I.

INTRODUCTION

A. BACKGROUND OF THE STUDY

Power, vitality and integrity, these values are already innate to women which makes them unique. They have the ability to reproduce. They are considered to be the child-bearers wherein they carry the baby for about 9 months. On that whole duration, they experience many changes and challenges that they have to surpass for the good of the baby. Being pregnant is the most brilliant and astounding thing that would come not only for the becoming-mother and father but also the people who surrounds them. It is a precious gift from God that should be treasured. Pregnancy is the carrying of one or more offspring, known as a fetus or embryo, inside the uterus of a female. It is the period of conception to birth. After the egg is fertilized by a sperm and then implanted in the lining of the uterus, it develops into the placenta and will become embryo, and later into a fetus. Pregnancy usually lasts 40 weeks, beginning from the first day of the womans last menstrual period, and is divided into three trimesters, each lasting three months. Human pregnancy is the most studied of all mammalian pregnancies. It is also part in this study on how human pregnancy is being delivered and one of its ways is NSVD or Normal Spontaneous Vaginal Delivery. NSVD occurs when a pregnant woman goes into labor without use of drugs or techniques to induce labor, and delivers her baby in the normal manner, without a cesarean section. In other words, it is the natural birth of a child, simply without the intervention of modern techniques devised by humans. Research shows that millions of women get pregnant in a year and most of these women choose NSVD process in giving birth. The importance of this study is much recognized since it would build up competence and enhance skills to the group in dealing such scenario again. Moreover, it was observed that perfect way to widen the groups knowledge in handling with this type of labor is to conduct a study to a postpartum mother who undergone NSVD process. Some women take pregnancy as a suffering. Maybe because it was an unwanted pregnancy or she was a rape victim. Usually these women resort to abortion. Fortunately, most women think pregnancy is a blessing from God though they will have to adapt the pregnant state for 9 months but still the pain and sufferings are worthy.

B. RATIONALE OF THE STUDY

GENERAL OBJECTIVE This study aims to broaden the knowledge of the researchers and readers and also to come up with a detailed study about postpartum and to identify, as well as to provide an appropriate, accurate and effective nursing measures and intervention and responsibilities to consider while taking care of the patient. SPECIFIC OBJECTIVE This study aims to: 1.Assess properly to determine the contributing factors regarding to the clients condition and identify any deviation from normal post partum process

2.Develop an individualized plan considering client characteristics or the situation and setting a specific, measurable, attainable, realistic and time bounded plan that reflect the onset, date of problem identified 3. Provide appropriate interventions for every problem encountered and monitor the client's response to treatment and therapies through means of physical assessment and communication with the client. 4.Broaden the knowledge of each member through further research about the latest news articles and journals regarding to the client disease.

C. SIGNIFICANCE OF THE STUDY

Nursing student: 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 the client who has undergone normal spontaneous delivery (NSD) and episiotomy procedure. To be able to design a nursing care plan for the patient who has undergone NSD and episiotomy procedure. To be able to facilitate the practice of the skills learned through lectures and discussions, thus enabling the student to be more familiar with the procedure and be able to perform proper techniques of rendering care and health teachings to the patient of post-partum period. To gain knowledge from the experience and apply.

Clinical instructor: Will be able to identify the students weaknesses and can able to focus on what aspects of the procedure must be discuss further so that the skill would be performed better. Patients Family: acquire knowledge about Normal Delivery, and the importance of taking care of a family especially the mother and the New born child.

D. Scope and Limitations

The scope of this study involves only the case of patient EF from the moment we received the patient

from the Delivery Room on Sept 02, 2011 in Rizal Provincial Hospital in Morong. Each day comprises of 8 hours of exposure at the ward until the time the patient was discharged from the hospital. Within these 2 days, the nursing student of group A3b tried to accomplish, attain and gather all information needed. Information was gathered through interview, Assessment of the patient and going through her chart.

E. Theoretical Framework

Reva Rubin Theory: Rubin introduced the concept of Maternal Role Attainment in the late nineteen sixties.(Rubin, 1967). She described the maternal role as a complex cognitive and social process which is learned, reciprocal, and interactive. Maternal identity is considered the culmination or end-point of MRA, characterized by the womans comfort in her role.

Rubins work focused on traditional mothers and dealt with MRA from the point of acceptance of the pregnancy to one month postpartum. RUBIN'S POSTPARTUM EMOTIONAL PHASE 1. Taking-in phase - Basic and primary needs of mothers are their own food, water, clothing, sleep. -Mother becomes attention seeker; she always talk about her experience during labor and delivery. The nurse should be a good listener in interpreting these events. -Not a good time for health teachings. 2. Taking-hold phase - Mother is sensitive in doing the "mothering" role right. - Mother is more in control of her emotions. - Best time for health teachings. 3. Letting-go phase - varied Mothers may grieve over the separation of the baby from her body. - May display dependent-independent behaviors where she wanted to feel secure while making decisions. -Time when post-partum blues may develop. -Time when bonding process is facilitated and parenting skills are enhanced . REVA RUBINS PHASES OF PUERPERIUM

Taking In Phase
The patient needs another person to attend her needs, She was clothed by her mother, She needs another person to assist her in moving like positioning herself in the bed. She tends to sleep after admitting in the OB ward.

Taking hold Phase

The patient breastfed her baby. Helping her mother when clothing the baby. The nurse suggest that it is best to clean first the nipples of the mother before breastfeeding her baby.

Letting- Go Phase The patient is

bonding with her baby, during breastfeeding. The mother accepted that her baby is now outside her body. She is attending the needs of her baby

---------

II.
A. Patient Profile

NURSING ASSESSMENT

Name: FE Address:Bagong Bayan Ext., Darangan, Binangonan Rizal Age: 22 Sex: Female Status: Single Occupation: None Educational Attainment: High School Ethnic Origin: Filipino Dialect/Language spoken: Tagalog Religion: Roman Catholic Chief complaint:Labor pains G2P2 LMP: December 4, 2010 EDC: September 2, 2011 AOG: 39-40 weeks

B. History of Past Illness

Upon interview patient was asked about her menstrual history, she told us that at the age of 13, she had her first menstrual period or menarche. Her menstrual cycle was regular, in her 28 day cycle and normally last for

5 days.

C. History of Present Illness

During the interview patient E.F told us that since September 2, 2011, she was experiencing on and off pain in her lower abdomen and she cant sleep because of the pain. Patient E.F was admitted in the OB ward with the chief complaint of labor. pains. Around 4:35 in the morning, the patient was brought to the delivery room because the bag of water has ruptured. She delivered to a live baby girl weighing 3.15 kg and (_______???)(length in cm) with statistics: Head circumference: 33 cm Chest circumference: 33 cm Abdominal circumference: 31 cm Patients placenta was expelled simultaneously by ________(time) with blood pressure of 120/70 mmHg. After her delivery, she was admitted to the OB ward with repaired episiotomy. Post partum doctors orders were as follows which was carried out:

DAT (diet as tolerated) VS: September 2, 2011 T = 36.8 C

PR=66bpm RR=20bpm BP=120/70 mmHg

D. Family Health History

No records of past illness and hospitalization on both maternal and paternal side.

E. Physical Assessment

Physical examination follows a methodical head to toe format in the Cephalocaudal assessment. This is done systematically using the techniques of inspection, palpation, percussion and auscultation with the use of materials and investments such as the penlight, thermometer, sphygmomanometer, tape measure and stethoscope and also the senses. During the procedure, I made every effort to recognize and respect the patients feelings as well as to provide comfort measures and follow appropriate safety precautions.

BODY PART

ASSESSMENT TECHNIQUE Inspection Palpation

NORMAL FINDINGS Fair complexion, absence of scars &lesion Good skin turgor.

ACTUAL FINDINGS Normally brown in color, no areas of increased vascularity. Not too dry with minimum perspiration and slightly cooler in temperature than the rest of the body. There is a presence of lineanegra in the center of abdomen vertically. No lice and nits. Intact. No lumps and lesions. Evenly disturbed black hair,smooth in texture & shiny. Symmetrical face movement,symmetricalna sobial folds 20/20 vision,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 Hair evenly disturbed with skin intact,present bilaterally, symmetrical and without lesions and scaling. Skin intact,symmetrical and no infectious and tumors upon inspection and can raise both symmetrically Same color as facial skin,symmetrical. Auricle with outer canthus of eyes about 10 degree of vertical,mobile firm and not tender,free from lesions. No voice tone audible & able to understand spoken words. With nasal package (merocel) Proportional and symmetrical with face. Pink in color,smooth,no lesions.

ANALYS IS NORMA L

1.Skin

Inspection 2.Scalp Palpation Inspection 3.Hair

No lice & nits. No lumps and lesions. Evenly distributed hair,color varies mostly in black. Smooth in texture & shiny.

NORMA L NORMA L

4.Face 5.Eyes

Palpation Inspection Inspection

Symmetrical face movement,symmetricalnasolabial folds 20/20 vision,roundcornea,blackcolor;whitescler a.Reacts to light &accommodation.

NORMA L NORMA L

Inspection 6.Eyebrow Inspection 7.Eyelids Inspection Palpation

Hair evenly disturbed with skin intact,symmetrically aligned with equal movement Skin intact,nodischarge,nodiscoloration.lids able to close symmetrically Same color as facial skin,symmetrical. Auricle with outer canthus of eyes about 10 degree of vertical,mobile firm and not tender,free from lesions.

NORMA L

NORMA L

NORMA L

8.Ears

9.Hearing acuity 10.Nose 11.Mouth 12.Lips

Inspection Inspection Inspection Inspection

No voice tone audible & able to understand spoken words. Midline & symmetrical to face,nolesions,no nasal discharges or flaring uniform in color,air moves freely. Proportional and symmetrical with face. Pink in color,smooth,no lesions.

NORMA L

NORMA L NORMA L

13.Teeth 14.Tongue

Inspection Inspection

Complete without dentures. Toungue floor is in central position,pink in color,moist,no lesions or swelling. Symmetrical during lung expansion & recoil. No lesions and abnormal grating sound.

Inspection Palpation Percussion 15.Chest Auscultation

Complete without dentures. Toungue floor is in central position,pink in color,moist,no lesions or swelling. Symmetrical during lung expansion & recoil. No lesions and abnormal grating sound. Resonance. No abnormal breath sounds. Breast slightly engorged with colostrums ????????? Normal rate,rhythm,no murmur. No lesions,masses& tenderness. No abdominal bowel sounds. Tympany. Presence of Striae of pregnancy and Linea Nigra Fundus is at the level of the umbilicus Uterus is firm and contracted With laceration Perineal suture intact Moderate lochia rubra No erythema,, ecchymosis, or Edema Symmetrical to the body & no lesions. No tenderness,no palpable mass noted.palpable brachial & radial pulse. Able to move freely without discomfort;able to adduct,abduct,flex and extend. Pink in colorhand,no lesions. Nails are clean. Pink nail beds. Pink nail beds with capillary refill of 2 seconds Pink nail beds with capillary refill of 2 seconds.

NORMA L NORMA L NORMA L

Resonance. No abnormal breath sounds.

16.Heart 17.Abdome n

Auscultation Inspection Auscultation Percussion Palpation

Normal rate,rhythm,no murmur. No lesions,masses& tenderness. No abdominal bowel sounds. Tympany. No lesions,masses or tenderness

NORMA L NORMA L

18 perineum

????????????

???????????????????

Inspection Palpation 19. Upper extremities Inspection on abduction,adduction,fle xion, Extension. Inspection Inspection Inspection Inspection 22.Toenails

Symmetrical to the body & no lesions. No tenderness,no palpable mass noted.palpable brachial & radial pulse. Able to move freely without discomfort;able to adduct,abduct,flex and extend.

NORMA L

19.Palms 20.Fingerna ils 21.Lower extremities

Pink in colorhand,no lesions. Nails are clean. Pink nail beds. Pink nail beds with capillary refill of 1-3 seconds. Pink nail beds with capillary refill of 1-3 seconds

NORMA L NORMA L NORMA L NORMA L

A. Gordons 11 Functional Health Assessment

FUNCTION

BEFORE HOSPITALIZATION

DURING HOSPITALIZATION * Still eats whatever she likes

INTERPRETATION

Nutrition

* Eats 3x a day *she loves to eat processed food like hotdog, itlog, longanisa anything fried but makes sure in the afternoon she'll cook meal that has vegetable in it.

* The doctor ordered DAT diet to the patient

* Drinks water a lot Elimination * She is able to urinate normally by herself

* Drinks lots of fluid * She expressed pain when voiding

* For rehydration * Pain related to her repaired laceration

* Deficates irregularly

* She was able to deficate with assistance

Sleeping

* Has a regular sleeping pattern

* Disturbed sleeping pattern

* Due to adherence to time of medication, vital signs monitoring and nurturing of her newborn

Cognitive-Perceptual Pattern

* Has a normal cognitive perception

* She is responsive & can communicate well

* Portraying Cooperativeness

* Can comprehend well * She responds appropiately to verbal and physical stimuli

Self- Perception Self-Concept

* Perceived herself as a good friend, mom and daughter

* Still thinks she is the same person and nothing has changed

* Due to her ability to establish good relationship with Family and friends

F. Laboratory Diagnosis

Date Ordered 09-02-11

Diagnostic Exam Hematology Hematocrit Hemoglobin WBC Segmenters Lymphocyte

Normal values

Result

Significance

0.35 0.50 vol % 0.60 g/L 5.20 x 10 /L 0.40 0.60 0.20 0.10

1.22 vol % .32 g/L 10. 0 x 10/L . 80 1.5

Normal???????? Normal????????? Normal??????????? Normal?????????? Normal??????????

Blood Type RH Typing

A , B,O and AB (+) or (-)

A (+) - positive

III. ANATOMY AND PHYSIOLOGY NORMAL NON PREGNANT REPRODUCTIVE ORGANS

A. Female Reproductive Organs

1. Uterus

Normal - The average adult uterus is about 3 inches long, 2 inches wide, and 1 inch thick.

Pregnant- A 6-week uterus is compared with an egg, and 8-week uterus measures approximately the size of a small orange, then a large one at week 10,

- It functions to nourish and house the fertilized egg until the unborn child or offspring is ready to be delivered.

2. Ovaries Normal - The normal size of ovaries in cm is about 3 cm x 1.5 cm x 1.5 cm. Pregnant - Ovary size during pregnancy normally increases.

- The ovaries are the main source of female hormones, which control the development of female characteristics such as breast, body shape and body hair. They also regulate the menstrual cycle and pregnancy.

3. Cervix Normal The normal size of the cervix measures 7 to 8 mm at its widest in reproductive-aged women. Pregnant- its opening now widens to 10 centimeters to allow the babys head to pass through to the vagina.

- During menstruation the cervix stretches open slightly to allow the endometrium to be shed. This stretching is believed to be part of the cramping pain that many women experience. Evidence for this is given by the fact that some women's cramps subside or disappear after their first vaginal birth because the cervical opening has widened. During childbirth, contractions of the uterus will dilate the cervix up to 10 cm in diameter to allow the child to pass through.

4.

Vagina Normal - It is about 2.5 cm wide and 7 cm to 9cm long Pregnant It has a great capacity to distend for childbirth.

- The vagina serves as conduit for menstrual flow from the uterus. During childbirth, the baby passes through the veagina.

5. Urethra Normal The size of the female urethra is about 3.8 to 5 cm long.

Pregnant The size of the urethra do not increase or decrease when in pregnant state.

- The urethra is the opening that allows the urine to be discharged from the urinary bladder.

6. Fallopian Tube Normal - Each tube is about 10cms long. The width varies at different parts along the length, being more towards the ovarian side and thinner but more muscular towards the uterine side. Pregnancy Theres no changes in the size during pregnancy.

- The fallopian tubes play an integral role in ovulation and conception. Without the fallopian tubes, the egg cannot become fertilized and an embryo cannot reach the uterus for implantation. 7. Hymen - Thin membrane which completely or partially occludes the vaginal opening. The hymen is a fold mucous usually present at birth at the orifice the vagina.

8. Labia Majora - Labia Majora can range in size and shape from long and thin to short and thick. This typically varies from woman to woman. - The Labia Majora refers to the two large outer folds which cover a womans labia minora.

9. Labia Minora - The Labia Minoraprotects the inner mucous membrane and close off the vaginal entrance.

B. Fetal Development : Full Term

The First Two Months In the first three weeks of pregnancy, the fertilized egg burrows into the lining of the uterus, also known as implantation. Within 30 days, all organs will start developing. During the second month, the heart will start beating, facial features will begin to form, and extremities will form.

Third Month During this month, the heart starts developing valves, and teeth start to form. It is considered a fetus starting at 11 weeks. It will start moving, and developing reflexes.

Fourth and Fifth Months During the fourth month, It will start producing urine and sensing light. In the fifth, the skeleton will harden, genitals become visible, senses develop, and she is producing meconium, her first bowel movement.

Sixth and Seventh Months Eyebrows and eyelids develop in the sixth month as well as her pancreas. In the seventh month, her skin becomes more smooth, nerves in the ears grow more sensitive, and she sleeps on a more regular schedule.

Eighth and Ninth Months In the eighth month, the head grows larger to accommodate her growing brain and she gains nearly a half a pound a week. In the ninth month, her nervous system and lungs grow stronger, and she will shed much of the

hair on her body. The Last Weeks A pregnancy is full-term at 37 weeks, but you may not deliver until 41 weeks. During this time, your baby continues to put on weight.

C. Uterine Involution

- The process by which the uterus and other genital organs return to their normal pre-pregnant state in the post partum period after delivery of the fetus is called involution. -The gradual decrease in size of the uterus during involution occurs due yo a decrease in size but not decrease in rthe number of uterine muscle. - The uterus which weighs about 900 grams at the end of labor, weighs only about 60 grams at the end of the postpartum period, 6 weeks after childbirth.

IV. DRUG STUDY

DATE ORDERED 9/2/11 MEDICATION, , ROUTE DOSE, FREQUENCY Amoxicillin 500mg 1cap PO BID for 7 days ACTION INDICATION NURSING CONSIDERATION Urinalysis Be alert for superinfection: increased fever, sore throat, vomiting, diarrhea, black/hairy tongue, ulceration, or changes of oral mucosa, anal/genital pruritus Question history of allergies, especially penicillin and cephalosporin. Store capsules, tablets at room temperature. 9/2/11 Mefenamic Acid 50mg 1cap P0 q 6 hr as needed, the analgesic efficacy of mefenamic acid is documented for inflammatory and noninflammatory pain. Its use for acute pain is well known: pain after dental interventions or after traumas are significantly reduced with mefenamic acid.. Whether mefenamic acid should be used for other acute pain or fever is controversial as there are other better tolerated Relief of moderate pain when therapy will not exceed 1 wk do not exceed 1 wk of therepy Pregnancy, lactation, allergies. Skin color and lesion, orientation. Nonsteroidal antiinflammatory drugs (including mefenamic acid)

Bactericidal; Inhibits synthesis of cell wall of sensitive organisms, causing cell death (drug classification) antibiotic

in pregnancy; Amoxicillin is used for the treatment of skin or skin structure infections;.

analgesics (e.g. paracetamol). (drug classification) NSAID

may rarely increase the risk for a (sometimes fatal) heart attack or stroke. This effect does not apply to low-dose aspirin Intervention; Be aware that patient may be at increased risk CV events, GI bleeding; monitor accordingly.

Methylergonovinemaler ate/ IM May be repeated every 2-4 hr IV Infuse slowly over at least 60 sec.

Methergine (methylergonovin e maleate) is a semi-synthetic ergot alkaloid used for the prevention and control of postpartum hemorrhage. (drug classification) OXYTOCIC

Metheregine tab. TID

For routine management after delivery of the placenta; postpartum atony and hemorrhage; subinvolution. Under full obstetric supervision, it may be given in the second stage of labor following delivery of the anterior shoulder.

Vaginal bleeding Intervention; administer by IM injection or orally unless emergency require IV use. Monitor postpartum woman for BP changes and amount and character of vaginal bleeding This drug should not be administered I.V. routinely because of the possibility of inducing sudden hypertensive and cerebrovascular accidents. If I.V. administration is considered essential as a lifesaving measure, Methergine (methylergonovine maleate) should be given slowly over a period of no less than 60 seconds with careful monitoring of blood pressure. Intraarterial or periarterial injection should be strictly avoided. Do not use in patients hypersensitive to

9/2/11

9/2/11

Ferrous sulphate 1 Cap BID PO

Most of the iron in the body is present as haemoglobin. The remainder is present in the

Iron-deficiency anaemia.

storage forms femitin or haemosiderin, in the reticuloendothelial system or as myoglobin with smaller amounts occurring in haem-containing enzymes or in plasma bound to transferrin.

any of the ingredients in the formulation. Must not be used in anaemias other than those due to iron deficiency. Iron preparations are contraindicated: - in patients with haemochromatosis, paroxysmal nocturnal haemoglobinuria and haemosiderosis - in patients receiving repeated blood transfusions. - when used concomitantly with parental iron therapy

V.
M- Medication taken Amoxicillin500mg 1cap TID Mefenamic Acid50mg 1cap/day

`DISCHARGE PLANNING

Methylergonovinemalerate/ Metheregine tab. TID Ferrous sulphate1 Cap BID

Instruct the client about the way of taking her medicines. Explain the proper measurement and time of intake. E- Exercise Encourage the client to do some exercise every morning such as simple walking. T-Treatments Advice the client not to engage in any house chores that might jeopardize her health. H- Health teaching Encourage and explain the importance of breast feeding to the client especially the first milk, colostrums, 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. O- Out-patient follow up Instruct the client to go back for the follow up checkups. D-Diet Advise 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. S-Spiritual Encourage the client to attend a mass every day and just believe in God, because it may help them to cope in a new situation in their lives.

CARE MANAGEMENT AFTER DELIVERY

First 1-2 hours recovery period every 15 minutes v/s, fundal assessment, & amount of bleeding Once taken to the PP unit baseline assessment assessment of clients level of knowledge & continuation of teaching as applicable

PROMOTING COMFORT

Sit on a pillow Use an ice pack Moist or dry heat Topical applications may be ordered Cleanse perineum with a squeeze bottle warm showers, sitz baths, skill 13-4

PP EXERCISES

TIGHTENING BUTTOCKSAVOIDS DIRECT TRAUMA TO PERINEUM KEGEL EXERCISESPERINEAL TIGHTENING, PROMOTES HEALING PELVIC TILT-RELIEVES STRAIN ON LOWER BACK, STRENGTHENS BACK MUSCLES

AMBULATION

REDUCES RISK OF INFECTION OR THROMBOSIS LESSENS CHANCE OF RESPIRATORY, CIRCULATORY, AND URINARY PROBLEMS LESSENS CONSTIPATION PROMOTES RETURN OF STRENGTH

NUTRITIONAL STATUS

THREE WELL-BALANCED MEALS QD HIGH FIBER DIET INCREASE CALORIES BY 500 PER DAY IF BREASTFEEDING INCREASE FLUIDS, MILK SUPPLY AVOID GAS-FORMING FOODS

PARENT-INFANT ATTACHMENT

FAST FOCUS13-2 CUDDLES INFANT MAKES EYE CONTACT SPEAKS & SINGS TO INFANT ADMIRES INFANT, CALLS BY NAME STROKES AND MASSAGES INFANT

SIBLING PREPARATION FOR BABY

ENCOURAGE TO FEEL FETUS MOVE TAKE ON PRENATAL VISIT INCREASE INVOLVEMENT OF FATHER WITH THE CHILD GIVE A GIFT TO CHILD WHEN BABY COMES HOME