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I. Introduction

Pregnancy is the carrying of one or more offspring, known as a fetus or

embryo, inside the uterus of a female human came from Latin word graviditas. In

a pregnancy, there can be multiple gestations, as in the case of twins or triplets.

Human pregnancy is the most studied of all mammalian pregnancies. Obstetrics

is the surgical field that studies and treats pregnancy. Midwifery is the non-

surgical field that cares for pregnant women. Childbirth usually occurs about 38

weeks from conception approximately 40 weeks from the last menstrual period.

Pregnancy is divided into three periods and every period has three months each.

The first trimester is from conception to partial fetal development. The second

trimester is from 4 to 6 months this is the period when the first fetal movement is

observed. The third and last trimester is from 7 to 9 months and it is

characterized by popping out of abdomen, fetus can now move regularly.

After nine months of pregnancy it is now time to face the most crucial and

complicated stage of labor. It is the time when the woman faces chances

between life and death wherein a new form of life is to be given a chance to live.

Every woman undergoes pregnancy unless they dont want to have children.

Childbirth is the process whereby an infant is born. It is considered by many to be

the beginning of a persons life and age is defined relative to this event in most

cultures. A woman is considered to be in labor when she begins experiencing

regular uterine contractions, accompanied by changes of her cervix primarily

effacement and dilation. While childbirth is widely experienced as painful, some

women do report painless labors, while others find that concentrating on the birth

helps to quicken labor and lessen the sensations. Most births are successful

vaginal births, but sometimes complications arise and a woman may undergo a

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caesarean section. A Primi-gravida woman fears what will happen during and

after delivery thinking about the pain, the deformities and life threats. A woman

undergoes many changes before reaching up delivery stage. This changes starts

from conception to full fetal formation. Physiological changes in pregnancy

include hormonal, musculoskeletal, cardiovascular, respiratory, physical,

metabolic, and renal.

Management on nutrition, weight gain, Immunological tolerance, and

psychological changes should be given focus.

During the time immediately after birth, both the mother and the baby are

hormonally cued to bond, the mother through the release of oxytocin, a hormone

also released during breastfeeding The first breast secretions contain colostrums

which can enhance anti-bodies of the baby for stronger immunity. Doing so can

maximize the purpose not only for the babies immune system but also for

bonding with the mother.

Upon this stage of pregnancy many questions will be raised not only by the

client but also from the family. Some of these questions may affect the view of

individuals upon labor. There is a need of giving right information to client so that

no misconception will happen. No matter what questions will be asked by the

relatives of client still only one thing is dearly shown and that is how much they

love the client.

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Theory of Aging Placenta

As the placenta mature more and more pressure is exerted on the

fundal portion, the usual placenta site and the most contractile portion of

the uterus, it is believed that the resultant diminished blood supply to the

area causes contraction.

Uterine Myometrial irritability/ Uterine Stretched Theory

The most acceptable theory) as the uterine muscle get stretched

with fetal growth and increasing amniotic fluids, irritability and contractions

to empty the contents of the uterus are likely to result.

Components of Labor

A. Passage

Is the shape and measurement of maternal pelvis and dispensability of

birth canal.

Fetal Presentation and Position

Attitude - describes the degree of flexion a fetus assumes during

labor the relation of the fetal parts to each other.

Good attitude: is in complete flexion: the spinal column is bowed

forward, the head is flexed forward so much that the chin touches

the sternum, the arms are flexed and folded on the chest, the thighs

are flexed onto the abdomen, and the calves are pressed against

the posterior aspect of the thighs.

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Moderate flexion: if the chin is not touching the chest but is in

alert or military position.

Engagement - refers to the settling of the presenting part of a fetus

enough into the pelvis to be at the level of the ischial spines, midpoint of the

pelvis.

Station refers to the relationship of the presenting part of a fetus to if

level of the ischial spines.

Station 0: when the presenting part is at the level of ischial spin

(Synonymous with engagement)

Minusstations (-1 to -4): if the presenting part is above the spines.

Plusstation (+1 to +4): at 3 to +4 station, the presenting part

at the perineum and can be seen if the vulva is separated (crowning)

Fetal Lie - is the relationship between the long (cephalocaudal) axis the

fetal body and the long (cephalocaudal) axis of a womans body.

B. Passenger

Is the fetus the body part of the fetus that has the widest diameter is the

head, so this is the part least likely to be able to pass through the pelvic ring.

Fetal Head - usually the largest part of the body, it has found effect

on the birthing process.

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Bones of the Skull - are joined by membranous sutures, which

allow for overlapping or molding of cranial bones during birth

process.

Anterior and Posterior Fontanels are the pints of intersection

for the sutures and are important landmarks.

Fontanels are used as landmarks for internal examinations

during labor to determine position of fetus.

Fetal shoulders may be manipulated during delivery to allow

passage of one shoulder at a time.

Molding is the change in shape of the fetal skull produced by

the force of uterine contractions pressing the vertex of the head

against the not-yelled- dilated cervix.

Types of presentation

Cephalic

Head is presenting part, usually the vertex (occiput), which is

the most favorable for birth. Head is flexed with chin on chest.

o Vertex Presentation

When the head is well flexed the

suboccipitobregmatic diameter and the parietal

diameter present. When the head is not flexed but

erect, the presenting diameters are occipitofrontal

and biparietal.

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o Brow Presentation

When the head is partial flexed, the brow or sinciput

becomes the presenting part.

o Face Presentation

When the head is extended to make the face the

presenting part.

o Mentum Presentation

The head is completely hyperextend the head to

present the chin.

Breech

Buttocks or lower extremities present first.

o Frank

Thighs flexed, legs extended on anterior body

surface, buttocks presenting.

o Full or Complete

Thighs and legs are flexed. Buttocks and feet (baby

is squatting position).

o Footling

One or both feet are presenting.

Shoulder

Presenting part is the scapula and baby is in horizontal or

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Transverse position. Cesarean birth indicated.

C. Power (uterine factors)

a. Uterine contractions (involuntary)

Frequency timed from the beginning of one contraction to the

beginning of the next.

Regularity discernable pattern: better established as pregnancy

progresses.

Intensity Strength of contraction; May be determined by the

depressability of the uterus during a contraction. Describe as

mild, moderate or strong.

Duration length of contractions. Contraction lasting more than

90 seconds without a subsequent period of uterine relaxation may

have severe implications for the fetus and should be reported.

Phases of contractions

o the increment, when the intensity of the contraction

increases

o acme, when the is at its strongest

o decrement, when the intensity decreases

Cervical Changes

o Effacement- shortening and thinning of the cervical canal.

Canal is approximately 1-2cm long.

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Primiparas effacement is accomplished before

dilatation begins.

Multiparas dilatation may proceed before

effacement is complete.

Dilatation- refers to the enlargement or widening of

the cervical canal from an opening a few millimeters

wide to one large enough (approximately 10cm) to

permit passage of the fetus.

b. Voluntary Bearing Down Efforts

After full dilatation of the cervix, the mother can use her abdominal

muscles to help expel fetus.

These efforts are similar to those for defecation, but the mother is

pushing out the fetus from the birth canal.

Contraction of levator and muscle

Premonitory Signs of Labor

Lightening- descent of the fetal presenting part into the pelvis

approximately 10-14 days before labor begins.

Signs of Lightening:

o Relief of Dyspnea.

o Relief of abdominal tightness

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o Increase frequency of urination, varicosities, and pedal

edema because of pressure on the bladder and pelvic

girdle.

o Shooting pain down the legs because of the pressure on

the sciatic nerve

o Increase amount of vaginal discharge

Increase Maternal energy- nesting behavior because of increase

level of epinephrine.

Braxton Hicks Contraction- extremely strong which may interpret

as true labor contractions.

Ripening of the cervix (Goodells Sign) - becomes soft as butter

that is seen only on pelvic examination.

Differentiation between True and False Labor Contractions

True Contractions False Contractions

Begin irregular but

become regular and

predictable.

Felt first from lower back

groin to abdomen in a

wave

Continue no mailer what

Begin and remain

irregular

Fell first abdominally

and remain confined to

the abdomen and groin

Often disappear with

ambulation and sleep.

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Mechanism of Labor

Passage of fetus through the birth canal involves a number of

different position changes to keep the smallest diameter of the fetal head (in

cephalic presentation) always presenting to the smallest diameter of the birth

canal. These position changes are termed the cardinal movements of labor:

descent, flexion, internal rotation, extension, external rotation and expulsion.

DESCENT - Is the downward movement of the biparietal diameter

of the fetal head to within the pelvic inlet. Full descent occurs when

the fetal head extrudes beyond the dilated cervix and touches the

posterior vaginal floor. Descent occurs because of pressure on the

fetus by the uterine fundus. The pressure of the fetal head on the

sacral nerves at the pelvic floor causes the mother to experience a

the womans activity

Increase in duration,

frequency and intensity

Achieve cervical

dilatation

Do not increase in

duration, frequency, or

intensity

Do not achieve cervical

dilatation

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pushing sensation. Full descent may be aided by abdominal muscle

contraction as the woman pushes.

FLEXION as the descent occurs and the fetal head reaches the

pelvic floor, the head bends forward onto the chest, making the

smallest anteroposterior diameter (the suboccipitobregmatic

diameter) the one presented to the birth canal. Flexion is also aided

by abdominal muscle contraction during pushing.

INTERNAL ROTATION The head flexes as it touches the pelvic

floor, and occiput rotates until it is superior, or just below the

symphysis pubis, bringing head into the best relationship to the

outlet of the pelvis. This movement brings the shoulders, coming

next, into the optimal position to enter the inlet. Putting widest

diameter of the shoulders in line with the wide transverse diameter

of inlet.

EXTENSION As the occiput is born, the back of the neck stops

beneath pubic arch and acts as a pivot for the rest of the head. The

head extends the foremost parts of the head, the face and chin, are

born.

EXTERNAL ROTATION almost immediately after the head of

the infant is the head rotates back to the diagonal or transverse

position of the early part labor. This brings the after coming

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shoulders 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 once the shoulders are born, the rest of the baby s

born easily and smoothly because of its smaller size. This

movement is the end of the pelvic division of labor.

Stages of Labor

A. First Stage

A first stage of dilatation, which begins with the initiation of true

labor contract and ends when the cervix is fully dilated. The first stage of

labor is divided into If phases: the latent, the active, and the transition

phase.

PRIMI: 12 1/2 hours

MULTI: 8 hours

a) Latent Phase

The latent or preparatory phase begins at the onset of

regularly perceived uterine contractions and ends when rapid

cervical dilatation begins. Contractions during this phase are

mild and short, lasting 20-40 second cervical effacement

occurs, and the cervix dilates from 0-3cm. the ph lasts

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approximately 6 hours in a nullipara and 4.5 hours in a

multipara. Maternal behavior: talkative, less anxious, alert,

excited and the woman. This stage is excited with some

degree of apprehension but still with the ability to

communicate.

Assessment:

i. Contractions: frequency, intensity, duration

ii. Membranes: intact, ruptured, color of fluid

iii. Bloody show, time of onset, cervical changes

iv. Time of last ingestion of food

v. FHR every l5mirts. Immediately after rupture of

membranes

vi. Maternal vital signs: temperature every 2 hours

membranes ruptured every 4 hours if intact

vii. Pulse and respirations every hour or when necessary

viii. Progress of descent

b) Active Phase

During the active phase of labor, cervical dilatation

occurs more rapidly. Increasing from 4-7 cm. contraction

grow stronger, lasting 40-60 seconds. and occur

approximately every 3-5 minutes. This phase lasts

approximately 3 hours in a nullipara and 2 hours in a

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multipara. Show (increased vaginal secretions) and perhaps

spontaneous rupture of membranes may occur during this

time. Maternal behavior: less talkative. More anxious; may

not want to be alone, fears of losing control, restless.

Increase anxiety. Maternal problem may hyper ventilate.

Assessment:

i. Cervical changes and increase bloody show

ii. Progress of descent

iii. Maternal and fetal vital sign

c) Transition Phase

During the transition phase, contractions reach their

peak of intensity. Occurring every 2-3 minutes with a

duration of 60-90 seconds and causing maximum dilatation

of 8-10 cm. by the end of this phase, both full

Dilatation (10 cm) and complete cervical

effacement(obliteration of the cervix) have occurred. If cervix

is intact, this period is marked by a sudden gush of amniotic

fluid as the fetus is pushed into the birth canal. Shows

become prominent. There is an uncontrollable urge to push

with contractions. The woman may experience intense

discomfort that may be accompanied by nausea and

vomiting. Maternal behavior: feeling of loss of control,

anxiety, panic and irritability.

Assessment:

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i. Progress of labor and cervical changes

ii. Mood changes: if irritable or aggressive may be tiring or

unable to cope

iii. Signs of nausea, vomiting, trembling, crying, irritability

iv. Maternal and fetal vital signs

v. Breathing patterns, may be hyperventilating

vi. Urge to bear down with contractions

B. Second Stage

The second stage of labor is the period from full dilatation and

cervical effacement to birth of the infant; with uncomplicated birth, this

stage about 1 hour. Contractions change from the characteristic

crescendo-decrescendo pattern to an overwhelming, uncontrollable urge

to push or bear down with each contraction as if to move her bowels.

Perineum bulges; grunting sounds. Increase bloody show with leg cramps

and bag of water ruptures. Maternal behavior: progresses from irritability

to participation, eagerness and excitement with need to bear down so she

pushes with uterine contraction spontaneously.

PRIMI: 80 mm.

MULTI: 30 mm

Assessment

i. Signs of imminent delivery

ii. Progress of descent

iii. Maternal and fetal vital signs

iv. Increase maternal pushing efforts

v. Vaginal distension

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vi. Crowning

vii. Birth of baby

C. Third stage

The third stage of labor, the placental stage, begins with the birth of

the infant and ends with the delivery of the placental separation and

placental expulsion.

PRIMI: 10 mm

MULTI: 10 mm

Signs of placental Separation:

Lengthening of the umbilical cord.

Sudden gush of vaginal blood

Change in shape of the uterus

Firm contraction of the uterus

Appearance of the placenta at the vaginal opening

Types of Placental Delivery:

Schultz Mechanism: 80% of the cases; fetal side, shiny clean and

inverted umbrella.

Duncans Mechanism: 20% cases. maternal side. rough dirty and

umbrella shape.

Assessment

i. Signs of placental separation

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ii. Mechanisms of placental separation

iii. Completeness of the placenta

iv. Status of mother and baby: babys apgar scores, blood

pressure, pulse, respirations, lochia and fundal status of the

mother.

C. Fourth Stage (recovery stage)

The first 1- 4 hours after birth of the placenta is sometimes termed

the fourth stage to emphasize the importance of the close observation

needed at this time. First two hours is the most crucial stage of the mother

due to unstable vital signs.

Assessment

i. Fundus: every 15 mm. for one hour and every 30 mm. for

the next four hours.

ii. Lochia: should be moderate in amount

iii. Bladder: full bladder is evidenced by the shifting of the

uterus to the right.

iv. Normally tender, discolored, edematous and intact

sutures

v. BP and HR: monitored closely 15 mm. during the 1 hour,

every 30 mm. for 2 hours.

vi. Rooming- in concept: the mother and the baby stays in

the same room in the hospital to promote the bonding and

encourage breastfeeding.

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vii. Firmness of the fundus and its position

viii. Lochia color and amount

Lochia Rubra Dark red 1-3 days

Blood and cellular

debris from

decidua

Lochia Serosa

Pinkish 4-10 days

Mostly serum,

some blood,

tissue debris

Lochia Alba Yellowish 11-21 days

Mostly, white

leukocytes with

deciduas,

epithelial cells,

ix. Perineum condition

x. Vital signs and medications and IV if any

xi. Infants pulse rate, respiration, appearance, reflexes and

vital measurements

xii. Palpate fundus every 15 mm. for the first 1-2 hours or

until stable

xiii. Monitor Mothers vital signs

xiv. Check vaginal discharges every 15 mm. for the first 1-2

hours

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III. Profile

Name : Dona P. Villlegas

Address : Flores Compound, Calaanan, Canitoan, CDOC

Civil Status : Married

Sex : Female

Age : 24 yrs. old

Height : 162.6 cm

Occupation : Teacher

Educational status : College Graduate

Income : N/A

Religion : Roman Catholic

Nationality : Filipino

LMP : December 10, 2008

EDC : September 17, 2009

Time of delivery : 2:38 pm

Type of delivery : Normal spontaneous delivery

Gravida : 1

Parity : 1

Term : full term

Premature : 0

Abortion : 0

Living : 1

Name of Hospital : J.R Borja General Hospital

Name Physician : Dr. John Paul L. Oliveros, M.D.

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Assessment

Assessment

1st Visit

(July 28, 09)

2nd Visit

(Aug. 28,09)

3rd Visit

(Sept.26,09)

4th Visit

(Oct. 2,09)

Temperature 36.5 C 36.3C 37.5C 37.4C

Pulse rate 76bpm 80bpm 82bpm 81bpm

Respiration rate 21cpm 19cpm 21cpm 21cpm

Blood pressure 120/90mmHg 100/60mmHg 120/80mmHg 110/90mmHg

Height 162.6 162.6cm 162.6cm 162.6cm

Weight 58.9kg 58.5kg 58.9kg 57.5kg

Age of gestation 26weeks 30weeks 34weeks Weeks

Fetal heart beat 128bpm 130bpm 135bpm 134bpm

Fundal height 26cm 30cm 34cm cm

Immunization:

Type of

immunization

dose date Place of

immunization

Tetanus toxoid 1 dose March 29,2009 Canitoan

Health Center

Tetanus toxoid 1 dose April 26,2009 Canitoan

Health Center

Food or drug allergy: No known food and drug allergies

Heredo-Familial Disease: No known Heredo-Familial Disease

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Received Blood in the past: she havent received blood in the past

IV. Ideal Nursing Intervention

A. Antepartum

Nursing Diagnosis

o Fatigue related to effects of physiologic changes of

pregnancy.

Nursing Interventions:

1. Explain to patient physiologic changes responsible for increased

feeling of fatigue during pregnancy.

Information provides knowledge that can

motivate an individual to make lifestyle

changes that will enhance energy level by

promoting adequate rest.

2. Assist patient in developing a plan to increase amount of rest

and sleep.

Mutually deciding on a plan increases the

likelihood that the patient will follow through

with the actions needed to successfully

implement the plan.

3. Instruct patient to limit fluid intake during the evening.

To prevent frequent awakenings from nocturia.

4. Instruct patient to position self in bed for maximum comfort.

Comfort promotes rest.

5. Assist patient in eliminating nonessential tasks from schedule.

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To prevent fatigue from excessive demands

and to allow time for additional rest periods.

Nursing Diagnosis

o Pain related to urinary tract infection.


1. Assess pain, noting location, intensity (scale of 0-10), and

urination

Provides information to aid in determining

choice/effectiveness of interventions.

2. Recommend bed rest as indicated.

Bed rest may be needed initially during acute

retention phase.

3. Suggest comfort measures, like backrub, deep-breathing

exercises, diversional activities and helping patient assume position

of comfort.

Promotes relaxation, refocuses attention, and

may enhance coping abilities

4. Encourage use of sitz baths, warm soaks to perineum.

Promotes muscle relaxation.

5. Administer medication as indicated:

Narcotics like meperidine (Demerol)

o Given to relieve severe pain, provide

physical and ental relaxation.

Antibacterial like methenamine hippurate

(hiprex)

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o Reduces bacteria present in urinary

tract as well as those introduced by

drainage system.

Antiplasmodics and bladder sedatives like

flavorate (urispas), Oxybutynin (ditropan).

o Relieves bladder irritability.

Nursing Diagnosis

Risk for ineffective breathing pattern related to respiratory

changes during pregnancy..

Nursing Intervention:

1. Investigate etiology of respiratory failure.

Understanding the underlying cause of the

patient particular ventilatory problem is

essential to the care of the patient.

2. Observe overall breathing pattern.

To identify if patient is experiencing

hyperventilation or hypoventilation.

3. Count patients respirations for one full minute and compare to

desired ventilator set rate.

Respirations vary, depending on problem

requiring ventilator assistance.

4. Elevate head of bed or place in orthopedic chair if possible.

Elevation of head is both physically and

psychologically beneficial.

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5. Keep resuscitation bag at bedside and ventilate manually

whenever indicated.

Provides adequate ventilation when patient

problems require that the patient be

temporarily removed from the ventilation.

Nursing Diagnosis

o Imbalanced nutrition, less than body requirements related to

nausea, vomiting and knowledge deficit of nutritional needs

during pregnancy.


1. Review 24-hour dietary intake and ask if this is typical of the normal

diet.

To provide baseline information of patients

nutritional habits.

2. Determine current knowledge of nutritional needs during

pregnancy.

To provide information needed to develop an

individualized teaching plan.

3. Use of food pyramid to teach patients to eat a nutritional diet;

provide them with a copy of the food pyramid.

A healthy diet should consists of that can be

adapted to accommodate cultural preferences.

4. Teach patient to report excessive nausea and vomiting to health

care provider.

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To allow for early intervention of alternative

forms of nutritional delivery if an oral diet

cannot be tolerated.

5. Avoid beverages with meals and foods that are spicy and greasy.

These have noxious odors can increase

episodes of nausea and vomiting.

Nursing Diagnosis

o Knowledge deficit related to normal changes of pregnancy

versus illness complications.

Nursing Interventions

1. Review avoidance of environmental risk factors.

Reduces potential for acquired infection.

2. Identify specific activity limitations.

Prevents undue strain on operative site.

3. Recommend planned progressive exercise.

Promotes return of normal function and

enhances feeling of general well.

4. Schedule adequate rest periods.

Prevents fatigue and conserves energy for

healing.

5. Review importance of nutritious diet and adequate fluid intake.

Provides elements necessary for tissue

regeneration.

6. Identify signs and symptoms requiring medical evaluation.

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Early recognition and treatment of developing

complications.

B. Intrapartum

Nursing Diagnosis:

o Anxiety: mild related to excitement, of onset of labor and fear

of the birth.


1. Support womans knowledge of labor.

To provide comfort measures to the mother

during labor and delivery process.

2. Explain all procedures performed or the process of labor.

Explaining the process of labor or childbirth to

the patient minimizes patients apprehensions.

3. Answer all questions and provide information as needed.

To provide reassurance to the mother and help

her to relax during childbirth.

4. Monitor VS, FHR and progress of labor.

Monitoring mothers VS and fetal heart rate is

needed to take baseline data and to take note

for any patients reactions during labor process.

5. Support womans preference for breathing and relaxation

techniques to be used at this time.

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Supporting the mothers preference for

breathing and relaxation techniques helps us to

implement or provide comfort measures and

help the mother to expel the newborn properly.

6. Administer anti-anxiety or anxiolytic medications as ordered.

Anxiolytic drugs or medications lowers level of

anxiety with the proper use of pharmacology.

Nursing Diagnosis:

o Fluid volume deficit related to decreased intake and

increased loss of fluid with the work of labor.

Nursing Interventions

1. Explain to woman and support person why oral fluids are

restricted or stopped at this time.

Explaining the necessary information

concerning fluid intake of the client was

necessary in order to gain cooperation from the

mother and to decrease urination during the 2nd

stage of labor (delivery stage).

2. Start and maintain IV infusion.

Intravenous infusion is necessary to maintain

adequate hydration during the labor process of

the client.

3. Provide ice chips or sips of clear fluids if allowed.

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To prevent dry mouth during labor process and also to

increase mothers energy in doing the bearing down

technique during contractions.

Nursing Diagnosis:

o Pain related to increasing frequency and intensity of uterine

contraction


1. Provide comfort measures (eg. back rub, change of position)

Back rubbing could provide non-pharmacologic pain

management, thus reducing the pain felt by the mother

during her labor stage.

2. Encourage diversional activities (e.g. TV, radio, socialization

with others )

Diversional activities are a mean of diverting patients

attention on others things, thus reducing the pain felt

by the mother during the labor process.

3. Eliminate additional stressors or sources of discomfort whenever

possible.

Patients may experience an exaggeration in pain or

decreased ability to tolerate painful stimuli if

environmental, interpersonal factors are further

stressing them.

4. Instruct or encourage the mother to use of relaxation exercises,

such as focused breathing, or listening to music.

Relaxation eases the painful sensation.

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5. Administer analgesics as ordered.

Analgesics provide pain relief to the patient during

delivery stage of labor.

Nursing Diagnosis

o Ineffective individual coping, related to anxiety, fear and

decreased problem-solving capability.

Nursing Intervention

1. Assess anxiety level.

To identify appropriate comfort measures to be given

to the client during her labor process.

2. Assess behavior of support person and its effect on the woman.

To help woman cope with increasing pain and anxiety

of active labor.

3. Provide information

Information concerning labor process reduces

mothers feeling of fear or anxiety during labor

process.

4. Assist woman and support person in focusing on breathing and

relaxation techniques to maintain control.

To Relieve from muscular aches

3. Give episiotomy Care

To relieve discomfort

To prevent further infection

4. Promote Perineal Exercises

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Aids comfort by providing circulation to the area and

decreasing edema.

To help regain her Pre-pregnant stage.

To reduce episiotomy discomfort

5. Administer Hot and Cold Therapy

To reduce perineal edema and possibility of

Hematoma formation.

To increase circulation to the perineum, provide

comfort and promote healing.

6. Administer Sitz Baths

To decrease inflammation by causing vasodilatation

in the area, and thereby effectively reduces

discomfort and promotes healing.

7. Provide pain management

To reduce incision line pain

To promote extra encouragement to try the pain

medications

To relieve perineal pain

Nursing Diagnosis

o Risk for infection (uterine) related to lochia and episiotomy


1. Provide Perineal Care

To remove transient microorganisms in the perineum

To avoid further infection

To promote hygiene

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2. Promote perineal self-Care

To teach the patient how to carry out own perineal care

Nursing Diagnosis

o Disturbed sleep pattern related to exhaustion and excitement

from and excitement of childbirth


1. Promote rest in the early postpartal period.

To encourage a period of rest to regain energy.

2. Listen to subjective reports of sleep quality.

To evaluate pattern of sleep and dysfunction.

3. Assist individual to develop schedules that take advantage. of

peak performance times as identified in chronological order.

To promote wellness.

Nursing Diagnosis

o Risk for bathing hygiene self-care deficit related to

exhaustion from childbirth.


1. Determine current capabilities and barriers to participation in

care.

Identifies need for/level of interventions required

2. Involve patient in formulation of plan of care at level of activity

Enhances sense of control and aids in cooperation and

development of independence.

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3. Encourage self-care. Work with present abilities: do not

pressure patient beyond capabilities. Provide adequate time for

patient to complete task.

Doing for one self enhances feeling of self-worth. Failure

can produce discouragement and depression.

Nursing Diagnosis

o Imbalanced nutrition, less than body requirements,

related to lack knowledge about postpartal needs


1. Promote Adequate Fluid Intake

Prevent dehydration

2. Emphasize importance of well-balanced, nutritious intake.

Provide information regarding individual nutritional needs and ways

to these needs within financial constraints.

To promote wellness and knowledge about own

nutritional needs

3. Ascertain understanding of individual nutritional needs

To determine what information to provide client.

4. Provide diet modification

To establish nutritional plan that meets individual needs

Nursing Diagnosis

o Risk for impaired urinary elimination or constipation

related to of bladder and bowel sensation after

childbirth.

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1. Promote Urinary Elimination

To achieve normal elimination pattern

2. Adequate fluids and roughage

To prevent constipation

3. Palpate bladder for retention

To assess the degree of interference

Nursing Diagnosis

o Risk for ineffective peripheral tissue perfusion related

to immobility and increased estrogen


1. Observe skin for pallor, redness. Manage with lotion, change

position frequently.

Compromised peripheral circulation increases risk of skin

breakdown

2. Assess skin for coolness, pallor, diaphoresis, delayed capillary

refill, and weak, thread peripheral pulses.

Vasoconstriction is a sympathetic response to lowered

circulating volume and/or may occur as a side effect of

vasopressin administration.

Nursing Diagnosis

o Pain related to primary breast engorgement


1. Promote Breastfeeding

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Prevent tenderness and soreness of primary breast

engorgement.

2. Promote Breast Hygiene

To prevent possible infection when breastfeeding

Nursing Diagnosis

o Health-seeking behaviors related to clients desire to

return to pre- pregnant weight and appearance


1. Teach methods to promote uterine involution.

To promote fast return to pre-pregnant state

2. Promote using proper body mechanics, getting adequate rest,

and performing prescribed exercises.

To help clients abdominal wall to return to good tone.

Nursing Diagnosis

o Attachment risk for impaired parent/infant! child


1. Interview parents, noting their perception of situation. Individual

concerns

2. Evaluate parents ability to provide protective environment,

participate in reciprocal relationship.

To provide a good environment to infant/child

3. Educate parents regarding child growth and development,

addressing parental perception. Helps clarify realistic expectations

To enhance behavioral of infant/child

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4. Involve parents in activities with the infant/child that they can

accomplish successfully. Enhance self-concept.

To enhance best functioning of parents

D. Immediate Newborn Care

Nursing Diagnosis

o Imbalance nutrition less than body requirement related

to poor sucking reflex


1. Assess nutritional status continually during nursing care noting

energy level, condition of the skin, nails, hair and oral cavity.

provides the opportunity to observe deviations from

normal

2. Weigh daily and compare with the admission date.

Establish baseline, aids in monitoring effectiveness of

therapeutic regimen and alerts the nurse to inappropriate

trends in weight loss or gain

3. Always hold the infant when feeding and propping the bottle when

feeding.

To promote bonding and gain trust of the infant

4. Feeding only breast milk or formula milk for the first year.

Feeding only breast milk for the first year is given since it

is theft main source of nutrition consumption because

ingestion of solid foods is not appropriate for infants

aging 0-4 mos.

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5. Avoiding use of honey and corn syrup.

Use of honey and corn syrup can make the infant

dependent on it with out taking new food preference that

contains more nutrition

Nursing Diagnosis

o Risk for ineffective airway clearance related to difficulty

establishing respirations and rapid respiratory rate


1. Assess respiratory rate every 15 mm. for about 1 hr. report any

increase in rate, retractions or development of nasal flaring or

grunting

Assessment provides a baseline foe evaluating changes.

Increase in respiratory rate and a retraction accompanied

by nasal flaring and grunting indicates respiratory

distress.

2. Position the newborn on his side with his head slightly lower

than the rest of the body

Positioning in this manner facilitates drainage of

secretions from airway

3. Change the position of the newborn frequently

Changing position frequently facilitates drainage of

secretions and thus promotes lung expansion

4. Suction mouth and nose with a suction bulb as indicated

Suctioning removes secretions and suctioning from

mouth to nose prevents aspiration of oral secretions

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5. Monitor newborn temperature and keep him warm via radiant

warmer. Wrap the newborn loosely with a blanket and place a cap

on head

Newborns have difficulty conserving body heat. Exposure

to cold environment increase metabolic rate, increasing

the need of oxygen and further increasing respiratory

rate.

Nursing diagnosis

o Risk for impaired parenting related to concerns about

skin color.


1. Allow parents to verbalize their concerns about the

discoloration.

Verbalization allows safe outlet for emotion and helps to

increase the parents awareness

2. Explain that Mongolian spats are normal variation to skin color

of the newborn. Inform them that the area usually disappears by

school age.

Explanation as normal provides information to help allay

parents fears and concerns

3. Point out other positive normal attributes of the newborn

Pointing out other positive areas helps the parents focus

on the uniqueness and special qualities of their child.

4. Encourage the parents to hold, talk and explore the newborn

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1. Assess environmental temperature (78 80F) and modify if

needed example providing warm and cooling blankets and increasing

room temperature.

Assessing would maintain and stabilizes newborns

temperature

2. Monitor newborn temperature and keep him warm via radiant

warmer. Wrap the newborn loosely with a blanket and place a cap

on head

Newborns have difficulty conserving body heat. Exposure

to cold environment increase metabolic rate.

3. Close doors and windows and regulate the cooling facility

To provide warm environment for the newborn thus

preventing him from chilling

4. Prevent exposing the newborns body for a long span of time

Preventing sudden and long exposure of newborns body

to the environment reduces chance of chilling

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Actual Nursing Intervention

A. Antepartum

During antepartal period, a pregnant woman may able to experience many

things related to her health such as headache, nausea, vomiting, and cramps

over the extremities. Due to this complication a pregnant woman may feel

depressed or may form a negative feeling towards her pregnancy. To solve

this complication or to prevent a pregnant woman to have further

complication, it is better for them to consult their physician or by visiting the

nearest health center in their town. The reason for visiting and consulting their

physician and health center is that they can monitor her condition. And so she

can understand why shes experiencing this condition.

During our assessment to our client, we were able to identify different

problems.

We were able to identify the following problems:

y Improper breathing pattern while sleeping

y Back pain

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EENT:

[ ] Impaired vision [ ] blind[ ] pain redden [ ] drainage[ ] gums [] hard of hearing [ ] deaf[ ] burning [ ] edema [ ] lesion teeth[ ] assess eyes ears nose[ ] throat for abnormality[x] no problem

RESP:[ ] Asymmetric [ ] tachypnea [ ] barrel chest[ ] apnea [ ] rales [ ] cough[ ] bradypnea [ ] shallow [ ] rhonchi[ ] sputum [ ] diminished [x] dyspnea[ ] orthopnea [ ] labored [ ] wheezing

[ ] pain [ ] cyanotic[ ] assess resp. rate, rhythm, pulse blood[ ] breath sounds, comfort [ ] no problem

CARDIOVASCULAR:[ ] arrhythmia [ ] tachycardia [ ] numbness[ ] diminished pulses [ ] edema [ ] fatigue[ ] irregular[ ] bradycardia [ ] mur mur[ ] tingling [ ] absent pulses [ ] painAssess heart sounds, rate rhythm, pulse, bloodPressure, circ., fluid retention, comfort[x] no problem

GASTROINTESTINAL TRACT:[ ] obese [ ] distention [ ] mass[ ] dysphagia [ ] rigidity [ ] pain[ ] assess abdomen, bowel habits, swallowing[ ] bowel sounds, comfort [x] no problem

GENITO U

RINA

RYAND

GY

NE[ ] pain [ ] urine [ ] color [ ] vaginal bleeding[ ] hematuria [ ] discharge [x ] nocturia[x] assess urine frequency, control, color, odor, comfort[ ] gyne bleeding [ ] discharge [ ] no problem

NEURO:[ ] paralysis [ ] stuporous [ ] unsteady [ ] seizure[ ] lethargic [ ] comatose [ ] vertigo [ ] tremors[ ] confused [ ] vision [ ] grip[ ] assess motor, function, sensation, LOC, strength[ ] grip, gait, coordination, speech [x ] no problem

MUSCULOSKELETAL and SKIN:

[ ] appliance [ ] stiffness [ ] itching [ ] petechiae[ ] hot [ ] drainage [ ] prosthesis [ ] swelling[ ] lesion [ ] poor turgor [ ] cool [ ] flushed[ ] atrophy [ ] pain [ ] ecchymosis [ ] diaphoretic moist[ ] assess mobility, motion gait, alignment, joint function

[ ] skin color, texture, turgor, integrity [x] no problem

Nursing Assessment (System Review and Nursing Assessment)

Name: Donna P. VillegasBP: 100/60 mmHg T: 36.5 C PR: 80 bpm RR: 19 cpm

Weight: 58.9kgs Height: 162.6cm

No problem

Linea nigra

Strae gravidarum

Back pain

Varicosity

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SUBJECTIVE OBJECTIVE

COMMUNICATION Comments[ ]Hearing Loss[ ]Visual changes[x]Denied

[ ]glasses [ ]languages[ ]contact lens [ ]hearing aideR 3-4mm L 3-4mm

Pupil size: 3-4mm [ ]speech difficultiesReaction: PERRLA

OXYGINATION Comments[x ]Dyspnea[ ]Smoking History________________

[ ]Cough[ ]Sputum[ ]Denied

Respiraatory: [] Regular []irregularDescription: RR is within normal range

R: right lung is symmetric to the left lungL: left lung is symmetric to the right lung

CIRCULATION Comments[x]Back Pain[x]Leg Pain[x]Numbness of the

Extremities[ ]Denied

Heart Rhythm: [] regular [] irregularAnkle Edema NONE

Pulse Car Rad DP FemR + + + N.OL + + + N.OComments: All pulse sites are palpable

NUTRITION CommentsDiet:DAT[x]N [x]VCharacter[ ]Recent change in

Weight, appetite[ ]Swallowing

Difficulty

[]dentures []none

Full partial with patientUpper [] [] []Lower [] [] []

ELIMINATIONUsual bowel pattern [x]urinary frequencyOnce in every two days 6 times per day

[ ]Constipation [ ]urgency

Remedy [ ]dysuria[ ]hematuria

Date of last BM: [ ]incontinenceSept. 25, 2009 [ ]polyuria[ ]diarrhea [ ]foly in place

Character [ ]denied

Comments: Bowel sounds:

Abdominal DistensionPresent []yes[]noUrine (color, consistency, odor)

If they are in place?

MGT. OF HEALTH & ILLNESS[ ]alcohol [ ]denied

[x]SBELMP: Dec.01, 2009

Briefly describe the patients ability to follow treatments

(diet, meds., etc.) for chroni9c health problems ( if present)

The patient did not experience any chronic problem.

Wala man koproblem sa akopanan-an asverbalized by thepatient.

Pag-maghigdako, galisod koug ginhawa.As verbalizedby the patient

Magbinhod

akong tiil ug sakitakong likod inighapon asverbalized by thepatient

Gasuka ko uggakalipong tagabuntag asverbalized by the

patient.

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Skin Integrity Comments[ ]Dry[ ]itching[ ]other[x]denied

[ ]dry [ ]cold [ ]pale[ ]flushed [ ]warm[ ]moist [] cyanotic

Rashes, ulcers, decubitus (describe size, location,drainage) No found any impaired skin integrity.

Activity/Safety Comments[ ]convulsion[ ]dizziness[ ]limited motion of joints[ ]ambulate[ ]Bathe self[ ]Other[x]denied

[ ] LOC and orientation: patient is well

oriented with time and date.Gait: [ ]Walker [ ]cane [ ]other

[ ]steady [ ]unsteady_______[ ]sensory and motor losses in face or extremities: NONE

[ ] ROM limitationsComfort/Sleep/Awake:[ ] pain (location, Comments

frequencyremedies)

[ ] nocturia[x]sleep difficulties[ ]denied

[ ]facial grimace[ ]guarding[ ]other signs of pain[ ]side rail release form signed (60+ tears)

Coping:Occupation: mother

Members of household: 5Most supportive person: mother and father

Observed non-verbal behavior:

The person and her phone number that can be reached anytime:

SPECIAL PATIENT INFORMATION N/A Daily weight N/A PT/OT

N/A BP q shift N/A Irradiation

N/A Nero vs N/A Urine Test N/A CVP/SG. Reading N/A 24 hours Urine Collection

Date Ordered Diagnostic/Laboratory

Exam

Date Done Date Ordered I.V Fluids/Blood Date Done

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HEALTH TEACHINGS

Medication Instruct the patient ordered by the doctor such as

to take ferrous sulfate a day after breakfast

Exercise y Advice to do antepartal exercise inpreparation for labor and delivery. It will

strengthen her muscle over perineum,abdomen, legs, and reduce backache and

numbness over the extremities.

y Demonstrate the antepartal exercise inher front and if possible she will follow

it afterwards. Demonstrate the following exercise:

Pelvic tilting or pelvic rocking Knee chest twist Leg raising Tailor setting Ribcage lifting Shoulder circling Knee bending Calf stretching

Treatment Instruct patient to increase fluid intake so thatthere would be increased in the amount of

amniotic fluid.

Out-patient Regular check-up to their health center

Check-ups Every Tuesday of the week Once a month before EDC

Diet Instruct patient to increase food intake such as:

Foods high in protein Food that has high iron such as chicken

liver and malungay.

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EENT:[ ] Impaired vision [ ] blind

[ ] pain redden [ ] drainage[ ] gums [] hard of hearing [ ] deaf[ ] burning [ ] edema [ ] lesion teeth[ ] assess eyes ears nose[ ] throat for abnormality[x] no problem

RESP:[ ] Asymmetric [ ] tachypnea [ ] barrel chest[ ] apnea [ ] rales [ ] cough[ ] bradypnea [ ] shallow [ ] rhonchi[ ] sputum [ ] diminished [ ] dyspnea[ ] orthopnea [ ] labored [ ] wheezing[ ] pain [ ] cyanotic[ ] assess resp. rate, rhythm, pulse blood[ ] breath sounds, comfort [ ] no problem

CARDIOVASCULAR:[ ] arrhythmia [ ] tachycardia [ ] numbness[ ] diminished pulses [ ] edema [ ] fatigue

[ ] irregular[ ] bradycardia [ ] mur mur[ ] tingling [ ] absent pulses [ ] painAssess heart sounds, rate rhythm, pulse, bloodPressure, circ., fluid retention, comfort[x] no problem

GASTROINTESTINAL TRACT:[ ] obese [ ] distention [ ] mass[ ] dysphagia [ ] rigidity [ ] pain[ ] assess abdomen, bowel habits, swallowing[ ] bowel sounds, comfort [x] no problem

GENITO URINARY ANDGYNE

[ ] pain [ ] urine [ ] color [ ] vaginal bleeding[ ] hematuria [ ] discharge [ ] nocturia[ ] assess urine frequency, control, color, odor, comfort[ x ] gyne bleeding [ ] discharge [ ] no problem

NEURO:

[ ] paralysis [ ] stuporous [ ] unsteady [ ] seizure[ ] lethargic [ ] comatose [ ] vertigo [ ] tremors[ ] confused [ ] vision [ ] grip[ ] assess motor, function, sensation, LOC, strength[ ] grip, gait, coordination, speech [x ] no problem

MUSCULOSKELETAL and SKIN:[ ] appliance [ ] stiffness [ ] itching [ ] petechiae[ ] hot [ ] drainage [ ] prosthesis [ ] swelling[ ] lesion [ ] poor turgor [ ] cool [ ] flushed[ ] atrophy [x ] pain [ ] ecchymosis [ ] diaphoretic moist[ ] assess mobility, motion gait, alignment, joint function[ ] skin color, texture, turgor, integrity [ ] no problem

Nursing Assessment (System Review and Nursing Assessment)

Name: Donna P. VillegasBP: 110/90 mmHg T: 37.4 C PR: 81 bpm RR: 21cpm

Weight: 58.5kg Height: 162.6cm

No problem

Lochia serosa

Itching

Back pain

No problem

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SUBJECTIVE OBJECTIVE

COMMUNICATION Comments[ ]Hearing Loss[ ]Visual changes[x]Denied

[ ]glasses [ ]languages[ ]contact lens [ ]hearing aideR 3-4mm L 3 -4mm

Pupil size: 3-4mm [ ]speech difficultiesReaction: PERRLA

OXYGINATION Comments[ ]Dyspnea[ ]Smoking History

________________

[ ]Cough[ ]Sputum[ ]Denied

Respiratory: [] Regular []irregularDescription: RR is within normal range

R: right lung is symmetric to the left lungL: left lung is symmetric to the right lung

CIRCULATION Comments[x]Back Pain[ ]Leg Pain[ ]Numbness of the

Extremities[ ]Denied

Heart Rhythm: [] regular [] irregularAnkle Edema NONE

Pulse Car Rad DP FemR + + + N.OL + + + N.OComments: All pulse sites are palpable

NUTRITION CommentsDiet: DAT[ ]N [ ]VCharacter[ ]Recent change in

Weight, appetite[ ]Swallowing

Difficulty

[]dentures []none

Full partial with patientUpper [] [] []Lower [] [] []

ELIMINATIONUsual bowel pattern [ ]urinary frequencyOnce adays 3 4 times a day

[ ]Constipation [ ]urgencyRemedy [ ]dysuria

[ ]hematuriaDate of last BM: [ ]incontinenceSept. 24, 2009 [ ]polyuria[ ]diarrhea [ ]foly in place

Character [ ]denied

Comments: Bowel sounds:No noted presence of abdominal sounds

Abdominal Distension

Present []yes[]noUrine (color, consistency, odor)

If they are in place?

MGT. OF HEALTH & ILLNESS[ ]alcohol [x ]denied

Dili ko gainom ug makahubog nga ilimnon[x]SBE Last Pap Smear: NONELMP: Dec.01, 2009

Briefly describe the patients ability to follow treatments(diet, meds., etc.) for chroni9c health problems ( if present)

The patient did not experience any chronic problem.

Wala man koproblem sa akopanan-aw asverbalized by the

patient.

wala man koproblema sa

akongpaginhawa.As verbalized

by the patient

Magbinhod

akong tiil ug sakitakong likod inighapon asverbalized by the

patient

wala man koproblema sa akongpagkaun asverbalized by the

patient.

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Skin integrity Comments[ ]Dry

[x ]itching[ ]other

[ ]denied

[ ]dry [ ]cold [ ]pale

[ ]flushed [ x]warm[ ]moist [] cyanotic

Rashes, ulcers, decubitus (describe size, location,

drainage) No found any impaired skin integrity.

Activity/safety Comments[ ]convulsion

[ ]dizziness[ ]limited motion of joints

[ ]ambulate[ ]Bathe self[ ]Other

[x]denied

[ ] LOC and orientation: patient is well

oriented with time and date.

Gait: [ ]Walker [ ]cane [ ]other[ ]steady [ ]unsteady_______

[ ]sensory and motor losses in face or extremities: NONE

[ ] ROM limitations Comfort/sleep/awake:[ ] pain (location, Comm ents

frequencyremedies)

[ ] nocturia[ ]sleep difficulties[ x]denied

[ ]facial grimace[ ]guarding[ ]other signs of pain

[ ]side rail release form signed (60+ tears)

Coping:

Occupation: teacher

Members of household: 6

Most supportive person: husband

Observed non-verbal behavior: the patient was conscious and

coherent

The person and her phone number that can be reached anytime:

SPECIAL PATIENT INFORMATION N/A Daily weight N/A PT/OT

N/A BP q shift N/A Irradiation N/A Nero vs N/A Urine Test

N/A CVP/SG. Reading N/A 24 hours Urine Collection

Date Ordered Diagnostic/Laboratory

Exam

Date Done Date Ordered I.V Fluids/Blood Date Done

gakatol angakongtinahian as

verbalized by

the patient

ok raman ako

pag-tulog asverbalized by

the patient

makalihok-lihok pamanko asverbalized by

the patient

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Immediate Newborn Care

Donna Villegas, a postpartum client, del ivered a healthy baby girl in a

normal spontaneous vaginal delivery. Last October 2, 2009 , we went to their

home and conducted our last assessment. When we arri ved to their home, we

found her feeding her baby through a milk bottle. She told us that her baby

has a good sucking reflex.

The mother is anxious about the red spot locate d at the lower

Right arm of the infant and we told her that the spot is n ormal for an infant. As

nursing intervention we advised the mother not to place pow der ointment or

baby oil on the babys skin if rashes occur. Vital signs were taken during the

assessment and it was in normal range. We noted little diaper rashes on the

infants inguinal area.

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HealthTeaching

Remind parents to hold infant properly when feeding and never

propping bottle when feeding.

Instruct parents to limit infants water intake to oz. 1 oz.

Instruct the mother not to leave infant unattended on bed, tables, or

other surfaces without side rails.

Encourage to sit comfortably and hold baby in a semi upright position :

hold bottle so that fluids fills the nipples and the air in the bottle does

not enter the nipple.

Encourage the parents to change position of the in fant alternately

during feeding; feed for half of feeding hold ing in 1 hour, and then

switch to the other arm.

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VII. Summary and Evaluation

Pregnancy represents a maturation crisis that requires an open

outlook, a pessimistic attitude that involves self awareness of the situation,

sense of preparedness and readiness. This event requires the involvement of

all family members.

The case studies itself was a great experience for everybody, for us, on

how to actually care and monitor childbearing woman until towards her post

partum care. It was a four months monitoring and studying. It gave way for all

of us the opportunity to incorporate the knowledge that we have learned in

school including the theories and principles behind the phenomenon called

pregnancy to the actual life experience in the persona of our client,

Mrs.Donna. In this way, the group was able to relate ideal nursing intervention

into actual nursing intervention during the said studies. Though along the

way there were undesirable moments that occurred, yet it did not stop the

group from this case studies.

As an overview, Ms. Donna Villegas was experiencing common

discomfort such as dyspnea in supine position, backache, fatigue and

frequent urination. She had a regular prenatal check up with her OB Gyne.

This is one advantage for pregnant women to be guided and be aware of their

conditions for the entire pregnancy months

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During our visit with Ms Donna Villegas, the group made sure that

we gave her health teachings related to her condit ion, such as antepartal

exercise and nutritional requirement to meet her day to day requirement

during the period of pregnancy. We also shared to her the importance of

prenatal check up and advised to have complete immunization to her children

and the group also discussed about family planning method, so that they will

know how they going to plan their family in the future. The group also

discusses or sites an example of danger sign of pregnancy if she will not be

careful.

With this case study, the group learned so much, we gained and

learned a lot from this, we get to have understanding and a good picture of

our goal and sticking to our objective on how to care, provide efficient and

effective care during antepartal period of pregnancy, but also the group

learned so much about themselves as individual person. A lot of drama

happened prior to the completion of this case study, we bonded together, we

laugh together, and we unite as one, agreed on one thing th ough there were

arguments that took place, some misunderstandings that leads to silent

moments.

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