Midwiferey Care Study

Midwifery Care Study of a Mother with a Normal Pregnancy at Ruiru Sub-District Hospital

October, 2012 1. Care Study of a Mother with a Normal Pregnancy at Ruiru Sub-District Hospital This work describes the care study of an expectant mother (Irene Magiri Karuthui) comprising of the care processes carried out for the client throughout her antenatal visits, the delivery process and the postnatal period. The new approach to Antenatal Care (ANC) emphasizes the quality of care rather than the quantity. In fact, for normal pregnancies, World Health Organization (WHO) recommends only four antenatal visits through focused antenatal care (FANC) aimed at helping expectant women maintain normal pregnancies through identification of pre-existing health conditions, early detection of complications arising during the pregnancy, health promotion and disease prevention, and birth preparedness and planning for complication readiness. In this care study report, the care provided to Irene will be described against the background of the recommended FANC and the health care policies of public health institutions in Kenya. Kenya introduced the comprehensive FANC service package as recommended by WHO, with additional components to respond to national health needs. The new components include Prevention of Mother-to-Child Transmission of HIV (PMTCT), intermittent presumptive treatment of malaria, developing an individual birth plan, tuberculosis (TB) screening, detection and treatment, and education on various topics, including rest, nutrition, and exercise in pregnancy, breastfeeding information, family planning, and planning for postpartum care, all of which were provided to the client in this care study with the exception of intermittent malaria treatment and TB screening. The work covered in this care study includes the ANC profile of the mother, the health care and education provided during the ANC visits, the prenatal home visit, the delivery process, and the postnatal period including the postnatal home visit before the professional relationship established at the beginning of this care study was terminated.
2. Client’s Profile
Maternal Profile
 Name: Irene Magiri Karuthui
 D.O.B: November 13, 1982
 Age: 29 years
 Phone Number: 0714477146
 ANC Number: 1796/11
 Marital status: Married
 Occupation: House Wife
 Level of Education: Secondary
 Residence: Gitambaya, Ruiru
 Parity: 1+0
 Next of kin: James Karuthui
 Last Menstrual Period: July 2, 2011
 Expected Date of Delivery: April 9, 2012
 Health Facility Attended: Ruiru Sub-District Hospital Gynaecological History
 Age When Menarche Began: 16 years
 Type of Menstrual Flow: Moderate Flow
 Frequency of Menstrual Flow: Regular
 Duration of Menstrual Flow: 4 days
 Length of Menstrual Cycle: 28 days
 Last Menstruation: July 2, 2011

3. Prenatal Period
3.1 First Prenatal Visit The client attended her first Antenatal Clinic visit for this second pregnancy on December 7, 2011. Her maternal profile was established and recorded as shown in the client’s profile. This was the second pregnancy for this client. She had never had any miscarriage or abortion. She had one male child who was born on December 18, 2009 with 3.2 kilograms weight through spontaneous vertex delivery. The child is alive and healthy. As far as the second pregnancy was concerned, Irene had her Last Monthly Period on July 2, 2011, thus making her Expected Date of Delivery to be April 9, 2012.
Family and Social History Irene is the second born in a family of seven siblings. She is married to James Karuthui with whom she has one other child, and they were expecting their second born in this pregnancy. There is no history of twins from both the paternal and the maternal sides. The client neither smokes nor abuses alcohol or any other substance. There is no history of allergies, chronic illnesses or genetic diseases in the family.
Medical/Surgical History Irene has never suffered any severe illness or been hospitalized. She also has never undergone any surgical operation or undergone blood transfusion. This client has no known allergy to foods or drugs.
Previous Pregnancy The client was para 1+0, meaning that this was her second pregnancy. In her first pregnancy in the year 2009, Irene attended four ANC visits before delivering a mature male infant through Spontaneous Vertex Delivery in Ruiru Sub-District Hospital. The labour lasted 18 hours and the baby weighed 3.2 kilograms at birth. The mother had a normal puerperium with no complications and the child is alive and well.
Physical Examination Physical examination on the first antenatal visit for this client revealed a fair general condition and no abnormalities were detected in the cardiovascular, respiratory and other body systems. There were no anomalies such as discharge in the breasts and genitalia of the client. The report also indicated a normal gastrointestinal system. The client weighed 70 kilograms on this day. On palpation, the fundal height was at 22 weeks, with a cephalic presentation, longitudinal lie and a foetal heart rate of 132 beats per minute. Foetal movements were also felt.
Antenatal Profile The mother was taken through a number of tests to determine her antenatal profile for this pregnancy. Blood grouping indicated that Irene has Blood Group B+ and Rhesus Factor positive. Her serology tests for VDRL showed negative results and PITC revealed a non-reactive HIV status on this date (December 7, 2011). Urinalysis test showed no puss, cells or proteins and the test for Malaria Parasite had negative results. The mother had no pallor and urinalysis indicated no abnormalities. She had a blood pressure of 120/70mmHg and a haemoglobin content of 12.0 grams per decilitre.
Preventive Services This being the second pregnancy, the mother was given the third dose of Tetanus Toxoid (T.T. 3) to protect the baby from neonatal tetanus. She was also given Iron and Folate supplements to increase her haemoglobin content, Mebendazole for deworming and an Insecticide Treated Net (ITN) to protect her from malaria-transmitting mosquitoes.
Health Education and Counselling The client attended health education and counselling given during this clinic regarding proper nutrition and personal care during pregnancy. Education was also given on infant feeding and exclusive breast feeding. The client was also counselled and tested for HIV. The date for the next visit was set to be January 3, 2012.
3.2 Second Prenatal Visit The client visited the Ruiru Sub-District Hospital for her second prenatal clinic on January 3, 2012. The findings during this visit were documented as follows:
 Urinalysis: no abnormalities we detected
 Weight: 71 kg
 Blood Pressure: 110/70 mmHg
 Haemoglobin: 11.9 g/dl
 Pallor: No pallor was observed
 Foetal Maturity: 22/40
 Fundal Height: 22/40
 Presentation: Cephalic
 Lie: Longitudinal
 Foetal Heart Rate: 132 beats/minute
 Foetal Movements: Present
The client reported no complaints about her pregnancy and general health. She was educated in a group of other expectant mothers about proper nutrition during pregnancy, avoidance of heavy work and the importance of sleeping under an insecticide treated mosquito net. The date of the third ANC visit was set to be on January 30, 2012.
3.3 Third Prenatal Visit
The mother attended her third ANC visit on January 30, 2012 and this is when the rapport to conduct the care study with the client was established. Irene consented to participating in this care study after discussing with her the full details and requirements of the study, leading to establishment of the professional relationship that was to last from this date up to the postnatal period when the care study would be terminated at the appropriate time. Her Maturation by Dates was 30 weeks and 2 days. The pregnancy was progressing well and there are no indications of any imminent complications.
Physical Examination
The client’s vital signs were taken and recorded as follows:
 Blood pressure: 105/70 mmHg
 Pulse: 76 beats per minute
 Respirations: 20 breaths per minute
 Weight: 72 kg
Head-to-Toe Physical Examination
On careful observation, the client appeared healthy and pregnant no obvious pallor, dehydration, jaundice, oedema, or cyanosis. A thorough systematic physical examination was conducted through inspection, palpation, and auscultation as necessary from the head to the toe and the findings were as described below.
Head: The mother had well-kept hair with no obvious signs of alopecia, wounds or fungal infections on the scalp. No dandruffs were observed.
Eyes: The eyes were symmetrical in both shape and size. There was no pallor or jaundice noted and no discharge was detected.
Ears: The ears were symmetrical and normally positioned. They were clean and there was no discharge or exudate from the ears. The parotids were non-tender and not swollen.
Nose: The nose was symmetrical with a normal non-deviating nasal septum. Nostrils were clean and patent and no discharge was observed.
Mouth: The mouth was clean, moist and all teeth were present. No central cyanosis was noted on the mucosal membranes. There was no stomatitis or halitosis in the client’s mouth.
Neck: Neck was symmetrical and no obvious scars, swelling or enlargements were observed.
Chest: On inspection, the skin was normal with no scars, rashes, hypopigmentation or hyperpigmentation. The breasts were symmetrical in shape and had no discharge. Nipples were retracted. The axilla region had no lymphadenopathy or masses.
On auscultation with a stethoscope, the respirations were normal and no murmurs were heard.
Palpation indicated no tenderness or masses on the breast tissue. There no physical indications of tumours. The client was educated on how to perform a self-breast examination (SBE) and report any abnormal findings such as lumps and masses to the hospital for appropriate intervention.
Abdomen: On inspection the abdomen was distended and assumed a globular shape, thus indicating a pregnancy. Striae gravidarum and linea nigra were present. On Palpation, there was no organomegally or tenderness detected. The fundal height was approximated to be 30 weeks. Other important findings were as follows:
 Presentation: Cephalic
 Lie: Longitudinal
 Position: Right Occipital Anterior
 Foetal Heart Rate: 136 Beats/Minute, Regular
Lower Extremities: There was symmetry of both lower limbs with all the digits were all present. The limbs had no pallor and no oedema was noted on the lower limbs and around the ankle area.
Review of Body Systems
Cardiovascular System: On auscultation, S1 and S2 were heard and there was no murmur. The client reported no complains.
Respiratory System: There were no additional breath sounds, no ronchi or wheeze. The client reported no complains.
Gastrointestinal System: The client complained of vomiting in the morning resulting from nausea due to consumption of anything in the morning. Advised to take a snack before getting out of bed in the morning and eat later in the day. No complaints were raised regarding elimination pattern, that is, there was no constipation or diarrhoea.
Genital Urinary System: The client reported no difficulty in passing urine, no lower abdomen pain or disturbing vaginal discharge, no incontinence or increased urgency.
Musculoskeletal System: Her skeletal formation had no deformity. Other than the striae gravidarum and linear niagra, there were no other scars on the muscular structure. She reported no complain regarding her muscle function and her bones.
Central Nervous System: The client reported no numbness experienced, no complains of her visual capability or her memory. There was no complains of headaches.
Health Education
A number of important health messages were shared with the client as outlined below:
 The client educated on the importance of taking a balanced diet made up of carbohydrates, vitamins, proteins and minerals. The client was also advised on taking sufficient clean water.
 Health messages on the importance of sleeping under an Insecticide Treated Net (ITN) were shared in order to prevent contracting malaria in pregnancy.
 Appropriate education was provided on the identification of danger signs of pregnancy including vaginal bleeding, severe headache and severe backache. The client was advised to seek medical attention immediately on identification of any danger sign.
 The client was also instructed to avoid straining and standing for too long to reduce edema of the lower limbs. She was also advised to have her legs raised during rest to improve peripheral circulation
 More health messages were shared on proper personal and environmental hygiene and self-care.
 The necessary education regarding adequate rest and sleep during pregnancy were reemphasized.
 The importance of ANC clinics was discussed and mother reminded of her next appointment.
3.4 The Fourth (Last) Antenatal Visit Attended As advised during her previous (third) antenatal visit on the January 30, 2012, the client showed up for the fourth visit on March 12, 2012. This was her last antenatal visit as gestation by weeks indicated that she was 36 weeks pregnant. Examination of the client was done as per the requirements of the last antenatal visit and documentation was done as indicated below.
Physical Examination
Irene was well-dressed in clean and appropriate maternal dressing and flat shoes. She looked well-nourished and had no signs of anxiety or depression. The mother generally appeared healthy with jaundice, cyanosis, pallor and dehydration having been ruled out.
Vital Signs
Blood Pressure: 110/70 mmHg
Pulse Rate: 76 beats per minute
Respirations: 22 breaths per minute
Weight: 74 kilograms
Head-to-Toe Examination
A systematic head-to-toe examination was conducted through inspection, palpation and auscultation and the findings were documented as below.
Head: On inspection the mother’s hair was well kempt. There were no signs of alopecia and fungal infections on the scalp.
Eyes¬: The eyes were symmetrical normal in shape and size. No pallor, jaundice or discharge was noted.
Ears: The ears were symmetrical, normal in position with no discharge. Parotids were non-tender and not swollen. Nose: The nose indicated a normal nasal septum. Nostrils were patent and no discharge was seen.
Mouth: The mouth was inspected and there was no central cyanosis in the mucous membranes in the mouth which could indicate a hypoxic state in the client.
Neck: Neck was symmetrical and no obvious enlargements were observed and masses or lymphadenopathy were ruled out.
Chest: Inspection revealed normal skin coloration of an African with no hypo-pigmentation or hyper pigmentation and no scars were observed. There were no obvious masses on observed on the chest and respirations were symmetrical. On palpation, the axilla region had no lymphadenopathy or masses. On auscultation the respirations were normal and no murmurs were detected. The breasts were symmetrical in shape and had no discharge and the nipples were not retracted. The breast tissue was non -tender and no masses or tumors were felt on the breasts. They were not dimpling. Breasts had no lumps. The client was educated on how to perform a self-breast examination (SBE) and report any abnormal findings such as lumps to the hospital for appropriate intervention.
Arms: On inspection the fingers were symmetrical and had no koilonychias which could be indicative of iron deficiency anaemia was observed. Tremors and tetany were ruled out. The nails were pink, concave and thin and no pallor, koilonychias were not observed. The palms were not pale and had no other congenital malformations.
Abdomen: On inspection the abdomen was distended and globular in shape. Striae gravid arum and linea nigra were present. On Palpation no organomegally, and there was no tenderness over the woman’s kidney area.
Fundal height was approximated to be at 36/40 weeks.
Presentation: Cephalic
Lie: Longitudinal.
Position: Right Occipital Anterior.
On auscultation foetal heart rate was regular beating at 138 beats/minute.
Genitalia: The client reported that there was no problem abnormality in the genitalia.
Lower Extremities: The skin on the extremities was smooth with no lesions or scars. No sign of oedema and dehydration were seen. Skin was of moderate temperature thus no risk of deep venous thrombosis. The extremities were symmetrical with no obvious signs of swelling or injury. The digits were also symmetrical and no extra digits were observed. No oedema was noted on palpation. The calf of the legs was non-tender.
Health Messages Shared on the Last (Fourth) Antenatal Visit
The following health messages were shared with the client regarding the general health, pregnancy, and the expected delivery:
 The client was advised on the importance of taking a balanced diet consisting of carbohydrates, vitamins, proteins, minerals and adequate water.
 The client was also educated on the importance of sleeping under ITNs so as to reduce the chance of getting malaria in pregnancy.
 Minor disorders of pregnancy were highlighted and revisited with the client as well as their management.
 The client was cautioned on use of un-prescribed drugs as such drugs may have an impact on the development of the foetus.
 Importance of fresh air, moderate exercise and adequate sleep were emphasized to ensure that the client remained health throughout her third trimester. She was also advised to avoid heavy luggage.
 Danger signs of pregnancy (frontal headache, vaginal bleeding, and severe leg oedema) were highlighted to the client. She was advised to seek medical attention immediately once she experienced them.
 Proper personal hygiene, self-care, adequate rest and sleep were reemphasized.
 The individualized birth plan was revisited to ensure that the client and her family remained adequately prepared for the expected delivery and childcare.
Return Date
The client was advised that labour and delivery may occur on the expected date of delivery, or anytime within two weeks before or after the expected date of delivery (April 9, 2012). She was advised to look out for the true signs of labour as taught and report to the facility immediately to avoid any complications. She was also advised to show up at the facility immediately in case of any danger sign of pregnancy or any other health problem requiring specialized attention.
3.5 Prenatal Home Visit
A prenatal home visit to the client’s home was carried out on Saturday March 31, 2012 at 2 p.m. in the client’s residential home in Gitambaya, Ruiru.
The objectives of this prenatal visit were as follows.
 To identify self to the family and familiarize with other family members (the husband and their first-born child).
 To assess the environment surrounding the family with regard to their health and any environmental risks to the pregnancy.
 To evaluate the family’s preparedness for the delivery process and care for the expected baby.
 To assess the family`s support system during the pregnancy in terms of attitudes, feelings and expectations concerning the pregnancy and the expected child.
Observations Made During the Visit
The family members and neighbours were friendly and welcoming. They client’s husband was present and eager to know of the outcome of her spouse`s pregnancy. He reported his willingness and readiness to welcome the second-born member into their family.
The compound was clean, neat and well-tended. The client lived together with her husband in a two bed roomed house. The house was adequate for the family. The rooms were well furnished with adequate space, good lighting and ample ventilation.
The family uses piped water from community water project. The water is clean and safe for use. They use water treatment agents (Waterguard) to purify the drinking water.
They use bins to dispose their kitchen and other household waste and dispose them in a rubbish pit outside their compound.
The family usually thrives on a balanced diet. Most of the times, their food comprises of githeri, rice and ugali taken with, beans, 'sukumawiki ', and occasionally chicken, beef or fish as stew. The family also buys fruits at least once every week from the local market.
The perishable foods like fruits and vegetables are bought in small quantities from the local market to avoid wastage through rotting while the non-perishables like maize and beans are stored while dry inside the house.
The client ensures that she takes a balanced diet, and eats many fruits to boost her health and immunity. At night she sleeps under an insecticide treated mosquito net to protect herself from mosquito bites and hence, from malaria. She also ensures a personal hygiene by taking daily baths, putting on clean clothes and ensures environmental hygiene by maintaining a clean house, compound and other environments she frequently visits.
In preparation for the arrival of the new-born baby, adequate clothes for the baby were already in place. These included a baby 's cot and enough unisex baby clothes, shawls and napkins. Both the husband and the wife were happy and eagerly waiting for the new-born.
Health Education
This being the last contact with the client until the time of delivery, the relevant health messages were shared as follows:
 The client and her family were advised on the importance of continuing taking a balanced diet made up of carbohydrates, vitamins, proteins, minerals and adequate water.
 She was also educated on the importance of sleeping under an Insecticide-Treated Net to reduce the chance of getting malaria in pregnancy through mosquito bites.
 Irene and her husband were educated on the danger signs of pregnancy to include vaginal bleeding, severe headache, gush of fluid from the vagina, swelling of lower limbs, and severe backache. They were advised to seek medical attention immediately once she experienced them.
 The true signs of labour were discussed with the client and her husband. They further enlightened on recognizing true labour in good time and reporting to the chosen health facility immediately for safe delivery.
 She was also advised to avoid standing for too long to reduce peripheral oedema of the lower limbs and to have the legs raised as she rests to improve peripheral circulation
 Proper personal hygiene, self-care, adequate rest and sleep were reemphasized.
 The importance of delivering the child in hospital with the assistance of a certified birth-attendant was discussed.
Finally, to ensure that the pregnancy progressed on well and to guarantee adequate preparation for the safe delivery of a health child and the care thereafter, Irene’s individualized birth plan was revisited as follows:
 The exact expected date of delivery was discussed. The expected date of delivery was April 9, 2012.
 The choice of a birth partner (to accompany client to hospital on the day of delivery). The client identified one of her close neighbour to be the birth companion.
 The specific health facility for delivery was discussed. She preferred Ruiru Sub-District Hospital because it is the nearest health facility with a labour and a maternity ward.
 Source of funds for hospital bill was discussed. She said that she and her husband had budgeted for the expected delivery process and for any emergency.
 Means of transport to health facility was discussed. She said that the husband would arrange for transportation to the facility with a taxi a week before the expected date of delivery for convenience.
At the conclusion of the visit, the client and her husband appreciated the visit, and were more than willing to continue caring for their family especially with the expectation of a second-born into their family.
4. Intra-partal Period
4.1 First Stage of Labour
The mother went to Ruriru Sub-District Hospital on April 10, 2012 at around 2:30 p.m. in the company of her sister. She complained of lower abdominal pains which were increasing in duration and intensity and radiating to the back. She reported that the pains had started early that morning. On admission, a general physical examination was conducted and the findings were as follows.
General appearance: The client looked strong but very anxious with no pallor, jaundice or cyanosis. Dehydration was ruled out.
Abdominal Examination: A systematic abdominal examination was done using examination techniques, that is, inspection, palpation and auscultation (Bennett, 2001).
Inspection: The abdomen was globular in shape and distended. Linea nigra and striae gravidurum were present. No pulsations detected, no signs of multiple pregnancy detected.
Palpation: No splenomegaly, liver was non palpable. No guarding or tenderness was detected. The patient’s bladder was empty. Other findings from palpation were as listed below:
 Presentation -cephalic
 Lie - longitudinal.
 Fundal height- 38/40weeks
 Position - left occipitoanterior
 Descent -3/5 downwards
 Fundal height- 38/40
Auscultation: Foetal heart beat was heard. Foetal heart rate was 136 beats/min, was clear and regular.
Findings on Vaginal Examination:
 External genitalia: No presence of FGM scars
 Vagina was warm and moist
 Cervix: well effaced; cervical dilatation was 6cm
 There was show
 Membranes were intact
Pelvic Examination: Chinombo (2007) suggests pelvic examination as a means of determining adequacy of the pelvis for delivery of the baby. It was evaluated and the following findings were recorded:
 The Ischia spines were blunt
 Sub-pubic angle was greater than 900
 The sacral promontory was not prominent
 Intertuberous diameter well accommodated four knuckles
Amniotomy: Amniotomy (Artificial rupture of membranes) was done and the liquor was clear. Following amniotomy, another vaginal examination (VE) was done to rule out cord prolapse as recommended by Ebrahim et al. (1998).
Vital signs:
 Blood pressure-120/80mmhg
 Pulse-76 beats per minute
 Respirations- 20 cycles per minute
 Temperature- 36.60 Co
The client was admitted into the first stage room for monitoring and management of labour. According to Bonnie (2001), it is of utmost importance to get the patient to be involved in all the stages of labour. One way of involving mothers is by informing them about the labour process as well as giving them health education. Health education given to the patient included:
 To empty the bladder regularly to avoid obstructing the descending of the head.
 To breathe through the mouth to avoid premature pushing of the infant and also to prevent foetal hypoxia.
 To lie on left lateral position to enhance blood supply to the foetus.
 To report when she feels like bearing down to the immediate midwife
 To rub her back during contraction to relieve pain.
Foetal heart was auscultated every 30 minutes and blood pressure taken half hourly. The results were appropriately recorded in the patient’s file and the partograph. Vaginal examination was done after four hours; the patient’s cervix was fully dilated, an indication of the second stage of labour.
4.2 Second Stage of Labour
Full dilatation of the cervix was confirmed at 8:26 p.m. and the client was advised to lie in lithotomy position and encouraged to bear down during contractions and to relax between contractions. The foetal heart was auscultated as recommended after every contraction (Van De Broek, 2008). The client was advised to hold her breath and assisted to gently lift the head when bearing down to aid in delivery. During relaxation, the client was advised to breathe deeply through the mouth to prevent foetal hypoxia. The client gave birth to a live male infant at 8:42 p.m. by Spontaneous Vertex Delivery. She was shown the sex of the baby and she confirmed it correctly. She was then congratulated for her co-operation and for the successful gestation and delivery.
Immediately after delivery of the baby, syntocinon 10 IU were given intramuscularly to facilitate contraction of the uterus and reduce bleeding and aid placental separation from the uterus in the third stage of labour. APGAR score done at one minute was 9/10 and at five minutes was 10/10. An identification tag was put on the baby who was wrapped in warm towels. The assistant nurse weighed the baby and reported that he weighed 3.6kgs. Baby was given vitamin K 0.5ml stat dose to prevent haemorrhagic disease of the new-born. 1% tetracycline eye ointment was applied as a prophylaxis against ophthalmic neonatorum. All the procedures were documented as appropriate in the patient’s file.
4.3 Third Stage of Labour
A gush of blood per vagina was detected together with lengthening of the cord and these two signs indicated placental separation (Katharyn 2002). A vaginal examination was done to confirm separation. The placenta was removed through active management of third stage of labour (AMTSL) which involved controlled cord traction (CCT) to ensure no placental products remained in the uterus (K’Okul, 2001). The uterus was massaged gently to expel products of conception (POCs) that could be still within the uterus. The placenta and membranes were then examined for completeness, infarcts, retro-placental clots and other abnormalities.
The placenta and membranes were found to be complete and healthy. The blood supply to the placenta was satisfactory. No false or true knots were detected on the cord and the three blood vessels were present (two veins and one artery). There was no indication of an extra lobe. The placental length was 50 cm and it weighed 600gms. All blood clots were expelled to prevent postpartum haemorrhage (PPH).
The perineum, vagina and cervix were examined for lacerations and tears. There were no lacerations and tears and, therefore, suturing was not required. Total blood loss was 150 mls. The patient was advised to breastfeed the baby exclusively and frequently to prevent hypoglycaemia. She was also advised to perform uterine massage frequently to facilitate uterine contraction and involution.
4.4 Fourth Stage of Labour
During this stage, the mother was closely monitored for per vaginal bleeding. The following parameters were also monitored: temperature, blood pressure, pulse and respirations AND the findings were as follows:
 Temperature - 36.50Co
 Pulse - 78 beats/min
 Respirations - 18b/min
 Blood Pressure - 126/80mmHg
The mother was advised to do Kegel’s exercises regularly to allow pelvic muscle contraction back to the pre-gravid state.
4.5 First Examination of the New-born
The baby scored 9/1, 10/5, 10/10 on the Apgar score and weighed 3.6 kg. Head to toe examination findings were as follows:
Head: Both the frontal and occipital fontanelles were present and normal. The nose was patent with no septal deviation, polyps, nostril flaring or bleeding. Head circumference was not measured. There was no discharge from the eyes and the ears were well placed in relation to the outer canthus of the eyes.
Chest: There was uniform chest expansion and respirations were well established. The chest moved in rhythm with respiration.
Abdomen: No distension and no organomegally.
Extremities: They were symmetrical, equal in size with no extra digits or birth injury. Hip joints were normal.
Genitalia: The genitalia were determinate and normal. The labia were normal. Anatomical deformities were not detected. The anal patency was tested using a thermometer and established to be patent.
The following observations were recorded:
Temperature - 36.5°C
Respirations - 36 breaths per minute
Heart rate - 140 beats per minute
4.6 Labour Summary
Total labour duration was summarized in a table as follows:
Stage Hours Minutes
First 6 10
Second 0 15
Third 0 05
Total 6 hours 30 minutes
5. Peuperium
5.1 Immediate Care
Maternal parameters (blood pressure, temperature pulse and respirations) were closely monitored. Uterine contraction, lochia loss and amount of urine were monitored. The client was encouraged to initiate bonding and initiate breast-feeding. She was also advised to lie on her back with legs crossed to leave her comfortable and decrease the risk of postpartum haemorrhage (PPH). The mother and the new-born were then transferred to the post natal ward where monitoring was continued until they achieved stability.
Examination of the Mother at Postnatal Ward
The aim of the observations was to monitor the general condition of the mother post-delivery for early detection of complications that may arise so that timely management could be effected. On general observation, the client looked exhausted but in a jovial mood on account of safe delivery. The vital signs were taken in the right frequency and the very initial findings were:
 Temperature - 36.6°C
 Pulse – 76 beats per minute
 Respiration – 20 breaths per minute
 BP - 125/75 mmHg
Vital signs were monitored until stability was established. The uterus was well contracted. Involution was taking place and when measured it was 5cm below the umbilicus. There was no tenderness or abnormal distension. Lactation was immediately established and there were no crackled nipples, breast engorgement or sore nipples. Lochia appeared red and scanty with no discharge. The lower extremities were equal in size with no oedema.
Health Education Given to the Mother
Exclusive breastfeeding for six months was emphasised. The mother was also educated on lactation positions and techniques, as well as effective and efficient initiation and termination. On general baby care, the client was advised to do top tailing but to avoid in unfavourable weather to prevent upper respiratory tract infections. She was advised on keeping the baby dry through frequent change of nappies and/or diapers. She was also taught on how to detect signs of sickness in the baby and was advised to take him to the clinic in good time in case she detected any health problem.
Baby eye care: the client was taught on how to do eye care to include wiping each eye with separate clean cloth and seek care if eyes drain pus.
Cord care: the client was advised to wash hands before and after cord care (this is use of saline water and five pieces of clean cotton wool). Proper cord cleaning was demonstrated to her and asked to repeat.
On diet: the client was advised on the need and importance of a balanced diet. She was advised to eat foods rich in iron (like kales, spinach, liver, etc.). She was also supposed to increase her protein, fluids and vitamin intake.
Exercises: the mother was explained to how to strengthen abdominal and perineal muscles through Kegel’s exercises.
Family planning was also discussed.
The importance of attending the Child Welfare Clinic (CWC) was emphasized to ensure that the new-born would be immunized according to the schedule and for growth and development monitoring of the baby.
Importance of post natal visit was not overlooked. She was advised to come back to the hospital for post natal check-up (To check for uterine involution, possibility of post-partum haemorrhage, and lochia loss. She was also to report any problem she would have during this visit).
Discharge: The baby received his first dose of BCG and birth polio vaccine the following morning after birth. The following morning (April 11, 2012), both the mother and the baby had achieved stability and, as such, were due for discharge. When the husband arrived (at around 9am), the client was discharged home with their child. She was directed on how to book post natal clinic for April 17, 2012 and issued with a birth notification card. After paying the hospital bill, the client, husband and their baby started their way home.
5.2 First Postnatal Home Visit on April 21, 2012
The first postnatal was conducted on April 21, 2012. I had informed the client of the visit prior to this date and thus we were expected. The visit lasted for approximately two hours at their residence in Ruiru. The aims of the visit were:
 To assess how the family was coping with the introduction of a new member.
 To evaluate the client’s physical health status and rule out signs of anaemia and urinary tract infections.
 To ensure that the client follows up the immunization schedule for the baby through reemphasis on the importance of immunization.
Generally, the emotional and physical states of the mother were normal; no anxiety or stress was detected. The client and her family were settled with the new family member in their home. The mother had no signs of anaemia, emotional stress and depression. The client was in a happy mood and reported no stressors at home.
Physical Examination
Face: Was symmetrical, no signs of oedema.
Eyes: The eyes were symmetrical normal in shape and size. The sclera was examined for pallor to rule out anaemia and there was no pallor on the sclera.
Ears: The ears were symmetrical, normal in position and no discharge was seen. Parotids were non-tender and not swollen.
Nose: It was patent and no discharge was seen. No obstruction and no signs of infection.
Mouth: There was no halitosis. There was no cyanosis in the mucous membranes in the mouth which could indicate a hypoxic state in the client.
Neck: On inspection, the neck was symmetrical and no obvious enlargements were observed. On palpation, masses or lymphadenopathy were ruled out.
Breasts: The breasts were not examined for privacy reasons and assessment relied on the client’s self-report that the breasts were equal in shape and discharging milk. The client also reported that the breast tissue was non-tender and no masses or tumours were felt on the breasts.
Arms: On inspection, the fingers were symmetrical and had no koilonychias which could be indicative of iron deficiency anaemia. Skin coloration, hydration and texture were normal. Capillary refill on the index finger took 2 seconds which indicated that the mother’s tissues were well perfused. The nails were pink and the palms were not pale. On palpation, no masses or tumours were felt. The upper arms had no atrophy or asymmetry.
Perineal area: Was not examined and relied absolutely on client’s report. The client reported experiencing a red vaginal discharge (lochia rubra). Otherwise she reported no experiences of incontinence or other abnormalities.
Lower Extremities: On inspection, skin coloration, hydration and texture were normal. No oedema was noted on the lower limbs.
Examination of the baby
The baby’s general appearance was good. On physical examination:
Head: Was symmetrical in shape. All sutures were present and in good shape- there was no moulding. Both the frontal and the occipital fontanels were good and present with normal shape. Eyes were well placed with no signs of jaundice. Nasal septum was centrally placed, no polyps, no flaring of nostril, no blockage, no bleeding.
Chest: There was uniform chest expansion. Respirations were well established.
Abdomen: Not distended and moving with respiration. The umbilical cord was clean.
Upper limbs: Equal in size with no extra digits or birth injury.
Genitalia: No abnormalities were detected.
Vital signs:
 Temperature - 36.8oC
 Respirations - 36/min
 Heart rate - 132 beats/min
Health messages shared:
 The mother was educated on the importance of exclusive breastfeeding up to six months. The benefits of this were discussed with the client who agreed to comply.
 She was also advised to visit the clinic after two weeks post-delivery (on April 24, 2011) for post natal examination. The client was informed that these check-ups were very crucial for her own health and the health of her baby. She promised to attend them as scheduled.
 To add on the above, the importance of healthy nutrition was emphasized. She was educated on importance of a well-balanced diet to include all nutrients (proteins, carbohydrates, vitamins, minerals and water). She was asked to continue consuming foods rich in vitamin C and iron. This would boost her immunity and prevent anaemia.
5.3 First Postnatal Check-up on April 24, 2012
The client showed up at Ruiru Sub-District Hospital on April 24, 2012 at around 9 a.m. for the postnatal check-up two weeks after delivery. She came to the hospital in the company of her child. Generally, the emotional and physical states of the mother were good. No anaemia, emotional stress or depression was noted. The client was in a happy mood and reported no stressors at home.
Physical Examination
During this examination, emphasis was put on abdomen, pelvis and breasts. No lumps, cracked or swollen nipples were noted. The breasts were symmetrical in shape and size. There was also no oedema around the eyes, face, hands and feet. Involution of the uterus was noted to be complete. The abdomen was cylindrical in shape, liver palpable, 2-3cm below right costal margin, the spleen was not palpable and the umbilical cord was dark in colour and appeared healed.
The pelvic muscles were regaining their strength as the mother reported to carrying out pelvic floor (Kegel 's) exercises regularly at home as she had been taught before discharge from hospital. Stress incontinence was subjectively ruled out. There was also no oedema around the eyes, face, hands and feet. No vomiting and constipation were reported. The mother was educated and instructed on self-examination of the breast, family planning and care of the baby and diet. Return visit was scheduled on May 1, 2012 for weighing and growth monitoring of the baby.
5.4 Second Postnatal Check-up on May 22, 2012
The mother turned up for the six weeks postnatal clinic visit on May 22, 2012. The objectives for this postnatal check-up were:
 To determine whether the patient is healthy and has returned to her normal activities
 To determine whether the infant is well and growing normally
 To determine whether breastfeeding has been satisfactorily established and still ongoing
 To determine whether contraception has been arranged to the patient 's satisfaction
 To determine whether the patient has been referred to a maternal and child health clinic for further care and to determine whether the patient has any questions about herself, her infant or her family
At the clinic, all the above objectives were met but there were no investigations that were done during this postnatal visit. One of the most important issues discussed during this visit was the issue of family planning with an emphasis on how to utilize the available contraceptive methods to get the targeted number of children and space them in accordance with how the client and her husband desired. However, not all methods of contraception were available and the client had to choose her method from the choice of combined oral contraceptives, progestin-only contraceptive and injectable contraceptives. Health education and information offered during the puerperal period was intensive and extensive. It was also agreed with the client that the therapeutic relationship was to be terminated a few weeks from then now that the mother and the child were doing well and were comfortable with the termination of the relationship.
5.5 Second Postnatal Home Visit on June 5, 2012
Aim of the visit: The aim of this visit was to assess the readiness and preparedness of the client to terminate the therapeutic relationship with the student nurse. If convenient to the client, the relationship would be terminated. Assessment of the client during the visit: the client reported no abnormality and was contented with her family and the parenting role.
Why termination of the therapeutic relationship was preferred at this particular date:
Given that it was eight weeks postpartum and the client and her child and family were doing really well both physically and psychologically, it was only necessary to bring this professional relationship to a halt. Besides, the mother was psychologically prepared to terminate the association. The mother was advised to continue with exclusive breastfeeding for six months and keep taking the child to the Child Welfare Clinic as advised at the clinic and to continue collaborating with her husband in bringing up a healthy family.
6. Comparison of Care Provided with the Ideal Care as Recommended in Literature
This section of the care study compares the care provided to the client with the recommended care as found in current literature to evaluate the appropriateness of the care reported in this care study. In that regard, individualized attention and tailored care are essential for positive outcomes in pregnancy. While it is practically impossible to provide ideal care, a fact due, in part, to the availability of resources, institutional norms and policies as well as patient-related factors, it is crucial to ensure that the care provided is as near to ideal as possible Chinombo (2007). Perhaps the most important rule is ensuring that all mothers meet the fundamental requirement of focused ante natal care such as being aware of danger signs, undertaking relevant tests and preparation for an individualized birth plan.
The care offered to the client was recommendable owing to the fact that other expectant women receive care that is less comprehensive, partly due to negligence by health personnel, the clients themselves, lack of relevant medical technology or other factors mentioned above. Analysis and evaluation of care provided to the client established that there existed areas that require addressing for improvement. Some of these are discussed below.
6.1 Prenatal care
According to Bennet and Brown (2001), the care given to a mother and her family must be aimed and shaped to achieve certain objectives. These objectives include:
 To sensitize her regarding family planning and;
 To attend the under 5 children accompanying the mother, if any
 To detect high risk cases and give them special attention;
 To foresee complications and prevent them;
 To remove anxiety associated with pregnancy;
 To reduce maternal and infant mortality and morbidity;
 To teach elements of child care, nutrition, hygiene and sanitation;
 Promote, protect and maintain the health of pregnant women;
The care provided to the client was aimed at achieving these objectives. However, some of these goals were not attained. For instance, the client did not come with the under five children she has so it was not possible to attend them. Of comfort is the knowledge that all other objectives were achieved.
Along the same lines, Ebrahim et al. (2007) assert that the first visit is very crucial in the sense that the history collected as well as the assessments done constitutes the baseline information upon which future history findings and assessments are based. Any deviation from the findings is accorded the attention that it deserves and if it necessitates correction, such correction is timely done. Clients at risk are identified during this visit and appropriate and timely care is commenced. If this is ignored the client could be having undiagnosed complications, yet she and the medical care personnel are not aware. This can be life threatening to the mother and her developing baby.
Negative effect to the mother and the baby is enough jeopardy but the effect that such pregnancy poses to the family (separation, loss of mother figure, family disharmony, just to name a few) is what escalates the problem to an issue that calls for absolute seriousness. The care given to my client during this visit was aimed at detecting any possible complication or risk involved. However, the client was not at risk, and, as such, did not necessitate specialized care.
There exist varied reactions about testing the mother of the HIV virus and how often it should be done. While some scholars contend that one test is enough, others advocate for a confirmation test (Katharyn, 2002). For the client’s case, serology for the HIV was done once during the first visit. This was so due to the fact that the hospital policies had to be adhered to, and, as such, the care provider had to weigh the benefits of carrying out a confirmation test verses a contravening the hospital guidelines.
According to Van den Broek and his colleagues (2008), this is supposed to be done more than once because it cannot be known whether the mother was in the window period for HIV at this time or contracted it immediately after the test, unless they are repeated. For this client, testing was, however, not repeated. Prevention of mother to child transmission (PMTCT) is an issue that has been accorded undivided attention. Given that it is quite a weighty matter, it was not taken lightly during the visits.
When ANC visits should start is an issue that varies from state to state and country to country. The America’s Expert Panel on the Content of Prenatal Care proposes that prenatal visits should start at 4 to 6 weeks gestation (United States Department of Health and Human Services [U.S. DHHS] (2009). This may not be practical in most of the instances in the third world countries. For instance the Kenyan ministry of health proposes that mothers should begin their antenatal care visits at 16 weeks. At this gestational age however, it may be quite late to solve some complications that would have developed in the first trimester, such as the teratogenic and congenital abnormalities.
Effort must be made by the health care personnel to educate and encourage mothers and communities to seek antenatal care earlier as abnormalities can be detected and treated before they cause harm (Katharyn and Laura, 2002). Thorough history should be taken on the first visit the mother attends clinic (Donaldson et al, 2002; Katharyn and Laura, 2002). For the client, comprehensive history was captured as seen on the mother’s card.
6.2 Intrapartal Period
Emotional support: Everybody wants to feel loved and appreciated in all fields of life; maternity is not exceptional. It is this feeling of belonging that drives the mother and enables her to go through the stages of labour. For the client, the midwife displayed a tolerant non-judgmental attitude ensuring that the mother was accepted irrespective of her reactions to labour. Good communication with the mother is vital (in fact, indispensable) in all the stages of labour. It goes a long way in allaying the mother’s anxiety, not to mention that such communication makes the mother feel wanted, important and role player (K’Okul, 2001). The health care team employed good communication to the mother thus reducing anxiety. The midwife also spent time to actively listen to the mother during labour. The mother was explained to about the procedure she was yet to go through and its importance.
Observations: Pulse rate was recorded half hourly during first stage and in forth stage it was taken only once as opposed to the ideal which should be quarter hourly. Temperature was taken once in first stage and once before the mother was transferred to post natal ward. Blood pressure was taken four-hourly during the first stage and once post-delivery before the mother was transferred to post natal ward. Respiration were taken half hourly in first stage and also in forth stage. Foetal heart rate was taken half hourly in first stage; however it was not done after every contraction in second stage. Vaginal examination was done four hourly to check the descent of the head and cervical dilatation. All these observations were recorded in a partograph though.
Pain control: Respiratory exercises: The client was guided, as the uterine contractions began, to inhale and exhale, breathing through the mouth slowly and deeply. This technique was used during the active phase of labour. Lumbosacral region massage (back rub): The woman was oriented to the massage and advised to rub the lower back during contractions. The midwife also rubbed and massaged the lower back of the client during contractions .According to Mohamed; touch in varying forms can convey pain reducing messages depending on the nature and circumstances of the touch (Mohamed, 2008).
Bladder care: During first stage the mother was encouraged to frequently empty the bladder because a full bladder may prevent the foetal head from entering the pelvic brim and/or reduce the capacity of the uterus to contract thus increasing the risk of post-partum haemorrhage.
Medications: In second stage intramuscular Syntocinon 10 IU was administered immediately after the delivery of the baby after it was confirmed that there was no second twin. The South African guidelines are that immediately after the birth of the infant the midwife must make sure, by abdominal palpation, that there is no undiagnosed twin. If there is no second baby, 10 IU Syntocinon I.M is administered (Katharyn, 2002).
Pushing: Valsava manoeuvre method (where the mother holds her breath as long as possible to build up the intra-thoracic pressure which assists in expelling the foetus) was used to expel the foetus. However, Ebrahim et al (2007) found out that Valsava manoeuvre of more than six seconds resulted in impaired oxygenation and impaired placental blood flow. This may result in decreased foetal blood PH, decreased partial pressure of carbon dioxide and increase in foetal heart rate abnormalities. The team proposed open glottis manoeuvre (gentle pushing) as opposed to valsava manoeuvre.
Clamping of the cord: In the actual delivery of this care study, the clamping of the cord was carried out immediately after birth. However the ideal cord clamping should be done when the cord pulsation has ceased. It has been suggested that this practice may reduce the volume of blood returning to the foetus by as much as 75-125 ml which may affect the neonatal haemoglobin levels (Bennet, 2001).
6.3 Puerperium
Every year in Africa, at least 125,000 women and 870,000 newborns die in the first week after birth, yet this is when coverage and programmes are at their lowest along the continuum of care (K’Okul, 2001). The first day is the time of highest risk for both mother and baby. Postnatal care (PNC) programmes are among the weakest of all reproductive and child health programmes in the region. The postnatal period – defined here as the first six weeks after birth – is critical to the health and survival of a mother and her new-born. The most vulnerable time for both is during the hours and days after birth. Lack of care in this time period may result in death or disability as well as missed opportunities to promote healthy behaviours, affecting women and new-borns.
Half of all postnatal maternal deaths occur during the first week after the baby is born, and the majority of these occur during the first 24 hours after childbirth. The leading cause of maternal mortality– accounting for 34 percent of deaths in Africa – is haemorrhage, the majority of which occurs postnatally. Sepsis and infection claim another 10 per cent of maternal deaths, virtually all during the postnatal period. With this in mind, absolute care and vigilant observation postnatally should be carried out (Bonnie, 2001).
Reviewing the client’s medical/obstetric history in the client’s file and notes is also crucial to planning for the kind of nursing care to offer in the postnatal ward (Chinombo, 2007). Reviewing the client’s notes for any significant psychosocial needs e.g. women with issues related to mental health, substance abuse, domestic violence, history of sexual abuse, and previous abuse of an infant, intellectual disability, attachment, physical disability or serious/chronic medical problems is important as well. Maternal/infant bonding and adequate periods of rest should be advocated (Chinombo, 2007). For this client, this was not done. Upon admission to the postnatal unit, time was limited to look into her notes partly because of the large workload the attending midwifes had.
The client was retained in the postnatal ward for twenty four hours as she was monitored. This is recommended because this is the time that most life threatening complications of delivery manifest such as postpartum bleeding, collapse of the circulation, cardiac failure, to mention but a few. This risk may be more in women with pre-existing medical conditions like anemia (United States Department of Health and Human Services. (2009).
Concerning immunizations, it is recommended that BCG vaccine is delayed as the HIV status of the child is determined if possible owing to its fatal outcome in children with HIV (Van den Broek et al, 2008). Although the client was HIV negative, no other tests were done and the vaccine was given to the child on assumption he was negative of the virus.
The objectives for the postnatal check-up at 6 weeks include to determine whether the patient is healthy and has returned to her normal activities, to determine whether the infant is well and growing normally, to determine whether breastfeeding has been satisfactorily established and still ongoing, to determine whether contraception has been arranged to the patient 's satisfaction, to determine whether the patient has been referred to a maternal and child health clinic for further care and to determine whether the patient has any questions about herself, her infant or her family (Government of Kenya, 2002).
During her postnatal visit to the clinic, all the above objectives were met though not exhaustively. For example, not all the methods of family planning were available much as the client was educated on them. This could be a danger to the mother becoming pregnant again before she could even start her periods, though on a minimal scale. 5% of women can become pregnant, as early as 4 weeks after delivery, even before they start menstruation (Bonnie and Williams, 2001). Health education and information offered during the puerperal period was intensive and extensive. Although not every bit could be addressed it was of great help to the mother.
6.4 Home visits
Home visits like the ones reported in this care study are not commonplace in developing countries due to unavailability of midwives among other logistical and financial challenges. Actually, it is expected that the client will come to the hospital and if she fails, that becomes the end of care. No follow up is done by midwives. No midwife will know there was such a client within the hospital’s catchment area. In the developing world (where the communication infrastructure is not well laid) a mother can fail to attend her visits and no health worker will identify this (K’Okul, 2001). Home visits should be encouraged as in countries such as Britain where they are more practical, the outcomes of the pregnancies are better and safer than in the Kenyan situation (K’Okul, 2001). However, this does not go without a challenge. In the first place, it is pretty expensive to lay out and execute such strategies. Besides, some clients view it as an inconvenience as their normal daily schedule is interrupted.
When condcuting home visits, the midwife should carry observation tools and equipment relevant to the visit. These include, but may not be limited to thermometer, sphygmomanometer and other observation machines to the client’s home (Ebrahim et al, 2008).
Also crucial in the visit is documentation (Bonnie, 2001). It was established that most of the information was not recorded in the client’s file. Documentation is vital to ensure that the continuity, safety, and quality of care endure across the multiple handovers made by the many clinicians involved in the client’s care. A primary purpose of documentation and recordkeeping systems is to facilitate information flow that supports the continuity, quality, and safety of care. For the home visits that were conducted during the study, no observations were done as relevant equipment was not available. For instance, hoping to borrow a sphygmomanometer from Pumwani Maternity hospital would be rather ambitious given that the hospital policies caught allow.
7. Summary and Conclusions
Pregnancy and childbirth, for most mothers, are two important stages of their life. Apart from fulfilling the societal expectation, these two stages are a major source of happiness, not only for the mothers but the entire family as well. However, this is a period that is endured with absolute tension and uncertainty especially by nulliparous mothers. As a matter of fact, pregnancy is no joke for some fathers; a myriad of symptoms, worries, fears, and pathologies exhibit themselves in men whose wives are pregnant, thus calling for attention to the problems of the husband whose very real anxieties may get lost in the shuffle and preoccupation with the needs of the expectant mother. There is, therefore, a need for agencies to step in and help the couples to cope with pregnancy-related challenges.
It is crucial for the government to improve its antenatal care and expand its coverage so as to reach as many expectant mothers as possible. There is need for vigorous health education and community awareness to be conducted by the ministry of public health and sanitation and other stakeholders to empower the community with the knowledge to take charge of their health care, to include maternal and neonatal care. No two gardens are similar; similarly different individuals have dissimilar needs. Therefore, when doing home visits, care offered to the mothers should be personalized. Moreover two days in the same garden are completely different. Therefore, one time’s need should not be assumed as the next time’s need even for the same client.
The pregnancy of this client was planned given that she dropped contraceptive use for the purpose of conception with the aim of getting a second child following her agreement with her husband. Hers was a pregnancy that was well carried to full term without any risk or complication. Considering the set standard in Kenya pertaining to FANC, she started her visits on time. Each visit was successful because it was integrated (a number of services were provided under one roof). Counselling and testing for HIV was done during the first visit and was negative. Other important tests include urinalysis, haemoglobin level and VDRL. She also received all ANC immunizations and medications.
On the day of delivery, the mother was brought to the hospital at around 2:30 p.m. on April 10, she delivered a live male infant who weighed 3.6 kg and scored 9 in one minute and 10 in 5 minutes (Apgar score). The new-born was given vitamin K orally and tetracycline eye ointment prophylactically. Upon head to toe examination of the new-born, no abnormality was noted. With no overt signs of abnormality or complication, both the mother and the new-born were discharged after twenty four hours. The baby is exclusively breastfeeding and is gaining weight steadily. Growth and development of the baby is at par with the expectations.
8. Evaluation
Availing individualized care and conducting a study on the care provided to an expectant mother from the date of identification until after Puerperium can be challenging but equally rewarding. In spite of the fact that it is quite involving, the entire process is educative, fulfilling as well as inspiring. It is a voyage from the known to unknown; a journey that makes the learner dig deeper in literature than it can ordinarily be fathomed.
It is indubitable that a great deal of cooperation by all stake holders, especially the client, is indispensable. A lot of cooperation and willingness to provide information was demonstrated by the client and family during the entire care study period. The entire process could not be successful without the contribution of the client and her family members, her husband in particular. The family was welcoming and it was confident that they would embrace the health education shared with them. The whole study was a success, to say the least.
Concisely, home visits are way more important than it has ever been imagined. Perhaps it is time the concerned reproductive health sector (Ministry of medical services in collaboration with Ministry of Public Health and sanitation) implemented and promoted viable strategies to ensure that it is effectively carried out. This could go a long way in ensuring that positive prognosis of many pregnancies is produced and related complications are accorded the best interventions. That way, the issue of prenatal and maternal mortality can become a thing of the past. 9. References
Bennett, R. and Brown L. (2001). Myles Textbook for Midwives. (13th Edition). London: Harcourt Publishers Ltd.
Bonnie W. and Williams S. (2001). Nutrition in Pregnancy and Lactation. (8th Ed.) London:Mosbey
Chinombo, A. (2007). Community Empowerment: A Strategy for Healthy Communities. Geneva: International Nursing Review, ICN.
Ebrahim, G. et al. (1998). Maternal and Child Health and Practice. London: Macmillan Education.
Government of Kenya. (2002). Clinical Guidelines for Diagnosis and Treatment of Common Conditions in Kenya. Nairobi: Regal Press.
K’Okul, R. (2001). Maternal and Child Health in Kenya. Nairobi: Finnish Society for Development.
Katharyn, M. and Laura R. (2002). Maternal and Neonatal Nursing: Family-Cantered Care. (5th Ed.). Philadelphia: J B Lippincott Company.
Kelie, J. (2000). Social Perspectives on Pregnancy and Childbirth for Midwives, Nurses and the Caring Professions. Buckingham: Open University Press.
Mohamed, K. (2008). “Blood Transfusion for Iron-Deficiency Anaemia during Pregnancy.” The Cochrane Library. Issue 4. Chichester.
United States Department of Health and Human Services. (2009). Caring for Our Future: The Content of Prenatal Care. Washington DC: Author.
Van den Broek N., White S., and Neilson J. (2008). “The Relationship between Asymptomatic HIV Infection and the Prevalence and Severity of Anaemia in Pregnant Women.” In: American Journal of Tropical Medicine and Hygiene.

References: Bennett, R. and Brown L. (2001). Myles Textbook for Midwives. (13th Edition). London: Harcourt Publishers Ltd. Bonnie W. and Williams S. (2001). Nutrition in Pregnancy and Lactation. (8th Ed.) London:Mosbey Chinombo, A Ebrahim, G. et al. (1998). Maternal and Child Health and Practice. London: Macmillan Education. Government of Kenya. (2002). Clinical Guidelines for Diagnosis and Treatment of Common Conditions in Kenya. Nairobi: Regal Press. K’Okul, R Katharyn, M. and Laura R. (2002). Maternal and Neonatal Nursing: Family-Cantered Care. (5th Ed.). Philadelphia: J B Lippincott Company. Kelie, J. (2000). Social Perspectives on Pregnancy and Childbirth for Midwives, Nurses and the Caring Professions. Buckingham: Open University Press. Mohamed, K United States Department of Health and Human Services. (2009). Caring for Our Future: The Content of Prenatal Care. Washington DC: Author. Van den Broek N., White S., and Neilson J. (2008). “The Relationship between Asymptomatic HIV Infection and the Prevalence and Severity of Anaemia in Pregnant Women.” In: American Journal of Tropical Medicine and Hygiene.