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Aguinaldo Highway, Talaba IV, Bacoor Cavite

School of Nursing and Allied Health Studies In partial fulfillment of the requirements in Nursing Care Management 104

A Case study on a Post Partum Care of a Normal Spontaneous Delivery (NSD) Submitted by: Janer, Ivy Monica P. Ladan, Danra-Ann R.

BSN 3A Group 4

Submitted to: Ms. Tita B. Buenaobra, RN, MAN December 14, 2011

Normal Spontaneous Delivery
LEARNING OUTCOMES For at least four weeks of duty, I have encountered several constraints with regards to the implementation of interventions. It was not that easy specially that what I am dealing with are lives, lives through which if jeopardized, can either put me in an obnoxious situation or be blameworthy for any complications. Three days of multi-tasking and time management, the OB- NURSERY ward exposure has taught me how to appropriately handle pregnant and post partum women. The idea of caring for mothers and newborns which is not in my lineage is hard. Hard, because some of the patient¶s are uncooperative and non compliant. It isn¶t that smooth to establish an interacting relationship specially that most of the patient¶s admitted in the institution has a low educational attainment. Therefore, I cannot expect them to fully comprehend the instructions I have imparted. However, it was a marvelous experience since I was exposed to various kinds of maternal paragons and procedures which weren¶t return demonstrated yet. Fortunately, there is our clinical instructor who persistently supervised us and assisted us to make it through with just minimal errors. Now, let me get this straight. This is my first time to manage an individual case study. Adding to that is the fear of making a physiologic structure of my opted case. One false move and I am screwed. I have learned to thoroughly assess my patient to comply with the requisites. Also, I have acquainted myself with regards to establishing rapport with my patient to have a trusting relationship

BREAST Patient¶s breasts are slightly unequal in size, left breast is slightly larger, rounded in shape and generally symmetric. Fullness feeling in the left breast as verbalized by the client. Skin is intact, dry and has no discoloration. No lesions and scars noted. There was presence of striae on both breasts. Patient verbalized slight pain, 2 out of 5, on left breast. Areolas are round, dark brown in color, equal in size, bilaterally the same and bigger than the normal. Nipples are not inverted, equal in size and similar in color. Skin on axilla is dark, hairless and odorless, no masses or tenderness noted. UTERUS The fundus of the uterus was firm and one fingerbreadth below umbilicus. BLADDER When the hypogastric region was palpated, bladder was not distended. BOWEL 20 ± 25 bowel sounds per minute noted upon auscultation. LOCHIA Dark red discharges in minimal amount noted on the diaper pad as verbalized by Mrs. Lopez. EPISIOTOMY Patient refused to be assessed on the genitourinary area. We were not able to inspect the episiotomy for redness, edema, ecchymosis, discharges and approximation. HOMAN¶S SIGN To test for Homan¶s Sign, the leg was extended and the foot was dorsiflexed. No pain on both legs as verbalized indicating negative Homan¶s Sign. EMOTION We observed that our client was very dependent as evidenced by asking for the remote, for water and many things. Since it is her first baby, she still needs the assistance of her mother in caring of the infant.

It is recommend that you go to the hospital when the contractions are five minutes apart. stronger and closer together over time. At this point the woman may feel a burning or stinging sensation. Active management utilizes oxytocic agents . lasting more then 60 seconds for at least an hour. Pain medication is often given at this stage. Early or Latent Phase. Active labor is marked by regular contractions that become longer.Upon the interview of our clients she shared to us that she is very happy that the delivery of the baby was finish. Stage 2. this stage usually lasts 12 to 16 hours and shorter on subsequent pregnancies. The series of events that expel the infant from the uterus are referred to collectively as labor. During the early or latent phase. The third stage can be managed either expectantly or actively. cramping and backache. Placental Stage This begins with the birth of the baby and ends with the delivery of the placenta. Expectant management (also known as physiological management) allows the placenta to be expelled without medical assistance. At the end of the first stage. Breastfeeding soon after birth and massaging of the top of the uterus (the fundus) causes uterine contractions that encourage delivery of the placenta. The cervix is 4-7 centimeters dilated. A tightening feeling in the pubic area and increasing pressure in the back is felt. There are three phases on the first stage: the early or latent phase. Breathing techniques may already begin.´ Stage 3. The duration of the first phase is the longest. Maternal blood loss is limited by contraction of the uterus following delivery of the placenta. Ideally it has successfully also passed below the interspinous diameter. Stage 1. from 8 to 10 centimeters. the widest diameter of the head has successfully passed through the pelvic brim. Average length for all vaginal deliveries ranges from five-to-fifteen minutes. the cervix dilates to 4 centimeters. lasting from 30 minutes to two hours. The pain may be intense. At the beginning of the normal second stage. as the cervix stretches and the baby descends into the birth canal. the cervix is dilated to 10 centimeters. The pain felt at this early stage may be similar to menstrual pain: aching. The four stages of the childbirth process are based on changes in the uterus and cervix as labor progresses. fullness. also called parturition. The cervix is opening the last few centimeters. In mothers having their first child. the shortest. all that will remain is for the fetal head to pass below the pubic arch and out through the introitus. This is assisted by the additional maternal efforts of ³bearing down´. Dilatation and Effacement First stage of labor which is the longest begins with the onset of regular contractions which progress to cervical dilatation and effacement. If these have been accomplished. Contractions may be irregular. progressing to rhythmic and methodical. Normal blood loss is less than 600 ml. This is the narrowest part of the pelvis. Measuring the contractions from the start of one contraction to the beginning of the next must be done. Expulsion Stage This begins with delivery of the newborn and ends with delivery of the placenta. is the culmination of pregnancy. It usually occurs within 15 days of the calculated due date. Transition is the most difficult phase of labor. the head is fully engaged in the pelvis. the active phase and the transition phase. and fortunately. averaging around 8 hours. STAGES OF LABOR Childbirth. She said that she still feels the experience of labor and delivery through the pain of her surgical incision in the perineum. This is also known as the ³ring of fire. Average length for first time mother ranges from one to two hours and shorter on subsequent births. The fetal head is seen to µcrown¶ as the labia part.

as discussed below. In this stabilization phase.0 cm) to suboccipitobregmatic (9. it encounters resistance from the bony pelvis or the soft tissues of the pelvic floor. This is followed by the delivery of the fetus' head. resulting in passive flexion of the fetal occiput. or at the level of the maternal ischial spines. where the largest transverse diameter of the fetal occiput is the biparietal diameter) enters the maternal pelvis to a level below the plane of the pelvic inlet. Expulsion After the fetus' head is delivered. Extension With further descent and full flexion of the head. . usually in the transverse position. is rotated about 45° to anteroposterior (AP) position under the symphysis. the presenting part is at 0 station. Mechanism of Labor The ability of the fetus to successfully negotiate the pelvis during labor involves changes in position of its head during its passage in labor. followed by the posterior shoulder and the rest of the fetus. the presenting part. The oxytocic agents augment uterine muscular contraction and the cord traction assists with rapid delivery of the placenta. the uterus makes its initial readjustment to the nonpregnant state. Upward resistance from the pelvic floor and the downward forces from the uterine contractions cause the occiput to extend and rotate around the symphysis. and the presenting diameter changes from occipitofrontal (11. The rate is greatest during the second stage of labor. This occurs intermittently with contractions. Internal rotation brings the AP diameter of the head in line with the AP diameter of the pelvic outlet. the base of the occiput comes in contact with the inferior margin of the pubic symphysis. The anterior shoulder is then rotated under the symphysis. returning to its original anatomic position in relation to the body. it untwists about 45° left or right. Stage 4. The primary goal is to prevent hemorrhage from the uterine atony and the cervical or vaginal lacerations. are described in relation to a vertex presentation.5 cm) for optimal passage through the pelvis. The chin is brought into contact with the fetal thorax.[2] Engagement The widest diameter of the presenting part (with a well-flexed head. as is the case in 95% of all pregnancies. Internal rotation As the head descends. The mechanisms of labor. Restitution and external rotation When the fetus' head is free of resistance. Although labor and delivery occurs in a continuous fashion. Descent The downward passage of the presenting part through the pelvis. Flexion As the fetal vertex descents.and controlled cord traction. Recovery Stage This begins with the delivery of the placenta and ends from one to four hours after birth. On the pelvic examination. the cardinal movements are described as 7 discrete sequences. further descent brings the anterior shoulder to the level of the pubic symphysis. also known as the cardinal movements.

As verbalized by the patient¶s daughter D. C. HISTORY OF PRESENT ILLNESS Prior to admission. cephalic floating. patient felt of giving birth at that time because of labor pain and uterine contraction that she was experience.5. She doesn¶t smoke and drink alcohol. Her first hospitalization is when she knows that she is pregnant. Uterine contraction ³Humihilab ang tiyan ko´. Address: 8. foods and environment. when she tells to her husband that she felt pain. PR: 90bpm. The patient doesn¶t have any allergies in medications. DEMOGRAPHIC DATA 1. 1 month after she was pregnant. Female 26 yrs old November 24. Labor pain Pain scale of 7/10 2. Gender: 3. beg. they decided to go to Ospital ng Muntinlupa. Eff positive bow. her childhood illnesses were common cough. She takes Ferrous sulfate. Educational Background: 9. 2011 at 3o¶clock am with vital sign of temp:36. SOURCE AND RELIABILITY OF INFORMATION The source of information was exactly the patient who is reliable and capable in giving data. colds and fever. CHIEF COMPLAINT 1. Birthday: 5. Occupation: 10. They made internal examination and the fetus is 1cm dilated. RR: 22cpm and BP:140/80 in the emergency room.G. Religion: 7. Client's Initial: 2. Civil Status: 6. We also gather information from the mother-in-law of the patient and from the chart of patient. She diagnose for having UTI when she had a regular check-up on April 2011. She also completed her vaccination with her 1 brother. that¶s the time she went to hospital. E. Muntinlupa City College Graduate Call Center agent Hospital B. vitamin C and antibiotics when the doctor prescribed it to her. According to the patient. . PAST MEDICAL HISTORY OF PAST HEALTH According to the patient. S. Age: 4. 1985 Married Christian Poblacion. She admitted on December 5. She didn¶t experienced any injuries or accidents. Usual source of Medical Care: Ms.A.

Baby C LEGEND: Female Baby Patient Male Ms S. X Mr. S. M (Husband) (Brother) Mr. G is the first child of Mrs. Y (Father) Ms. 26 years old Call center agent .G. According to Ms.F. Z (Mother) Mr. they had history hypertension. Z and Mr. FAMILY HISTORY Mrs. S. she quit on her job to take a rest and care for being pregnant.G. while on his father is diabetes mellitus G. Mr. SOCIO-ECONOMICS-INCOME According to the patient. she and her husband provides for the necessity of their starting family with the help of their family.G. But when she know that she is pregnant.S. Y. She belong in middle class. on history of mother side. is a call center agent while her husband. Ms. M is a sales representative. DEVELOPMENTAL HISTORY Ms.G. S. especially their parents. H.

Use leisure time creatively for her bonding and enjoyment.     Patient Started a new stage of life. parenting Decide with her partner about the things happen in their life. 20 to 40 years) Description The Intimacy vs. Address: Poblacion. I. The sense of trust provide the base on which the person will feel safe and secure to give affection and expect the same affection in return for the ultimate purpose of establishing a permanent intimate relationship. OB GYNE History Assessment of a Pregnant Woman Health History: Name: Ms.Theory Erik Erickson (Psychosocial Theory) Intimacy vs.2011 AOG Upon admission G1P0(0000) . S. Give time and effort for a family.G. 2011 EDC December 11. Isolation (Young Adults. Muntinlupa city Age: 26 years old Civil status: Married Religion: Christian Chief complaint: Labor pain and uterine contraction History of Present Condition: Menarche: 14 years old Length and duration of menstrual cycle: 5 days duration (regular) Reg cycle: 3 pads per day Obstetric History LMP March 4. Isolation stage of Young is the ability to form intimate relationship requires that the person has achieved the sense of trust.

Date of birth: December 5. Babinski patent .05kg Body length: 50cm Head circumference: 33cm Abdominal circumference: 28cm Hepatitis B vaccine ± right thigh 12-5-11 Apgar Scoring 12-5-11 Heart rate Respiratory effort Muscle tone Reflex irritability Color Total: Ballard 39weeks Maturity Activity Tone Cry Color Temperature Spine Reflexes Anus 1 min 2 2 2 2 1 9 5 min 2 2 2 2 1 9 Term good good good pinkish hypothermic no deformities positive moro. 2011 Time: 09:54 am Diagnosis: term male 39weeks delivery via NSD wt.05kg AGA Weight: 3. 3.Final diagnosis G1P1(1001) NEWBORN RECORD Name: Baby boy G.grasp.

II. y Her head is round and symmetrical. y Few pigmentation on face y No lesions and bruises seen Palpation: y Soft and smooth skin y Dry and warm to touch y Skin returns immediately to original position when it pinch y Her hands have slight edema. Inspection: y Hair distributed equally y Hair color is black y No parasite seen Inspection: y No clubbing of fingers Palpation: y capillary refill is normal from 2 seconds Inspection: y The patient¶s head is proportionate to the body size. General Physical Survey The patient is conscious and coherent but weak. Head . Integumentary Skin Hair Finger/Nail C.2011 Time: 6am-3pm shift Vital Signs: Temp: 36. During the interview and physical examination the patient had an eye to eye contact and he was cooperative. Inspection: y Color of skin is white but she¶s a bit pale than usual and lighter colored of palms and soles. REVIEW OF SYSTEM Procedure Done: December 5. B.5oC PR: 90 bpm RR: 22 cpm BP: 140/80 mmhg Weight: 140kg A. y (-) tenderness in the scalp.

Inspection: y Presence of pigmentation in some areas on her neck. Nose and sinuses G. Breast and Axillary J. Mouth and throat H. Palpation: y No enlarge gland and inflamed nodes palpated y Smooth. Respiratory y Symmetric facial movement Palpation: y No nodules and masses palpated Inspection: y Pupils are equal. Ears F. round and reactive to light and accommodation y Palpebral conjunctiva is shiny and pinkish in color y The pupil¶s shape is round and color black. Eyes E. Inspection: y Located symmetrically y Patient responds to medium voice stimulation y No discharge seen on both ears Palpation: y Firm and not tender Inspection: y Placed symmetric and straight y no discharge seen Palpation: y No tenderness of frontal sinus Inspection: y Complete teeth. Neck I. . Palpation: y warm to touch y no palpable mass and lesions Inspection: y The chest expansion is symmetrical.D. dry and dark lips with pinkish gums y The color of the hard and soft palate is pink and is intact. firm and not tender Inspection: y chest appearance is symmetrical y Areola is large and dark in color. y The eye brows are evenly distributed. y When percussed the sound is resonance.

Turbid URINARY TEST CHEMICAL Microscopic Pus Cells/Hpf: 6-10 RBC/Hpf: 2-5 . weakness Inspection: y The patient is conscious and cooperative but weak y Patient is alert. Urinary N.K. Laboratory results  PHYSICAL Color: light Yellow Reaction: 7. Inspection: y Presence of Striae gravidarum y Large due to fundus which 2 breaths away from the umbilical cord. Cardiovascular L. Auscultation: y There¶s pain upon palpation Inspection: y Urinates 8 times a day. Inspection: y Lochia is red y Patient still in pain Inspection: y Patient stand with assistant y Slow movement. Neurologic Palpation: y Symmetrically expanded on upper and lower tract when breathing upon palpated. Inspection: y Patient blood pressure is 130/80 mmhg y capillary refill is normal from 2 3seconds Auscultation: y Distinct sound heard when auscultated the heart y Rhythm is regular y Patient¶s heart rate is 82 bpm y PMI is located in the apical pulse. spontaneous and oriented III. Genitalia O. Gastrointestinal M.0 Transparency: SL. Musculoskeletal P. Auscultation: y When auscultated murmurs and crackles are absent.

She eliminates 8 times a day and defecates once a day but characteristics were not stated. She prefers to drink milk every morning. Prayers helped her to become strong. toileting. S. Health Perception ± Health management Pattern Ms. She prefers walking in the mall with her mother-in-law. She is just only practice sleeping late at night but she did things that are good for health.Specific Gravity: 1. grooming and general mobility. She tried to take a nap at least two hours in the afternoon. She stated that health is very important so she maintain for having no vices. phosphate: Moderate J. especially when they are going to mall. FUNCTIONAL ASSESSMENT 1. 4. Self-Concept / Self Perception Pattern According to Ms. They always go to church every Sunday and they love to be with God. she made decision by herself and her husband. She quit working in a call center when she knows that she is pregnant. dressing. Sleep / Rest Pattern Ms.010 Epithelial cells: Moderate Bacteria: few Mucus thread: Moderate Crystals A. she drink plenty of water and had a proper hygiene always. She drinks 8-10 glasses of water a day and takes vitamins.G. practiced sleeping late at night. it¶s also her exercise. She doesn¶t have allergies and has no preferences when it comes to food. Sexuality ± Reproductive Pattern . has a daily exercise by walking.G. had always taking care of herself by exercise and proper diet. S. 2. S. she had a good appetite for eating. There was no change in her appetite even after or before her pregnancy. Her urine and bowel elimination are good. She fears to have illness that she cares for herself and for her baby. The foods that she eat every day are fish and vegetables because it is rich in fiber and minerals. She usually had a bonding everyday by the people in their house. He does not use any sleeping pills. she quit on her job and she started walking. Nutritional / Elimination According to the patient.G. bathing. She eats healthy foods because she wanted to have a healthy baby. 5. She has full self-care in her ability for feeding. Self-Esteem. 6. 3. She stated that she follows doctors order by taking medications and have a good habit. S. According to her it¶s because of her work that she is a night shift time. When she got pregnant. When she was diagnose UTI. She eats three times a day plus having a midnight snack. Activity ± Exercise pattern Ms.G.

Their house is near the Puregold. S. Ms.G. S. 8. .G. But when she knows that she¶s pregnant. She had a good relationship with her husband. G stated that they live in Muntinlupa city. She and her husband support also their family in financial aside from their parents. She doesn¶t drink and smoke. S. 7.Ms. G is living in a house with his family and other relatives. menstruation started when she was 14 years old and it was usually last for 5 days and in moderate amount. Personal/ Social History Ms. Vehicles and cars pass in their street. She works as a call center agent. KFC and Red ribbon. she quit in her job to have a rest and taking herself for her baby. Environment History Ms. S. They are nine people in their house and composed of helper with her granddaughter. She goes to church every Sunday. is a simple person. Mercury. She focus to her family and be a good wife.

rubra first day. alternate use of each breast. take all the medication with exact time and dosage.  Apply hot and cold compress to promote healing  Advised patient to have adequate sleep and rest and y E ± Exercise Walking and deep breathing Kegels exercise at home y T .  Health teaching about lochia.Treatment Drug maintenance.  Strengthened the pubococcygeal muscles  Advised patient to take all the medications prescribed by the physician  Reduce stress and anxiety  Encourage environmental modification to enhance safety and prevent injury. Compliance y M .  Instructed patient to massage the breast and clean before breast feeding. DISCHARGE PLANNING Content 1.VII. y H ± Healthy teachings Adequate rest.  Encouraged patient to have exercise by exercise every morning.  advised her to comply with the orders of her doctor including all her medications.Medication Strategy Take home drugs for continue medication : Co-amoxiclav Mefenamic Acid Senokot tab Avoid lifting objects Prescribed dosage: 625mg BID for 7days 500mg TID OD for 5 days  Avoid lifting anything heavier than the baby for 3-4 weeks. serosa above 48 hours and alba for 1 week. Proper diet .

y O .2011 High in iron  Advised patient to have her regular check-up.  Instructed mother to clean the umbilicus with 70%alcohol and cotton. y D .Diet y S ± Signs and Symptoms Observe if complication happen 2. VIII. Follow up/Check-up ± Check-up. ONGOING APPRAISAL December 5. 1 week after discharge.  Instructed patient to eat green leafy vegetables and increased fluid intake. check for any changes happen in the body.OPD Follow up Check-up 1week after discharge December 13-14.2011 03:00am .  Instructed mother to change diaper of the baby as needed.  Advised mother to assess reflex and proper hygiene.  Advised the client how to have a healthy lifestyle.  Instructed mother to expose sunlight daily and don¶t apply manzanilla on baby¶s body  Instructed mother to burp baby after each only the foods that are indicated for her.  Encouraged patient to eat foods high in iron like meat and green leafy vegetables.patient admitted on emergency room .  Upon discharge.

.monitored vital sign every 4 hour . .Induction of anesthesia done 09:54am .procedure finished .Placed patient to lithotomy position .Hooked to O2 via nasal cannula 2-3lpm and D5LR + 10u oxy .Provided complete bed rest Instructed patient to increase fluid intake .5 0C *PR: 90 bpm *RR: 22 cpm *BP: 140/80 mmHg .positioned patient in comfortable position .patient was conscious and coherent .Initial vital sign taken and hooked to cardiac monitor.Monitored input and output .vaginal pack inserted .Procedure started .taken and recorded V/S as follows *T:36. .conscious but weak .Baby out 10:10am .gave medication Co-amoxiclav 625mg BID for 7days Mefenamic Acid 500mg TID Senokot tab OD for 5 days -provided interaction and communication -physical assessment to observe overall condition. .Instructed NPO .watch out for any bleeding -Transferred patient to DR table safely .2011 .provided breastfeeding to the baby .patient was lying on bed sleeping .Received patient 27 years old female with chief complaint of labor pain with pain scale of 7/10 and uterine contraction .on DAT diet .instructed mother to clean the umbilicus of the baby with 70%alcohol and cotton. -provide health teaching to the care was rendered -endorsed to private ward December 6.

-may go home -provided bed rest while waiting ..Advised mother to assess reflex and proper hygiene of the baby. Provided bonding between mother and the baby .Instructed mother to burp baby after each feeding.