CHAPTER ONE

INTRODUTION

A case study is a record of somebody’s treatment and how they were dealt with, especially by a
doctor or social worker. The identified client will be followed up and taken care of during,
antenatal, intra partum and postnatal period both in hospital and at home. Her family members
are closely involved in the care which entails creating a close interpersonal relationship
between family and caregiver. The family is helped on how to identify problems and how to
solve them or where to find them. This case study is based on Mrs. M twenty nine (29) years
old who is a primi gravida with Multiple pregnancy.

Multiple pregnancy is one of the conditions that we’ve come to learn of during our midwifery
training at Lusaka school of midwifery. We have chosen to write on the case of multiple
pregnancy so that we can look at what can be done to help Mrs. M reach term or near term
putting in consideration her heath status and that of the fetuses, and to ensure that she has a
safe delivery to live mature infants without complications. The case study is written as a
requirement in partial fulfillment of diploma in nursing/midwifery program.

Reasons of conducting a case study

Mrs. M has raised blood pressure and has abnormal pregnancy which is multiple pregnancy.

General Objectives

The general objective of this case study is to study and understand the condition multiple
pregnancy and apply to Mrs. M

Objectives

1. To gain greater knowledge, understanding and application of midwife’s role regarding

the care of a pregnant woman with multiple pregnancy.
2. To identify and refer complications when they arise.
3. To give information, education and communication on hygiene, good nutrition and
danger signs in pregnancy.
4. To identify problems which could be a danger to the woman and refer to appropriate
institution for further management.
5. To try and assist Mrs. M achieve her role of safe motherhood and satisfaction by having
a live mature and healthy infants.
6. To study and understand the condition of multiple pregnancy and relate it to our clients
condition
7. To build a trusting relationship with Mrs. M and her family
HOW WE MET OUR CLIENT

It was during our clinical allocation in B02 at University Teaching Hospital when we met Mrs. M.
she came for her second visit at UTH B02 on 25th July 2014. We introduced ourselves as student
midwives. We came to know of her condition after examining her. The height of fundus was
larger than the gestational age and was confirmed by the scan which revealed live twin
pregnancy. We became interested in knowing how she was coping with her multiple pregnancy.
We explained her condition and asked if we could pick her for our case study for which she
accepted. We explained to her that we would be following her up at home to monitor her
condition until she delivers safely without complications and to ensure that her health status
and that of her fetuses is satisfactory after which we will close the study. We explained that we
will come with our tutor during one of the visits to confirm the care that we will be rendering to
her and her family. We will also inform her that we will be using her initials throughout the
study for ethical reasons.

MRS M’S PROFILE

HISTORY TAKING

History taking is important because it gives a background of the client and her health status.
History taking helps us to manage the client better. It also helps us to rule out hereditary
conditions such as hypertension, asthma, and diabetes mellitus.

SOCIAL HISTORY

NAME: Mrs. M
AGE: 29 YEARS
HOUSE NUMBER: 50/114 JOHN LAING
MARITAL STATUS: married
EDUCATION STATUS: grade 12
OCCUPATION: secretary
RELIGION: Christian [Pentecostal holiness]
TRIBE: Tonga
CULTURAL TABOOS: No breastfeeding in public to prevent breast swelling.
HOBBIES: Reading and singing
SOCIAL HABITS: Does not smoke or drink beer.
NEXT OF KIN: Mr D.M
RELATIONSHIP: Husband
OCCUPATION: Business man
SOCIAL HABITS: Does not drink or smoke.
The above information was taken for identification of our client for follow up information
education and communication. This will help us after our client is discharged and goes home.

ENVIRONMENTAL FACTORS
ACCOMODATION
Mrs. M. lives with her husband and other two dependants in a two roomed house with one
sitting room and one bedroom. The house is electrified and two big window in each room.
There are only four occupants of this house therefore, it is well ventilated and not
overcrowded. Our client is not at risk of any airborne communicable diseases such as
Tuberculosis.

WATER SUPPLY

She uses chlorinated tap water but she further boils it to prevent diarrheoal diseases like
dysentery and cholera.

TOILET FACILITY
She said herself and her family uses flush toilet located outside the house. She uses surf and
harpic to clean the toilet to prevent diarrheal diseases such as dysentery and cholera.
REFUSE DISPOSAL

They use plastic bags and when they are full they are collected by the council . This history is
obtained to rule out the risk of diarrheal diseases and give appropriate information, education
and communication.

SURROUNDING

She sweeps her surrounding daily to promote cleanliness; there is no stagnant water which may
provide breeding environment for mosquitoes. There is a backyard garden and she grows
vegetables like chinese, rape and tomatoes.
FAMILY HISTORY
There is history of hypertension, asthma and multiple pregnancies in her family but no history
of tuberculosis contact, diabetes mellitus, epilepsy, sickle cell diseases and mental illness. This
history is taken because the above named conditions run in families and they may be
aggravated by pregnancy. In this case our client is predisposed to multiple pregnancy, asthma,
and hypertension.
PERSONAL MEDICAL HISTORY
Mrs. M has not suffered from tuberculosis, hypertension, epilepsy, diabetes mellitus, asthma,
psychosis, sickle cell anemia, sexually transmitted infections, anemia, urinary tract infections,
cardiac disease or repeated attacks of malaria.
This history is taken in order to find out the diseases she had suffered from or she is suffering
from because they tend to reoccur or become exaggerated in pregnancy and may cause harm
to both the mother and the fetuses. She is currently on Haemup. It was good to know this
history because some medications are teratogenic to the fetuses.
PERSONAL SURGICAL HISTORY
Mrs M has no history of injury to the spine, pelvis, or lower limbs. We collected this data
because these can alter pelvic diameters and angles of inclination resulting in cephalopelvic
disproportion.
She has no history of abdominal surgery, abdominal surgery may cause adhesions which may
restrict uterine growth as the uterus becomes an abdominal organ while operations on the
uterus may cause rupture during very strong contractions in labor. She has not received any
blood transfusion. This history was taken in order to rule out ISO immunization, the mother is
Rhesus negative and also possibilities of HIV and hepatitis B transmission.
MENSTRAL HISTORY
She attained her menarche at the age of 12years. She menstruates for 3 days and the flow is
minimal. She has the regular cycle of 28 days. This history is taken in order to know her fertility
range and advise her adequately on family planning and also to rule out preconception of
anemia which occurs in heavy menstrual bleeding.
CONTRACEPTIVE HISTORY
Mrs. M has some knowledge about family planning, but has never used any method. This
history is taken in order to know her fertility period and assess knowledge about family
planning and determine whether the pregnancy was planned for or not.
PAST OBSTETRIC HISTORY
Past obstetric history is taken to help us know the problems encountered in the previous
pregnancies and be able to plan and manage the present pregnancy well. Mrs. M is a
primigravida and she has no history of abortion.
PRESENT MEDICAL HISTORY
Her first day of her last normal menstrual period was on 18.02.14. Her expected date of
delivery was calculated as follows:
LMP 18. 02. 14
+7. +9
25 .11 .14
The gestational age of the delivery day was calculated as follows;
MONTHS TOTALS DAYS WEEKS DAYS
February 10 1 3
March 31 4 3
April 30 4 2
May 31 4 3
June 30 4 2
July 25 3 4
20 17= 2 r 3
7
20
+2

22weeks 3 days
Quickening
She experienced quickening at 18 weeks. This history is important because it helps to calculate
the pregnancy by dates and see if it corresponds with the height of fundus.
Table 1: Antenatal visit summary.

DATE G.A FUNDU PRESENTATIO DESCENT FETAL B/P OEDEM WT ALB GLUCOS HB NEXT
S N HEAR A E VISIT
T
25/05/1 13 und Undefined undefine FMF 149/9 Nill 63k neg Neg 14.9g/d 24/06
4 Week d 4 g l /
s MmHg 14
24/06/1 18 22cm Undefined undefine FHR 140/9 nill 63k Ne Neg Not 1/07/
4 weeks d 0 g g done 14
MmHg
1/07/14 19 23cm Undefined undefine FHR 130/9 Nill 64k Ne Neg Not 22/07
weeks d 0 g g done /
MmHg 14
22/07/1 23 25cm 1 cephalic 5/5 FHR 140/8 Nill 65k Ne Neg Not 19/08
4 weeks 1 breech 0 g g done /
MmHg 14

HEALTH DURING PREGNANCY

Health during pregnancy had been good. She experienced some minor disorders during the first
trimester such as nausea, vomiting and excessive salivation [ptyalism]. This information was
asked in order to rule out any illness affecting her and the baby in the uterus.
HIV STATUS
She had knowledge about HIV transmission and prevention. She had received counseling and
was tested, she is aware of her status which is negative.
MEDICATION INCLUDING TETANUS TOXOID
She received fansidar for malaria prophylaxis 3 tablets stat dose on 24.06.14 then on 22.07.14.
She was also on haemup.
She had received 3 vaccines of tetanus toxoid during the school immunization programme and
received the fourth one during the recent pregnancy. We asked her in order to know if she is
protected against tetanus together with her babies.

DIETARY INTAKE
She only experienced poor appetite in the early stages of pregnancy when she was having
minor disorders but later on, she developed good appetite. She mostly used to eat 2 to 3 times
daily. The meals comprised vegetables, kapenta, beans, fish and sometimes chicken or meat
when available. She also eats fruits like guavas, oranges, bananas and apples.
BIRTH PREPAREDNESS
This include social support, birth plan and complication preparedness.
Social Support
Her husband is the main support who provides her with needs and food at home.
Birth Plan
She would like to deliver from hospital because of her condition which is multiple pregnancy.
Complication Preparedness
She has already started keeping some money in case of any problems such as transport.
GENERAL OBSERVATIONS

Gait good posture, walking upright with no limp stature, medium height and well built
appearance. She looks well nourished and appears calm.
Weight; 65kg
Height; 157cm

Shoe size: 05

VITAL SIGNS OBSERVATION

Temperature; 36.2 degrees Celsius

Pulse; 88 beats per minute
Respirations; 22 breaths per minute
Blood pressure; 140/80mmHg
These observations were done in order to establish baseline data for subsequent antenatal
visits and to rule out deviations from normal. The height and size of the shoe was done to know
the size of the pelvis. This was done because mothers who are of height less than 150cm and
shoe size less than 04 are at risk of having a small pelvis and risk of cephalopelvic disproportion.
URINALYSIS
Urine amount; 210mls
Color; Amber
Smell; Aromatic
Proteins; Nil
Acetone; Nil
Sugar; Nil
PHYSICAL EXAMINATION;
Head; hair looked clean and well combed, healthy normal texture and no alopecia.
Eyes; the conjunctiva was pink and moist no abnormal discharge pallor or subconjuntival
hemorrhage able to see and read well.
Nose; it was clean with no abnormal discharges or polyps or epistaxis.
Mouth; the mucous membrane was pink, no sores on the tongue, no pallor, no lesions or dental
carries.
Ears; they were clean with no discharge or growths, no earache and was able to hear with no
problems. There were no peri ocular lymph nodes palpable.
Neck; there were no visible swellings, no distended jugular veins, no enlarged thyroid gland or
palpable cervical lymph nodes.
Upper Limbs; they were symmetrical, nail beds and palms were pink with good venous return
on pressure. There was no occult oedema on the knuckles.
Axillae; both armpits were clean and well shaved; there were no sores, no abscesses and no
palpable enlarged lymph nodes which would suggest infection of the breast or chest.
Breasts; on inspection they were symmetrical, both primary and secondary areola were present
with no sores and were prominently suitable enough for breastfeeding. On palpation, they
were soft, no lumps detected and on expression no milk was seen produced.
ABDOMINAL EXAMINATIONS [LATEST]
Inspection; size appeared large for gestation. The shape was broad and big, with no scars. Skin
had striae gravidarium and linea nigra indicating signs of pregnancy. Fetal movements seen
excessively over wide area of abdomen
Palpation; To ascertain the height of fundus, lie and presentation and to detect the fetal parts,
height of fundus 25cm by measuring tape.
Fundal palpation; One soft mass non ballot able denoting fetal buttocks and one hard ballot
able mass denoting a fetal head.
Lateral palpation; Smooth continuous curve were felt denoting the fetal back on the right and
the left side.
Pelvic palpations; Hard balloting mass denoting fetal head.
Auscultations; Two fetal heart sounds heard on two different points by one student midwife
and the doctor with the difference of 10 beats per minute suggestive of twin pregnancy.

SUMMARY OF ABDOMINAL EXAMINATION

Height of fundus; 25cm

Lie; longitudinal
Presentation; one cephalic, one breech
Position; Not clear.
Decent; 5/5 palpable
Fetal heart sounds; 130 beats per minute and 140 beats per minute regular, normal rhythm.
Vulva; It was clean with no sores, warts, varicose veins, oedema or any abnormal discharge. It
was nicely shaved.

Perineal and Anal area; there were no hemorrhoids, fissures, fistulae or rectocele noted.

Back; the spine was well curved with no kyphosis, scoliosis or sacral edema.

INVESTIGATIONS

Blood for hemoglobin estimation to rule out anemia was collected the result was 14.9g/dl on
25.05.14.
Blood for rapid plasma regain was collected on 20.05.14, testing was done and the result was
non reactive.
Blood for HIV/AIDS testing was collected after the counseling process on 01.07.14 and the
result was non reactive.
Urine was collected for urinalysis and there was no glucose, albumin, or any other abnormality.
Ultrasound scan done on 15.05.14 it revealed live twin pregnancy with adequate liquor with
gestation age of 13 weeks 6 days.
PROBLEMS/NEEDS IDENTIFIED

Need to know the danger signs of pregnancy.

Need to know the signs of labor.
Need to know the importance of review dates

NURSING DIAGNOSIS

Inadequate knowledge on the danger signs of pregnancy and signs of labor.

PLAN OF ACTION
To give adequate advice to the client on all problems/needs identified respectively.
INFORMATION EDUCATION AND COMMUNICATION
She was educated on danger signs of pregnancy so that in case she experiences problems like
persistent frontal headache, dizziness, blurred vision, epigastric pain, vaginal bleeding, fever
and painful micturation, she must report to the hospital or clinic.
She was educated that the signs of true labor are severe backache, severe abdominal pains and
thick mucoid blood stained vaginal discharge and so when she experiences that she must go to
the clinic or hospital.
She was also advised that it is important to come for review so that she is closely monitored,
supervised by the midwife or obstetrician so that she plans her delivery well.
MEDICATION
She was given the following routine prophylactic medications;
FANSIDAR; 3 tablets per oral stat times 3 doses in 4 weeks intervals to prevent malaria.
Action; It is an antimalarial.
Side effects; anorexia, atrophic glossitis, aplastic anemia, leucopenia, headache and
thrombocytopenia.
FERROUS SULPHATE
Action; increases hemoglobin regeneration by providing essential components for hemoglobin
formation.
Indications; iron deficient anemia and prevention of anemia in pregnancy.
Dose/Route; 200mg once daily
200mg three times daily in severe anemia
FOLIC ACID
Action; stimulates normal erythropoesis and nucleo protein synthesis.
Indications; megaloblastic anemia secondary to iron deficiency and excessive hemolysis.
Side effects; bronchial spasms, general body malaise rash and allergic reaction.
Nursing implications; store at room temperature.
She was also given 500 mg mebendazole tablet stat for prevention of worms. She was also
given a fourth dose of tetanus toxoid for protection against tetanus
CHAPTER 2

Introduction

This chapter deals with the disease process of multiple pregnancies. The chapter therefore
discusses the topic according to various literatures available on the subject and its comparison
with the diseases process occurring to the client.

Disease process

Multiple pregnancy is the term used to describe the development of more than one fetus in utero
at the same time. (Diane M. Fraser et al, 2010)

Incidence

The incidence of twining remains relatively constant and has a definite racial influence. The
incidence in the three main racial groups in the world show vastly different rates.

• Negroid race (Africa) 1:50 viable pregnancies

• Caucasian race (Europe) 1:85 viable pregnancies

• Mongoloid race (Asia) 1:150 viable pregnancies

Management of multiple pregnancies is therefore directed towards prevention of its

complications like preterm labour, intrauterine growth retardation, mobidity and mortality rate of
both the mother and the babies. To do this highly trained personnel are required.(Sellers P.M
2013)

Classification of twins

There are two main types of twins

Uniovular / monozygotic or identical twins

In this type of twin pregnancy only one ovum is fertilized by one sperm. During its early
development, the zygote divides into two or more similar separate zygotes. The reason for this
separation is not known but maybe environmental.

Babies who develop from these zygotes are similar in appearance and colouring with very
similar or identical finger prints and electro encephalograph pattern and they are of the same sex.

In most instances they share one placenta and one chorion but each has its own amnion, less
often they will share all three. The circulation of fetuses may anastamosis to a greater or lesser
and this can be seen on the fetal surface of the placenta after delivery. This can result in the
cardiovascular system of one twin development disproportionally more than the other.
Development anomalies are more common in monozygotic twins resulting in high abortion rate
and if zygotes do not separate completely, conjoined twins can result. Uniovular twins are
usually of the similar mass unless there is anastomosis of the circulation where one could be
bigger than the other. Usually there is insufficiency in the third trimester, this occurs in both
uniovular and binovular twins although as a whole the combined weight of uniovular twins is
less than that of binovular twins.

Figure 1

Monozygotic / uniovular

4-7
days
Conjoined (Siamese twins)

These arise when the separation in uniovular twins is not complete. The degree of union may be
greatly from the joining of the skin only to a sharing the thoracic cage and even the internal
viscera occasionally two headed monsters develop. The success of surgical depends upon the
degree of union and the involvement and sharing of internal organs also the degree of expertise
available.
Binovular twins

Other names for binovular are dizygotic twin or non identical twins. In this type of multiple
pregnancy, two or more ova are each fertilized by a separate sperm. The resulting babies may be
the same sex or maybe of different sex.

If they are a different sex, they are immediately recognized as dizygotic twins. The similarities
between is such as may arise with any sibling of the same family. The incidence of binovular
twins is three times greater than that of uniovular twins.

There is definite familial background with binovular twins although elder mothers also tend to
have greater incidence of dizygotic twins and drugs of infertility also produce multiple ova.

Binovular twins have each their own placenta, chorion and amnion but the placenta may fuse and
appear as though only one is present.

Dizygotic / binovular twins

2chorions
amnion amnion
Table 3 difference between binovular and uniovular

Twins

Binovular twins Uniovular twins

Two ova One ova

Two spermatozoa One spermatozoa

Two placentae One placentae

Two chorions One chorion

Two amnions One amnion

Non identical Identical

Incidence rate 75% Incidence rate 25%

Same or different sex Same sex

Causes of multiple pregnancy

The cause of twining is not known but there are some predisposing factors

Predisposing Factors

1. Hereditary factors especially maternal lineage

2. Maternal parity and age:- the older and more children a woman has, makes one have twin
pregnancy
3. Drugs that stimulate ovulation such as chlomifene and in here twins are usually diazygotic
4. Maternal height and weight in certain average sized or obese women are more likely to have
twins than short or tiny women.
5. Demographic group black women have a high incidence of twins.

General Signs and Symptoms Of Multiple Pregnancy

1. Exaggerated minor disorders of pregnancy such as nausea vomiting and pica

2. Large abdomen than dates
3. Pressure symptoms are exaggerated such as oedema
4. Multiple fetal parts felt
 5. Multiple pregnancy have some complications than ordinary pregnancies such as
polyhydramnious and anaemia.

Effects of twins on pregnancy

1. Increases abortions
2. The incidence of preclampsia is greatly increased in multiple pregnancy
3. Placenta abruptio and antepartum haemorrhage
4. Poly hydramnious is increased which can either be acute or chronic resulting in malpresentation.
Cord prolapsed and preterm labour.
5. Anaemia due to depletion of iron stores
6. Placenta praevia is increased leading to antepartum haemorrhage.
7. Accentuated minor disorders of pregnancy such as morning sickness, heartburn etc.
8. Increase pressure symptoms such as varicose veins, oedema, haemorrrhage and difficulties in
breathing
9. High percentage in fetal abnormalities multiple pregnancy varies widely from 2 vertex
presentation, breech and vertex presentation some of these abnormal lies and presentation can
cause a series of complications like locked twins.

Effects of twins on labour

Multiple pregnancy have serious effects on labour, with each subsequent baby providing greater
problems and some emergency situations may easily arise

Some of the problems are:-

1. Preterm labour is very common

2. High incidence of caesarean section which has become a mode of delivery in some community.
However in developing countries caesarean section is only resorted to in the following
condition:-
a) Previous caesarean section
b) Umbilical cord presentation or in cord prolapse
c) Conjoined twins
d) In inevitable preterm labour with breech presentation as there is a danger of the breech slipping
through a not fully dilated cervix.
3. There is raised still birth, neonatal mortality and morbidity and the rates are high especially with
the second twin due to reduction in circulation when the volume of the uterus is reduced after
birth of the first twin.
4. Ante partum haemorrhage from placenta praevia and abruption
5. Uterine inertia may occur before the first twin because of atony of uterine muscles
6. Post partum abnormalities due to anaemia, uterine atony and inertia as well as a large placental
site.
EFFECTS OF MULTIPLE PREGNANCIES ON THE BABY

Certain fetal abnormalities occur only in the multiple pregnancy and the incidence of other conditions is
increased.

1. A very high perinatal mortality rate

2. Twin transfusion syndrome
3. Asphyxia neonaturum
4. Preterm babies
5. Small for gestation age babies
6. Birth injuries particularly due to manipulation which may be necessary for malpresentations
7. Fetal malformation such as conjoined twins or locked twins.

Complications of multiple pregnancy

Twin transfusion syndrome

This occurs in uniovular twins and is due to the anastomosis of the fetal circulation. When the
placenta is shared, one twin derives most of the blood and therefore also nourishment while the
other 25 deprived of blood and nourishment. There is a great disparity in mass. Both twins are at
risk for different reasons.

The recipient twin

At birth, this twin may present with the following:

 Large and heavier twin

 Suffers from polycythenia
 May have congestive cardiac failure
 May have respiratory distress
 Has a high mortality rate both intrauterine and neonatal death

The donor twins

 Smaller or lighter for gestational age

 Has anaemia
 Has hypoglycaemia
 High mortality rates both intrauterine and neonatal foetus papyraceous

When one twin dies in utero as a result of twin transfusion syndrome or because the heart and the
circulation have not developed normally, the fetus shrinks, becomes flattened, compressed, pale and
paper like is known as foetus papyraceous.
 MANAGEMENT

Diagnosis

Up until the use of ultrasound scanning in obstetrics, twin pregnancy was often difficult to diagnose until
labour has commenced and the first baby was born. However, in our days with the coming of ultrasound
scan, the diagnosis of multiple pregnancy is made with extreme ease based on a good history and a
critical examination done at each antenatal visit.

Abdominal examination

Inspection

1. The uterus will be broad and round

2. The uterus will look larger than the gestational age
3. There will be excessive fetal movement seen.

Palpation

1. The height of fundus will be higher than period of gestation particularly in the first and second
trimester.
2. Two fetal heads will be felt
3. The heads will be smaller as compared to get gestational age
4. An unusual number of fetal party may be felt.

Auscultation

Two fetal hearts will be heard by two examining midwives at the same time with a minimum difference
of 8 – 10 beats / minute

Diagnostic

1. Ultra sound scanning from 8weeks can show two fetal sacs. It’s a confirmatory investigation
2. X – Ray from after 32weeks can also be done.

Antenatally
• The diagnosis of multiple pregnancy should be made early enough so that a baseline on
which to work is drawn
 • Pregnant woman should be seen fortnightly at the ANC until 30-32 weeks after which
she can be seen weekly until she delivers
• Refer all cases of multiple pregnancy to a big hospital where facilities are available to
treat and mange such cases. Watch for complications such as anaemia, polyhydramnios
and pre-eclampsia and admit to hospital if they arise

• Advise patient on need for good nutrition, mothers carrying two or more fetuses need
more calories, protein, and other nutrients, including iron.
• Higher weight gain is also recommended for multiple pregnancy.
Some women may also need Bedrest - either at home or in the hospital depending on
pregnancy complications or the number of fetuses.
Higher-order multiple pregnancies often require bedrest beginning in the middle of the
second trimester.
• Advise mother to avoid strenuous manual work such as travelling or carrying heavy
loads on their heads as these predisposes to premature onset of labour
• Maternal and fetal testing may be needed to monitor the health of the fetuses,
especially if there are pregnancy complications.
• Tocolytic medications may be given, if preterm labor occurs, to help slow or stop
contractions.
• These may be given orally, in an injection, or intravenously.
• Tocolytic medications often used include terbutaline and magnesium sulfate.
Labour
• Delivery of multiples depends on many factors including the fetal positions, gestational
age, and health of mother and fetuses.
• In twins, if both fetuses are in the vertex (head-down) position and there are no other
complications, a vaginal delivery is possible.
• If the first fetus is vertex, but the second is not, the first fetus may be delivered
vaginally, then the second is either turned to the vertex position or delivered breech
(buttocks are presented first).
• These procedures can increase the risk for problems such as prolapsed cord (when the
cord slips down through the cervical opening).
• Emergency cesarean birth of the second fetus may be needed.
• Usually, if the first fetus is not vertex, both babies are delivered by cesarean.
• Most triplets and other higher-order multiples are born by cesarean.
• Vaginal delivery may take place in an operating room because of the greater risks for
complications during birth and the need for cesarean delivery.
• Ideally all twin pregnancies should be delivered in the hospital
• During the first stage of labour the usual routine observations are carried out
• A doctor, pediatrician and midwife should be present at the delivery
• An IV line should be erected accordingly so that it is available if and when it should be
necessary
• Heavy sedation and analgesia are to be avoided especially where babies are possibly
premature
• When membranes rupture it is necessary to do a vaginal examination to rule out cord
prolapse, ascertain presentation and assess progress of labour
• Ascertain the lie and presentation of the first twin
• Prepare for the delivery by acquiring extra equipment such as additional swabs, cord
clamps, scissors, ligatures, episiotomy scissors, resuscitation equipment, suction and
oxygen, incubators, Wrigley’s forceps, local anesthesia e.t.c
• Prepare the woman both mentally and physically by explaining the whole procedure of
delivery to her.
• Obtain written consent for the operation should this be necessary
• Position patient in the lithotomy and empty her bladder if she has been unable to pass
urine
• Labour is usually shorter in twin pregnancy, if progress is slow explore for the cause and
treat
• Delivery
• The obstetrician, pediatric team, and anesthetist should be at hand because of the risk
of complications
• Possibility of caesarian section is ever present and therefore the operating theatre
should be ready to receive the mother at short notice
• Confirm the commencement of the second stage of labour by doing a vaginal
examination
• An episiotomy should be performed for preterm or breech delivery
• When first baby is delivered, time and sex are noted and is identified as twin one and
put in warm cot
• The umbilical cord should be clumped in two places and cut between the clamps to
prevent haemorrhage should there be uniovular twins
• Once the first twin is made comfortable the mother’s abdomen is immediately palpated
to determine the lie, presentation and position of the second twin and auscultate the
fetal heart
• Continue to monitor the condition of the mother and fetus and patient must be kept
warm while awaiting recommencement of the contractions
• Contractions usually recommence soon after the birth of the first twin, however, if they
do not recommence 5-7 minutes palpate the mother’s abdomen without delay to
ensure that the lie is longitudinal
• Perform a vaginal examination to ascertain the presentation and rupture the
membranes to stimulate the uterus to contract
• Deliver the second baby noting the time and sex
• The mother is allowed to hold both babies if their condition is satisfactory and if she
wishes to do so
• The babies must be kept warm all the time
• Delivery of the second twin is at greater risk than twin one, and causes a high fetal
mortality rate
• The longer the delay in delivering the second twin, the greater the fetal mortality due to
anoxia resulting from the separation of the placenta, excessive retraction of the
placental site, and prolapse of the cord
• A final abdominal palpation must be done to ensure that there are no more babies
before delivering the placenta
• Delivery of second twin should be completed within 45 minutes of the first twin as long
as there are no signs of feta distress in the second twin
• If fetal distress second twin is usually delivered by caesarian section
• Active management of the third stage of labour should be undertaken without delay
• Emptying the uterus enables bleeding to be controlled and postpartum haemorrhage
prevented
• Observe for bleeding in the first 24 hours, as there is a very large placental site which
usually encroaches the lower uterine segment where there are fewer criss-cross fibers
to control postpartum bleeding
• If any episiotomy or perineal tears must be sutured
• The placenta must be examined carefully for completeness, number of amniotic sacs
chorins and placentae
• If babies are of different sexes they are dizygotic, if placenta is monochorionic they are
monozygotic, if they are of the same sex and placenta is dichorionic then further tests
are necessary
• Management of the pueperium
• Immediate care at delivery is the same as for a single baby.
• These babies are usually preterm and small for gestational age and therefore need to be
nursed in the special care unit until their condition improves.
• The mother also needs help and advice with regard to the feeding of babies.
• Care of the babies
• Carry out a full examination on each baby to exclude birth injuries and any congenital
abnormality
• If babies are preterm at birth, they may require artificial surfactant for hyaline
membrane disease
• Keep the babies warm and may need to be nursed in the incubators.
• Maintain the thermal environment relatively warm.
• Clothing may be light but warm and allow air to circulate.
• Check babies temperature regularly and must be recorded, if below normal range
rewarming may be necessary
• Babies are kept in the hospital until their body weight improves
• Ensure that babies are breastfed either simultaneously or separately
• It is advisable to give the babies alternate breasts and bottle feed to allow the mother to
rest especially so for wealthy mothers who can afford artificial feeding when discharged
• If babies are not able to suck adequately at the breast, encourage mother to express
breast milk regularly the early postnatal period the mother may be worried that the
breast milk is not sufficient for her two babies, reassure her that lactation responds to
the demands of the babies sucking at the breast.

• Monitor carefully the weight gain of the babies by weighing them daily
• Encourage mother to participate actively in the care of her babies whatever method is
used to feed them
• Hypoglycemia is likely to occur therefore regular capillary blood glucose estimations
may be necessary
• Care of the mother
• Involution of the uterus is likely to be slower because of the increased bulkiness.
• After pains may be troublesome and she needs an analgesia or sedatives to help her
have enough time to rest
• In case mother opts to breastfeed, encourage her to have adequate diet rich in proteins,
and high calories
• Encourage mother to be doing postnatal exercises, physiotherapist may be involved
 REFRENCES
1. Bassavanthappa B.T. (2006); Midwifery and Reproductive Healthy Nursing. First
Edition, Jaypee Brothers, Medical Publishers (P) Limited, New Delhi.
2. Margret A. cooper. (2003); Myles Text Book for Midwives. 14th Edition, Churchill
Livingstone, London.
3. Pauline M.S. (2008). Midiwifery Text Book for Midwives in Southern Africa. 10th Edition
Volume 2, Pauline McCall Sellers, Lansdowne.
4. Sellers P.M (2012). Textbook for midwifery, 2nd Edition, Juta and compony ltd, Capetown
South Africa.
 CHAPTER THREE

Introduction

This chapter is about the management of twin pregnancy,midwifery and obstetrical management based
on the problems identified. It also deals with the discharge plan and the information education and
communication (IEC) given.

Aims

1. To prepare physically and psychologically both the client and the husband for labour.
2. To correct and treat any ailment before the woman goes into active labour.

Antenatal Management

As soon as the twins have been diagnosed, a close check on haemoglobin levels is done until she
delivers. A balanced diet rich in proteins, vitamins, iron should be prescribed.

Iron and folic preparations are given until 4 weeks after delivery. Mothers are encouraged to drink a lot
of milk about 1-3 liters if they can afford daily for calcium supplement. Signs of pre eclampsia are closely
monitored if present mother will have to be coming for weekly checkups.

She was encouraged to put extra pillows when laying on her side or to tuck the pillow under the
abdomen to relieve discomfort. Adequate rest is very important so as to help increase blood flow to the
placenta.

Some mild sedatives may be used in case of overstretching of muscles or excessive movements causing
pain. She was admitted in established labour on 14 th December 2014 at 38 , 5days.

Mrs. M was advised to have enough rest due to exaggerated pressure symptoms. She was also advised
to have a hospital delivery due to twin pregnancy as twin one was breech by scan. From 30 weeks she
was told to be attending antenatal clinic (ANC) weekly till a date of her planned delivery is set. Before
admission she was advised to be elevating the legs to improve on venous return and to put pillows at
night for propping the head end of the bed to relieve the dyspnoea and prevent supine hypotension.

Obstetrical management

Mrs. M was attending antenatal at UTH, an ultra sound scan was done and a diagnosis of multiple
pregnancy was made, height of fundus was undefined and gestational age was 13weeks. The scan
showed that one twin was breech and the other twin was cephalic. She was advised to deliver from the
hospital.
Investigations Done On our Client

1. History which reviewed twins in the family

2. HIV test was done which was nonreactive and RPR nonreactive
3. Hemoglobin levels which was 14.9g/dl
4. Abdominal ultra sound scan confirmed twin pregnancy. One in breech presentation and the
other twin in cephalic presentation.

Medical Management

Mrs. M was commenced on the following drugs

 Ferrous sulphate
 Folic acid
 Vermox
 Fansidar
 Fully immunized against tetanus.

Table : medication for Mrs. M

Drug Dosage Indication Action Side effects

Ferrous sulphate 200mg twice Treatment and Heamoglobin Gastral intestinal

daily orally prevention of levels improved disturbance
iron deficiency

Folic acid 5mg once daily Treatment and Folic acid serum Allergic reactions
orally prevention of levels improved general malaise
folic acid and broncho
deficiency spasms

Vermox 500mg stat orally Treatment and Paralysis of Gastrol intestinal

prevent ion of worms leading to disturbance
helminthes expulsion

Fansidar 3 tablets x 3 Treatment of Killing malaria Hypersensitivity

 doses at least 2 malaria plasmodium reactions to
months apart sulphanomides

Midwifery management

On 22nd JULY, 2014 Mrs. M attended antenatal clinic and after being seen by the obstetricians
investigations were ordered that is an ultrasound which revealed that twin one was in breech and twin
two cephalic at 23 weeks gestation with a blood pressure of 140/80mmhg it was decided that she be
admitted for elective caesarean section on 14 th November 2014. Psychological care was given to Mrs. M
about the condition and why there was need to deliver the babies by caesarean section, this was done
to allay anxiety, fear and to gain her co-operation in her care as well as to increase knowledge pertaining
to her condition, her family was also involved in the care and were explained to as to why she was
admitted, this was to enable close monitoring of her condition.

She was also encouraged to rest to relieve her of exaggerated pressure symptoms that is oedema and
discomfort. While on the ward she was encouraged to put her legs on a pillow when sleeping and
pillows were used to prop up the patient. This was to increase venous return to the heart and to support
the uterus hence relieving the discomfort. This helped also as the client was able to breath well.

Signing of consent

As Mrs. M was of legal age she signed the consent form after being explained to.

Nutrition

On the day of admission she was put on nil orally but she was put on intravenous fluids i.e dextrose
alternating with normal saline in preparation for caesarian section. It was explained that if she takes
food orally it causes complications such as aspiration pnuemonia.

PREOPERSTIVE MANAGEMENT

AIMS

1. To provide psychological care.

2. To monitor fetal and maternal wellbeing before surgery.
3. Prevent infection.

PHYSICAL PREPARATION

i. On 15th November 2014, Mrs. M was cannulated for infusion of fluids during surgery and for
drug administration post operatively.
 ii. A urinary catheter was inserted to drain the urine and to prevent trauma to the bladder
during the operation.
iii. Labelling of the client was done so that the procedure to be done to her was known and for
identification. The label had her name, sex, age, type of procedure and date.
iv. Confirmation of the signing of a consent form was done as evidence that she knew and
agreed that the operation be carried out.

Observations

i. These were taken to act as baseline data for the operating theatre crew and to detect any
abnormalities. Blood pressure was 140/90mHg which was a normal reading. Pulses 98b/min
and respiration 22b/min as well as temp 37.2 oC, the fetal heart rates were checked was 150
b/min regular and 148b/min regular.

Hand over of the patient

At 21:40 hrs Mrs. M was taken to the theater and a hand over was given to the theater
crew.

POST OPERATIVE BED

ii. A postoperative bed was prepared for her in the ward in readiness for continued care of
Mrs. M .Oxygen source, suction machine, and TPR tray was put in place for use after
operation in case need arise.

During surgery

The following procedure was done under spinal anesthesia

iii. The abdomen was swabbed and draped. A lower segment caesarean section was done. At
22:30 hours a live mature female infant with an agars score of 9/10 was extracted as twin I.
then at 22: 33hours a live mature male infant also with an apgar’s score of 9/10 was
extracted as twin II.
iv. Placenta and membranes were delivered and appeared healthy and complete.
v. Uterus was mopped and closed with vicryl 2.0 in 2 layers sheath closed with chronic catgut
(CCG) number 2. Skin closed with number 2 silk. Wound was cleaned and closed. Vaginal
toilet also done.
vi. Needle, swabs and instrument count was done before closure of the wound / abdomen.
Estimated blood loss 400m/s.

Post Operative Care

Post Natal Care Was As Follows

 i. Transfer the patient to B03 and care for spinal anesthesia. Nurse patient in supine position
for 8hours.
ii. Patient to be maintained on nil orally
iii. Intravenous fluids 1 litre 2 – 3 hours until vital signs stabilize (3liters dextrose saline / 24
hours)
iv. Pethidine 100mg 6hourly x 4 doses
v. Injection x – pen 2 MU 6hourly x 5/7 days
vi. Injection gentamycin 80mg three times daily X 5/7 days
vii. Flagyl 500mg intravenously three times x 5 to 7days
viii. Monitor intake and output of fluids and chart.
ix. Monitor vitals ¼ hourly for one hour

Post operative vital signs

Temperature 36.9 c

Pulse 90bpm

Respirations 20bpm

Blood pressure 150/80mmHg

The client was taken to the ward at 00:00hrs and on the ward the vital signs were as follows.

Temperature 36.2oC

Pulse 80bpm

Respirations 20bpm

Blood pressure 150/100mmHg

Babies notes and care

At 22:30 hours a mature Female infant was extracted, with apgar score 9/10 as twin I cord clamped and
cut short. Baby wiped shown to mother for sex identification weighted and labeled and wrapped warmly
then taken to B03 nursery.

At 22:33 hours a mature male infant apgar’s score 9/10 was extracted as twin 2. Cord clamped and cut
short and secured. Baby wiped shown to mother for sex identification, weighed, labeled and wrapped
warmly then taken to B03 nursery as well.

On the ward a physical examination was done on the babies and the following were the findings:-
Table 5: physical examination

General examination Findings twin I Twin II

Length 50cm 48cm

Head circumference 36cm 34cm

Caput No caput No caput

Moulding No moulding No moulding

Fontanels Not bulging and not sunken Not bulging, not sunken

Mouth No cleft lip or palate No left lip or palate

Chest 33cm and symmetrical 33cm and symmetrical

Abdomen No hernia, or exomphalos No hernia or exomphalos

Gentalia Well formed scrotal creases Well formed scrotal creases

present present

Upper limbs 10 fingers counted no extra 10 fingers counted no extra

digits and no webbing digits no webbing

Lower limbs Symmetrical counted 10 toes Symmetrical counted 10 toes

no extra digits no webbing no extra digits no webbing

Reflexes
Present Present
Grasp
Present Present
Rooting
Present Present
Suckling
Present Present
Moro
Present Present
Primitive walk
back No spinal bifida No spinal bifida

Management of the client post operatively nursing care plan – post operative

a) To observe vaginal bleeding and bleeding from the site of the incision
b) To prevent infection
c) To promote rest and comfort
d) To encourage breastfeeding and bonding

Table 6: Nursing care plan

Date Need/problem identified Goal objective Nursing Rationale Evaluation

intervention
16.11.14 Need to observe vital To detect Vital signs of life To detect any No
signs that is complications checked ¼ abnormalities complications
temperature, pulse, early and to hourly for the 1st early or
respiration and blood intervene on hour abnormalities
pressure time Hourly for the detected
throughout next 2 hours Temp – 36.2o C
hospitalization Hourly for the pulse – 80bpm
next 3 hours and resp – 24bpm
4 hourly Bp –
thereafter 130/80mmHg
16.11.14 Patient in pain To relieve pain Pethidine To relieve pain Pain relieved,
and promote injection 100mg evidence by
comfort 6houly given patient not
throughout intramuscularly complaining
hospitalization in 24hours about pain.
16.11.14 Inability to turn To relieve Patient turned 2 To prevent Pressure sores
pressure on hourly pressure sore prevented as
pressure points formation patient did not
To improve develop any
blood circulation sores while in
To provide hospital
comfort
16.11.14 Need for a bath/oral To promote Patient bathed To promote Patient
care/changing of comfort and in bed and oral hygiene comfortable
perineal pads and bed good personal care done. To improve and clean
linen hygiene and to perineal pads blood circulation
 prevent changed To provide
infections whenever comfort
soiled. Soiled
bed linen
changed
16.11.14 Need for observation of:- To detect any Frequent To detect any Lochia rubra
- Wound abnormalities checking for bleeding from with minimal
- Lochia early and bleeding of the the wound. flow
- Catheter intervene wound To note any Normal intake
- Intravenous line appropriately Pads checked heavy or and out put
for the type of abnormal
lochia and vaginal bleeding
Accurate To prevent
recording of the circulatory
fluid on the overload and
chart ensure normal
kidney function
16.11.14 Need for rest To promote Patient nursed To provide a Patient
rest in a quit quiet comfortable
environment environment and resting
Procedure timed and promote
to avoid rest
unnecessary
disturbances of
the patient
Restrict number
of visitors
Oiling all trolley
that are noisy
16.11.14 Need to remove To prevent Catheter Voiding prevents Patient general
catheter and promote voiding removed and full bladder as a condition
ambulation To promote patient full bladder as a improving
blood encouraged to full bladder Bladder
circulation to all void frequently hinds good emptied
parts of the Assist patient to uterine
body get out of bed contraction
and take a tub Early ambulation
bath sitting in promotes good
chair blood circulation
and helps in
healing
16.11.14 Need to have wound To prevent Cleaning done a To promote The wound is
cleaned infection and spirit swab three quick healing clean not
promote quick times daily and To prevent infected and
wound healing it is exposed infection gapping
To observe for
wounds
16.11.14 Promotion of nutrition To give A light nutritious To promote Good
nutritious diet diet given like good nutrition nutritious food
inorder to light porridge To repair worn given to
nourish baby and average out tissues and patient
juice given help build new
 Food rich in ones
protein,
vitamins and
carbohydrates
given
16.11.14 Promotion of To initiate and Mother To promote Patient breast
breastfeeding and sustain encouraged to breastfeeding feeds well
bonding breastfeeding start and bonding
breastfeeding Promotion of
Mother production of
demonstrated milk
to on how to Prevent breast
position and encouragement
attachment of Creates baby
the baby mother bonding

Discharge plans by the obstetricians

On the 3rd day post operatively, the patient’s general condition was satisfactory and she had no
complaints, she was able to do her daily care with minimal assistance. Observations of the vital signs i.e.
temperature, pulse, respiration and blood pressure were within the normal range.

Blood pressure 120/80mmHg

Pulse 70bpm

Respirations 22bpm

Temperature 36.0oC

The wound was clean and was healing well. The babies were feeding well and were cared for. The
mother’s hemoglobin was 12.5g/dl on 19.11.14. The doctor was satisfied with the findings and the
condition and he planned for discharge. The doctor discharged her on the following orders:-

Medications

- Tablet amoxyl 500mg 8hourly for 5days

- Tablet flagyl 400mg 8hourly for 5days
- Ferrous sulphate 200mg once daily for 1 month
- Folic acid 5mg once daily for 1 month
- To come for removal of stitches on the 23 rd of November 2014
 - To come for review after 2weeks on the 30 th of November 2014

Before the patient was discharged from hospital, a post natal examination was done in order to make
sure that she was fit as she goes home. The following were the findings:-

i. Blood pressure 120/80mmHg

ii. Temperature 36.1oC
iii. Pulse 72 bpm
iv. Respirations 22bpm

Appearance – she looked clam, happy that she was going home

Head – the hair was clean, had no signs of malnutrition or any chronic illness.

Eyes – no pallor or jaundice on the conjunctiva and sclera

Neck – no enlarged lymph nodes and thyroid gland

Axilla – no enlarged lymph nodes

Hands – no pallor, good venous return on the nail bed and no knuckle oedema

Breasts – full, nipples prominent, suitable for breastfeeding and no breast engongement

Abdomen – uterus well contracted and fundal height measured 18cm above the symphysis pubis.
Wound was healing well.

Legs – no oedema, varicose veins, culf tenderness or pain

Vulva – clean, no sores, lochia rubra normal flow.

Back – no sacral oedema

Urinalysis not done as there were no reagents on the ward on discharge

Table 7: Summary of physical examination of the babies on discharge

General appearance Twin 1 skin pink and active Twin 2 skin pink and active

Temperature 36.2 o C 37.0o C

Apex beat 120 bpm 122bpm

Head circumference 35cm 34cm

Chest circumference 33cm 33cm

Length 50 cm 48cm

Colour of skin Pink no jaundice Pink no jaundice

Abdomen Soft, not distended Soft, not distended

Umbilical cord Cord clamping situ no Clamp in situ no bleeding

bleeding

Elimination Passing urine and meconium passing urine and meconium

Weight 2.355kg 2.615kg

General condition Satisfactory Satisfactory

Note: the babies were given BCG and OPVO immunizations before discharge from the hospital and
mother advised to finish immunization schedule at local clinic.

Health IEC education on discharge

After a postnatal examination, the following advice was given:-

 Importance of eating a mixed diet to promote good nutritional status of the body and build up
worn out tissues and high fluid intake to promote milk production
 Taught on the danger signs during puerperium and identification of danger signs and seeking
medical attention immediately they are identified.
 To continue taking the prescribed medications to promote wound healing, prevent infection and
help raise haemoglobin levels
 To continue with good personal hygiene especially the perineal area and frequent changing of
pads to prevent ascending infections also advised to wash and iron pants before use.
 To remember to come for review on the given dates so that progress can be monitored and to
remove the sutures
 Discussed also on the different types of family planning
 Taught on how to do cord care and encouraged to do it 3 times daily to promote healing and
prevent infections
 To exclusively breastfeed the babies for 6months to minimize chances of infections such as
diarrheoa.
 To watch out and identify danger signs in the new born such as fever, bulging or sunken
fontanels, convulsions, distended abdomen and inability to breastfed
 To take the babies to children’s clinic for immunization and growth monitoring
  To take the birth records to the civic centre for issuing of birth certificates within 21 days
 Therefore, she was given her medications. The babies were wrapped for warmth and I escorted
them (with my clients husband) to the vehicle outside. I reconfirmed my appointment to them
in a few days’ time.

COMPARISON OF CLIENT’S CONDITION WITH LITERATURE REVIEW.

Client’s condition Literature review

Inspection Inspection
The size of the abdomen was larger than the In multiple pregnancy, the abdomen looks
gestation age. larger than the gestation age.
The uterus was broad and round. The uterus looks broad and round.

There were excessive fetal movements. There will be excessive fetal movements.

Palpation Palpation
- The height of fundus was high than The height of fundus will be higher than period
period of gestation. of gestation.
- Two fetal heads were felt. Two fetal heads will be felt.
- Unusual number of fetal parts were Unusual number of fetal parts maybe felt
felt.
Auscultation Auscultation
- Two fetal hearts were heard by two - Two fetal hearts will be heard by two
examining midwifes at the same time examining midwifes at the same time
with a minimum difference of 8-10 with a minimum difference of 8-10
minutes. minutes.
 She had no complications such as May have complications such as
polihydramnous and anemia polihydramnous and anemia

CHAPTER 4

This report is about the follow up visit we carried on Mrs M’s home from the time we met her
until the closure of the case study.
1st visit on 24th July, 2014

Objectives

i. To locate Mrs. M’s home

ii. To meet members of her family
iii. To assess her home environment and give necessary I.E.C. on 21.06.2014 in the morning we
started off for our visit. We carried a digital BP machine and urine sticks to monitor the
blood pressure, urine for protein, glucose and ketones respectively.

We located the home without any problems and we found Mrs. M seated outside the house chatting
with family members. When she saw us she was happy and welcomed us and introduced us to her
relatives. We didn’t find the husband as he had gone for work in town. We then explained the purpose
of our visit. She gave consent for us to go ahead with the investigations.

Blood pressure was checked which was 140/80mmHg and gave her a gallipot for urine and checked
for proteins, glucose and albumen which were negative. We advised her to be resting enough and
reduce on stressful things to try and maintain the blood pressure at a lower rate. We also advised
her to eat a diet rich in protein, iron to help maintain the haemoglobin (Hb) levels and help in the
growing of the fetuses.

The environment was clean the house well ventilated and very clean. The surrounding was clean.
There was a tap outside the house where they draw water for domestic use. They boil drinking
water and use a pit latrine which is cleaned using soap water and a pit for waste disposal. We later
asked our client if she had any problems concerning her health. She had no complaints and said she
was feeling well. We thanked Mrs. M, for allowing us to carry out the investigation and for the
cooperation. We then started off back to school.

2nd visit on 24th November, 2014

OBJECTIVES

- To monitor the general condition of the mother and how she is managing with the wound.
- To conduct a postnatal exam
- To monitor the general condition of the baby’s and if she was breastfeeding well.
- To remind her to take the children for BCG and OPV.

On the material day we started off as a group to go and Visit Mrs. M. We found her home with
her mother and her relatives who had gone to visit her as well. We were warmly welcomed as
usual and introduced to everyone present at home as a student midwife’s who were carrying out
a case study on her condition.

Were happy that Mrs. M had no physical complaints on that day. She appeared happy and health
when asked if she had any problems, she said she was feeling slight pain at the site of the
incision. She had no other problems and had enough breast milk. We later asked if we could
conduct a full physical examination on her and her babies. We asked if her mother would be
present during the examination. She said we could go ahead as she had no problems with health
workers as they are carrying out their duies.

The examination of the babies was done in the presence of Mrs.M and the following were the
findings:
Table no 1;Physical examination of the babies

General appearance Twin 1skin pink and active Twin 2skin pink and active

Temperature 36.5oC 37oC

Apex beat 124 bpm 126 bpm

Head circumference 33cm 35cm

Chest circumference 31cm 32cm

Length 48cm 50cm

Colour of skin Pink no jaundice Pink no jaundice

Abdomen Soft, not distended Soft not distended

Umbilical cord Cord clamp in situ not Navel clean

bleeding

Elimination Passing urine and passing urine and

meconium meconium

Weight 1.800kg 2.50kg

General condition satisfactory satisfactory

Full examination of the mother

The full examination of the mother (physical) Mrs.M was done in the sitting room and the
following were the findings:-
Vitals

Blood Pressure; 130/90mmHg

Temperature; 37degrees celcius

Pulse; 98b/min

Respiration; 18b/min

Table no 2; full examination of the mother

General condition Appeared healthy and happy

Hair Hair was well plated

Eyes No jaundice and no pallor

Ears No discharge

Nose No polyps

Mouth Teeth clean no dental carries

Neck No enlarged lymph node thyroid gland

Axillae No enlarged lymph nodes

Breasts Full nipples prominent, soft suitable for

breastfeeding and were lactating

Abdomen Uterus well contracted 14cm above the

symphisis pubis. Surgical incision healing
well sutures removed.

Lower limbs No oedema, pain, varicose veins or calf

tenderness

Vulva Clean, no sores, warts or rash, lochia alba,

minimal flow and not offensive

Anus No hemorrhoids
 Back No sacral oedema

Information education and communication given

We advised her on the importance of nutrition as she required the nutrients for growth and repair
of new cells is the body. We advised her to eat foods rich in iron like kalembula, for increased
hemoglobin levels and vitamins especially vitamin C to enhance absorption of iron.

• We explained the importance of rest so as to allow the body to absorb enough nutrients
from the food.

• We explained the importance of exclusive breastfeeding and discouraged her to give

mixed feeding

• We explained the importance of keeping the babies warm to prevent hypothermia

• We encouraged her to continue cleaning the wound and encouraged her to support the
incision site whenever she wanted to cough. We discouraged her from carrying heavy
items.

• We reminded her about the review date and stressed the importance of postnatal review
and importance of under five children’s clinic

• We also encouraged her to take all her prescribed medications.