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INTRODUCTION
embryonic and fetal periods to birth. It lasts approximately 266 days (38 weeks)
from the day of fertilization but it is clinically considered to last 280 days (40
weeks; 10 lunar months;91/3 calendar months) from the first day of the last
The first few months of pregnancy are the most critical for the developing
infant, because during this period the infant’s brain, arms, legs, and internal
organs are form. For this reason, a pregnant woman should be especially careful
about taking any kind of medication except on the advice of a physician who
knows that she is pregnant. Pregnant women should avoid x rays, smoking and
alcohol consumption.
Delivery, the process by which the baby is expelled from the uterus
through the birth canal and into the world, begins with irregular contractions of
contractions increase in frequency and severity. The usual length of labor for a
has given birth previously. Wide variations exist, however, in the duration of
labor.
[1]
II.GENERAL DATA
Name : L.B.P.
Age : 36 y.o.
Sex : Female
Citizenship : Filipino
Status : Married
suddenly felt lower abdominal pain and strong frequent uterine contractions. She
Upon admission, the patient noted to be on her active labor. Her vital
signs were taken as soon as she arrived in the hospital with the following results:
pulse rate was 80 beats per minute, respiratory rate was 22 cycles per minute,
body temperature was 36.6 0C, and blood pressure was 100/70 mmHg.
[2]
Patient had her menarche at the age of 12 years old with regular monthly
cycle lasting for 5 days consuming 2-3 pads per day. She was negative for
dysmenorrheal and amenorrhea. Her first sexual contact was at the age of 24
OBSCORE :G5T4P0A0L4M0
Patient’s general state of health is good. On her early childhood, she had
chickenpox and measles. When she had a fever, her mother wiped her whole
body to relieve the heat. She ate more oranges and a well balanced diet. She
sometimes had headache and diarrhea but she will just take a medicine for it. At
the age of seven, she had a severe fever and her parents brought her to the
hospital for a checkup. She had a diagnosis of a dengue fever. She remembers
that, she feels so tired at that time. She received a complete immunization. She
was not able to undergone any operation and was never experienced to be
[3]
V. GORDON’S HEALTH PATTERN
The patient perceived her health in a state of wellness. She said that in
woman, being pregnant is just normal and natural. During her pregnancy, she
easily coped up with the signs and symptoms she felt because she already had
an idea on how it is going to be. She makes sure not to miss any scheduled
prenatal checkup. She followed what the physician advised her to do like eating
The patient usually eats rice and egg during breakfast; rice, fish and
vegetables for lunch; and, for suppertime, she eats rice and meat. She eats
snacks in between breakfast and lunch around 10 am, in between lunch and
supper around 3 pm, and before going to sleep around 10 pm. Her snacks
usually composed of bread, biscuit, and juice. Water is the fluid she usually
intakes. She has no problem with her appetite. She takes iron supplements and
vitamin C as what her physician prescribed her. Her weight changed in last six
Elimination Pattern
The patient does not have any problem with her urination and defecation.
She defecates every other day usually in the evening. Her stools vary depending
[4]
Activity - Exercise Pattern
The patient is a fish vendor in the market. She spends her leisure time
watching television shows, listening to the radio, and sleeping. Walking from her
house to the market was her usual exercise. When she became pregnant, she
does simple stretching exercises. She can take care of herself without any help
from others.
time is 5 am. She usually gains 7-8 hours of sleep excluding naptime. She takes
The patient was conscious, responsive and coherent. She can see clearly
without an aid of an eyeglass. She can hear clearly and her other senses are
functioning well. She does not have any skin allergy. She knows how to read and
The patient does not have any interest in make-ups or putting any art in
her body unlike when she was still in her adolescence stage. She is contented of
what she looks. Her concern focuses more on to her children especially to the
newest member of their family. She felt happy upon delivering a normal and
[5]
Role- Relationship Pattern
The patient can speak Tagalong, a little bit of English and a Visayan
language but she speaks Visayan language every day. Her speech is clear and
relevant to the situation. She can easily express herself verbally. She lived
together with her husband and children. Whenever she had problem, she will ask
for help to her friends, mother and husband. Praying rosary every night together
with her family is their daily activity. She is the one who usually disciplines her
children. In terms of making decisions, she and her husband will have to decide
for it. She has a good relationship with her family and can communicate well.
whenever they had coitus. During pregnancy, she experienced altered sexual
relations and she does not want to have coitus with her husband. She said that
The patient analyzes first the situation before making decisions. She
always makes decisions together with her husband. If she were stress, she
would just find ways to make herself enjoy like watching television shows and
[6]
Value - Belief System
The patient’s source of strength is her family and God. For her, God is
very important to her life. She prays rosary, visits churches and hear masses
together with her family. Before she delivered her baby, she prayed to her God to
have a safe delivery and after delivery, she was very thankful to Him for she had
a safe, normal delivery and a new healthy baby girl. In addition, she always
praise and thank God for all the blessings she had.
simple and approachable. She might have a slow voice but she said she is
[7]
talkative. During her high school years, she loves to be with her friends. She may
look strict but deep inside she is friendly especially if she first gets a smile. She
works hard especially when she became a mother and wife. She spends her free
time in watching television shows or listening to radio. She spent her vacant
periods sleeping to relax herself. She eats three times a day excluding snacks.
She usually sleeps at between 9 pm to 10 pm. Her rising time is 5 am. Whenever
she had problem, she will ask for help to her friends, mother and husband. She
does simple exercise every morning like stretching and considers her household
C. ENVIRONMENTAL HISTORY
Cebu. They live in that place for almost seven years. On their rented house, she
said that they are fine and comfortable with the place even though sometimes it
is noisy, but they already used to it. The space of their house is just enough for
them. They have their own comfort room, water and electrical supply. Their
[8]
VII. PHYSICAL ASSESSMENT
from Bateria, Daanbantayan Cebu was admitted due to lower abdominal pain
Patient was seen transferred from a stretcher to her bed, conscious, coherent
Vital Signs taken during the first contact with the patient:
Temperature : 36.5 0C
Skin: brown in color; has lesions on lower extremities; warm and dry; has
Hair: wavy; black in color; shoulder length; not extremely oily; evenly distributed;
[9]
Head: normocephalic; with smooth contour; without masses; symmetrical;
proportion to body
masses
Eyes: eyelids appear symmetrical with no drooping; eyelashes are black in color
and well curved; lacrimal apparatus has no discharges upon palpation and
no pain felt; with 20/20 vision; pupils are equally round and reactive to light
and accommodation with a size of 3mm; conjunctiva is clear and pale pink;
iris is round
Ears: symmetrical and at level of eyes outer cantus; brown in color; smooth; can
discharges; airways are patent and free from obstructions; sinuses are
negative for congestion and no pain felt upon palpation; nasal Mucosa is
certain microorganisms
Mouth: teeth are complete, no dentures, slightly yellow in color with no indication
of any tooth decay or other tooth related problems; gums are pinkish with
[10]
no bleeding; tongue is red in color, symmetrical to the midline of the mouth,
moves freely; lips are pale pink in color, closes symmetrically and negative
for lesions
Neck: free from any aberration or injury; chloasma noted; no inflammation noted
on the thyroid glands; lymph nodes are not inflamed; no masses of any
type were noted in the general area of the neck; no bounding of jugular
vein.
Chest: slightly dark pigmented; no lesions noted; equal chest expansion and
cycles per minute from the normal range of 16-20 cycles per minute.
Heart: with normal heart sounds; has a regular rhythm with 75 beats per minute
from the normal rate of 60-100 beats per minute; no visible pulsations
Breasts: both left and right breast are engorged; have smooth contour; no
Abdomen: slightly protruded due to still ongoing involution (1 hour post partum);
linea nigra and striae gravidarum noted; with 3 bowel sound per minute
[11]
upon auscultation; no masses were noted on the general area; warm to
touch;
Upper Extremities: equally grip; low strength; warm to touch; good skin turgor;
both hands have five fingers; nails are short slightly pinkish; slightly dark
Lower Extremities: equal strength; negative for edema formation; lesions are
noted; nails are clean and short; warm to touch; good skin turgor
VIII.DEVELOPMENTAL DATA
[12]
gibuhat.”
[13]
gusto.Peru, dili man daw siya
[14]
Maglisod kuno siya ug tubag sa uban
esplikar.”
[15]
sa klase day. Pangtagaan naman mi
[16]
akong mga amiga manlaag. Malingaw
walay klaro.”
[17]
Intimacy
oneself into
[18]
• FEMALE REPRODUCTIVE SYSTEM
Mons pubis
It is the most visible part of the woman's external genitalia, which is the
pad of fatty tissue that covers the pubic bone and is commonly covered by pubic
hair.
Labia majora
The labia majora are two thick folds of skin running from the mons pubis to
the anus. The outer sides of the labia are covered with pigmented skin,
sebaceous (oil-secreting) glands, and after puberty, coarse hair. The inner sides
are smooth and hairless, with some sweat glands. Beneath the skin layer, there
is mostly fatty tissue with some ligaments, smooth muscle fibers, nerves, and
[19]
blood and lymphatic vessels. The labia majora correspond to the scrotum in the
male.
Labia minora
The labia minora, two smaller folds of skin between the labia majora,
surround the vestibule of the vagina; they have neither fat nor hairs. The skin is
smooth, moist, and pink and has sebaceous and sweat glands.
Urethra
Clitoris
The two labia minora meet at the clitoris, a small, sensitive protrusion that
called the prepuce, which is similar to the foreskin at the end of the penis. Like
Perineum
The perineum is the area of skin between the vaginal opening and the
anus.
[20]
Hymen
Bartolin’s gland
Are located besides the vaginal opening and produce a fluid (mucus)
secretion.
Vagina
genitals to the uterus. In the reproductive process, the vagina functions as a two
way street, accepting the penis and sperm during intercourse and roughly nine
months later, serving as the avenue of birth through which the new baby enters
the world.
[21]
Uterus
fertilized egg and to protect a fetus during development. It is divided into two
parts: the cervix, which is the lower part that opens into the vagina, and the main
body of the uterus corpus. The corpus is highly muscular so that it can enlarge to
hold a developing baby. A chemical through cervix allows sperm to enter and
Ovaries
These small, oval – shaped glands are located on either side of the
uterus. The ovaries produce ova, the female cell of reproduction, and produce
hormones.
Fallopian tube
These narrow, muscular tubes are attach to the upper part of the uterus
and serve as tunnels for the ova to travel from the ovaries to the uterus, where it
Cervix
millimeters, depending upon the time in the cycle the measurement to which
taken. The cervix is sometimes plug with cervical mucus to protect the cervix
[22]
from infection, during ovulation, this mucous becomes a thin fluid to permit the
passage of sperm.
MALE
FEMALE
(XY
Chromosomes) (XX
Chromosomes)
SPERMATOGENESIS PRODUCTION OF OOCYTES
SPERMATOZOA OVULATION
OVA
INTERCOUSRE
OVULATION OR
INSEMINATION OF THE EXPULSION OF MATURE
SEMINAL FLUID FROM OVUM FROM THE
THE MALE URETHRA GRAFIAN FOLLICLE INTO
INTO THE FEMALE THE PELVIS
VAGINA
SPERM MEET THE
EGG
FERTILIZATION
ZYGOTE FORMATION
LABOR
[23]
UTERINE CONTRACTIONS
NSVD
BIRTH OF THE
The birth of a baby starts from within the body of a mother. At conception,
the gametes unite to form cell that eventually becomes the developing fetus. The
process that begins now of fertilization and continues even after birth.
Fertilization occurs when the sperm penetrates the ovum. The ovum is
receptive to fertilization for approximately 24-48 hours, after release from the
ovary, and the sperm are viable for 24-72 hours after ejaculation into the female
approximately 300-600 million sperm. However, only one sperm will fertilize the
of the uterus, thus facilitating the transport of sperm. Conception usually occurs
when the ovum is in the ampulla (the outermost half) of the fallopian tube.
[24]
Once fertilization is complete, the zygote migrates toward the body of the
uterus. It takes 3-4 days for the zygote to reach the body of the uterus. During
this time the mitotic cell division or cleavage occurs. By the time the zygote
reaches the body of the uterus, it consists of 16-50 cells and is already termed as
the morula. Once implanted, the zygote is now called the embryo. The placenta
arises out of the trophoblast tissue, a group of cells found in the outer ring of the
zygote.
This placenta serves as the fetal lung, kidneys, gastrointestinal tract, and
of two arteries and one vein. The function of the cord is to transport oxygen and
nutrients to the fetus from the placenta and to return waste products from the
fetus to the placenta. The development of organs and organ systems proceeds in
become functional in the uterine life. After 28th week of pregnancy, the heart rate
respiratory and digestive tracts exist as a single tube during the 3rd week of the
intrauterine life. The nervous system develops as early as the 3rd-4th week of
pregnancy. Digestive tract separates from the respiratory tract by the 4th week.
Meconium, the fetal waste forms in about 16th week while the ability of the GI
tract to secrete enzymes for CHO and CHON digestion matures in the 36th week
of pregnancy. For the musculoskeletal system, fetal movements can be felt in the
20th week while bone ossification begins in the 12th week. For the reproductive
[25]
chromosomal analysis. For the urinary system, fetal urine is formed by the 12 th
week and is excreted into the amniotic fluid by the 16th week of gestation. In
integumentary system, the skin appears thin and almost translucent. A soft
downy hair called lanugo and a cream cheese-like substance called vernix
caseosa that covers the skin. The average time for gestation is usually about 38
weeks. Within this time, labor can be experience. It is a series of events in which
uterine contractions; abdominal pressure expels the fetus and placenta from the
woman’s body.
D. SYPTOMATOLOGY
pregnancy; taken as single entities, they could easily indicate other conditions.
These findings, discussed in connection with the body system in which they
occur, are largely subjective in that they are experienced by the woman but
• breast changes
• nausea
• vomiting
• amenorrhea
• frequent urination
[26]
• fatigue
• uterine enlargement
• quickening
• linea nigra
• melasma
• striae gravidarum
signs of pregnancy. Although they are more reliable than the presumptive signs,
they still are not positive or true diagnostic findings. They are also discussed in
• Chadwick’s Sign
• Goodell’s Sign
• Hegar’s Sign
• Ballottement
[27]
POSITIVE SIGNS OF PREGNANCY
Positive signs of pregnancy are those which cannot be mistaken for any
other condition—they are considered absolute evidence that you are, in fact,
pregnant. They rely on the senses: sound, sight and touch, as interpreted by your
caregiver.
Signs of Labor
• Lightening
• Uterine Contraction
[28]
• Felt first from the lower back and sweep around to the
abdomen in wave
X. MEDICAL MANAGEMENT
A variety of positions can be used for giving birth. These positions include
the lithotomy position, which is used frequently by hospitals, in which stirrups are
attached on both sides in foot part to the labor table to facilitate birth in this kind
of position. Alternative birth positions include the dorsal recumbent, semi sitting,
The woman must push with contractions and rest between them, is one of
the most effective pushing techniques during second stage of labor; also allow
[29]
her to push using the position she feels best can contribute in promoting effective
pushing.
• PERINEAL CLEANING
Clean the perineum by pouring warmed antiseptic and then rinse with a
Clean the vagina from front to back and include a wide area. When cleaning is
• BIRTH
During the second stage, the woman is encouraged to use her abdominal
muscles to bear down during contractions while the fetus continues to descend
and rotate to the anterior position. Fetal descent is usually slow but steady for the
downward progress for several hours during active labor, will suddenly descend
and be born with one push. When he fetus is at the station +4, he proceeds to
followed by delivery of the shoulders and expulsion of the rest of the body.
After the infant is born, the infant is then laid on the abdominal drape of
the mother while the cord is cut. The cord is clamped using two Kelly forceps
[30]
placed 8-10 inches from the infant’s umbilicus is cut between them. Cord clamp
is then applied & vessels are then counted to check if they are present.
• PLACENTAL DELIVERY
Signs that indicate the placenta is separating from the uterine will consist
of a gush blood, lengthening of the umbilical cord, and a globular shape to the
Expulsion by Schultze’s indicates that the fetal or shiny side of the placenta
delivers first. Duncan’s mechanism specifies that the maternal or rough side of
B. MEDICATIONS
C. DIAGNOSTIC PROCEDURES
• Urinalysis
[31]
URINALYSIS
[32]
COMPLETE BLOOD COUNT
MCH 29.7 pg 27 – 31 pg
D.DIET
The physician advised the patient to take a regular or full diet. The regular
or full diet contains essential requirements. The diet follows the principles of food
[33]
A. ACTUAL CARE GIVEN
One primary nursing care given to the patient was taking vital signs.
These were done to monitor patient’s condition for signs of infection, abnormal
increase in blood pressure. Vital signs taking were done every after 15 minutes
for 1 hour prior to delivery, then every hour until vital signs are stable, then
continued monitoring vital signs every after 4 hours. Monitoring and measuring
patient’s intake and output. Giving medications were done as ordered by the
physician. I encouraged patient to have adequate rest and sleep, and do self-
perineal care to prevent infection. A health teaching was done such as muscle
quality nursing care. The patient was very obliging as well as cooperative and
was very aware of her health needs and status. I was able to perform the needed
good and stable blood circulation throughout the system for faster recovery and
[34]
living. She was advice to take adequate rest period to relieve fatigue and to eat
nutritious food for her health as well as for her lactating infant. I encouraged
D. EVALUATION
different problems in the future in relation to health. She shared on what she felt
especially during her labor and delivery experience. She was very open in talking
about her life. She was so nice. When I asked her some questions, she merely
answered it.
E. PATIENT TEACHING
for the infant. I taught her the proper way of cleaning her nipples and self-
perineal care, and techniques on how to massage fundus until it becomes firm. I
reminded her to have a regular check up to know her and her infant’s health
status, not to forget the medications prescribed by the physician like taking
to have adequate rest, deep breathing exercise and not to lift heavy objects, to
[35]
have a plain breastfeeding to the infant, and eat a well balanced diet for her to
XII. A. CONCLUSION
and don’ts of pregnancy, especially the first timers or the primigravida mothers.
heath teachings. Understanding and valuing life is one of the important aspects
Inorder for a health care provider to render enough and quality care. Basic
needs further understanding on the part of the health care providers. The primary
goals of nursing care are to deliver the baby safely with put further problems and
complications during delivery. Pregnancy does not only deal with physical
The significance of this study is to learn on how to care for the new born and post
and to her family. An outcome of care is determined through the response of the
patient in terms of the nursing care they receive and fell which given by the
nurse.
B. RECOMMENDATION
[36]
This study promotes the growth and interest both on the parents and as
well as the nurses. This also recommends on the scope of maternal and prenatal
care. Current trends and issues should be examined and next should undergo
regards that they can appreciate and incorporate in giving care to this kind of
people. The concept on maternal and child nursing is a dynamic and a never
static concept. It changes as time goes by. As society changes, people change
A. NURSING EDUCATION
and maximize the knowledge and skills of the nurses (especially the student
challenge to nurses and to the other health care team members. Changes and
evolution of care concerning pregnancy was brought about by the rapid change
of technology nowadays. The health of the mother and the child involves a
newly born baby, and to keep and prevent in from further complications and
infections brought about by the environment itself. Maternal and child health in
care does not only deal with rendering care to the sick and disabled but also with
[37]
the care of pregnancy and childbirth which are considered the important aspect
B. NURSING PRACTICE
utilization of nursing concepts, which includes nursing care plan, nursing process
etc. This is important in nursing practice because in this stage where nursing
patient and also to broaden the concept of the student nurse in rendering care. In
this way, the student nurse will be able to prioritize his or her focus of care and
apply the principles in the clinical setting, which he or she learns. Nursing is
Prioritizing care, which learned, developed and evolved in this phase. The ever-
changing role of the nurses in terms of giving care plays an important role not
just to the sick and disabled but also to the community. Its role is to broaden the
knowledge of the people in terms of the importance of maternal and child health
is. As a conclusion, the student nurses can emphasize their skills in terms of
giving care. The importance to serve and give care even in the evolution of
trends and technology of new care settings and the changes and acceptance of
C. NURSING RESEARCH
[38]
The implication of this study to nursing research is that, it helps broaden
the knowledge of the student in terms of maternal and child health. It helps
for nursing mothers. The care of the mother and its newborn child does not end
once the baby was delivered and was exposed to the real world. It follows the
pattern of care from pregnancy, labor and delivery and post – partum period of
the life of the mother and to her baby. The goal of nursing research is to promote
primary, undefeated and effective care to both the mother and to her newborn
baby. Rendering the effective care helps the post – partum mother gain and be
relieve from post – partum discomfort in fast and easy manner. Health promotion
and health restoration of mothers must carried out to improve their self – esteem
and a feeling of control and give them assurance that delivery is normal to make
[39]