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We the Group A3 of College of Nursing-Norzagaray College with our
beloved Clinical Instructor in OB-ward, Ms. Airies L. Borromeo, RN, was
conducted an interview in Norzagaray Municipal Hospital at OB-ward as part of
our case study.
The significance of the study is for us third year student to apply the
principles and concept that we have learned in the NCM (maternal and child
Nursing) in our rotation in NMH with the following objectives:

 To be able to review concept on theories in maternal and child nursing.

 To be able to describe the development, physiology and nursing care of a

client who has undergone normal spontaneous vaginal delivery (NSVD)
and episiotomy procedure.

 To be able to design a nursing care plan for the patient who has
undergone NSVD and episiotomy procedure.

 To be able to provide information and health teaching to the patient of the

post-partum period.

 To be able to establish a good working relationship with the patient and

hospital staff.

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Name: AA
Age: 19 y/o
Sex: female
Date of birth: June 11, 1990
Place of birth:Tondo, Manila
Civil status: living in

Address: blk 26 lot 13 ph 2 FVR1

Occupation: housewife
Spouse: RR
Religion: Roman Catholic
Citizenship: Filipino
Date and time admitted: 8-19-09/1:30 am
Hospital no.: 00103

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As the interview was conducted, patient AA told us that since august 17,
2009, she was experiencing on and off pain in her lower abdomen and she can¶t
sleep because of the pain. August 19, 2009 at 1:30 in the morning,

Patient AA was admitted in the OB ward with the chief complaint of labor
in pain. Around 4:30 in morning the patient brought to the delivery room because
the bag of water was ruptured. Almost 5:35am, she was delivered an alive, 7 lbs
and 53 cm in length baby boy with this statistics:

Head circumference: 33 cm

Chest circumference: 34 cm

Abdominal circumference: 32 cm

Patient AA¶s placenta was expelled simultaneously by 5:45 am with

blood pressure of 120/90 mmHg. After her delivery, she was admitted to the OB
ward with repaired episiotomy. Post partum doctor¶s orders were as follows
which was carried out:

DAT (diet as tolerated)

Ice pack over hypogastrium

Perennial care

Syntocinon 10 units infused to IVF

Amoxicillin 500 mg 1 capsule TID

Mefenamic 500 mg 1 capsule TID

Methergin tablet 1 tablet TID

Ferosulfate tablet 1 tablet OD

G  8/19/09
 T = 36.7 c
RR= 24 cpm
PR= 61 bpm
BP= 130/70 mmHg

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Upon interview the patient was asked about her menstrual history, she
told us that at the age of 13, she had her 1st menstrual period or menarche. Her
menstrual cycle was regular, in her 28 day menstrual cycle; she had her period
for 5 days.

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Our overview of the reproductive system begins at the external genital
area or vulva which runs from the pubic area downward to the rectum. Two folds
of fatty, fleshy tissue surround the entrance to the vagina and the urinary
opening: the labia majora, or outer folds, and the labia minora, or inner folds,
located under the labia majora. The clitoris, is a relatively short organ (less than
one inch long), shielded by a hood of flesh. When stimulated sexually, the clitoris
can become erect like a man's penis. The hymen, a thin membrane protecting
the entrance of the vagina, stretches when you insert a tampon or have
intercourse.


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The vagina is a muscular, ridged sheath connecting the external genitals to the
uterus, where the embryo grows into a fetus during pregnancy. In the
reproductive process, the vagina functions as a two-way street, accepting the
penis and sperm during intercourse and roughly nine months later, serving as the
avenue of birth through which the new baby enters the world.

   
The vagina ends at the cervix, the lower portion or neck of the uterus. Like
the vagina, the cervix has dual reproductive functions.
After intercourse, sperm ejaculated in the vagina pass through the cervix,
then proceed through the uterus to the fallopian tubes where, if a sperm
encounters an ovum (egg), conception occurs. The cervix is lined with mucus,
the quality and quantity of which is governed by monthly fluctuations in the levels
of the two principle sex hormones, estrogen and progesterone.
When estrogen levels are low, the mucus tends to be thick and sparse,
which makes it difficult for sperm to reach the fallopian tubes. But when an egg is
ready for fertilization and estrogen levels are high the mucus then becomes thin
and slippery, offering a much more friendly environment to sperm as they
struggle towards their goal. (This phenomenon is employed by birth control pills,
shots and implants. One of the ways they prevent conception is to render the
cervical mucus thick, sparse, and hostile to sperm.)







The uterus or womb is the major female reproductive organ of humans. One
end, the cervix, opens into the vagina; the other is connected on both sides to the
fallopian tubes.
The uterus mostly consists of muscle, known as myometrium. Its major
function is to accept a fertilized ovum which becomes implanted into the
endometrium, and derives nourishment from blood vessels which develop
exclusively for this purpose. The fertilized ovum becomes an embryo, develops
into a fetus and gestates until childbirth.




The Fallopian tubes or oviducts are two very fine tubes leading from the
ovaries of female mammals into the uterus.
On maturity of an ovum, the follicle and the ovary's wall rupture, allowing
the ovum to escape and enter the Fallopian tube. There it travels toward the
uterus, pushed along by movements of cilia on the inner lining of the tubes. This
trip takes hours or days. If the ovum is fertilized while in the Fallopian tube, then
it normally implants in the endometrium when it reaches the uterus, which signals
the beginning of pregnancy.



The ovaries are the place inside the female body where ova or eggs are
produced. The process by which the ovum is released is called ovulation. The
speed of ovulation is periodic and impacts directly to the length of a menstrual
cycle.
After ovulation, the ovum is captured by the oviduct, where it travelled
down the oviduct to the uterus, occasionally being fertilised on its way by an
incoming sperm, leading to pregnancy and the eventual birth of a new human
being.
The Fallopian tubes are often called the oviducts and they have small
hairs (cilia) to help the egg cell travel.




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Pain in the abdominal tract

Pressure

Uterine contraction

Increment Uterine relaxes

Decrement

Effacement

Cervical dilatation begins

Increase the diameter

Fluid filled membranes
of the cervical canal
press against the cervix

Cervical dilatation occur more rapidly

Increase vaginal secretions and perhaps

spontaneous rupture of the membrane

Contractions reach their peak of intensity

Causing maximum dilatation

They will rupture as a rule of pull dilatation

Sensation in abdomen maybe so intense

 Contractions change from the
characteristics crescendo-descrecendo

Fetal presenting part as its widest diameter

reaches the level of the ischial spine of the
pelvis

Downward movment of the biparietal diameter

of fetal head until it reaches the pelvic inlet

Shortest head diameter passes through the pelvis

Fetal head reaches the pelvic floor

Fetus enter the pelvic inlet to the maternal pelvis

Fetal head passes beneath the symphysis pubis

Shoulder rotate internally to fit the pelvis

Expulsion occurs first as the anterior

Then the posterior shoulder passes

under the symphysis pubis

After the shoulder delivery rest of the

body follows

Folding the separation of the placenta occur

Active bleeding on the maternal surface of the placenta

begins and separation

Separation completed
 The placenta sinks to the lower uterine
segment of the upper vagina

The placenta is delivered either by the natural bearing

down effort of the mother or by gentle pressure on the
contracted uterine fundus by the physician

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1st stage 12 ½ hr (1 -4 cm. Uterine contractions,

(average) which may follow a regular pattern
& may be accompanied by:
Abdominal cramps
Backache

Rupture of membranes
Show (blood-tinged)
Mucoid vaginal discharge
Passage of mucous plug

 


(4-8 cm)Uterine contractions

become stronger, longer (40-45
seconds) more frequent and may
 be accompanied by pain

  

(8-10 cm) Uterine

contractions stronger, longer (50-
60 seconds) and may be accompanied
by amnesia b/w contractions.
Generalized dis-comfort.
Hiccoughing. Irritable abdomen.

Abrupt changes in behavior (ie:

Don't touch me) Marked restlessness,
Sudden n/v,, Perspiration on
upper lip and forehead, Profuse
dark, heavy show, Rupture of
membranes, Severe low backache,

Shaking of legs. Stretching

sensation deep in pelvis.
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Full dilatation of Cervix,

½ to 2 hours accompanied by:
(average) Contractions which may be 1-2
minutes apart, becoming
increasingly expulsive in nature.
Expulsive grunt when exhaling
Rectal bulging with flattening of

perineum.
Increased amnesia between
 contractions.
Gradual appearance of presenting
part at vaginal opening

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Contractions temporarily cease upon

10 to 20 minutes birth of baby. When they resume,
(average) they usually are painless and may

be accompanied by a rising of the

uterus in abdomen;
Uterus assuming globular shape.
Visible lengthening of umbilical cord
as placenta moves into vagina.
Trickle or gush of blood.

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Duration is variable. Uterus - Firm, midline, initially halfway

between sym-pubis and umbilicus,
Minimum of 1 hour then raises 1-2 cm above the
up to 12 hours, umbilicus by 12 hrs. Lochia - Rubra,
heavy-mod.
depending on
*continuous oozing should not occur
condition and/or
episiotomy - clean and dry
complications
bladder - may distend and need to
void/catheterize.
patient may experience shaking chill
due to vasomotor/nerve reaction
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The skin is normally brown in color, no areas of increased
vascularity. No evidence of lesions and presence of birthmark at the right
arm. The skin is not too dry with a minimum perspiration and slightly
cooler in temperature than the rest of the body. There is a presence of
edema in the lower extremities and presence of linea negra in the center
of the abdomen vertically.

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The head is normocephalic and symmetrical. The skull is smooth,
non-tender and no palpable masses. The color of the hair is dark black
and it is thick, slightly curl and shiny. There are presences of few lice. The
scalp is shiny, intact and no lesions. The general features of the face are
symmetrical and the face is oval in shape.

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The muscles of the neck are symmetrical and no palpable masses.
The lymph nodes are not visible or inflamed upon inspection. The lymph
nodes are palpable but not exceeded to 0.5cm in diameter. The shoulders
are symmetrical.

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The eyes are symmetrical, the pupil are deep black in color and
round in shape. Pupils constrict briskly to direct light accommodation. The
conjunctiva is pink and moist and no swelling, lesions and foreign bodies.
The corneal surface is moist and shiny and no discharge, cloudiness,
opacity and irregularity. The lens is transparent in color. The eyelids are
symmetrical and no infectious and tumors upon inspection and palpation
and the patient can raise both eyelids symmetrically. The eyebrows are
present bilaterally, symmetrical and without lesions and scaling.

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The breath smell fresh, the lips and membranes are pink and moist,
no evidence of lesions on inflammation. The tongue is in the midline of the
mouth and the teeth are yellowish in color and there are presences of
dental caries.
 

The chest expansion is symmetry, respiratory rate is normal, the
breath sounds are normal, the heart sounds is normal. The breast and
axilla are flesh colored, and the areola areas and nipples are darkened.
The breast is symmetrical and slightly large. No palpable masses in
breast, axillary, areolas and nipples and presence of yellowish discharge.


There is presence of linea negra in the center. The abdomen is
bilaterally symmetrical and no palpable masses or nodules.

X


Both upper and lower extremities are symmetrical in length and
size. The number of fingers and toes are complete. There is a presence of
edema in the lower extremities and the temperatures are slightly cooler.

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The patient¶s sleep pattern was normal, she was sleeping 7-8 hours a
day her bedtime rituals are watching TV and sometimes reading books,
magazines or newspapers.

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The patient actually and exercise during pregnancy walking while In pain
and she just do the households.


The patient food preferences were vegetables, rice, mat, and fish. She
eats three times a day in normal amount.


The frequency of the patient bowel pattern was 1-2 a day, hard in
consistency, slightly black in color and aromatic odor. The frequency of
urinary pattern was 5-8 times a day, the consistency was transparent,
clear and ammonia like odor.
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 Amoxicillin
 Mefenamic acid
 Ferosulfate
Instruct the client about the way of taking her medicines. Explain the proper
measurement and time of intake.
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Encourage the client to do some exercise every morning such as simple

walking.

&



Advice the client not to engage in any house chores that might jeopardize
her health.
&

 

Encourage and explain the importance of breast feeding to the client.

Breastfeeding especially the first milk, ³colostrums´, can reduce postpartum
bleeding/hemorrhage in the mother, and to pass immunities and other benefits to
the baby. Advice client to let her child expose to mild sunlight in order to balance
and avoid excess bilirubin in the body.

Instruct and teach the client about proper bathing of the baby.
&

 
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Instruct the client to go back for the follow up check ups.
&
 

Advice client to eat proper diet. Encourage her to eat more vegetables and
frequent intake of liquids. Advice her to eat food which are rich in protein, iron
and vitamin C. protein helps to repair body tissues, iron provides formation of
Red Blood Cells and Ascorbic Acid for helping absorption of iron.
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TABLE OF CONTENTS


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