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A Normal spontaneous delivery (NSD) occurs when a pregnant woman goes into labor
without use of drugs or techniques to induce labor, and delivers her baby in the normal
manner, without a cesarean section.
There are three stages of normal human birth these are First stage, second stage and third
stage. The first stage of labor starts classically when the effaced cervix is 3 cm dilated.
The second stage begins when the cervix is fully dilated, and ends when the baby is
finally delivered. In the third stage, the uterus expels the placenta (afterbirth). Maternal
blood loss is limited by the compression of the spiral arteries of the uterus as they pass
though the lattice-like uterine muscles of the upper segment. Normal blood loss is less
than 600 mL. The placenta is usually delivered within 15 minutes of the baby being born.
DEMOGRAPHIC DATA:
MEDICAL HISTORY
OBSTETRICAL HISTORY
Roselyn Cal has two lived children. The first baby reach the term, the 2nd baby is
preterm. Gravida 2 Para 2 ( 1102 ).
PRESENT ILLNESS
None
PAST ILLNESS
Breastfeeding causes the release of prolactin and oxytocin. Oxytocin is a hormone that
causes uterine contractions. The release of oxytocin while breastfeeding speeds uterine
involution. This may also cause cramps while breastfeeding in the postpartum period.
Involution of the uterus involves two main process. First, the area where the placenta was
implanted is sealed off to prevent bleeding. Second, the organ is reduced to its
approximate pregestational size.
The uterus of breast-feeding mother may contract even more quickly, because oxytocin,
which is released with breast-feeding, stimulates uterine contractions.
DRUG STUDY
• Assess
patient for
any sign of
infection
Hematocrit 42%
WBC 13.05
Neutrophils 84%
Lymphocytes 16%
ABO type B
Rh blood type Positive
The Normal values of hemoglobin for female is 12 -14 g/100ml, for hematocrit it should
be at the range of 36% - 47% with the average of 40%. Neutrophils should be within the
range of 54% - 57% and for lymphocytes it should be 25% - 40%.
All pregnant women are tested for the Rh factor during the early weeks of pregnancy. A
mother and fetus may have incompatible blood types, the most common is Rh
incompatibility. Rh incompatibility occurs when the mother's blood is Rh-negative and
the father's blood is Rh-positive and the fetus' blood is Rh-positive. The mother may
produce antibodies against the Rh-positive fetus which may lead to anemia in the fetus.
Incompatibility problems are monitored and appropriate medical treatment is available to
prevent the formation of Rh antibodies during pregnancy.
DISCHARGE PLAN
M – MEDICATION
• Cefalexin
• Mefenamic Acid
• Methylergonometrine maleate
Instruct patient about the way of taking her medicines. Explain the proper
measurement and time of intake. E.g. 500 mg of Cefalexin should be taken for 1
week three times a day. 500mg/cap of mefenamic acid should be taken for one
week every six hours and methergin three times a day or four times a day for three
to 1 week.
E - EXERCISE
T – TREATMENT
Advice client not to engage in any house chores that might jeopardize her health.
H – HEALTH TEACHINGS
Encourage and explain the importance of breast feeding to the client.
breastfeeding especially the first milk, colostrum, can reduce postpartum
bleeding/hemorrhage in the mother, and to pass immunities and other benefits to
the baby. Advice client to let her child expose to mild sunlight in order to balance
and avoid excess bilirubin in the blood.
O – OUT PATIENT
D – DIET
Advice client to eat proper diet. Encourage her to eat more vegetables and
frequent intake of liquids. Advise her to eat food which are rich in protein, iron
and vitamin C. Protein helps to repair body tissues, iron provides formation of
Red blood cells and ascorbic acid for helping absorption of iron.
S – SPIRITUAL
Many cultures feature initiation rites for newborns, such as naming ceremonies,
baptism, and others.
The doctor ordered DAT diet for patient because the patient is
conscious and in order for the patient to cope up at once for the speed
recovery
SIENA COLLEGE
CASE STUDY
IN
OB WARD
SUBMITTED BY:
CHARLES A. FLORENDO
BSN – 3B