Siena College

Taytay, Rizal
Nursing Department

In Partial Fulfillment of the Requirements

In

RELATED LEARNING EXPERIENCE V

A Case Study At Angono General Hospital

OB WARD

Entitled:

“Normal Spontaneous Delivery”

Submitted by:

Charm Abyss D. La Morena

BSN – 3rd year Group 4
Submitted to:

Ms. Charlie Alzate

 A. BACKGROUND OF THE STUDY

Vaginal delivery is a natural process that usually does not require

significant medical intervention. Management guided by current knowledge
of the relevant screening tests and normal labor process can greatly
increases the probability of an uncomplicated delivery and postpartum
course. Once a woman is in labor, management should focus on the goal of
delivering a healthy newborn while minimizing discomfort and complications
for the mother. Once a patient has been admitted to the hospital, providing
her with continuous emotional support can improve delivery outcomes and
the birthing experience. Epidural analgesia is effective for pain control and
should not be discontinued late in labor to reduce the need for operative
vaginal delivery. Once the infant has been delivered, active management of
the third stage of labor decreases the risk of postpartum hemorrhage.

Labor consists of a series of rhythmic, involuntary, progressive

contractions of the uterus that cause effacement (thinning and shortening)
and dilation of the uterine cervix. The stimulus for labor is unknown, but
digitally manipulating or mechanically stretching the cervix during
examination enhances uterine contractile activity, most likely by stimulating
release of oxytocin by the posterior pituitary gland. Normal labor usually
begins within 2 wk (before or after) the estimated delivery date. In a first
pregnancy, labor usually lasts 12 to 18 h on average; subsequent labors are
often shorter, averaging 6 to 8 h.

STAGES OF LABOR
FIRST STAGE OF LABOR

Patients in labor are usually admitted to the hospital during the first
stage of labor. It is important to differentiate between the active and latent
phases because women admitted in latent labor tend to spend more time in
the labor ward and have more interventions than those whose admission is
delayed until the active phase. When a patient is admitted during the latent
phase, physicians should set reasonable expectations for labor progress to
avoid unnecessary interventions and anxiety. In GBS-negative women who
are at term, admission to the labor ward should be delayed until the active
phase of labor begins.

The most common intervention in the first stage of labor is pain

control. There are numerous nonpharmacologic methods available to ease
the discomfort of labor and improve the experience, including positioning,
ambulation, massage, aromatherapy, and acupressure. However, there are
limited published data available on these methods. Pharmacologic pain
control is often used during labor; the most common interventions are
intravenous narcotics and epidural analgesia. Epidurals have been shown to
effectively decrease pain during labor, but may lead to an increase in
instrumental vaginal delivery.

Fetal heart rate monitoring during labor has become common in the
United States; it was used in 85 percent of deliveries in 2002, used to
determine the well-being of the fetus. Fetal electrocardiogram (ECG)
monitoring is a newer technology that has shown potential because it
reduces acidosis and the need for operative vaginal delivery when used as
an adjunct to continuous fetal heart rate monitoring.

SECOND STAGE OF LABOR

 During the second stage of labor, the fetus descends through the
maternal pelvis and is ultimately expelled. Tremendous stress is placed on
the passageway, often resulting in trauma to the genitourinary tract, most
commonly the perineum. Spontaneous tears that require suturing occur in
approximately one third of women in the United States, and anal sphincter
tears occur in less than 1 percent.

Reduction in perineal trauma is desirable because affected women

have an increased risk of long-term perineal pain, long-term dyspareunia,
urinary problems, and fecal incontinence. Antenatal perineal massage can
reduce the need for laceration repair or episiotomy, and can reduce
prolonged pain in women without prior vaginal delivery. Although these
benefits were modest, the technique has no known deleterious effects and
may be beneficial in some primigravidas.

Maternal pushing methods can impact second-stage outcomes.

Coached pushing with sustained breath holding (closed glottis pushing)
results in a slightly shorter second stage (by 13 minutes) compared with
spontaneous exhalatory pushing (open glottis pushing). Delayed pushing
(i.e., waiting until the maternal urge to push is strong instead of encouraging
pushing immediately at complete cervical dilatation) prolongs the second
stage of labor, but shortens the duration of pushing and results in an
increased number of spontaneous deliveries.

There is conflicting evidence about maternal position in the second

stage of labor. Upright or lateral position may allow more effective pushing
and may be preferred by some patients to the supine position with stirrups.
Because good evidence is lacking to support one particular birthing position,
the patient should be allowed to deliver in the position most comfortable for
her.
 Episiotomy, an intentional incision in the perineum, was first
introduced in the United States in 1850, but it did not become common until
the 1920s. More than 2 million episiotomies were performed in 1981; this
decreased to about 1 million in 1997. These numbers appear to be heavily
driven by local norms, physician experience in training, and physician
preference.

Nonsuturing of the perineal skin in first- and second-degree tears and

episiotomies results in less pain for up to three months after delivery and
less dyspareunia at three months after delivery. Nonsuturing of the muscle
layers is not recommended because of poorer wound healing at six weeks
postpartum. When repair of the perineum is required, use of a continuous,
knotless technique is preferred over interrupted suturing. The knotless
technique reduces short-term pain and the need for postpartum suture
removal without compromising wound healing or long-term outcomes. Repair
with absorbable synthetic suture is preferred to catgut. Synthetic suture
decreases analgesic use and decreases dyspareunia at 12 months.

THIRD STAGE OF LABOR

During the third stage of labor, the uterine muscle must contract
adequately to slow maternal blood loss once the placenta separates from the
uterine wall. A prolonged third stage of labor, which is diagnosed after 30
minutes if spontaneous placental delivery does not occur, may require
further intervention.

Postpartum hemorrhage is defined as excess blood loss from the

uterus (more than 500 mL) during and after delivery. Causes of postpartum
hemorrhage include uterine atony, retained tissue, trauma to the genital
tract, and coagulopathies.
 Active management of the third stage of labor includes administration
of an oxytocic agent after delivery of the anterior shoulder, early cord
clamping, and controlled cord traction. This management decreases
maternal blood loss, risk of postpartum hemorrhage, length of the third
stage, and the need for blood transfusion.Despite an increase in maternal
nausea and vomiting, active management of the third stage is strongly
encouraged. Placental cord drainage, which involves clamping and cutting
the cord after delivery and then immediately unclamping the maternal side
(allowing blood to drain freely), decreases the length of the third stage of
labor

POSTPARTUM CARE IN THE HOSPITAL

Postpartum care encompasses management of the mother, newborn,

and infant during the postpartal period. This period usually is considered to
be the first few days after delivery, but technically it includes the six-week
period after childbirth up to the mother's postpartum checkup with her
health care provider.

Purpose

Immediately following childbirth, new mother experiences profound

physical and emotional changes. She may stay in the hospital or birthing
center a very short time, even as little as 24–48 hours after delivery. The
physical and emotional care a woman receives during the postpartum period
can influence her for the remainder of her life.

Precautions
 During the postpartum period the mother is at risk for such problems
as infection, hemorrhage, pregnancyinduced hypertension, blood clot
formation, the opening up of incisions, breast problems, and postpartum
depression.

The initial phase of the postpartum period encompasses the first one
to two hours after delivery. It takes place most often in the birthing room or
in a recovery room. Once this initial phase is over, the woman has passed
through the most dangerous part of childbirth. Assessments of pain, the
condition of the uterus, vaginal discharge, the condition of the perineum, and
the presence/absence of bladder distension (followed by appropriate
interventions) are part of the initial postpartum evaluation; and should be
done every 15 minutes for the first hour, then generally every 30 minutes for
the second hour, and every four to eight hours thereafter depending on
facility policy.

PAIN/DISCOMFORT. The degree of pain and discomfort from incisions,

lacerations, and uterine cramping (afterbirth pains) is assessed by hospital
staff. The woman may also complain of muscle pain after a prolonged labor.
If the level of pain warrants it, analgesic medications are given, usually
orally. Women who have undergone cesarean births may have more pain
than women who have given birth vaginally, and may need injectable
analgesics. If a woman complains of pain in her calf, she should be evaluated
for thrombophlebitis. Also, if a woman complains of a headache, her blood
pressure should be checked to rule out the presence of pregnancy-induced
hypertension. A woman who received epidural anesthesia during delivery
may develop a "spinal headache." A spinal headache is due to the loss of
cerebrospinal fluid from the subarachnoid space that may occur during the
administration of the spinal anesthesia. Spinal headaches should be treated
by the anesthesiologist or nurse-anesthetist. Treatment for this type of
headache typically includes keeping the patient flat in bed, encouraging
increased fluid intake, and administering pain medication.

Breast engorgement is characterized by low-grade fever and the absence of

systemic symptoms. It is usually bilateral; the breasts feel warm to the touch
and appear shiny. Pain from breast engorgement can be minimized for the
breastfeeding mother by mild analgesics, the application of warm packs, and
frequent nursing. For the mother who is not breastfeeding, this pain can be
minimized by mild analgesics and the application of cold packs. A nursing
mother may find that the use of a lanolin-based preparation or a nipple
shield (although controversial) provides relief for sore or cracked nipples.
Changing positions for the nursing baby also can help in reducing irritation
and minimizing stress on sore spots.

A plugged duct can also cause breast pain. Breast pain caused by a plugged
duct is distinguished from breast engorgement by the fact that it is usually
confined to one breast and the breast is not warm to the touch. This pain
may be relieved by heat packs, gentle massage of the breast toward the
nipple, and changing positions for nursing the baby.

FUNDUS. The condition of the uterus is assessed by evaluating the height

and consistency of the fundus (the part of the uterus that can be palpated
abdominally). Immediately after delivery, uterine contractions begin
triggering involution. Involution is the process whereby the uterus and other
reproductive organs return to their state prior to pregnancy. To properly
palpate the uterus, the woman is positioned flat on her back (supine). The
health care provider places one hand at the base of the uterus above the
symphysis pubis (the interpubic joint of the pelvis) in a cupping manner (to
support the lower uterine ligaments). Then, she presses in and downward
with the other hand at the umbilicus until she makes contact with a hard,
globular mass. If the uterus is not firm, light massaging usually results in
tightening. Massaging of the uterus should not be so vigorous as to cause
the mother pain. A mother who has had a cesarean delivery should be
medicated, if possible, prior to assessment of the fundus; and the health care
provider should use the minimal amount of pressure necessary to locate her
fundus. The height of the fundus after the first hour following delivery is at
the umbilicus or above it. Every day the fundal height decreases by
approximately the width of one finger (one cm).

The fundal height may be palpated off of midline because of a distended

bladder. If possible, the woman should be encouraged to empty her bladder
prior to assessment of the fundus. A full bladder can prevent uterine
involution.

A woman sometimes receives the medication oxytocin (Pitocin) after the

delivery of the placenta. Oxytocin causes the uterus to contract and can
decrease the amount of postpartum bleeding. The health care provider
should assess the condition of the uterus frequently, and may need to
massage the uterus gently to encourage its clamping down on itself,
especially when oxytocin has not been given. If the uterus does not firm to
gentle massage, then a clot may be present inside. Gentle pressure on the
uterus following massage, and while simultaneously supporting the base of
the uterus, may expel the clot.

If massaging the uterus does not result in a firming of the fundus, then the
physician or nurse-midwife should be contacted immediately. The existence
of severe atony or a retained fragment of placenta may result in excessive
loss of blood.

VAGINAL DISCHARGE (LOCHIA). The color and amount of vaginal

discharge (lochia) is assessed by frequently removing the perineal pad and
checking the flow of lochia after delivery. An excessive amount could be a
sign of a complication such as clot formation or a retained portion of the
placenta. The vaginal discharge is red for one to three days following
delivery and is called lochia rubra. Between days two and 10, the discharge
changes to a pink or brownish color and is called lochia serosa. The last
phase occurs when the vaginal discharge turns white. This vaginal discharge
is referred to as lochia alba and may occur from 10–14 days postpartum. The
spotting can continue for another six weeks. It is common in mothers who
breastfeed their babies. A constant trickling of blood or the soaking through
of a perineal pad in an hour or less is not normal and should be further
evaluated.

PERINEUM. The condition of the perineal area is assessed for an episiotomy

or laceration repair. An episiotomy is the surgical procedure whereby the
physician or nurse-midwife extends the vaginal outlet immediately prior to
delivery of the baby. The incision is repaired with sutures after delivery.

Generally an episiotomy will be 1–2 inches (2.5–5 cm) in length. By 24 hours

postpartum the edges of the episiotomy should be fused together. An
episiotomy may be covered over with edematous tissue and not easily
visible, so the examination must the done carefully. If the laceration or
episiotomy is infected it appears red and swollen, and discharges pus.
Treatment depends on the severity of the infection and may include sitz
baths; application of an antibiotic cream to the wound; oral antibiotics; or
opening the wound, cleansing the site, and resuturing it.

When the perineal area is examined, the patient should also be checked for
the presence of a hematoma (a round area filled with blood) that is caused
by the rupturing of small blood vessels on the surface of the perineum.
After observing the perineum, the rectal area also is evaluated for
hemorrhoids, making note of their size, character, and number.

The following measures are effective in providing relief of perineal

discomfort:
 • Application of cold packs to the perineum for the first 24 hours after
delivery.
• Application of warm packs to the perineum after the first 24 hours.
• Rinsing of the perineal area with warm water after every void and/or
bowel movement. (This is also helpful in preventing infection and in
promoting healing.)
• Use of anesthetic sprays and creams. Cleaning the area with witch
hazel pads (Tucks) is also soothing.
• Sitting in a sitz bath—a small basin that fits on top of the toilet through
which warm water flows—three or four times a day. After discharge a
woman may use her bathtub at home for this purpose.

BLADDER DISTENTION. In the first 48 hours after delivery it is normal to

have an increase in the formation and secretion of urine (postpartum
diuresis). A full bladder can cause the uterus to shift upwards and not
contract effectively. An overdistended bladder can even cause injury to the
urinary system. A woman should be encouraged to void within her first hour
postpartum; and her bladder should be checked after voiding, since urinary
retention can be a problem.

Case:
A 17 year old primigravida was admitted to the hospital for labor pain
at 41 weeks age of gestation. She does not have any complications during
her pregnancy. She delivered her baby via normal spontaneous delivery
without difficulty on expulsion of the fetus and the placenta. She was
diagnosed as gravida 1 para 0 with a TPAL score of 1001 pregnancy uterine
full term, cephalic in labor. Ms. Kate delivered a healthy baby girl at her
young age. During her experience at the delivery room she stated that it was
difficult and painful but as soon as she saw her baby she seems relieved and
ready to face the entity of the new world for them. Upon admitted at the OB
ward she seems very exhausted and in pain due to the delivery, uterine pain
and episiotomy.

I chose the case of Ms. Kate as part of my study to know better about
normal delivery and its prior complications among postpartum primigravida
woman. As part of our curriculum it is better for us, student nurses, to be
alert and aware of those cases regarding the risk factors during labor and
delivery, and to have a valid and frequent nursing management that we can
do during postpartal period of our client and how we can implement our
interventions especially to the first time mothers.

B. RATIONALE (Objectives)
General Objective:

 To obtain the correct knowledge, skills, and attitude in assessing a

client who is in postpartal period and to be able to use such skills in
rendering comprehensive care in the recovery of the client using the
nursing process.

Specific Objectives:

 To promote safety and comfort of the client during the recovery period.

 To give the appropriate discharge plan to the client for a continuous

and successful recovery outside the hospital.

 To broaden my knowledge as a student nurse by doing an in-depth

research about normal spontaneous delivery.

 To impart knowledge to the client as to the importance of living a

healthy lifestyle in order to avoid any further complications.
 C. SIGNIFICANCE OF THE STUDY

This case study can be very beneficial to many people. First is the
Student Nurses which are able to establish good communication skills with
the patient, family and staff, obtain knowledge about the disease in order to
provide necessary care and health teachings to the patient and the family
and also to provide necessary actions to prevent and cope with the disease
and last but not the least is to become competent and critical nurses. Second
are the Clinical Instructors/ Staff Nurses which they identify the
deficiency of this study, to obtain necessary information regarding the
patient and her condition, to give more knowledge and ideas for more
effective and reliable case study and to be able to obtain methods for better
discussions. And third but not the least is the Patient / Family which them
to have a full understanding about her current condition, to gain knowledge
as to the proper management of health during the recovery period. For the
family, to learn all the necessary information about the proper care of the
patient after discharge to ensure the full recovery of the patient
 D. SCOPE AND DELIMITATION

We started our clinical experience at Angono General Hospital at the

OB ward. It was last August 19 to August 20, 2010. We take cared those who
are postpartal clients in almost 8 hours of our duty. We were assigned to
monitor OB ward clients and I was assigned to do my nursing management
on behalf of Ms. Kate, a primigravida, on her posrpartum period.

I received the client last August 19, 2010 from the delivery room and I
do monitor the vital sign of the patient together monitoring her IV fluid in
every hour, checking her fundus if the uterus was contracted and firm. I also
monitor the amount of blood being discharged in the vagina to know if there
was any sign of hemorrhage. We started from 6 o’clock in the morning until 2
in the afternoon. I continue my care the next day August 20, 2010 by
assisting the client doing her perineal care and doing morning care for her
baby girl. We were the one who give her the medication on time for her to be
more relieved about her pain. For our 8 hours of duty I ensure Ms. Kate
safety. We give also health teaching to Miss Kate, so that after she was
discharged she knew how to care herself even though without the need of
neither nurse nor physicians.
 E. THEORETICAL FRAMEWORK

Lydia Eloise Hall (1906-1969)

The "Core, Care, and Cure" theory was developed in
the late 1960's. She postulated that individuals could be
conceptualized in three separate domains: the body (care),
the illness(cure), and the person (core).
Hall believed patients should receive care ONLY from
professional nurses. Nursing involves interacting with a
patient in a complex process of teaching and learning. Hall was not pleased
with the concept of team nursing--she said that "any career that is defined
around the work that has to be done, and how it is divided to get it done, is a
"trade" (rather than a profession).
Nursing functions in all three of the circles (core, care, and cure) but
shares them to different degrees with other disciplines. For example, the
nurse's function in the cure circle is limited to helping patients/families deal
with the measures instituted by the physician. She felt that the care circle
was exclusive to nursing. The core circle was shared with social workers,
psychologists, clergy, etc.
• Care, Core & Cure - Nursing functions in all three of the circles (core,
care, and cure) but shares them to different degrees with other
disciplines.
• Lydia Hall’s page at the Hall of Fame. - American Nurses
Association. Core, Care and Cure Nursing Model.

Core, Care and Cure

Lydia Hall’s model for nursing provides a framework to encourage open

communication between patients and nurses. The model has three
interrelated circles that represent medical and clinical management nurses
give to patients.

In relation to my case study the care circle is the intimate care to me

as student nurse that provides establishing rapport to my client. Gaining her
trust was the first priority of my purpose to take care of her. I show her that I
value her and I do care for the goodness of her health. Sharing of thoughts to
gain more trust and let her feel that I value her safety and comfort. The core
circle symbolizes the emotional and social structure of the patient. The core
represents how I as student nurse helps the client on her daily activities and
helping her doing bed bathing, and assisting her on the proper way of taking
care of her child, since it was her first baby. And lastly the cure in which was
pertaining to the medication treatment of the client as ordered by the
physician during her hospitalization and a follow medication on her way
home. I also conduct a heath teaching on her diet and breastfeeding for
better recovery of her energy. It was her first baby and also she was still in
the minor age, supposed to be in that care further assistance and proper
health teaching needs to be explained to her. The model is not static, but
rather the patient can be in an individual circle or the circles can overlap
depending on the needs of the patient during management of their pain.
Patients who have their care, core, and cure needs met have improved self-
esteem and awareness of the importance of risk factors about disease
management and improved quality of life. The care, cure, core model
provides an opportunity for Patients to develop trust and communicate their
fears and concerns in relation to further disease management.
A. PERSONAL DATA

File Case No. : 311-66522

Admitted : August 19, 2010 Time: 6:30 am
Name : Ms. Kate
Age : 17 years old
Sex : Female
Birthday : August 14, 1993
Address : Brgy. Calumpang Binangonan, Rizal
Civil Status : Single
Religion : Catholic
Chief Complaint: Labor pain upon admission
LMP : November 4, 2009
AOG : 41 weeks / LMP
Diagnosis : G1P0 (1001) PUFT CIL

B. CHIEF COMPLAINT

Ms. Kate’s complaint was labor pain upon admission and

experienced vaginal and uterine pain after delivery and upon admitted
to the OB ward.

C. IMPRESSION AND DIAGNOSIS

Ms. Kate is recovering. She was ambulatory and can perform

some movements.
D. HISTORY OF PAST ILLNESS

Ms. Kate had a complete immunization but that time Hepatitis B

vaccine was not yet approved. Although Hepatitis B vaccine was not
yet established during that period she does not have any threatened
diseases for such of hepatitis. For the past 5 years, Ms. Kate does not
have any history of any diseases.

E. HISTORY OF PRESENT ILLNESS

Before admission, Ms Kate never had a complication during her

pregnancy, even edema did not occur in her 39 weeks age of
gestation. She does not have any history of allergies. She was healthy
as she was when she was not yet pregnant.

F. OBSTETRICAL HISTORY

Ms. Kate was a Gravida 1 Para 1 with a TPAL score of 1001. She
was 41 weeks age of gestation and delivered her baby through NSD
upon her last menstrual period last November 4, 2009. Her mother
delivered them in Normal Spontaneous Delivery and not encountered
any complications. Her menstrual period before she got pregnant
occurred monthly with no problems occurring. Her menstrual flow was
normal and last for 3 to 4 days without experiencing dysmenorrhoea.

G. FAMILY HISTORY
 As of the family history of Ms. M, there was no record of any
diseases in her family. She stated that no history of illness involve in
their race. There family have complete immunization and has no
allergy encountered.

H. PHYSICAL EXAMINATION ASSESSMENT

GENERAL ASSESSMENT
August 19, 2010 9:30am

PHYSICAL METHOD NORMAL ACTUAL ANALYSIS

ASSESSMENT FINDINGS FINDINGS

I. Head

A. Hair Inspection Hair is Hair is brown Moist and

normally in color. Thin stickiness of
lustrous, and tough in hair strand
silky, strong texture. is caused by
and elastic. Moist and lack of
Tend to sticky to proper
increase in touch. No hygiene.
growth. No presence of
falling hair. falling hair.
Softening
and thinning
are
common.
B. Scalp Inspection Symmetrical There is no Moisture
Palpation , rounded presence of and sticky
normocephal flakes. Moist scalp is
ic and sticky caused by
No presence scalp lack of
of flakes and Symmetrical proper
lesions. No , rounded hygiene
signs of normocephal upon
deformities. ic. No signs admission.
of
deformities.

C. Face Inspection Face is Face is pale Face

Palpation normally and the face expression
proportional expression shows minor
and shows pain due to
symmetric. anxiety and her uterine
Movements minor pain. pain and
are equal Skin color is episiotomy.
bilaterally. fine.
Symmetric
and
proportional.

D. Eyes Inspection Sclera is Sclera is Weary eyes

white in white. Eyes may due to
color. Bright look weary. being
and not Eyelids close exhausted
sunken or completely after
bulge. and have delivery
Symmetrical equal eyes.
and free of PERRLA
nystagmus. (Pupils are
Eyelids close Equal,
completely. Round,
No lesions, Reactive to
scaling or Light and
inflammatio Accommodat
n. PERRLA. ion).
E. Nose Inspection Nose is Movements Normal
Palpation midline in of nares
face, septum when
is straight, breathing
and nares are patent.
are patent. No
No discharge congestion
or or foul odor.
tenderness No
is present. tenderness
Turbinates on sinuses.
are pink and
free of
edema. No
tenderness
palpated on
sinuses.

F. Lips Inspection Lips appear Lips appear Normal

Palpation pink and pink and
moist. No moist. No
lesions are lesions are
present. present.

G. Teeth Inspection Teeth are Teeth are Normal

white and no white and no
presence of presence of
dentures, dentures,
staining and staining and
tartar. No tartar. No
missing missing
tooth and tooth and
dental dental
carries. carries.

H. Gums Inspection Gums are Gums are Normal

Palpation pink in color. pink in color.
No bleeding No bleeding
and and
gingivitis. gingivitis.
 I. Speech Inspection Speech is Speech is Normal
coherent. No coherent.
presence of
slurring,
rambling,
dysphagia
and aphasia

J. Ears Inspection Tymphnic Cerumen is Cerumen is

membranes present. No present due
clear; presence of to lack of
landmarks inflammatio proper
visible. n and hygiene.
masses. The
pinna cross
the eye
occiput line.

K. Breath Inspection Breath Breath has a Morning

should have morning breath smell
no odor. breath is due to
lack of oral
hygiene

L. Throat Inspection Throat pink, Throat is Normal

no redness pink in color.
or exudates. No redness
and
exudates.

M. Neck Inspection Smooth, no Smooth, no Normal

Palpation tender, tender,
small small
cervical cervical
lymph nodes lymph nodes
may be is palpable
palpable

II. Thorax Inspection Symmetrical Symmetrical Normal

. No pain in . No pain in
moving. moving
 A. Breathi Inspection Respiratory Respiratory Normal
ng Percussion rate of 12 to rate of 23
Auscultatio 20 counts counts per
n per minute. minute. No
Lung sounds presence of
are clear to deep,
auscultation shallow
bilaterally. breathing.
Lung sounds
are clear to
auscultation
bilaterally.

B. Heart Auscultatio Heart rate of Heart rate of Normal

Rate n 60 to 100 64 beats per
beats per minute.
minute.

C. Breast Inspection Breast size Nipples are Hyperpigme

Palpation is increased symmetrical n-tation of
and nodular. and brown in nipples and
More color. Breast areola are
sensitive to size is present
touch. increased because of
Colostrum is and nodular. melasma.
excreted Hyperpigme
and. ntation of
Hyperpigme nipples and
ntation of areolae.
nipples and There is also
areolae are presence of
evident. breast milk.
Nipples are
symmetrical
and brown in
color.

D. Abdomen Inspection Striae and Striae and Striae and

Palpation linea nigra linea nigra linea nigra
Interview are normal. are present. is present
No mass or And there due to
scars are no melasma.
present. masses or As of August
 The uterus scars 20, 2010
contracts present. 6:00 am the
and feels The uterus is uterus is
firm. contracted located at
Intensity of and firm. the right
the uterus Intensity of side due to
may be mild, the uterus is full bladder.
moderate or firm to Pain felt is
firm to palpation due to
palpation. upon uterine pain
difficulty in assessment and
voiding or on August 9, episiotomy
Defecating 2010. As of
Normally August 20,
defecates 2010 6:00
once in a am the
day. uterus is
located at
the right
side.
No difficulty
in voiding or
defecating.
Pain or
irritations
felt.

III. Genitalia Inspection Scars from Presence of Normal

Interview episiotomy episiotomy.
are present Bright red
and relax. discharge
There are no after
discomfort delivery.
or Presence of
deformities.. lochia rubra.
No
deformities
observed.
IV. Limbs Inspection Joints are in Color of nails Normal
full range of and nailbeds
motion and are pink.
no swelling, Temperature
redness or rate of
tenderness. 36.9°C on
Muscle size both axillary.
and strength Joints are in
is equal. full range of
Nails and motion.
nailbeds are
pink. Normal
temp. of
36.5°C to
37.5°C.

V. Mental State Observatio Conscious Conscious Normal.

n and aware of and aware of
his or her his or her
surroundings surroundings
. .

VI. Activities Observatio Ambulatory Ambulatory Normal

n and can and can
dangle and dangle and
sit up. sit up.

VII. Diet Interview Diet as Diet as To speed up

tolerated tolerated. the healing
Eating foods process of
rich in iron the uterus
and green and sutures
leafy
vegetables.

VIII. Hygiene Observatio Complete Perineal care Normal

and ns Bed bath, done every
Comfort oral care morning.
and perineal
care.

I. GORDON’S HEALTH FUNCTIONAL PATTERN

 Pattern Before During Analysis
Hospitalization Hospitalization

I. Health The patient The patient told us The patients

Perception / Health manage her health that this is her first usually go to
Management properly by eating time to be health center or
Pattern nutritious food, admitted in the hospital if she had
she’s not usually hospital for the health problems.
get sick, and also longest time. The
she does not have patient is in the
any serious health soft diet and she
issue in the past had been taking
years. But she medication
usually go to the prescribed by the
health center or physician.
hospital if she had
health issues.

II. Nutritional The Patient’s The Patient was The patient is a

Metabolic Pattern appetite is good prescribed by the very healthy
she eats anything physician to have a person in terms of
that is healthy, she soft diet. the nutrition that
does not have any she needs, she was
allergies in foods, aware on what is
and she takes good for her
ferrous sulfate as health.
her supplement.

III. Elimination The patient voids 4 The patient urine The patient has a
Pattern to 5 times a day, and bowel regular urine and
she has a regular movement is in bowel movement
bowel movement. regular pattern output
after her 4 days
recovery.

IV. Activity-Exercise The Patient usual Patient’s activities Patient’s activities

Pattern exercise is walking. are limited. She is are limited due to
Activities include experiencing risk of bleeding.
self care, house Edema due to
work and prolonged
socializing with admission in the
friends. hospital and
prolonged bed rest
since November
24, 2009

V. Sleep-rest Patient’s able to She sleeps for She feels very

Pattern sleep for 8 hours about 4 hours a uncomfortable
each night. day. about her
environment.
 J. LABORATORY EXAMINATION
HEMATOLOGY

Date Diagnostic Normal Result Indication

Ordered Lab Exam Values

August 19, Hgb M: 14-18 12.5 g/dl Normal

2010 g/dl
F: 12-16
g/dl
Hct 38% Normal

M: 40-54%
F: 37-47%

WBC counts 10.85 x Normal

10°/L
5-10 x
10°/L

Neutrophils Neutrophils
89% above normal
range could
50-70 % indicate
common
finding with
Lymphocyte acute bacterial
s 11% infections.

25-40% Decreased
lymphocytes
may indicate
Blood Type “O” viral infections
Rh BT +
A, B, AB, O
,+

Hemoglobin is a protein-based component of red blood cells which is

primarily responsible for transferring oxygen from the lungs to the rest of the
body. Hemoglobin also plays an important role in maintaining the shape of
the red blood cells. Abnormal hemoglobin structure can, therefore, disrupt
the shape of red blood cells and impede its function and its flow through
blood vessels.

Hematocrit also known as the "Hct", "crit" or PCV (packed cell

volume) determines the percentage of red blood cells in the plasma. The
term hematocrit means "to separate blood.” Hematocrit will be decreased
because the plasma volume has compensated for fluid loss while the red
blood cells that have been lost cannot be replaced for days.

White blood cells (WBCs), or leukocytes (also spelled "leucocytes"),

are cells of the immune system defending the body against both infectious
disease and foreign materials. An increase in the number of leukocytes over
the upper limits is called leukocytosis, and a decrease below the lower limit
is called leukopenia.

Neutrophil is a type of white blood cell, specifically a form of

granulocyte, filled with neutrally-staining granules, tiny sacs of enzymes that
help the cell to kill and digest microorganisms it has engulfed by
phagocytosis. Neutrophilia, an increased proportion of neutrophils in the
blood, is a common finding with acute bacterial infections.Neutropenia, a
decreased proportion of neutrophils, may be seen with viral infections and
after radiotherapy and chemotherapy.

A lymphocyte is a type of white blood cell in the vertebrate immune

system. Not all large granular lymphocytes are more commonly known as
the natural killer cells (NK cells). The small lymphocytes are the T cells and B
cells. Lymphocytes play an integral role in the body's defenses.

A blood type (also called a blood group) is a classification of blood

based on the presence or absence of inherited antigenic substances on the
surface of red blood cells.
ANATOMY & PHYSIOLOGY OF FEMALE REPRODUCTIVE SYSTEM

EXTERNAL STUCTURES
A. Mons Veneris

• A pad of adipose tissue located over the symphisis pubis, the pubic
bone joint.

• It protects the junction of pelvic bone from trauma.

B. Labia Minora

• Just posterior to the mons veneris spread two hairless folds of

connective tissue.

C. Labia Majora

• Two halves of adipose tissue covered by loose connective tissue and

epithelium.

D. Vestibule

• Flattened smooth surface inside the labia.

• The space wherein we can see the vaginal and uretral opening.

E. Clitoris

• Small rounded erectile tissue at the forward junction of the labia

minora.

• Sensitive to touch and temperature center of sexual arousal and

orgasm.

F. Skene’s Gland

PARAURETRAL GLANDS

• Located just lateral to urinary meatus.

• It produces lubricating fluid that helps to maintain the moistness of the

vestibule.

Bartholin’s Gland (vulvovaginal)

• Located just lateral to vaginal opening.

 • It secretes mucus to provide vaginal lubrications.

G. Fourchette

• Ridge of tissues formed by the posterior joining the two labias.

INTERNAL STRUCTURES

A. Ovaries

• Almond shaped

• Produce, mature and discharge ova

• Initiate and regulate menstrual cycle

• 4 cm long, 2 cm in diameter, 1.5 cm thick

• Produce estrogen and progesterone

B. Estrogen
 • Promotes breast development & pubic hair distribution prevents
osteoporosis and keeps cholesterol levels reduced & so limits effects of
atherosclerosis Fallopian tubes.

C. Fallopian tubes

• Approximately 10 cm in length

• Arises from each corner of the uterine body

• Conveys ova from ovaries to the uterus

• Site of fertilization

• Parts: interstitial

• isthmus – cut/sealed in (Bilateral Tubal Ligation)

• ampulla – site of fertilization

• infundibulum – most distal segment; covered with fimbria

D. Uterus

• Hollow muscular pear shaped organ

• uterine wall layers: endometrium(inner); myometrium(middle);

perimetrium(outer)

• Organ of menstruation

• Receives the ova

• Provide place for implantation & nourishment during fetal growth

• Protects growing fetus

• Expels fetus at maturity

 • Has 3 divisions: corpus – fundus , isthmus (most commonly cut during
CS

• delivery) and cervix.

E. Uterine Wall

• Endometrial layer: formed by 2 layers of cells which are as follows:

• basal layer- closest to the uterine wall.

• glandular layer – inner layer influenced by estrogen and progesterone;

thickens and shed off as menstrual flow.

• Myometrium – composed of 3 interwoven layers of smooth muscle;

fibers are arranged in longitudinal; transverse and oblique directions
giving it extreme strength.

F. Vagina

• Acts as organ of copulation

• Conveys sperm to the cervix

• Expands to serve as birth canal

• Wall contains many folds or rugae making it very elastic

G. Fornices

• Uterine end of the vagina; serve as a place for pooling of semen

following

coitus.

• Bulbocavernosus – circular muscle act as a voluntary sphincter at the

external opening to the vagina (target of Kegel’s exercise).
PLACENTA

• It serve s as the fetal lungs, kidneys and gastrointestinal tract and as a

separate endocrine organ throughout pregnancy.

CIRCULATION

• The fetus is connected by the umbilical cord to the placenta, the organ
that develops and implants in the mother's uterus during pregnancy.

• As early as the 12th day of pregnancy, maternal blood circulation

begins to collect in the intervillus spaces of the uterine endometrium
surrounding the chronic villi.

• By the 3rd week of pregnancy, through the blood vessels in the

umbilical cord, the fetus receives all the necessary nutrition, oxygen,
and life support from the mother through the placenta..

• From there, the nutrients are being transported back to the growing
embryo.

• Waste products and carbon dioxide from the fetus are sent back
through the umbilical cord and placenta to the mother's circulation to
be eliminated.

The blood from the mother enters the fetus through the vein in the
umbilical cord. It goes to the liver and splits into three branches. The
blood then reaches the inferior vena cava, a major vein connected to
the heart.

Inside the fetal heart

• Blood enters the right atrium, the chamber on the upper right side of
the heart. Most of the blood flows to the left side through a special
fetal opening between the left and right atria, called the foramen
ovale.

• Blood then passes into the left ventricle (lower chamber of the heart)
and then to the aorta, (the large artery coming from the heart).

• From the aorta, blood is sent to the head and upper extremities. After
circulating there, the blood returns to the right atrium of the heart
through the superior vena cava.

• About one-third of the blood entering the right atrium does not flow
through the foramen ovale, but, instead, stays in the right side of the
heart, eventually flowing into the pulmonary artery.

• Because the placenta does the work of exchanging oxygen (O2) and
carbon dioxide (CO2) through the mother's circulation, the fetal lungs
are not used for breathing. Instead of blood flowing to the lungs to pick
up oxygen and then flowing to the rest of the body, the fetal circulation
shunts (bypasses) most of the blood away from the lungs. In the fetus,
blood is shunted from the pulmonary artery to the aorta through a
connecting blood vessel called the ductus arteriosus.
 DRUG STUDY

Medication
Date treatment Action Indication Nursing
Ordere Drug Dose Responsibility
d Frequency

Augu Cefuroxime Pharmacodynamics  Treatment  Do skin test.

st 19, 500 mg 1 tab : of infection  Absorption of
2010 x 7 days Interfere with the caused by Cefuroxime is
cell-wall-building susceptible enhanced by
Classification: ability of bacteria bacteria food.
Antiineffective when they divide.  Monitor patient
Antibiotic for signs and
Second Pharmacokinetics: symptoms of
Generation  Absorption: GI superinfection
Cephalosporin tract with peak  Monitor vital
plasma signs.
concentration  Note
 Distribution: respiratory
enters status,
breastmilk; increase rate,
crosses depth and
placenta adventitious
 Metabolism: sounds.
liver  Monitor I&O
 Elimination: rates and
urine patterns
 Peak: 15-  Report onset of
60mins. loose stools or
 diarrhea.

Mefenamic Pharmacodynamics  For pain  Assess

Acid : and patient’s pain
500 mg 1 cap Inhibits the inflammatio before therapy.
TID for pain enzymes n  Monitor for
cyclooxygenase possible drug
Classification: and reduces the induced
Nonsteroidal formation of adverse
Anti- prostaglandins and reactions.
inflammatory leukotrines. It also  Monitor blood
Drugs (NSAIDs) acts as an counts and
antagonist at liver function
prostaglandin during long-
receptor sites. It term therapies.
has analgesic and  May cause
antipyretic drowsiness
properties with that may affect
minor anti- ability to
inflammatory act. perform skilled
tasks.
Pharmacokinetics:
 Should be
 Absorption: GI taken with
 Peak: 2-4hrs food.
 Distribution:  Advice patient
enters to report
breastmilk immediately
 Metabolism: persistence of
Hepatic via failure to
enzyme relieve pain.
 Excretion: urine
52%

DRUG STUDY

Medication
Date treatment Action Indication Nursing Responsibility
Ordere Drug Dose
d Frequency

Augu Methergin Pharmacodynamics  Prev  Contraindicated in

st 19, 1 tab TID x 3 : ention pregnant patient
2010 days Synthetic drug and sensitive to ergot
related to treatmen preparations, and
Classification: ergonovine. Acts t of in patient with
Therapeutic: directly on the postpart hypertension or
oxytoxic uterine smooth um toxaemia.
Pharmacologic: muscle to stimulate hemorrh  Monitor and record
Ergot alkaloids the rate, tone and age BP, PR, and uterine
the uterine caused response. Report
contractions. by sudden change in
uterine vital signs,
Pharmacokinetics: atony or frequent periods of
 Onset (uterine subinvolu uterine relaxation
contractions): 5- tion and character and
10 mins. amount of vaginal
 Duration: 7 hrs. bleeding.
 Elimination: 3-4  Monitor
hrs. contractions which
may continue 3
hours or more after
Po administration.
 Should be given 3
times a day in 3
days after delivery.

FeSO4 Pharmacodynamics  Iron  Has an adverse

1 cap OD x 30 : deficienc reaction of nausea,
days Provides elemental y epigastric pain,
iron, an essential vomiting,
Classification: component in the constipation, black
Vitamins & formation of stools, diarrhea,
Minerals (Pre & hemoglobin. anorexia.
Post Natal) /  Between meal
Antianemics Pharmacokinetics: doses are
 Onset: 4 days preferable.
 Peak: 7 – 10  Oral iron may turn
days stools black.
 Duration: 2 – 3 Although this
months unabsorbed iron is
harmless, it could
mask melena.
 Monitor hbg levels,
hct and
reticulocyte count
during therapy.
 Iron overload mat
decrease uptake of
technetium 99m
and thus interfere
with skeletal
imaging.