postnatl case study

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INTRODUCTION

This is a case study of Mrs. Samala village, she was admitted at Ndilande Health Centre

due to spontaneous labor pains around 5pm on the 27th of May, 2009.

She delivered a live full term female infant on the same day around 9:25am, immediately

after delivery she was admitted in the post natal ward at 0950am where she was identified

as a client for this case study.

Mrs. R.C was taken care of for a period of 48hours before discharging her in consultation

with the qualified midwives of Ndilande Health Centre.

Postnatal period of peuperium is the period between the third stage of labor and 6 th week

after delivery (Dickson, E.J Et al 1993). It is a period where the body regains its

prepregnant state through various physiological processes.

This write up is about the postnatal care given to Mrs. RC for the period she was admitted

in the postnatal ward to the time of discharge.

The paper describes a review and an analysis of antenatal and labor and delivery records,

any other significant data collected a draft of a care plan and a series of interventions

rendered and the discharge plan for Mrs.RC and her neonate.

PERSONAL HISTORY

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Name: Rhoda Chimaliro

Age: 19 years

Address: Makata, Ndilande

Home Village: TA Msamala, Balaka.

Religion: Baptist

NOK: Mai Jera, (Mother)

Marital Status: Married

Educational Level: Form 2

Date of Admission: 26/05/09.

Time of delivery 09:25am, 27/05/09.

PRESENT COMPLAINT

Mother complained that she is feeling pain on the perineum due to tear, and lower

abdominal pains. She is able to pass urine, but has not yet passed stools. She verbalized

that she had painful labor and delivery experience because of the tear.

Baby is able to breastfeed and eliminate.

REVIEW OF AND ANALYSIS OF COLLECTED ANTENATAL, LABOUR AND

DELIVERY DATA.

The review of antenatal, labor and delivery data is important in the care of a woman in

peuperium, this acts as baseline information for which subsequent assessments, care and

evaluative measures are based on.

The collected data may also help the midwife to provide effective and client centered

health education.

Antenatally, Mrs. RC stated Antenatal Care (ANC) at 24 weeks gestation, she attended

three visits and received two doses of Fansidar for Intermittent Presumptive Treatment

(IPT) and three doses of Iron tablets. She had normal blood pressure ranges and she had

a steady weight gain. Hemoglobin level and VDRL were not checked, her HIV status was

negative.

Mrs. RC received two doses of TTV and the third dose is due in September, her height

was 160cm,

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Obstetric history indicated that this was her first pregnancy, she had no any problem

during antenatal period, her last menstrual period was on the 17 th of September 08 and

her expected date of delivery was on 24th June 5, 2009.

Mrs. RC attained menarche at the age of 13 years and since then her menstrual cycle has

been regular-28days cycle. She menstruates for 5 days and the nature of her menstrual

flow is moderate. She said she does not experience any dysmenorrhoea. Additionally shehas never had an abortion or ectopic pregnancy.

Mrs. RC displayed adequate knowledge in family planning. She explained that she

knows various methods like pills, injection, condoms and bilateral tubal ligation,Bu has never used any family planning method, however she opts to use Depo-Provera

after delivery as a family planning method.

This was not a planned pregnancy, both the client and her spouse accepted it, that is whythey kept this pregnancy up to term.

Mrs. RC is the first and only wife to Mr. Chimaliro. Her husband went to school up to

form four. None of them smokes nor takes alcoholic beverage.

Currently, Mrs. RC stays with her mother in-law because her husband went to SouthAfrica in search of greener pastures when she was 7months pregnant. All the support

comes from her mother in-law, she doesnt have any income generating activity.

Mrs. RC said she has adequate knowledge of six food groups and she said she is providedwith the six food groups without any problems from her mother in- law, the previous day

before she came to the hospital she had tea with bread in the morning, oclock, nsima

with boiled eggs and vegetables for lunch and during supper she said she had nsima,beans and vegetables plus banana.

There is nothing significant about family history, medical and surgical history

According to FANC guidelines it advisable for a woman to start ANC as soon as she

notices that she is pregnant or between 12 and 16weeks gestation. This is done to detect

problems related to pregnancy as early as possible in order to prevent complications.

The ANC records also shows that Mrs. RC attended 3 visits, this shows that she had a

good number of visits though she stated ANC late, and within these three visits she

finished the recommended dose of Fansidar.

The records also show that Hemoglobin (Hb) level and VDRL tests were not done. It is

important to know the level of Hb in a pregnant woman because it provides the baseline

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data during labor and delivery and postnatal care. Furthermore, it helps rule out anemia in

pregnancy which can bring complications during labor and delivery and postnatal period.

VDRL test is done to establish whether the mother has syphilis or not, syphilis is a

dangerous infection in pregnancy because it crosses the placenta and infects the

developing fetus and this can lead to abortion, fetal defects and premature birth.

Therefore early detection of the infection requires prompt treatment to avoid

complications.

Labor was spontaneous, lasting for 7hours, she had two vaginal examinations, labor was

progressing well, with normal fetal heart rate, the time of rapture of membranes was not

indicated, there was no caput, no molding, maternal condition monitoring was not done,

initial assessment of the neonate was not done, immediate vital were not done. She

sustained a second degree tear and it was repaired.

Monitoring and recording of observations, examinations and any drug treatment on the

partograph is important, because this helps to establish normal from abnormal when labor

is established. According to the records on the labor chart, it shows that maternal

condition was not monitored during and after delivery. This is dangerous because during

labor the mother may develop complications, and his may lead to mismanagement of the

mother during labor and after delivery.

Fetal condition was being monitored, this is good because it helps to detect complication

as early as possible and also to know the response of the fetus to labour.

Initial assessment of the baby was not recorded which means it was not done. Initial

assessment is important because it helps to identify abnormalities for immediate

attention.

INITIAL PHYSICAL EXAMINATION

MOTHER

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GENERAL CONDITION

Health looking, well kempt, energetic, well hydrated, with an anxious face.

VITAL SIGNS

BP 110/60mmHg, RR 24breaths per minute, PR140beats per minute, T37.2degrees

Celsius.

HEAD TO TOE EXAMINATION

HEAD: black coarse texture, no tinea, no dandruff, no scars seen, no alopecia.

EYES: pink conjunctiva, estimated hemoglobin of 9.9g/dl, no eye discharge, no lesions

no eye discharge.

MOUTH: pink mucus membranes, no oral thrush, no kaposis sarcoma lesions.

EARS: no lesions, no eye discharge, pre and post auricular lymph nodes not palpable.

NECK: no distended jugular veins no enlarged deep and superficial nodes.

CHEST: symerical movement with breathing, no swelling, no scars seen,

On auscultation, normal air entry, no wheezes, normal heart sounds.

BREAST: symmetrically located, medium size, nipples not inverted,

On palpation, nodes not palpable, breast tissue soft and not tender, no lamps

felt, colostrums expressed.

ABDOMEN: no distention, bladder empty no lesions, strea gravidulum present linea

nigra present, bowel sounds present. On palpation, no tenderness, no

organomegally, rectus diaastasis-2 fingers.

UTERUS: mildline, well contracted, below umbilicus, fundal height 15cm.

UPPER EXTREMITIES: no pallor, capillary refill less than 2seconds.

LOWER EXTREMITIES: symmetrical, warm, no cuff tenderness, no varicosities, no

edema.

GENETALIA: no sores, no warts, no hemorrhoids, tear, second degree, not bleeding,

Intact sutures, lochia, mild, fresh, not offensive.

IMPRESSION

A primi para 4hours post SVD adapting well to pre pregnant state.

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MIDWIFERY DIAGNOSIS IDENTIFIED FOR THIS CLIENT

1. Altered comfort pain, related to uterine contraction and tear.

2. High risk for hemorrhage related to raw placental site.

3. High risk for infection related to altered skin integrity (tear).

4. Potential for altered sleep and rest pattern related to pain on tear and new attained

motherly role.

5. Knowledge deficit on postpartum, self and baby care, related to inadequate

information and experience.

INTIAL PHYSICAL EXAMINATION/BABY

General condition

Health looking baby, active, pink, well flexed, no obvious abnormalities seen.

VITAL SIGNS: T36.6degrees Celsius, WEIGHT 4000g, RR33 breaths per minute,

HR130 beats per minute.

HEAD: proportion to the body, well distributed hair, black in complexion, palpable

anterior and posterior fontanelles but not bulging or sunken. Caput present, head

circumference 34cm. crown to heal 54cm.

EYES: symmetrically located, no discharge seen, pink conjuctiva, clear corneas, well

positioned.

EARS: symmetrically located, well formed, no septic spots

NOSE: well placed, no cleft, no flaring, no growth, no discharge seen.

MOUTH: no cleft, no oral thrush, no teeth, pink mucus membranes, well formed gums ,

no bleeding.

CHEST: symmetrical movements with breathing, no central cyanosis, no chest in

drawing, no masses no growth seen, two breast present, symmetrically located

not engorged, with adequate areola. Clear lung fields and normal heart sounds.

Heart rate 133beat per minute.

ABDOMEN: round shaped, no distention, bowel sounds present, no organomegally on

palpation, cord clean and dry, no redness, no pus and no bleeding seen.

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UPPER EXTREMITIES: symmetrical, no fractures, grasping reflex present, no extra

digit, no webbing seen.

LOWER EXTREMITIES: symmetrical, warm, plantar and walking reflex positive. no

extra digit, no webbing seen.

GENETALIA: well developed labia mijora and minora, urethra and vaginal orifice

Present and patent. Anal orifice present and patent.

BACK: no spinal bifida, no growth or deformity observed.

IMPRESSION

4hrs old female neonate adapting well to extra uterine life.

MIDWIFERY DIAGNOSIS IDENTIFIED

1. High risk for hemorrhage related to exposed blood vessels.

2. High risk for infection related to open would

3. High risk for hypothermia, related to poor wrapping of the baby.

MIDWIFERY CARE PLAN FOR THE MOTHER.

27/05/2009

MIDWIFERY GOAL INTERVENTION RATIONALE EVALUATION

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DIAGNOSIS

High risk for

hemorrhage

related to rawplacental site.

High risk for

infection related

to altered skinintegrity (tear).

Mrs.RC. will

not develop

hemorrhagethe first

48hours.

Mrs. RC will

not develop

infectionthroughout

her period of

hospitalization

Encourage Mrs.

RC to frequently

empty her bladderand rectum

Encourage Mrs.

RC to exclusivelybreastfeed her

baby.

Encourage

mobilization.

Advise Mrs. RC

to put on dry

clean pads and tochange at least

3times a day and

whenever they arewet.

Encourage Mrs. C

on general body

hygiene.

To facilitate

uterine

involution andcontraction

there bypreventinguterine atony.

This will help

in the releaseof oxytocin

which will

enhanceuterine

contraction

therebyreducing

bleeding.

This will help

in the

expulsion of

clots bygravity,

thereby

facilitating

uterineinvolution.

Dry and clean

pads will help

to preventinfection as

wet pads

habourinfections.

Dirty skin and

clothes

habour

Check the

uterus for

contractility4houry.

Check for a fullbladder 4houry.

Check the

sanitary pad foramount and

consistency of

lochia.

Check the odor

of lochia and

inspect the tear12 hourly.

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Altered comfort,

pain related touterine

contractions and

tear.

Mrs. RC will

verbalizereduced pain

after 30

minutes ofmidwifery

interventions.

Advise Mrs. RC

to clean perineum

from front to back

Promote bed rest

and sleep,especially when

the baby is asleep.

Explain the

source of pain to

Mrs. RC.

Provide diversion

therapy, forexample, chat

with the Mrs.C.

Encourage client

to do sitz baths8hourly.

Administer

infections

This will

prevent fecal

matter fromcontaminating

the suturedarea.

Unnecessary

movementsexert pressure

on the tear

and wouldirritate nerve

endingstherebycausing pain.

This will help

the client to

avoid actionsthat will cause

pain.

This will

distract theclient from

concentrating

on pain.

This will

reducepressure on

the tear. Sits

baths alsohave a

soothing

effect.

This will

Observe pain

cues.

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Potential for rest

and sleepdisturbance

related to

perineal tear and

new attainedmotherly role.

Mrs. RC will

not experiencesleep

disturbance

throughout the

48hours ofhospitalization

Paracetamol 1g

every 8hours.

Provide a

comfortable bedfor sleep.

Nurse client in aquite and calm

environment

Provide care inblock

Advise the mother

to take advantage

of sleep when thebaby is sleeping.

Advise the mother

to breastfeed the

baby exclusively.

Advise the mother

inhibit the

production ofprostaglandins

that cause

pain.

This provides

physicalrelaxation and

rest

This preventsanxiety,

physical and

psychologicalstress.

This willprevent

interruption as

allinterventions

are done at

once.

This will

enable her to

have time tosleep and rest

as it is

difficult tosleep when

the baby is

awake.

Adequately

breastfed

babies wouldnot frequently

cry, thereby

providing themother with

time to rest.

To avoid

Observe for

signs of fatigue.

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Knowledgedeficit on self

and baby carerelated to

inadequate

information and

experience.

Mrs. RC willdemonstrate

understandingin postpartum

self and baby

care.

on bladder

emptying beforesleeping.

Give thoroughhealth education

on the following;exclusive

breastfeeding,

hygiene,

exercises,nutrition, rest and

sleep, family

planning, self andbaby care, how to

keep baby warmand how tomaintain

attachment and

bonding.

waking up

during thenight.

Knowledgeon these areas

will help toprevent

postpartum

complications

and promotephysiological,

psychological,

and emotionalreturn to pre

pregnant state.

Mrs. RC willverbalize

understandingof postpartum

self and baby

care.

MIDWIFERY CARE PLAN FOR THE BABY

MIDWIFERY

DIAGNOSIS

GOAL INTERVENTIONS RATIONALE EVALUATION

High risk for

hemorrhage

related toexposed blood

vessels.

High risk for

There will be

no bleeding

from the cordfor the first 48

hours of

admission.

The cord will

Teach the mother

to observe and

report any signs ofbleeding from the

cord.

Advise the mother

to avoid touchingthe cord

unnecessarily.

Teach the mother

To detect

signs of

bleeding assoon as

bleeding

occurs.

This can make

the cord looseand induce

bleeding.

To prevent

Check the

tightness of the

cord twice aday.

Check for signs

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cord infection

related to openwound.

High risk for

hypothermia,

related to poorwrapping of

the baby.

not develop

infectionduring the

period of

hospitalization

and afterdischarge

The baby will

not develop

hypothermia,the first

48hours.

on how to do cord

care using the fiveswab technique at

least three times a

day using spirit or

salty water.

Advice the motherto wrap the babys

nappy below the

umbilicus.

Teach the mother

how to wrap the

baby.

Advise the mother

to keep the babyclose to her body.

Advise the mother

on exclusive

breastfeeding.

Advise the motheron frequent change

of nappies

whenever they aresoiled.

infection from

the cord.

To keep urineaway from the

cord

To prevent

hypothermia

by notexposing the

baby.

This will

enhance heattransfer from

the mother to

the baby

therebypreventing

hypothermia.

Milk from the

mother is

warm and itwill help to

maintain heat.

A soilednappy makes

the baby feel

cold and thismay induce

hypothermia.

of infection for

exampleredness, pus

and fever.

Check

temperature

every 4hoursfor the first

48hours.

MIDWIFERY CARE RECORDS

27/05/09

9:50 am

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Mother admitted from Labour ward.

Bed was prepared for her and patient was orientated to the ward.

Assisted the mother to a comfortable position.

Vital signs: Respirations 22 breaths/minute, Pulse rate 100 beats/minute, Temperature37.2 degrees Celsius, Blood pressure 110/60 mmHg.

Uterus was firm, well contracted and in midline position.

Lochia was red and moderate.

Paracetamol 1g orally given. Mother explained the cause of pain.

Mother advised to take some food and to continue breast feeding.

Advised the mother to frequently empty the bladder and to report any heavy bleeding.

Mother advised to rest.

1:30pm

Mother reported that she was bleeding moderately and reduction in pain.

Mother advised to change sanitary pads whenever they are wet to prevent infection.

Advised the mother to do sitz bath 3 times a day.

Mother educated on; exclusive breast feeding, positioning, Nutrition, perineal care, cord

care.

4pm

Observed the mother breastfeeding the baby.

Vital signs; Temp 37 degrees Celsius, pulse rate 100 beats/minute, Respirations 24

breaths/minute, Blood pressure 110/60mmHg.

Uterus was well contracted; Lochia was red (rubra) and moderate.

28/05/09

8:30am

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S: Mrs. RC complained about general body pains, she has passed urine three times since

yesterday, but has not yet passed stools since delivery. She report moderate flow of

lochia, with no clots. She has changed pads which were half soaked two times since 6pm

yesterday.

She also reported that the baby has been crying at night and she dis not have adequate

rest and sleep, baby is breastfeeding well, has passed stools twice and urine three times

since yesterday from 6pm.

O: Mother

General condition: well kempt, happy looking face, well hydrated and well nourished.

Vital signs: BP 110/60, T36.7 degrees Celsius, RR24breaths per minute, PR100beats per

minute.

Eyes: pink conjunctiva

Mouth: pink mucus membranes

Neck: no distended jugular veins

Breast: symmetrical, soft, not tender, erect nipples, colostrums expressed.

Abdomen: not distended, uterus, midline, well contracted, Fundal Height 14cm, bladder

empty.

Upper Extremities: no edema, adequate capillary refill.

Lower extremities: warm, no edema, no cuff tenderness no varicosities.

Genitalia: sutures intact, no redness, no pus. Lochia fresh red, mild flow, no odor and no

clots.

IMPRESSION

23 hours post SVD adapting well to prepregnant state.

A: Altered comfort, pain related from uterine contractions and friction from the tear.

High risk for hemorrhage related to raw placental site

High risk for infection related to open wound

Potential for rest and sleep disturbance related to pain from the perineal tear and new

attained motherly role.

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P: refer to the care plan

Subsequent Assessment of the Baby:

T36.5 Degrees Celsius.

General appearance

Health looking, well flexed, pink, active.

Head: fontanelles flat and no calput, no hematoma

Eyes: pink and clear cornea,

Nose: no congestion, no flaring.

Chest: symmetrical, normal up and down movements with breathing, no chest in

drawing, no stridor.

Abdomen: soft and pink, not distended, cord not bleeding, clean, no signs of infection.

Lower extremities: warm.

IMPRESSION

23 hours old neonate, adapting well to extra uterine life

A: High risk for hemorrhage related to open blood vessels

High risk for infection related to open wound on the cord.

High risk for hypothermia related to poor wrapping of the baby.

P: refer to care plan

830am

I:Sitz bath done

Cord care done

Health education on the following areas given; cord care, perineal care, frequent change

of pads whenever they are soiled and keeping the perineum dry all the time.

1000am

Polio 0 and BCG vaccines given to the baby.

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Educated mother on the immunization schedule and the importance of having all the

immunizations given to the baby according to the schedule.

Attachments observed and collection made on how well to position the baby.

1100am

Chrolaphenicol eye ointment given to the baby.

Encouraged mother to continue breastfeeding 8-12 or more times a day.

Encouraged mother to rest whenever the baby is asleep

Vital signs rechecked, BP110/60, RR23breaths per minute, PR 98beats per minute,

T37.0degrees Celsius.

Left mother and baby sleeping.

1230pm

Observed mother taking nsima, eggs and vegetables.

200pm

Sitz bath done.

Cord care done.

Observed mother breastfeeding the baby.

230pm

Reminded mother to continue with cord care and perineal care after discharge, also

reminded her to come for postnatal check up at 1 and 6weeks, to continue with exclusive

breastfeeding, to take note of the danger signs whenever they occur. To note signs of

infection on the cord and to always remember to eat a balanced diet.

300pm

Left mother and baby to rest.

445pm

E: Uterus checked and it was well contracted

Bladder was empty

No signs of infection observed on the cord and perineum

Cord tight and clean.

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Vital signs checked BP110/60mmHg, T37.0degrees Celsius, RR24b/m, PR100b/m.

Handover given to the night duty nurse on the condition of the client and the neonate.

29/05/09

8:00am

S: there was no complaint raised, she said that she spent the night well except for the

mild pain from the perineum, she has passed urine three times and stools once. She had

nsima with beef and vegetables, this morning she had tea with bread, and baby is

breastfeeding well, has passed urine three times and meconium once and that theres no

bleeding from the cord.

O: mother looks happy, well dehydrated, well nourished and well kempt.

Vital signs: T 36.2 degrees Celsius, BP 120/60, RR23 breaths per minute, PR 92 beats

per minute.

Eyes: pink conjunctiva, clear , no jaundice.

Mouth: no oral thrush, pink mucosa

Neck: no distended jugular vein.

Breast: soft, no sores, not tender, nipples erect, milk expressed.

Upper Extremities: no edema, no pallor, capillary refill less than 2seconds.

Abdomen: not distended, soft, not tender, uterus firm, midline position, well contracted,

fundal height 13cm.

Lower extremities: warm, no cuff tenderness, no edema, no varicosities.

Genitalia: sutures intact, but some pus seen around the suture area, lochia rubra, mild

flow, fresh, no odor.

A: A prim Para 46hours post SVD adapting well to pre pregnant state.

Infection related to altered skin integrity, (tear) as manifested by the presence of pus on

the sutured area.

Subsequent assessment of the baby

T37.0 Degrees Celsius.

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General appearance

Health looking, well flexed, pink and active.

Head: fontanelles flat and pulsating

Eyes: pink, clear conjunctiva,

Nose: no congestion, no flaring.

Chest: symmetrical, visible up and down movements with breathing, no chest indrawing,

no stridor.

Abdomen: soft and pink, not distended, cord not bleeding, clean, no signs of infection.

Lower extremities: warm.

A: 46 hours old neonate adapting well to extra uterine life.

P: administer Erythromycin 500mg tds for 5days.or the plan of the baby.

Refer to care plan f

9:00am

I: observed mother doing sitz bath

Mother educated on perineal care 3times a day.

Advised mother to wipe perineum from front to back to prevent fecal matter from

Contaminating the sutured area.

Advised the mother on change of sanitary pads whenever they are wet and to put on

dry sanitary towels.

10:30am

Reminded mother on breast feeding, hygiene , nutrition, elimination, family planning,

post natal check ups at one and six weeks, and about the danger signs that might occur to

the baby and herself.

E: mother was able to verbalize understanding of exclusive breast feeding, cord care,

baby care, and the importance of eating a well balance diet and rest

Mother was able to do a return demonstration of how to wrap the baby, cord care and

breast examination.

CONSTRAINTS EXPERIENCED IN THE PROVISION OF CARE

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There was only one Blood Pressure machine, and one weighing scale, for labor ward and

postnatal ward, this resulted in fragmented care.

The hospital does not have warm water and it was difficult for the client do sitz bath and

to bath the baby.

It was also difficult to convince the client to stay in the hospital for 48hours because it is

a routine that postnatal mothers are discharged after 24 hours.

DISCHARGE CRITERIA

Some of the counseling issues that we discussed with Mrs. RC in preparation for

discharge are as follows:

Advice on Perineal care and not to insert anything in the vagina

rest and sleep

importance of personal hygiene

nutrition (six food groups) for the mother

exclusive breast feeding

family planning

Immunizations and growth monitoring

Umbilical care.

Lactation was established, there was good attachment, and mother demonstrated

knowledge on breastfeeding skills.

The uterus was well contracted and involution had stated taking place.

There was minimal lochia which was not offensive it was flowing mildly.

DISCHARGE PLAN

Discharge plan stated during the time of admission to the postnatal ward throughout

hospitalization and during the time of discharge. This included the importance of

exclusive breastfeeding, danger signs for the mother and the baby during peuperium,

postnatal exercises like Kegel exercises to improve the muscle torn of the perineal

muscles. The importance of rest and sleep, How to wrap the baby to avoid hypothermia,

frequent change of pads and babys nappies whenever they are soiled, family planning

counseling, the importance of immunization for both the mother and the baby, and

postnatal check ups at 1week and at 6weeks.

RECOMMENDATIONS

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There is need for adequate resources at the hospital, for example, BP machine, weighing

scale and water heater.

There is also need to intensify proper monitoring of women in labor and those who have

just delivered.

Women should also be told that the length of stay in the hospital depends on individual

outcome of labor and delivery and its recommended that women in postpartum care may

stay in the hospital for a minimum of 24 to 48 hours.

SUMMARY OF THE CARE GIVEN

Mrs. RC was cared for a period of 48hours using the midwifery care processes, healtheducation was an ongoing activity. The care given was also cultural sensitive. By the time

she was discharged she and the baby had met the criteria for discharge and she had

gained knowledge on the care of the baby and herself.

REFERENCE

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Frazer, D.M.; Copper, M.A. & Nolte, A.G.W. (2006) Myles Textbook for Midwives14th Ed. Churchill Livingstone. Philadelphia.

Myles, M. (1989). Textbook for midwives: Longman, London.

Obstetrics life skills training manual for Malawi (2000): Safe Motherhood-Helping toprevent maternal deaths; Ministry of health and population.

Olds, S.B.; London, M.L.; Ladewig, P.A. & Davidson, S.V (2000). Obstetrics Nursing.Addison-Wesley Publishing Company. Menlo Park, California.

Sellers, P.M. (2001) Midwifery. Cape Town; Juta & Co.

postnatl case study

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