GOVT COLLEGE OF NURSING

BILASPUR (C.G.)
CASE STUDY
ON
SUBJECT - OBSTETRIC AND GYNAECOLOGICAL NURSING
TOPIC –LOW BIRTH WEIGHT

SUBMITTED TO SUBMITTED BY
DEMONSTRATOR MSC.NURSIG 1 ST YEAR
MSC.NURSING (OBG) GOVT COLLEGE OF
GOVT COLLEGE OF NURSING NURSING BILASPUR C.G.
BILASPUR (C.G.)
INTRODUCTION
My patient name is baby of Savita admitted in NICU on date 08/05/2023 with chief complain
of low birth weight (1.5kg), muscle tone is poor, skull bone is soft with wide suture.

BIODATA
Name of patient -Baby of Savita
Age -4 days
Sex -female
Word - NICU
Bed number - 19
Registration number -20230117110910
Address - Sandri Bilaspur
Date of admission - 08/05/2023
Date of discharge - nil
Diagnosis - Low birth weight
Chief complain - baby of Savita having the low birth weight (1.5 kg) poor muscle tone,
skull bone is soft with wide suture.

BIRTH HISTORY
Antenatal History –
 during antenatal. no history of any drug reaction,
 she not having bad habits of alcoholism, tobacco chewing etc.
 During pregnancy she has taken injection tetanus toxoid 2 dose.
 During pregnancy in first trimester she has taken antiemetic drug for vomiting. She
has taken iron tablet.
 She has taken regular antenatal follow up.
Neonatal history - during the delivery time baby have poor growth and development and
low birth weight.
Postnatal History- after delivery having difficulty of feeding.
Immunization

Age Vaccine Remark

At birth BCG Done
OPV- 0dose Done
Penta – 0 dose Done
MEDICAL HISTORY
Present medical history
In present medical history my patient has low birth weight.
Past medical history
Baby of Savita not having any past medical history.

SURGICAL HISTORY
Present surgical History
Baby of Savita not having any present surgical history.
Past surgical history
Baby of Savita not having any past surgical history.

FAMILY HISTORY
My patient belonged to joint family and all family member health is good.

FAMILY COMPOSITION
Sno Name of Age Sex Relation to Education Occupation Health
. member patient status
th
1. Mr 50 Male Grandfather 10 Farmers Healthy
th
Mohanlal year 5
sahu

2. Mrs Durga 45 Female Grandmother 12th House wife Healthy

year
Mr Ritesh
3. sahu 28 Male Husband 12th Private jab Healthy
year
Mrs. Savita
4. 24 Female Mother Nil House wife Healthy
Baby of year
5. the Savita
4 Female Self Nil Unhealthy
days
FAMILY TREE
Mr. mohanlak sahu Mrs. durga sahu
50 year 45 year

Mr. Ritesh sahu Mr. Savita sahu

28 year 24 year
Baby of Savita -male
4 days
-female

SOCIOECONOMIC CONDITION
Baby is belong to middle class family. In their house having electricity facility, having three
rooms and they use the hand pump water for drinking purpose.
her family Income 10000 monthly this income is sufficient to run her family.

DIETARY HISTORY
Time of 1st feed – no feed
Breast feeding - no
Top milk - yes

ASSESSMENT OF VITAL SIGN

Temperature – 100f
Pulse - 84 b/min
Respiration - 40 b/min
BP. – 80/50 mmHg

ANTHROPOMETRY MEASUREMENT
Sno Parameter In child Expected Remark
.
1. Height 40 cm. 45-50cm Decreased
2. Weight 1.5 kg 2.5-3.5 kg Decreased
3. Head circumference 29 cm. 33-35cm. Decreased
4. Chest circumference 29 cm 33-38 cm. Decreased
5. Middle arm circumference 5cm. 10-12 cm. Decreased
MILD STONE
In book In patient
Child lie supine position, legs are grown up Present
and then the head one side when pulled to
sit, legs behind, hands are clenched, and
the grapes Relax is strong.

REFLEXES
In book In patient
 Rooting reflex Present
 Sucking reflex Present
 Swallowing reflex Present
 Gaging reflex Present
 Dolls eye Absent
 Sneezing reflex Present
 Palmer reflex Present

PHYSICAL EXAMINATION
General appearance
Nourishment – proper
Body build – poor nourished
Health -unhealthy
Height -40 cm.
Weight – 1.5 kg
Head to foot examination
CNS
Consciousness – conscious
Look - dull
Pupil reacting to light -reacting
Head
Box-shaped /bossing – normal
Fontanels - open
Suture - closed
Cephalohematoma – absent
Caput succedaneum – absent
Hair - - normal
Eyes
Sclera - normal
Discharge - absent
Sgaint - absent
Oedema - absent
Conjunctiva - absent
Eyelids - normal
Ears
Discharge - absent
Wax - absent
Shape - normal
Lesion - absent
Foreign body - absent
Nose
Depressed - absent
Drainage - absent
Polyp - absent
Bleeding - absent
Foreign body - absent
Mouth
Lips colour – pink
Gums - normal
Texture – dry
Tongue - normal
Tonsils - normal
Lesion – absent
Neck
Rigidity - absent
Movement – slightly moveable
Lymph nodes – not palpable
Chest
Shape – dome shaped
Expansion – normal
Ribs – normal
Breast – secretion absent
Respiratory system
Respiratory rate-40b/min
Rhythm – regular
Air entry – equal
Breath sound – normal
Lungs - normal
Cardiovascular system
Radial pulse - present
Heart rate – 100 b/min
Rhythm – regular
Heart sound – normal
GI system
Appearance – rounded
Umbilical cord – normal
Liver - no enlargement
Spleen - no enlargement
Mass - absent
Bowel sound – present
Urinary system
Frequency – at day time 4-5 times, at night time 3-4 times
Incontinence – absent
Genitalia
Vagina – normal
Labia majora – normal
Labia minora -normal
Buttocks and anus
Buttock – normal
Anus – opening normal
Fistula - absent
Bowel activity – regular
Diarrhoea – absent
Extremities
Range of motion – normal
Flexion – normal
Fracture and dislocation - absent
Back
Spina bifida – absent
Meningomyocele – absent
Lordosis – absent
Scoliosis - absent
Integumentary system
Skin – pinkish colour
Cyanosis – absent
Scar or wound – absent
Nail – normal
INVESTIGATIONS
Sno Investigation Patient value Normal value Remark
.
1. Haemoglobin 16 gm 18 gm Decreased
2. Hb grouping A positive A,b,AB ,O Normal
3. WBC 8000/cmm 4000-11000/cmm Normal
4. Neutrophils 78% 40-75% Increased
5. Lymphocytes 33% 20-45% Normal
6. Eosinophil 2% 1-6% Normal
7. Monocytes 3% 2-10% Normal
8. Basophil 0% 0-1% Normal
9. Serum bilirubin 0.9 mg/dl Up to 1 mg /dl Normal

DIAGNOSIS
On the basis of all above history and physical examination and investigation the patient
diagnosed as Low birth weight.
MEDICAL MANAGEMENT
Sno Name of drug Dose Route Action Side effect Nurses
responsibilit
y
01. Syp 1 ml Orally Antipyretic and Thrombocytopeni -Monitor vital
Paracetamol unclear pain a signs.
relief May Rash, dizziness. -Check intake
result from output.
inhibition of
Post glanding
synthesis in
CNS with
subsequent
blockage of
pain impulse.

2. Injection 3ml Iv Antibiotics Dizziness Assess

ofloxacin interfere with Chest pain patient to
conversation Nausea previous
of Vomiting sensitivity
intermediate Rash reaction.
DNA fragments
into the high
molecular
weight .

3. Dextrose 5% 100 Iv Need for Headache -Check for

ml adequate vomiting any
utilization of constipation sensitivity
amino acid oliguria reaction.
decrease Dyspnoea -Monitor
protein flow rate for
nitrogen loss, overdose.
prevent
ketosis.

4. Inj. Amikacin 175 Iv Inhibits Headache -monitor GI

Sulphate mg/ synthesis in Confusion status.
250mg/2ml 1 susceptible lethargy, dizziness -monitor the
ml stains of Chest pain vital sign.
ground Hypertension - administers
negative nausea, vomiting, low IV
bacteria cell diarrhoea - monitors
membrane Rashes, side effects.
appears to be leukemoid
disrupted reactions.
causing cell
death.
LOW BIRTH WEIGHT
INTRODUCTION
Low birth weight is a term used to describe babies who are born weighing less than
2.5kg(8ounces,5 pounds) and average new-born usually weight about less than 2.5 kg. a low-
birth-weight baby may be healthy even though he/she is small but low birth weight baby can
also have many serious health problems. Some low-birth-weight babies are healthy but
other have serious health problem that need treatment.

DEFINITION
According to WHO has defined low birth weight as one who birth weight is less than 2.5 kg
irrespective of the gestational age, very low birth weight infant weight 1.5 kg or less and
extremely lower the weight baby infant weight is 1000 grams or less.
Low birth weight – any infant with a birth weight of less than 2.5 kg within one hours of
birth regardless of gestational age.
Grading

Birth weight Grade

2500-2000 gm Low birth weight
2000- 1000 gm Very low birth weight
<1000 gm Extremely low birth weight

INCIDENCE
 More than 20 million infants worldwide representing 15.5% of all birth weights are
born with low birth weight.
 As per WHO criteria incidence after low birth weight in India is 33% each year.
 Premature in the world Single biggest cause of new born death and second leading
cause of all child deaths after pneumonia.

ETIOLOGY
In book In patient
History
 Previous history of induced or Absent
spontaneous abortion or preterm
delivery
 Recurrent urinary tract infection Absent
 Smoking habits Absent
 Low socioeconomic and nutritional Absent
status
 Demobilization of present Absent
pregnancy
Maternal
 Pregnancy complication Absent
 Uterine anomalies Absent
  Medical and surgical illness Absent
 Genital tract infection Absent
Fetal
 Multiple pregnancy, congenital Absent
malformation, IUD
Placental
 Infection, thrombosis, placenta Absent
previa or abruptio placenta
 Iatrogenic Absent

CLINICAL MANIFESTATION
In book In patient
 The weight is 2500 gm or less Seen in my patient
 The length is usually less than 45cm. Seen in my patient
 Head and abdomen are relatively
large. Not seen in my patient
 Eyes are kept closed.
 The muscle tone is poor. Seen in my patient
 The skull bone are soft with wide Seen in my patient
suture. Seen in my patient
 The skin is thin, red and signing due
to lack of subcutaneous fat and Seen in my patient
covered by vernix cassosa.

MANAGEMENT
In book In patient
General management
1.prevention of prematurity Done in my patient
 to prevent preterm onset of Labour
if possible.
 To arrest the preterm labour if not
contraindicated.
 Appropriate management of labour.
2.management of preterm labour Done in my patient
 To prevent birth asphyxia and a
development of RDS
 Birth trauma duration of Labour is
usually short.
 First stage- the patient is put to bed
to prevent early rupture of the
membranes.
 To ensure adequate fetal
 oxygenation by giving oxygen to the
mother by mask.
 A strong selective should be avoided
epidural analysis if of choice.
 Labour should be watched by
intensive clinical monitoring or with
continuous electronic monitoring.
 In case of delay are anticipating a
traumatic vaginal delivery it is better
to delivery by caesarean section
equipped neonatal care unit is sign
on to get a good result of abdominal
delivery.
 Second stage- the birth should be
gentle and slow to avoid rapid
comparison and decompression of
the head.
 Episiotomy may be done under local
anaesthesia to minimums.
 The card is to be clamped
immediately at birth to prevent
hypervolemia and hyperbilirubimia.
 Toshiba baby to the intensive unital
care unit harder than the care of a
neonatologist.
3.Care of preterm baby after birth
Immediate management Done in my patient
 The cord is to be clamped quickly
and to prevent hypervolemia and
developmental hyperbilirubimia.
 The cod length is kept along about
12 cm. in case exchange transfusion
is required.
 The air passage should be cleared of
mucus promptly and gently using a
mucus sucker.
 Adequate oxygenation through
mask, nasal catheter in
concentration not exceeding 35%.
 The baby should go be wrapped up
inducting head in the sterile warm
towel.
 Aqueous solution of vitamin K1 mg
is to be injected in IM to prevent
haemorrhage manifestation.
 Adequate codification to counter
balance increased in sensible water
 loss
 To prevent infection
 To maintain nutrition and adequate
nursing care
Adequate nursing care
 The most important single factors is Done in my patient
standard of nursing care trained
nurses can adequately take care of
the two or three infants.
 The temperature should be taken
twice daily and the baby should be
waited daily to know whether over
or under weighted.
 Constant supervision especially
during the day the crucial first 48
hours in operative.
 Mother is taught for the general
care of the baby and manual
expression of breast milk of pressing
over the areola and the nipple.
 Check favrable signs of progress.
 The colour of the skin remains
pinched all the time.
 smooth and regular breathing
 Monitor should be allowed to her
baby in the nursery.
 Premature babies are discharged
 When they attained sufficient
weight
 Attain good vigor.
 Able to suck the breast successfully.
 Advice on discharge
 If possible, the supervision to be
continued at home by public health
nurses are health visitors following
the following the following devices
are given to on discharging-
 Advice about feeding schedule
 Prescribe as mentioned earlier
 To attend the child welfare clinic for
subsequent checkup immunization
and guidance.

NURSING CARE PLAN

Nursing care plan 1st day
ASSESSMEN DIAGNOSIS GOAL PLANNING IMPLMENTATIO EVALUATIO
T N N
SUBJECTIVE Altered To maintain -To assess -Vital sign Patient
DATA- thermoregulatio the normal the vital checked temperatur
The mother n related to body sign. Temp.-100f e has been
complain infection as temperatur Pulse-100b/min reduced.
says that her evidence by e. Respiration-
baby has increased body 40b/min
warm, temperature.
sweating -Provided the
and -Provide cold sponging.
weakness. cold
OBJECTIVE sponging. - provided the
DATA- keep and calm
On -To provides environment.
observation keep and
I found that calm
patient body environmen - provided the
is warm t. healthy diet to
And has the patient.
fever - to provide
healthy diet - administer anti
to the pyrolytic
patient. medication as
- to Dr prescription.
administer syp PCM 1 ml
anti-pyritic orally.
medication
as
prescribed Encouraged
by doctor. mother for
breast feeding.
- Encourage
mother for
breast
feeding.
2nd day nursing care plan
ASSESSMEN DIAGNOSI GOAL PLANING IMPLMENTATIO EVALUATIO
T S N N
SUBJECTIVE Fluid and To To assess the Assessed the After giving
DATA- electrolyte improve general patient education
Mother imbalance the condition of condition. patient
complain related to electrolyt the patient. electrolyte
that baby is disease e balance. imbalance is
not taking condition To To encouraged improved.
adequate as encourage the mother for
feed. evidenced for give give breast feed.
OBJECTIVE by less breast feed.
DATA- intake of
on feed To educate Educated about
observation I about the change
found that change the position.
baby skin is position.
loose and
dry. To provide Provided
education education about
about the hygiene.
maintain
hygiene.

To provide Provided
dextrose to dextrose 5%
client through iv line
through iv
line.

To provide Provided
the psychological
psychologica support to the
l support to mother.
the mother.
3rd day nursing care plan
ASSESSMEN DIAGNOSIS GOAL PLANNING IMPLMENTATIO EVALUATION
T N
SUBJECTIVE Sleeping To To assess Assessed that After provide
DATA- pattern promot the general patient is having care to the
My patient disturbed to e sleep condition of insomnia. client her
mother says hospitalizatio of the patient sleeping
that she is n as evidence patient pattern
not sleep by patient To provide Provided noise increased
from one verbalization. noise free free some level as
day. environmen environment to manifested by
OBJECTIVE t to the the patient. client mother
DATA- patient verbalizations.
On .
observation To provide To provided
I found that comfortable comfortable
dull face, position to position.
dull activity patient.
and dark
circles To Encouraged the
around the encourage patient mother
eyes. the patient for breast
mother for feeding.
breast
feeding.

To
Encouraged the
encourage
mother to
the mother
maintain the
to maintain
personal
the
hygiene.
personal
hygiene.
4th
day nursing care plan
ASSESSMEN DIAGNOSIS GOAL PLANNING IMPLEMENTATIO EVALUATIO
T N N
SUBJECTIVE Fear and To Assess the Assessed the level My patient
DATA- Anxiety reduce level of of anxiety. mother fear
my patient related to fear anxiety. and anxiety
mother disease and reduced.
complained condition and anxiety I will provide Provided the
that I am hospitalizatio . psychologica psychological
having fear n as evidence l support support to client
about by client family. family.
problem. verbalization.
OBJECTIVE Give Given education
DATA – knowledge about fever and
on about fever. how to do
observation treatment.
that my
patient Introducing Introduced about
mother about the the rules and
having rules and regulations of
anxiety. regulations hospital.
of the
hospital.

-provide Provide calm and

calm and quiet
quit environment.
environment

Maintain Maintain the

good good
interpersona interpersonal
l relationship.
relationship.
5th day nursing care plan
ASSESSMENT DIAGNOSIS GOAL PLANNING IMPLMENTATIO EVALUATIO
N N
SUBJECTIVE Knowledge To To assess Assess the My client
DATA – deficit and improve the knowledge level mother
My patient low self- the knowledge of the patient knowledge
mother esteem knowledg level of mother. and self-
complained related to e level client esteem
that she had disease and mother about
no knowledge condition and improve disease
about disease hospitalizatio the self- To educate Educated the condition is
condition. n. esteem. the client client mother improved.
OBJECTIVE mother about hygiene
DATA- about measures.
I observed personal
that my hygiene.
patient
mother had To educate Educated the
no knowledge the client client mother
about the mother about the
disease about disease
condition and disease condition.
hospitalizatio condition.
n.
Educate the Educated the
client client mother
mother about side
about side effect of
effect of medication.
medication.

To provide Provided
psychologic psychological
al support support to
to client client mother.
mother.
COMPLICATIONS
IN BOOK IN PATIENT
 Hypothermia Not Seen in my patient
 Asphyxia Not Seen in my patient
 Pulmonary syndrome, shock. Not seen in my patient
 Cerebral haemorrhage Not seen in my patient
 Heart failure, oliguria, Not seen in my patient
 anuria, Not seen in my patient
 infection Not seen in my patient
 jaundice Not seen in my patient
 anaemia Not seen in my patient

PROGNOSIS
1ST DAY
 General condition of patient is poor She had conscious but hyperthermia.
 Doctor prescribe medicine syp pcm 2 drop orally ,
Syp ofloxacin 250 mg 2 drops orally
Iv dextrose 5% iv
 Check vital sign
Temperature-100F
Pulse- 100 b/min
Respiration- 40 b/min
 Iv fluid, medicine paracetamol, inj. oflxacin and iv dextrose 5% has given.
 Advice mother for initiate breastfeeding.
 To maintain personal hygiene of baby.
 Provide K M C care to maintain warmth.
 Educate mother for immunization of baby properly.

2nd Day
 Patient general condition of weak.
 Doctor prescribe medicine syp pcm 2 drop orally,
Syp ofloxacin 250 mg 2 drops orally
Iv dextrose 5% iv
 Check vital sign
 Temperature-100F
Pulse- 120 b/min
Respiration- 40 b/min
 Encouraged mother for iniate breast feed.
 Give education to mother about hygiene.
 Given skin care for baby.
 To maintain personal hygiene of baby.
 Provide K M C care to maintain warmth.
 Educate mother for immunization of baby properly.
 Provided electrolyte balance diet to mother.
3rd Day
 General condition of patient is poor She had conscious but hyperthermia.
 Doctor prescribe medicine syp pcm 2 drop orally,
Syp ofloxacin 250 mg 2 drops orally
Iv dextrose 5% iv
 Check vital sign
Temperature-100F
Pulse- 100 b/min
Respiration- 40 b/min
 Iv fluid, medicine paracetamol, inj. ofloxacin and iv dextrose 5% has given.
 Advice mother for initiate breastfeeding.
 To maintain personal hygiene of baby.
 Provide K M C care to maintain warmth.
 Educate mother for immunization of baby properly.
 provided psychological support to mother.
 Given education about fever and how to do treatment.
 Introduced about the rules and regulations of hospital. After giving this patient
mother anxiety has been reduced.
4th Day
 General condition of patient is improved.
 Doctor prescribe medicine syp pcm 2 drop orally,
Syp ofloxacin 250 mg 2 drops orally
Iv dextrose 5% iv
 Check vital sign
Temperature-99F
Pulse- 120 b/min
Respiration- 50 b/min
  Iv fluid, medicine paracetamol, inj. ofloxacin and iv dextrose 5% has given.
 Advice mother for initiate breastfeeding.
 To maintain personal hygiene of baby.
 Provide K M C care to maintain warmth.
 Educate mother for immunization of baby properly.
 provided psychological support to mother.
 Given education about fever and how to do treatment.
 Introduced about the rules and regulations of hospital. After giving this patient
mother anxiety has been reduced.
 Provided noise free environment to the patient.
 To provided comfortable position.
5th Day

 General condition of patient is improved.

 Check vital sign
Temperature-99F
Pulse- 120 b/min
Respiration- 50 b/min
 Iv fluid, medicine paracetamol, inj. ofloxacin and iv dextrose 5% has given.
 Advice mother for initiate breastfeeding.
 To maintain personal hygiene of baby.
 Provide K M C care to maintain warmth.
 Educate mother for immunization of baby properly.
 provided psychological support to mother.
 Introduced about the rules and regulations of hospital. After giving this patient
mother anxiety has been reduced.
 To provided comfortable position.
 Educated the client mother about side effect of medication. after giving the
education
patient mother knowledge level is increased.
HEALTH EDUCATION
Diet
 Encourage mother to take nutritious diet.
 Encourage mother to provide proper breast feeding.
 Advise the mother to take more carbohydrate diet.
 Advise the mother to avoid fat, spicy and fried food.
 Encourage the mother to take balance diet.
Care of the baby
 Explained about complications like breathing difficulty, fever, cold and its prevention.
 Explained about importance of keeping the baby warmer, kangaroo mother care.
Personal hygiene
 Encourage to maintain good oral hygiene.
 Encourage to change the pads daily cleans this area.
 Encourage for perineal care.
Follow up care
 Encourage the mother for follow up the postnatal visit regularly.
 Encourage the mother for proper immunization of baby and check-up,

CONCLUSION
The program reduce the rate of low birth weight deliveries in the medical population.
Pregnancy management is feasible and effective intervention as part of a managed care
organization. Membered needs care of and addressed for effectively with early risk
assessment and stratification.
BIBLIOGRAPHY
1) Annamma Jacob “A Comprehensive textbook of midwifery and gynaecological
nursing” 4th edition, the Health Science Publishers New Delhi page number-665
2) Basant Thapa BT “Textbook of midwifery and Reproductive Health Nursing” 1 st
edition 2006, published by Jitendra p. vij Jaypee Brother Medical Publisher Pvt Ltd
Page Number-381
3) Dutta DC “Textbook of gynaecology including contraception” new central book
agency Delhi 5th, edition, Jaypee brother Medical Publisher page number-527-540
4) Ghai OP “Essential paediatrics nursing” 7 th edition published by Dr OP ghai page
no.310
5) Indrani T.K. “Domiciliary care in midwifery”1 st edition 2004, published by Jaypee
brother medical publisher p ltd pp 401
6) Myles “Textbooks for midwives” xiv edition 2003 published by Drishti Library catalos
in publication data. Pp640
7) Neelam Kumari, sulani Sharma, Dr Preeti Gupta “Midwifery and gynaecological
nursing” first addition 2010, printed in the bond in India by imperial official printers.
pp 490
8) Salhan Sudha “Textbook of Obstetrics” first edition JP Brothers Medical Publisher Pvt
Ltd New Delhi Page Number-550
9) Vee pee “Essential of child health Nursing” page no 1005
10) Williams and Ross “Anatomy and physiology in health and illness” 10 th edition
Elsevier an imprint of Elsevier Limited page number -390 - 310