INTRODUCTION A mother and child case study as part of DR (delivery room) rotation in NCM501203 by BSN-3, A8, subgroup 1 students.

We had chosen our mother and child at Northern Mindanao Medical Center (NMMC) following the steps in the nursing process. This study is done through assessments, identifying nursing problem, diagnosis and nursing care plans which are prioritized and in order to minimize or eliminate identified mother and child nursing problems. This case study encompasses the nursing assessments, diagnosis and planning. The study is based on the clinical duty of A8 under Mrs, Elvyn Mabao RN at Northern Mindanao Medical Center(NMMC).This case study intends to help and provide therapeutic interventions to the chosen mother and child. With the help of this case study, the mother and child nursing problems are identified and the goals will be met using the nursing assessments, interventions, planning, diagnosis and evaluation PATIENT PROFILE Date admitted: May 9, 2011 Name: Aylin Tadle Margate Date of birth: August 15 1990 Address: Carinugan Balulang, Cagayan de Oro City Informant: Patient BP: 110/70 mmHg Temp: 37.0 Celsius Pulse: 80bpm Respiratory Rate: 19cpm Chief Complaints: labor pain and Bloody Show Admitting Diagnosis: pregnancy uterine 39 weeks age of gestation, cephalic, gravida 2, parity 2 , term 2 , abortion 0, Live birth. ALLERGIES: no known allergies PRENATAL MEDICATION: Ferrous Sulfate HEALTH HISTORY LMP: August 9, 2010 AOG: 39 weeks EDC: May 16, 2011 IE: 6cm, dilated, cephalic presentation, 80% effaced LABOR ONSET: 1pm Time: 03:30 pm Age: 20 years old Marital Status: Married Nationality: Filipino

FULL DILATATION: 3:45 pm CHILD BORN: 04:32 pm Operation: Right Mediolateral Episiotomy with repair POST PARTUM EXAMINATION: FUNDUS: contracted BP: 110/80 mmHg Respiration:20cpm Pulse Rate: 80bpm Temperature: 36.8

PSYCHOSOCIAL HISTORY Tobacco use: no Alcohol use: no Drug use: no

NEUROLOGICAL Orientation: oriented to time, place, and person MUSCULOSKELETAL Normal range of motion RESPIRATORY Clear and no secretions CARDIOVASCULAR Pulse: regular GASTROINTESTINAL Oral Mucosa: Normal Stool frequency and character: 1 or 2 times a day, soft Last bowel movement: May 8, 2011 GENITOURINARY Urine last voided: 3:00 pm NUTRITION General Appearance: well nourished Diet: diet as tolerated Appetite: Fair Meal pattern: 3times a day Urination: 6-10 times a day Color: yellow Bowel Sounds: Normal Edema: absent Perfusion: warm patient was a little weak Speech: clear

Signs of Labor Labor may begin with rupture of the membranes, experienced either as a sudden gush or as scanty, slow seeping of clear fluid from the vagina. Some women may worry if their labor begins with rupture of the membranes, because they have heard that labor will then be dry and that this will cause to be difficult and long. Actually, amniotic fluid continues to be produced until delivery of the membranes after the birth of a fetus, so no labor is very dry. Early rupture of the membranes can be advantageous if it causes a fetal head to settle snugly into the pelvis; this can actually shorten labor.

DIFFERENTATION BETWEEN TRUE AND FALSE LABOR CONTRACTION FALSE CONTRACTION -Begin and remain irregular. TRUE CONTRACTION -Begin irregularly but become regular and predictable

-Felt first abdominally and remain confined to the abdomen and groin.

-Felt first in lower back and sweep around the abdomen in a wave.

-Often disappear with ambulation and sleep.

-Continue no matter what the womans level of activity.

-Do not increase in duration, frequency -Increase in duration, frequency, or intensity. and intensity.

Mechanisms of Labor/ Cardinal Signs of Labor 1.Descent -the downward movement of the biparietal diameter of the fetal head to within the pelvic inlet. The pressure of the fetus on the sacral nerves causes the mother to experience a pushing sensation. 2.Flexion Pressure from pelvic floor causes the fetal head to bend forward onto the chest. The smallest anteroposterior diameter (suboccipitobregmatic) is one presented on the birth canal. 3.Internal Rotation Turning of the head so that the occiput moves interiorly towards the symphisis pubis. 4.Extension- Delivery of the head in vertex position. 5.External Rotation Head rotates from back to diagonal or transverse position. 6.Expulsion birth of the baby. First Stage: From the onset of the fist contraction (true labor contraction) to full cervical dilatation. 3 Phases: Latent Phase Begins at the regularly perceived uterine contractions and ends when rapid cervical dilatation begins Contractions are mild and short lasting 20-40 seconds Cervix dilates from 0-3 cm 8 hours in primigravida hours in multigravida

Active Phase Dilatation increases from 4 7 cm Contractions lasts 40-60 sec and occur every 3-5 minutes 4 hours in primigravida 2 hours in multigravida Show and spontaneous rupture of membranes may occur

Transition Phase Contractions reached their peak of intensity occurring every 2-3 minutes with duration of 60-90sec Maximum dilatation 8-10cm 1 hour in primigravida 10-15 mins in multigravida Complete cervical effacement (10 cm) Woman experiences intense discomfort accompanied by nausea and vomiting Woman may also experience a feeling of loss of control, anxiety, panic or irritability Second Stage/Delivery Stage: From fully dilated cervix to delivery of the baby and placental expulsion. the period from full dilatation to birth of the infant Contractions change from the characteristic crescendo-decrescendo pattern to overwhelming uncontrollable urge to push or bear down with each contraction as if to move her bowels Woman perspire and the blood vessels in her neck may become distended Panting at intervals and crowning takes place The need to push become intense and the woman cannot stop herself Contractions: Duration:60-90 seconds; Frequency: 2-3 minutes 50-60 minutes in primigravida 20-30 minutes in multigravida

Third Stage of Labor/Placental Stage: From the delivery of the baby to the delivery of the placenta. Signs of placental Separation:

Calkins Sign/ Changes in the shape and consistency of the uterus (Globular and firm). Uterus becomes mobile- it rises up into the uterus Gushing of blood Lengthening of the cord Types of Placental Delivery: 2 Phases: Placental Separation Signs: Calkins sign Uterus becomes mobile Sudden gush of blood Lengthening of the cord Placental Expulsion *Brandt Andrews Maneuver coil the cord slowly, winding it around the clamp until placenta spontaneously comes out rotating it slowly so that no membranes are left Types of Placental Presentation Schultze appearing shiny and glittering from the fetal membranes, inverted umbrella shaped, separation starts from the center then to the edges. Duncan it looks raw, dirty, meaty, red and irregular, umbrella shaped, separation starts from the periphery to the center. Stage 4 (Puerperium Stage) from the delivery of the baby to the first hour after birth Uterine contractions prevent bleeding from the placental site. Client may feel thirsty and hungry.

PHYSIOLOGY OF LABOR

MATURED FETUS

UTERINE MUSCLE CONTRACTIONS Stimulates Posterior Pituitary Gland to secrete Oxytocin Increase level of OXYTOCIN raise uterine muscle Calcium levels Through this MYOMETRIUM is capable of contraction Release of PROSTAGLANDIN stored in the uterine deciduas, umbilical cord and amnion Stimulates BIOCHEMICAL CHANGES in the uterine wall Stimulates UTERINE CONTRACTION

INCREASE LEVEL OF ACTIVITY -due to an increase of epinephrine release initiated by an increase in progesterone produced by the placenta.

RIPENING OF THE CERVIX -Butter-soft and softer -internal announcement that labor is close at hand.

BRAXTON HICKS CONTRACTIONS -strong contractions RUPTURE OF THE MEMBRANES -sudden gush or scanty -slow seeping of clear fluid from the vagina

SHOW -mucus plug is expelled

BLOODY SHOW

LIGHTENING -10 to 14 days before labor begins -uterus becomes lower and more anterior -abdominal pressure increases -increase vaginal discharge CERVICAL EFFACEMENT -urinary frequency from pressure in the bladder -thinning and shortening or obliteration of the cervix that occur before dilatation begins.

ENGAGEMENT -refers to the settling of the presenting part of the fetus far enough into the pelvis to be at the level of the ischial spines. DESCENT -full descent occurs when the fetal extrudes beyond the dilated cervix and touches the posterior vaginal floor.

FLEXION -pressure from the pelvic floor causes the fetal head to bend forward onto the chest. INTERNAL ROTATION -the head flexes as it touches the pelvic floor and the occiput rotates until it is superior, or just below the symphisis pubis, bringing the head into the best diameter of the pelvis. EXTENSION -as the occiput is born, the back of the neck stops beneath the pubic arch and acts as a pivot for the rest of the head. The head thus extends, and the foremost parts of the head, the face and the chin are born.

EXTERNAL ROTATION -The head rotates back to the diagonal or transverse position of the early part of labor almost immediately after the head of the infant is born. The after coming shoulders are thus brought into an anteroposterior position, which is best for entering the outlet. The anterior shoulder is born first, assisted perhaps by downward flexion of the infants head.

EXPULSION -immediately after external rotation, the anterior shoulder appears under the symphisis pubis and the perineum soon becomes distended by the posterior shoulder, gentle but firm pressure downward traction of the head is done to deliver the anterior shoulder then the head is raised to deliver the posterior shoulder, then the body follows without difficulty.

IDEAL NURSING INTERVENTION Nursing Diagnosis: Fatigue related to process of labor and delivery.

NURSING INTERVENTIONS

RATIONALE

Assess the patients expectations for fatigue The patient will need to be an active relief, willingness to participate in strategies to participant in planning, implementing and reduce fatigue, and level of family and social support. evaluating therapeutic intervention to relieve Fatigue. Social support will be necessary to help the patient implement changes to reduce fatigue.

Help the patient engage in increasing levels of physical activity and exercise.

Exercise can reduce fatigue and help the patient build endurance for physical activity.

Teach the patient signs and symptoms of over exertion with activity.

Changes in oxygen saturation, respiratory rate, and heart rate will reflect the patients tolerance for activity. Promoting relaxation before sleep and providing for several hours of uninterrupted sleep can contribute to energy restoration. Fatigue can have a profound negative influence on family processes and social interaction.

Help the patient develop habits to promote effective rest or sleep patterns.

Encourage the patient and family to verbalize feelings about the impact of fatigue.

NURSING CARE PLAN Cues Nursing Diagnosis Objectives Intervention Rationale Evaluation

Subjective:sakit kayo ang akong tiyan kongmag contract. As verbalized by the mother.

Altered comfort: pain related to increased uterine contractions and Objectives: pressure on pelvic : Rated pain as 9 structures in a scale of 1 to 10; 10 being most painful while 1 being least painful. :Facial grimacing noted Abdominal guarding noted Restlessness noted especially during exacerbation of Contractions.

Within our care, client shall experience increased comfort as evidenced by:

Within our care, the client was able to: Maintained v/s within normal range and Verbalize pain 2.Assess : This is to within tolerable contraction monitor limits and able to :Verbalization patterns, bloody the progress of Verbalize pain within show and the labor and the discomfort tolerable degree of pain condition of as controlled limits and its both with throughout characteristics, the mother and nonthe duration location, the baby. pharmacologic of labor. severity, Helps to methods duration, and identify areas Rated pain as 8 : Verbalize frequency. of chief in a scale of Discomfort concern, 1 10 Groaning, as controlled providing and facial with nonbaseline grimacing not pharmacologic for future noted. methods interventions. Was observed to Be restless when contraction occurs. :Left lateral and respond to 3. Provide comfort position questions and measures: increases venous answer properly. return and Encourage enhances comfortable placental positioning. circulation. Position the client Position changes in a left side lying promote comfort , position. reduce muscle tension, relieve Encourage the pressure and client to assume different

1. Monitor vital signs every 15 minutes for 2 hours and 30 minutes until stable.

:To obtain baseline data

position and change them regularly. Proper 4. Teach proper breathing breathing technique can technique. prevent exhaustion, therefore preventing prolonged delivery of the fetus and prolonged pain. Helps prevent 5. Provide any anxiety information and and update client on fears that may labor progress. exarberate pain. Dependent: Mechanism of Administer action to analgesia as reduce pain. ordered.

Cues

Nursing Diagnosis

Objectives

Intervention

Rationale

Evaluation

Subjective: gakahadlok ko sa akong pag panganak ug sa gakabalaka pod ko sa bata. As verbalized by the mother. Objectives: : Exhibit poor eye contact. : Facial tension observed :Impaired attention noted :Appears preoccupied decreased perceptual field.

Anxiety related to Within our care, hospitalizatioclient will n and manage upcoming anxiety with delivery. positive coping mechanism as evidenced by:

:To obtain After our care, baseline data the client was able to: Maintained v/s 2. Assess level Enhanced a within normal of anxiety nurse and client range through verbal relationship. T:37.0 Celsius and non verbal PR: 80bpm :Vital sign with in cues. RR: 19cpm normal range: BP: 110/70 mmHg T-36.5-37.5 3. employ a Provide a Verbalized that PR:60-100bpm calm and caring healthy outlet she is capable of RR:12-20cpm confident and of emotions delivering her BP:110-70 non and relieved baby. Mmhg Judgemental anxiety. Acknowledge approach. Claimed excited and discuss to see her baby. fears, 4.Allows client to Adequate She claimed that recognizing express fears and explanations she trusts the healthy and feelings of reduce anxiety, nurses in the unhealthy anxiety and sooth fears and hospital. fears. appropriately. provide Absence of facial assurance. tension and improve attention5.Offer support Provides span. By staying with feeling or Verbalizes The patient, sense of control of the pating her arms, security situation and brushing a and trust Verbalizes whisp of hair off between desire to her forehead, the nurse and participate in and provide a the labor cool cloth on her patient. process as forehead as tolerate. needed. Expresses confidence in herself, her support person, and the healthcare personnel.

1. Monitor vital Signs.

Acquires knowledge about childbirth and is better prepared to cope with future births. Dependent: Administer anti-anxiety medication as ordered by the physician.

Mechanism of action is to relieve anxiety

Cues

Nursing Diagnosis

Objectives

Intervention

Rationale

Evaluation

Subjective:Sakit kayo pag tahias verbalized by the patient.

Objectives: : Weak and exhausted :Facial grimacing is evident :Eyes are closed as observed

Altered Comfort: Pain related to tissue trauma secondary to medial episiorrhaphy

Within our care, 1. Assess the : Assessing After our care, Report pain level the pain level the client was reduction, of pain experienced Within our care, from a experience by the client the client: scale of 7 to 5 by the client anddetermines Reported pain Demonstrate her ability to her capability perception as use of perform to comply with having a numeric relaxation normal task such other value of 3 skills and as eating, interventions. :Able to perform diversional breastfeeding breathing exercise activities and dressing. :Able to exhibit Exhibit 2. Check vital Serves as minimal pain absence of signs comparison gramacing facial grimacing. from :RR= 18 cpm Manifest previous normal RR measurements (12-20cpm) thus Verbalized determine any methods that improvement provides relief. or further deterioration of the clients condition. 3.Review :Identify clients possible ways previous in how to handle experiences the pain with pain and experiences methods that by the clients. found helpful for pain control in the past. 4.Provide To provide comfort non-pharmameasures such cological as backrub and management. touch. 5.Encourage May help the use of decreased relaxation pain technique perception by

such as deep interrupting breathing and the imagery. conduction of nerve impulses.

Mechanism of action is to relieve anxiety

DRUG STUDY Drug Action Indication Contraindication Adversed reaction Hyper- or hypotension, nausea, vomiting, chest pain, dyspnea, headache, hematuria, thrombophlebitis, water intoxication, hallucinations, leg cramps, dizziness, tinnitus, nasal congestion, diarrhea, diaphoresis, palpitations, foul taste. Nursing precation Sepsis. Obliterative vascular disorders. Hepatic or renal disease. 2nd stage of labor. Nursing mothers.

Generic name: Directly Methylergometrine stimulates maleate uterine and vascular Brand name: smooth Methergine muscle. Date ordered: Therapeutic May 9, 2011 Effects: Uterine Classification: contraction ergot alkaloids Route,Dosage and frequency: IM/IV;200mcg(0.2 mg) q 24 hr for up to 5 doses.

Postpartum Hypertension. hemorrhage Toxemia. and uterine Pregnancy atony, subinvolution

DRUG STUDY Drug Action Indication Contraindication Nursing precaution Continuously CV: Hypertension, monitor increased heart contractions, rate, systemic fetal venous return, and maternal cardiac output heart GI:Na u sea rate, and , is vomiting maternal RESPIRATORY: blood pressure Anoxia,asphyxia and OTHERS: ECG. Low APGAR Discontinue score at 5 mins infusion if uterine hyperactivity occurs. Monitor patient extremely closely during first and second stages of labor because of risk of cervical laceration, uterine rupture and maternal and fetal death. Assess fluid intake and output. Watch for signs and symptoms of water intoxication Adversed reaction

TRADE NAME: Oxytocin Dosage and route: Available Forms: 10 units/ml in 1ml ampule, vial or syringe in compatible IV solution.

Pharmacologic To induce or Class: stimulate Posterior labor pituitary hormone Therpeutic Class: Uterine-active agent

-hypersensitive to drug when vaginal delivery is advised -cephalopelvic disproportion present -when delivery requires conversion as in transverse lie

Referral Husband: Raul Socorin Margate Patient: Ailyn Tadle Margate Our patient is from Balulang Cagayan de Oro City. We suggest that the patient will continue her check up at Balulang Health Center as ordered by her physician. If there is any sign and symptoms of postpartum complication the patient will seeks medical help immediately. And encourage the patient for the continuation of immunization of her child and for consultation, if there are manifestation of sickness that they should be guided properly by person who is working in any of the sector of health care. We advised the parents to be guided properly with the family planning method for greater good of their living. We give emphasis also on the sanitation and proper hygiene to avoid risk for sickness and diseases. We promote breast care and breast feeding in nourishing the newborn. We give also the mother some protective measures for the newborn since accident do happen no matter what.