

 Membranes ruptured at 5:00 pm 29/06/21

Mode of delivery

Normal vaginal delivery

Baby born on 30/06/21 at 8:15 a.m

Gender - male

Time - 8;15 am

Weight - 3kg

Apgar score -9/10

Condition - good

Placenta

 Delivered at 8:30 am

 Weight- 508 gm

 Length of cord- 60 cm
 Estimation of placenta and membranes- adequate and no cotyledons are absent

 Vaginal bleeding- normal.

PROGRESS NOTES

DATE CONDITION OF MOTHER CONDITION OF CHILD

30/06/2021 good good

NURSING DIAGNOSIS

 Acute pain, discomfort related to mechanical trauma, edema / tissue enlargement or

distention, hormonal effects.

 Self-care Deficit related to the weakness of the body.

 Breastfeeding ineffective related to the level of knowledge, previous experience, the

baby's gestational age, level of support, the structure of the physical characteristics of
the breast.

 Risk for injury related to biochemistry, regulatory functions (eg orthostatic

hypotension, eclampsia); the effects of anesthesia; thromboembolism; abnormal blood
profile (anemia, rubella sensitivity, Rh incompatibility).

 Risk for infection related to tissue trauma and / or damage to the skin, decreased
hemoglobin, invasive procedures and / or an increase in environmental improvement,
rupture of membranes in a long time, malnutrition.

INPUT
EXTERNAL ENVIRONMENT
 Pain in episiotomy area
 Constipation
 Impaired of Personal hygiene
 Weakness of the body
 Ineffective breastfeeding
 Risk of Infection
 Failed to pass urine
INTERNAL ENVIRONMENT
 Pain Scale- 6
 Temperature – 98.40 F
 BP- 110/80 mm.hg
 REEDA score- 12/15
 Pad changed:2-3
 Urine output: 20ml
FEEDBACK
ROY’S ADAPTATION THEORY
INTERACTION CAPSULE OUT PUT
 Acute pain, discomfort related to
FOCUSSTIMULUS mechanical trauma
 Sleeping disturbance related to improper
 Acute pain rest and ambulance as evidence by  Pain scale: 8/10
 Sleeping disturbance hospitalization.  Temperature: 98.40 F
 Ineffective of  Breastfeeding ineffective related to  BP: 120/80mm.hg
breastfeeding knowledge deficit.  REEDA Score: 14/15.
 Abdominal tightness  Abdominal tightness related to
 Pad changed: 6-8 a day
 Patient can’t move constipation.
 Urine output: 50 ml
properly.  Weakness of the body related to
delivery.  Sitz bath reduced the pain.
 Incomplete emptying
 Impaired urine output related to  Patient feel fresh after taking
of bladder.
incomplete emptying of bladder. rest.
 Personal hygiene  Impaired personal hygiene related to  Patient can feed the baby
impaired. deficite of knowledge.
properly by breastfeeding
IMPLIMENTATION technique.
CONTEXTUAL
 Provide sitz bath and Ibuprofen and
STIMULUS  Isobgol and fibrous food
antispasmodic to reduce pain.
provided for bowel clearance.
 Pain Scale- 6  Provide proper rest and ambulance to
 Catheterized the patient and
feel fresh.
 Temperature – 98.40 F urine output increased.
 Provide fibrous food or isabgol husk for
 BP- 110/80 mm.hg bowel clearance.  Advised to maintained
 REEDA score- 12/15.  Provide catheterization to pass the urine. personal hygiene and patient
RESIDUAL STIMULUS  Shown the Breastfeeding technique. feels comfort.
Nothing significant  Advise for maintaining personal
hygiene.
HEALTH EDUCATION

Rest and sleep:-

Advice about the importance of rest and sleep to feel fresh and can feed baby without
any obstacles.
Nutration:-
Teach importance of nutritions food like green leafy vegtables , fruits etc. advices to
regular intake of iron rich food , protein rich food and minerals. Advice to take laxative
foods. During breastfeeding complete one breast then go to another breast for good feedig.
Personal hygiene and breast care:-
Teach about importance of oral hygiene and need for daily bath in warm water. Teach
about cleaning breast lukewarm ater and adviced to pull out nipple between thumb of index
finger. Breast self examination should be done .
Regular checkup
Teach the importance of regular cheek up . encourage to came for follow up and
information about investigation to be done.
Breast feeding:-
Teach the importance of breast feeding and benefit for the baby . teach about the
techniques of breast feeding.
Immunization of baby :-
Nurse should teach about the immunization schedule for the baby.
Family planning
Teach about temporary and permanent method of family planning. And the health care
facilities available in the hospital.
BIBLIOGRAPHY:

1. Datta, P. (2014). Pediatric Nursing (3rd ed.). New Delhi, India: Jaypee Brothers

Medical.
2. Jacob, A. (2017). Manual of midwifery and gynecological nursing (3rd ed.). New
Delhi, India: Jaypee Brothers Medical.
3. Konar, H. (2017). DC dutta’s textbook of obstetrics (9th ed.). New Delhi, India:
Jaypee Brothers Medical.
 TRIPURA COLLEGE OF
NURSING
CASE PRESENTATION
ON
BREAST ENGROGEMENT

WARD: POSTNATAL WARD

SUBJECT:
OBSTETRICS AND GYNAECOLOGICAL
NURSING

SUBMITTED TO, SUBMITTED BY,

Ms. Sutapa Paul Miss. Sharmistha Debnath

Professor of TCN Roll: 07

Msc. Nursing,2nd Semester