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I. Introduction
A. Stages of labor
B. Mechanisms of labor
Having children is essential to the survival of the human species. It can also be a
joyful, emotionally powerful experience. No other experience carries quite the cultural
and personal importance that having a baby does, and it is an experience that humans
have shared since the beginning of time.
The way a child is conceived and born is, essentially, the same as it ever was: A
sperm and an egg meet, and a fetus develops in the mother’s uterus and a baby is born
approximately nine months later. Yet today there are many positive changes in social
attitudes, medical standards, and parenting methods that make rearing children a vastly
different experience from what it was a few generations ago.
Pregnancy brings both psychological and physical changes to a woman and her
partner. Clients are often interested in the changes pregnancy brings, because these
changes verify the reality and mark the progress of pregnancy.
The physiologic changes of pregnancy occur gradually but eventually affect all
organ system of the woman‘s body. Psychological changes occur in response not only to
the physiologic alterations that are occurring but also to the increased responsibility
associated with welcome a new and completely dependent person to the family. The
changes occur in order for the woman to provide oxygen and nutrients for the growing
fetus as well as extra nutrients for her own increased metabolism during the pregnancy.
They ready her body for labor and birth
PATIENT’S PROFILE
PERSONAL BACKGROUND
falls every May and was born in the year x and a Roman Catholic. She has 4
siblings and was the 4th daughter of Mr. and Mrs. x. Her partners Name is
x, they’ve been together for 10 years but they did not get married.
She was not able to go to school because of poverty. She also has no
working experiences.
x stands 5’3” and weighs 60 kgs. Vital signs were taken during my first
visit which will serve as our baseline data on our study. Results are as
follows:
TEMPERATURE : 36.8 oC
PULSE : 71 bpm
BP : 120/70 mmHg
RESPIRATION : 22 cpm
PAST HEALTH
HISTORY
any serious illnesses. Just like other people, Ritchel only encounters the
common minor illnessnes like for example cough, flu and fever.
HISTORY OF
PREGNANCY
abortion (G3P3). She experienced nausea and vomiting and absence of menstruation.
Her last menstrual period was May 10, 2005 and she only had her prenatal check-up
after she was 7 months pregnant, on December 7, 2005 and on a monthly basis
thereafter, she visited the center. However she was only vaccinated twice on
Her nutritional intake was quite normal. Ferrous Sulfate was the only
vitamins that she has taken. She made it a habit to exercise every morning like a
simple walking at their area. As she was told, exercise during pregnancy is
record was February 17 2006 but she was confined on February 13, 2006.
.
PHYSIOLOGY OF
LABOR
Labor is an event that follows pregnancy and is considered as the climax of the
entire maternity cycle. During the nine months of gestation certain physiologic and
psychological adaptations gradually have taken place in the pregnant woman, and
simultaneously the growth and the development of the fetus have progressed toward
maturity in preparation for the transition from intra-uterine to extra-uterine life.
As a result of the uterine contractions, two important changes are wrought during
the first stage of labor. These are effacement and dilatation of the cervix.
In its passage through the birth canal, the presenting part of the fetus undergoes
certain positional changes that constitute the 7 mechanisms of labor. It begins with
engagement when the biparietal diameter of the infant’s head is within the pelvic inlet
and is no longer movable. The first requisite for the birth of the infant is descent. This
refers to the downward movement of the fetus that occurs throughout the labor process.
Very early in the process of descent the head becomes so flexed that the chin is in
contact with the sternum and the very smallest anteroposterior diameter is presented to
the pelvis. This mechanism is known as the flexion. When it reaches the pelvic floor, the
occiput is rotated internally and comes to lie beneath the symphysis pubis. After the
occiput emerges from the pelvis, the nape of the neck becomes arrested beneath the
pubic arch and acts as a pivotal point for the rest of the head. Extension of the head
ensues, and with it the frontal portion of the head, the face and the chin are born. After
the birth of the head, it remains in the anteroposterior position only a very short time and
shortly will be seen to turn to one or another side of its own accord termed as restitution
or the external rotation. After delivery of the infants head and internal rotation of the
shoulders, the anterior shoulder rest beneath the symphysis pubis. The posterior
shoulder is born, followed by the anterior shoulder and the rest of the body. This phase
is termed as expulsion.
Stages of Childbirth
Prelabor is a period of irregular uterine contractions in which the cervix thins, softens, and may begin to
dilate. As the first stage of labor itself begins (top, left), the uterus contracts strongly and regularly. The
cervix (center) dilates with each contraction, and the baby’s head rotates to fit through the mother’s
pelvis. In the second stage (right) the mother pushes, or bears down, in response to pressure against
her pelvic muscles. The crown of the baby’s head becomes visible in the widened birth canal. As the
head emerges entirely (bottom, left and center) the physician turns the baby’s shoulders, which emerge
one at a time with the next contractions. The rest of the body then slides out relatively easily, and the
umbilical cord is sealed and cut. The third stage (right) occurs within ten minutes of the baby’s birth. The
uterus continues to contract, expelling the severed umbilical cord and placenta.
The third stage of labor is known as the placental stage that begins with the
delivery of the baby and terminates with the birth of the placenta. This stage is made up
of 2 phases, namely, the phase of placental separation and the phase of placental
expulsion.
Immediately after the delivery of the baby, the remainder of the amniotic fluid escapes,
after which there is usually a slight flow of blood. The uterus can be felt as a firm globular mass
just below the umbilicus. Shortly thereafter, the uterus relaxes and assumes a discoid shape. With
each subsequent contraction or relaxation the uterus changes from globular to discoid in shape
until the placenta has separated, after which time the globular shape persists. The 3 signs that
suggest that the placenta has separated are: (1) the uterus becomes globular in shape or the
Calkin’s sign, (2) lengthening of the umbilical cord, and (3) sudden gushing of blood.
Extrusion of the placenta then follows after the above signs are manifested. It
may take place by one of the 2 mechanisms. The Schultze’s mechanism refers to the
glistening or the fetal surface and the Duncan’s mechanism that is said to be the
maternal surface and commonly known as the rough and dirty part.
Trimesters of Pregnancy
The 40 weeks of pregnancy are divided into three trimesters. The developing
baby is called an embryo for the first 8 weeks, after which it is called a fetus. All of its
major organs develop in the first trimester. In the mother, nausea and vomiting are
common, especially in the morning. The breasts may enlarge and become tender, and
weight begins to increase. The second trimester fetus is obviously human and grows
quickly. The mother’s pregnancy is noticeable both externally and internally, as she can
feel the fetus moving. Her heart rate and blood pressure increase to accommodate the
needs of the fetus. In the third trimester, the fetal organs mature. Most babies born
prematurely at the beginning of the third trimester survive, and their chances increase
dramatically with each week in the womb. The pregnant woman finds herself easily hot
and uncomfortable by this point, and sleep, while even more important now, may be
difficult.
Throughout the entire pregnancy cycle several alterations in the woman’s body
can be observed that is one of the factors that bring about discomforts and
complications. The cycle is consists of 4 stages namely the antepartal stage, which is
divided into 3 trimesters, the intrapartal stage with its 4 phases, postpartum and the
immediate newborn care.
FIRST TRIMESTER
1. Breast changes, new sensations: pain, tingling
a. Wear supportive maternity brassiere with pads to absorb discharge may
be worn at night, wash with warm water and keep dry.
2. Urgency and frequency of urination
a. Encourage woman to do Kegel’s exercises.
b. Encourage to void before going to bed.
c. Encourage to void after meals.
d. Instruct the woman to limit fluid intake in the evening.
e. Provide reassurance that this is just a normal process.
f. Wear perineal pad.
g. Refer to physician for pain or burning sensation.
3. Languor and malaise; fatigue (early pregnancy usually)
a. Provide reassurance.
b. Rest as needed.
c. Well-balanced diet to prevent anemia.
4. Nausea and vomiting, “morning sickness”
a. Encourage the woman to eat low-fat protein foods and dry carbohydrates,
such as toast and crackers.
b. Encourage the woman to eat small, frequent meals.
c. Instruct the woman to avoid brushing her teeth soon after eating.
d. Instruct her to get out of bed slowly.
e. Encourage to drink soups and liquids between meals to avoid stomach
distention.
f. Instruct the woman in the use of antacids; caution against the use of
sodium bicarbonate because it results in the absorption of excess sodium
and fluid retention.
g. Teach her the importance of good nutrition for herself and her fetus.
Review the basic food groups with appropriate daily servings.
h. Advice to limit the use of caffeine.
i. Avoid empty or overloaded stomach.
j. Maintain good posture – give stomach ample room.
k. Stop smoking.
l. Avoid fried, odorous, spicy, greasy, or gas-forming foods.
m. Consult physician if intractable vomiting occurs.
5. Ptyalism – may occur starting 2 to 3 weeks after first missed period
Use of astringent mouthwash, chewing gum, support.
6. Psychological dynamics – mood swings, mixed feelings
a. Treatment same as prevention.
b. Both partners need reassurance and support.
c. Support significant other who can reassure woman about her
attractiveness, etc.
d. Improved communication with her partner, family, and others.
SECOND TRIMESTER
1. Pigmentation deepens (striae gravidarum, chloasma, linea nigra, finger nails,
hair, nipples and areolae); acne, oily skin
a. Not preventable.
b. Usually resolved during puerperium.
c. Reassurance given to women and their families about these
manifestations of pregnant state.
2. Spider nevi – appear during trimesters 2 or 3 over neck, thorax, face, and arms
a. Not preventable.
b. Reassurance that they fade slowly during late puerperium.
c. Rarely disappear completely.
3. Palmar erythema occurs in 50% of pregnant women; may accompany spider
nevi
a. Not preventable.
b. Reassurance that condition will fade within 1 week after giving birth.
4. Pruritus (itching)
a. Keep fingernails short and clean.
b. Not preventable; symptomatic: Keri baths; mild sedation.
c. Distraction; tepid baths with sodium bicarbonate or oatmeal added to
water; lotions and oils; change of soaps or reduction in use of soap;
loose clothing.
5. Supine hypotension
a. Side-lying position or semi-sitting posture, with knees slightly flexed.
12. Leukorrhea
a. Do not douche.
b. Hygiene, perineal pads, reassurance.
13. Headaches
a. Emotional support; prenatal teaching; conscious relaxation.
14. Periodic numbness
a. Maintain good posture.
b. Wear good supportive maternity brassiere.
c. Reassurance that condition will disappear if lifting and carrying baby
does not aggravate it.
15. Joint pain, backache, and pelvic pressure; hypermobility of joints
a. Teach the woman to use good body mechanics-wear comfortable, low-
heeled shoes with good arch support, try the use of a maternity girdle.
b. Instruct the woman in the technique for pelvic rocking exercises.
c. Encourage to take rst periods with her legs elevated.
d. Instruct the woman to dorsoflex the foot while applying pressure to the
knee to straighten the leg for immediate relief of leg cramps.
e. Local heat and back rubs.
THIRD TRIMESTER
1. Shortness of breath
a. Good posture.
b. Flying exercise.
c. Sleep with extra pillows.
d. Avoid overloading stomach.
e. Stop smoking.
2. Insomnia
a. Reassurance.
b. Conscious relaxation.
c. Back massage or effleurage.
d. Support of body parts with pillows.
e. Warm milk or warm shower before retiring.
3. Psychosocial responses: mood swings, mixed feelings, increased anxiety
a. Reassurance and support from significant other and nurse.
b. Improved communication with partner, family, and others.
4. Gingivitis and epulis
a. Well-balanced diet with adequate protein and fresh fruits and vegetables.
b. Gentle brushing and good dental hygiene; avoid infection.
5. Urinary frequency and urgency returns
a. Limit fluid intake before bedtime.
b. Reassurance.
c. Wear perineal pad.
6. Perineal discomfort and pressure
a. Rest, conscious relaxation and good posture.
b. Maternity girdle.
7. Braxton Hicks’ contractions
a. Reassurances, rest, change of position.
b. Practice breathing techniques when contractions are bothersome.
c. Effleurage; rule out labor.
8. Leg cramps
a. Use massage and heat over affected area.
b. Stretch affected muscle until spasm relaxes.
c. Stand on cold surface.
d. Oral supplementation with calcium carbonate or calcium lactate tablets.
9. Ankle edema
a. Ample fluid intake for “natural” diuretic effect.
b. Put on support stockings before arising.
c. Rest periodically with legs and hips elevated.
d. Exercise moderately.
THE INTRAPARTUM STAGE
Several comfort measures can be employed to restore calm and to help the
mother to relax enough to get some much needed rest and sleep. A soothing backrub,
change of gown and linen, a quiet conversation with the nurse or the husband in which
the patient is allowed to ventilate her feelings, an environment conducive for resting, are
all helpful (Bobac,1989).
The first hour following the delivery is a most critical one for the mother. It is at
this time that the postpartal hemorrhage is most likely to occur as the result of uterine
relaxation. Thus, it is mandatory that the uterus be watched constantly throughout this
period by a competent nurse who keeps her hand more or less constantly on the fundus
and at the slightest sign of diminishing contraction massages it, to make sure that it does
not relapse and balloon with blood. It is important for the nurse to be alert not only to the
condition of the mother’s uterus but also to any abnormal symptoms related to her
general condition. Checking of the maternal vital signs is usually included in the nursing
observations. These signs are checked as often as necessary until they become stable
(Reeder, et. al.,1966).
Certain observations should be made and recorded daily. These would include
such findings as temperature, pulse and respiration; urinary and intestinal elimination;
the physical changes which occur normally in the puerperium. The nurse should take
note the changes in the breasts, the height and consistency of the fundus, the character,
the amount and the color of the lochial discharge and the condition of the episiotomy.
Temperature, Pulse, Respiration
• A slight rise in the temperature may occur without apparent cause following the
delivery, but in general the mother’s temperature should remain within normal
limits during the puerperium which is below 38 C.
• In the early puerperium, the pulse rate is somewhat slower. The rate is usually
between 60 and 70 but may even become a little slower than this in 1 or 2 days
after the delivery. By the end of the 1st week or 10 days it will return to its normal
rate. On the other hand, a rapid pulse after labor may indicate shock or
hemorrhage.
After-Pains
Normally after the delivery of the first chills, the uterine muscle tends to remain in
a state of tonic contraction and retraction. In multiparas a certain amount of the initial
tonicity of the uterine muscle has been lost, and these contractions and retractions
cannot be sustained. Consequently, the muscle contracts and relaxes at intervals, and
these contractions give rise to the sensation of pain, the so-called “after-pains”(Reeder,
et. al., 1966).
Several nursing interventions that can be applied in this discomfort would be the
application of ice cap on affected area, administration of analgesics and encourage the
mother of early ambulation.
Nutrition
After delivery the mother is given small amounts of easily digested foods, such
as milk or tea and toast, for the first meal if it is not contraindicated. Thereafter she
enjoys a normal diet.
The daily diet of the lactating mother should be like that taken during pregnancy,
with the addition of 1,000 calories and amounts of the various nutrients such as protein,
calcium, vitamin A, iron, etc. These increased demands in the diet during lactation can
be supplied with the addition of a pint of milk, 1 serving of vegetables and 1 citrus fruit,
an egg and 1 large serving of meat. Often, these mothers become hungry in between
meals. For this reason it is advisable to see that they receive immediate nourishment
consisting of a nourishing beverage or a snack 3 times a day.
As soon as the infant is born, measures should be taken to promote a clear air
passage before the onset of respiration. As the head is delivered, it is necessary to wipe
the mucus and the fluid from the infant’s nose and mouth before he has the chance to
gasp and aspirate with the first breath. From the moment of delivery the infant should be
kept in the head-down position until his upper respiratory passage is cleared of mucus,
an amniotic fluid, etc. a small rubber bulb syringe, or a soft rubber suction catheter
attached to a mechanical suction or mouth aspirator, should be used promptly to suction
the oropharynx and to remove fluids which may be obstructing the airway.
Assess respiratory status and do Apgar scoring 1 and 5 minutes after delivery of
the baby. Look for meconium staining. Wrap the newborn baby in a warm blanket and
place in heated crib or give to mother and/or father to hold. Avoid excessive exposure as
body temperature is variable. Place infant on side or modified Trendelenburg’s to
facilitate drainage of mucus or blood. Suction mucus as needed with the bulb. The nurse
is to clamp the cord if the physician has not done so. The baby is then identified with
bands.
When the baby is passed to the nursery, another set of care is implemented.
After receiving the baby into the unit, the nurse will check the axillary temperature and
take the vital measurements such as the weight, length, head and chest circumference.
The baby is bathe and afterwards placed in the crib where his cord is to be cut and
dressed. The cord is to be applied with alcohol daily or as necessary. It must likewise be
kept dry. Palm and sole prints are done for identification purposes. The infant is then
dressed and Vitamin K is administered as ordered to facilitate blood coagulation. The
Crede’s prophylaxis is the application of an eye ointment, like the silver nitrate, to the
eyes to prevent the development of the ophthalmia neonatorum. Lastly, the infant is then
bundled and placed into crib. The bulb syringe is placed at the crib.
Vital signs of the infant such as his heart rate, respiration and temperature are to
be checked every hour for 2 to 3 hours and when necessary(prn).
CONTINUING CARE
The daily cleansing of the infant affords the nurse an excellent opportunity for
making the observations that are necessary during the immediate postpartal period.
Several decades ago the daily soap and water and oil baths were replaced with merely
wiping off excess vernix with dry or slightly moist cotton balls. The diaper area was
cleansed as necessary. However, babies do not receive a tub bath until the cord has
separated and until the umbilicus has healed. If the cord is left exposed to the air, some
physicians prefer that the based of the cord be wiped with alcohol daily to encourage
drying further and to discourage the possibility of infection.
ACTUAL NURSING CARE PLAN
Antepartum Period
NURSING
CUES OBJECTIVE INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective : Sleep pattern At the end of one Independent : 1. Overindulgence On the next day
disturbance day, Ritchelr will 1. Evaluate use of caffeine interferes with REM of visit, Ritchel
“Galisud gyud ko related to inability report and alcoholic beverages. (Rapid Eye Movement) reported to have
ug katulog sa to maintain improvement in sleep.
slept well in
gabii. Ambut comfort as sleep rest.
evidenced by
side-lying
ngano pirme ko dili 2. Suggest side-lying 1. Back discomfort may
difficulty in falling position with pillow between necessitate change position.
kumportable” as
asleep. legs for support, or place in position, use of
verbalized by
bed board under mattress. multiple pillows /body
Ritchel. pillow, or firmer
mattress.
Objectives :
1. dark circles 3. Suggest aids to sleep, 3. .Excess anxiety,
under the such as relaxation excitement, physical
eyes techniques/tapes, reading, discomforts, nocturia,
2. constant warm bath, and reduced and fetal activity all
yawning activity just before retiring. may contribute to
irritability sleeping difficulties.
.
4. Note reports of positional 4. Use of semi-Fowler’s
breathing difficulties. position allows the
Suggest sleeping in a diaphragm to
NURSING semi-Fowler’s position. descend, fostering
CUES OBJECTIVE INTERVENTION RATIONALE EVALUATION
DIAGNOSIS optimal lung
expansion.
.
5. Encourage participation in 5. Exercise at bedtime
regular exercise program may stimulate rather
during day to aid in stress than relax patient and
control/release of energy. actually interfere with
sleep.
Subjective : Alteration in At the end of the 1. instructed the proper 1.to prevent infection that
“sakit akong tahi sa comfort: Pain day, client will be perineal care or the precipitate pain
akong kinatao” as related to able to reduce or proper way to clean the
verbalized by perinial incision eliminates vagina
Ritchel. done factors that
precipitate pain. 2. instructed to do sitz bath 2. for faster healing of the
Objectives : or clean the vagina with episiotomy
warm water.
1. gravida 3 para 3
2. as verbalized by 3.administer pain 3. to relieve pain.
client medication like aspirin.
3. Facial grimaces
during walking 4. divert clients attention 4. diverting clients attention
like talking to the client will help in alleviating the
pain of the client.
SUMMARY
The knowledge about Ritchel’s pregnancy was not a shock to her family because this was her 3rd baby. For
she has 2 daughters she and her partner wanted to have a baby boy but as she was on her labor they found out
that it was again a baby girl. Though they wanted a boy, they accepted and love the new member of their family.
It was gathered from the interview and physical assessment that Ritchel had undergone a positive childbearing experience
during this pregnancy. Except for some minor discomforts normally experienced by most pregnant women, it could be said that
Ritchel had a healthy and uncomplicated pregnancy. Her prenatal care included proper nutrition, exercise and adequate rest and self-
care measures which all significantly contributed to the safe passage of her baby and her safety, as well. Being a multigravida, she
reported to have an easy and short labor. Her records at the center showed us that she has no any signs of fetal distress. Inspection of
the neonate did not also show molding which would evidence ineffective bearing down.
REFERRAL
Pediatric primary care involves all the health promotion and disease prevention needs of the child. To obtain the highest level
of wellness attainable, referrals as to immunization/vaccinations had been made as follows:
Moreover, instructions had been made to immediately contact the pediatrician for any abnormalities observed.
Bibliography
Pilliteri, Adelle. Maternal and Child Health Nursing (3rd Edition ). Lippincott Williams and Wilkins, Inc. 1999.
Nettina, Sandra. The Lippincott Manual of Nursing Practice (6th Edition). J.B. Lippincott Company. 1996.
Childcraft. Guide to Parents (Volume 15). World Book – Childcraft International, Inc. 1981.
HEALTH TEACHINGS
Name of patient: Ritchel Canaugon
Instructed the client to take vitamins that’s rich
HEALTH TEACHING
NAME OF PATIENT: x
During our fourth visit to our client, we taught her about proper hygiene, nutritions that she needed and the
post-partum exercise.
We emphasize our teaching to the proper hygiene because as we observed our client, we found out that she
does not care about herself or to her children. We could see that they have a dirty surroundings. If she continuous
to take for granted about proper hygiene this could affect her health and her children and mostly to her new baby.
We also taught her about the proper nutrition that she should take so that she would regain her energy and
could return to her lifestyle before she got pregnant and also to regain her blood loss.
And lastly we taught her about the 10 post-partum exercise that she could apply after giving birth. We
instructed her on how to do it for ten days and on what exercise it is about.