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TABLE OF CONTENTS

I. Introduction

II. Patient’s Profile

III. Physiology of labor

A. Stages of labor

B. Mechanisms of labor

IV. Ideal Nursing Interventions
A. Antepartal period
B. Intrapartal period
C. Postpartal period
D. Newborn Care
V. Actual Nursing Interventions
A. Antepartal Period
B. Intrapartal Period
C. Postpartal period
VI. Summary
VII. Referral
VIII. Bibliography
INTRODUCTION

Having children is essential to the survival of the human species. It can also be a
joyful, emotionally powerful experience. No other experience carries quite the cultural
and personal importance that having a baby does, and it is an experience that humans
have shared since the beginning of time.

The way a child is conceived and born is, essentially, the same as it ever was: A
sperm and an egg meet, and a fetus develops in the mother’s uterus and a baby is born
approximately nine months later. Yet today there are many positive changes in social
attitudes, medical standards, and parenting methods that make rearing children a vastly
different experience from what it was a few generations ago.

Pregnancy brings both psychological and physical changes to a woman and her
partner. Clients are often interested in the changes pregnancy brings, because these
changes verify the reality and mark the progress of pregnancy.

The physiologic changes of pregnancy occur gradually but eventually affect all
organ system of the woman‘s body. Psychological changes occur in response not only to
the physiologic alterations that are occurring but also to the increased responsibility
associated with welcome a new and completely dependent person to the family. The
changes occur in order for the woman to provide oxygen and nutrients for the growing
fetus as well as extra nutrients for her own increased metabolism during the pregnancy.
They ready her body for labor and birth

Despite the magnitude of some of these changes, it cannot be stressed
enough that they are extensions of normal physiology. This means that
pregnancy represents wellness, not illness. Because of this, the major
responsibility of the nurse caring for the pregnant woman and family is to help
the. family maintain a state of wellness throughout the pregnancy and into early
parenthood.

PATIENT’S PROFILE

PERSONAL BACKGROUND

My Client is Mrs. x, 20 years of age and a resident of x. Her birthday

falls every May and was born in the year x and a Roman Catholic. She has 4

siblings and was the 4th daughter of Mr. and Mrs. x. Her partners Name is

x, they’ve been together for 10 years but they did not get married.

She was not able to go to school because of poverty. She also has no

working experiences.

x stands 5’3” and weighs 60 kgs. Vital signs were taken during my first

visit which will serve as our baseline data on our study. Results are as

follows:

TEMPERATURE : 36.8 oC

PULSE : 71 bpm

BP : 120/70 mmHg

RESPIRATION : 22 cpm
PAST HEALTH
HISTORY

We might say that x is healthy woman because she didn’t encounter

any serious illnesses. Just like other people, Ritchel only encounters the

common minor illnessnes like for example cough, flu and fever.
HISTORY OF
PREGNANCY

This is the third pregnancy of

Ritchel with no history of miscarriage and

abortion (G3P3). She experienced nausea and vomiting and absence of menstruation.

Her last menstrual period was May 10, 2005 and she only had her prenatal check-up

after she was 7 months pregnant, on December 7, 2005 and on a monthly basis

thereafter, she visited the center. However she was only vaccinated twice on

tetanus toxoid (TT2)

Her nutritional intake was quite normal. Ferrous Sulfate was the only

vitamins that she has taken. She made it a habit to exercise every morning like a

simple walking at their area. As she was told, exercise during pregnancy is

important to prevent circulatory status in the lower extremities. It also offered

her a general feeling of well-being. Her expected date of confinement as per

record was February 17 2006 but she was confined on February 13, 2006.

.
PHYSIOLOGY OF
LABOR

Labor is an event that follows pregnancy and is considered as the climax of the
entire maternity cycle. During the nine months of gestation certain physiologic and
psychological adaptations gradually have taken place in the pregnant woman, and
simultaneously the growth and the development of the fetus have progressed toward
maturity in preparation for the transition from intra-uterine to extra-uterine life.

By definition, labor refers to the series of processes by which the products of
conception are expelled from the mother’s body. The exact mechanism that initiates
labor is unknown. But there are theories in labor, uterus becomes stretched and
pressure increases, causing physiologic changes that initiate labor, it is known as uterine
stretch theory. As pregnancy progresses, there is a gradual rise in the amount of
circulating oxytocin. As pregnancy advances, progesterone is less effective in controlling
rhythmic uterine contractions that normally occur. There also may be an actual decrease
in the amount of circulating progesterone. There is increased production of prostaglandin
by fetal membranes and uterine dicidua as pregnancy advances. In later pregnancy, the
fetus produces increased levels of cortisol that inhibit progesterone production from the
placenta.
Successful labor and delivery depend on adequate pelvic dimension wherein
there is adequate pelvic inlet or pelvic are in normal shape. Adequate midpelvis, ischial
spines do not protrude into bony canal, adequate outlet and adequacy of pelvic
dimensions determined by pelvic examination during pregnancy and again with the
onset of labor. Another factor affecting labor is the fetal dimension. Important fetal
dimensions influenced by fetal size, posture, lie, and presentation. Fetal position is also
important factor of successful labor. Successful labor also depends on uterine
contractions occurring at regular intervals and having adequate intensity. Uterine
contractions are involuntary. During uterine contractions, the active upper portion of the
uterus becomes thicker, while the lower uterine segment stretches and becomes thinner.
At the completion of a contraction, the upper uterine segment retains its shortened,
thickened cell size and with each succeeding contraction becomes thicker and shorter.
Cells of the lower uterine segment become thinner and longer with each contraction.
This mechanism is greatly responsible for the progress of the fetus through the birth
canal.
Before the real labor onset starts, a number of changes would indicate that the
time of labor is approaching. Lightening, is one of the preliminary events of labor, it is the
settling of the fetus in the lower uterine segment. It occurs 2-3 weeks before term in the
primigravida and later, during labor, in the multigravida. Breathing becomes easier as
the fetus falls away from the diaphragm. Lordosis of the spine is increased as the fetus
enters the pelvis and falls forward. Walking may become more difficult; leg cramping
may increase. Urinary frequency occurs because of pressure on the bladder. Vaginal
secretion may increase. Mucous plug is discharged from the cervix along with the small
amount of blood from surrounding capillaries referred to as “show” or “bloody show”.
Cervix become soft and effaced, membranes may rupture occasionally; rupture of the
membranes is the first indication of approaching labor. False labor contraction may
occur. False contractions may begin as early as 3 or 4 weeks before the termination of
pregnancy. They are merely an exaggeration of the intermittent uterine contractions,
which have occurred throughout the entire period of gestation but are now accompanied
by discomfort. They occur at decidedly irregular intervals, are confined chiefly to the
lower part of the abdomen and the groin and do not increase in intensity, frequency and
duration. The discomfort rarely is intensified if the mother walks about and may even be
relieved if she is on her feet. Internal examination will reveal no changes in the cervix.
The signs of true labor present a contrasting picture. True labor contractions usually are
felt in the lower back to the front of the abdomen. These contractions have definite
rhythm and gradually increase in frequency, intensity and duration. In the course of a
few hours of true labor contractions a progressive effacement and dilatation of the cervix
would be apparent. A sudden weight loss of about 1-3 lbs and sudden burst of energy is
experienced by some woman. There may be increased intense of backache.

The process of labor is divided, for convenience of description, into 4 distinct
stages. The first stage of labor is known as the dilating stage which begins with the first
true labor contraction and ends with the complete dilatation of the cervix. This stage can
further be classified into 3 phases namely the latent, active and the transitional phase.
During the latent phase the contractions are short, slight, about 10 to 15 minutes
or more apart and may not cause the patient any particular discomforts. She may be
walking about and between contractions comfortably. Contractions are generally mild
and she may experience back pain. There is cervical dilatation of about 1 to 3 cm. The
second phase then follows characterized by moderate contractions that sweeps from the
back to the anterior abdomen. Contractions recur at shortening intervals every 3 to 5
minutes, and become stronger and last longer. Cervical dilatation is about 3 to 7 cm. The
third phase then sets in where there is intense pain accompanied by a complete
dilatation of the cervix that is from 7 to 10 cm.

As a result of the uterine contractions, two important changes are wrought during
the first stage of labor. These are effacement and dilatation of the cervix.

Effacement is the shortening of the cervical canal from a structure 1 or 2 cm in
length to one in which no canal at all exist. It can simply be defined as the thinning of the
cervix. Dilatation of the cervix on the other hand meant an enlargement of the external
os from an orifice a few millimeters in size to an aperture large enough to permit the
passage of the fetus that is to the diameter of 10 cm.

By the time complete cervical dilatation is accomplished, the second stage of
labor then sets in. This stage is also known as the stage of expulsion that begins with
the complete dilatation of the cervix and ends with the delivery of the baby. Contractions
are now severe and long, lasting 50 to 70 seconds and occurring at the intervals of 2 to
3 minutes. Rupture of the membranes usually occurs during the early part of this stage
of labor by a gush of amniotic fluid from the vagina. During this stage, the muscles of the
abdomen come into play and when the contractions are in progress the patient will
strain, or “bear down”, with all her strength so that her face becomes flushed and the
large vessels in her neck are distended. Contractions now occur very rapidly, with
scarcely any interval between. At this time “crowning” may occur as the fetal head
travels down and encircles around the vulva. During this stage two forces are essentials,
namely, uterine contractions and intra-abdominal pressure.

In its passage through the birth canal, the presenting part of the fetus undergoes
certain positional changes that constitute the 7 mechanisms of labor. It begins with
engagement when the biparietal diameter of the infant’s head is within the pelvic inlet
and is no longer movable. The first requisite for the birth of the infant is descent. This
refers to the downward movement of the fetus that occurs throughout the labor process.
Very early in the process of descent the head becomes so flexed that the chin is in
contact with the sternum and the very smallest anteroposterior diameter is presented to
the pelvis. This mechanism is known as the flexion. When it reaches the pelvic floor, the
occiput is rotated internally and comes to lie beneath the symphysis pubis. After the
occiput emerges from the pelvis, the nape of the neck becomes arrested beneath the
pubic arch and acts as a pivotal point for the rest of the head. Extension of the head
ensues, and with it the frontal portion of the head, the face and the chin are born. After
the birth of the head, it remains in the anteroposterior position only a very short time and
shortly will be seen to turn to one or another side of its own accord termed as restitution
or the external rotation. After delivery of the infants head and internal rotation of the
shoulders, the anterior shoulder rest beneath the symphysis pubis. The posterior
shoulder is born, followed by the anterior shoulder and the rest of the body. This phase
is termed as expulsion.

Stages of Childbirth

Prelabor is a period of irregular uterine contractions in which the cervix thins, softens, and may begin to
dilate. As the first stage of labor itself begins (top, left), the uterus contracts strongly and regularly. The
cervix (center) dilates with each contraction, and the baby’s head rotates to fit through the mother’s
pelvis. In the second stage (right) the mother pushes, or bears down, in response to pressure against
her pelvic muscles. The crown of the baby’s head becomes visible in the widened birth canal. As the
head emerges entirely (bottom, left and center) the physician turns the baby’s shoulders, which emerge
one at a time with the next contractions. The rest of the body then slides out relatively easily, and the
umbilical cord is sealed and cut. The third stage (right) occurs within ten minutes of the baby’s birth. The
uterus continues to contract, expelling the severed umbilical cord and placenta.
The third stage of labor is known as the placental stage that begins with the
delivery of the baby and terminates with the birth of the placenta. This stage is made up
of 2 phases, namely, the phase of placental separation and the phase of placental
expulsion.

Immediately after the delivery of the baby, the remainder of the amniotic fluid escapes,

after which there is usually a slight flow of blood. The uterus can be felt as a firm globular mass

just below the umbilicus. Shortly thereafter, the uterus relaxes and assumes a discoid shape. With

each subsequent contraction or relaxation the uterus changes from globular to discoid in shape

until the placenta has separated, after which time the globular shape persists. The 3 signs that

suggest that the placenta has separated are: (1) the uterus becomes globular in shape or the

Calkin’s sign, (2) lengthening of the umbilical cord, and (3) sudden gushing of blood.

Extrusion of the placenta then follows after the above signs are manifested. It
may take place by one of the 2 mechanisms. The Schultze’s mechanism refers to the
glistening or the fetal surface and the Duncan’s mechanism that is said to be the
maternal surface and commonly known as the rough and dirty part.

An hour following placental delivery is classified as the stage of post-partum.
This is the fourth stage of labor. During this stage physiological restoration of the
reproductive organs to its normal state starts to take place.
Home Visit and Assessment
IDEAL NURSING
MANAGEMENT

Trimesters of Pregnancy

The 40 weeks of pregnancy are divided into three trimesters. The developing
baby is called an embryo for the first 8 weeks, after which it is called a fetus. All of its
major organs develop in the first trimester. In the mother, nausea and vomiting are
common, especially in the morning. The breasts may enlarge and become tender, and
weight begins to increase. The second trimester fetus is obviously human and grows
quickly. The mother’s pregnancy is noticeable both externally and internally, as she can
feel the fetus moving. Her heart rate and blood pressure increase to accommodate the
needs of the fetus. In the third trimester, the fetal organs mature. Most babies born
prematurely at the beginning of the third trimester survive, and their chances increase
dramatically with each week in the womb. The pregnant woman finds herself easily hot
and uncomfortable by this point, and sleep, while even more important now, may be
difficult.

Throughout the entire pregnancy cycle several alterations in the woman’s body
can be observed that is one of the factors that bring about discomforts and
complications. The cycle is consists of 4 stages namely the antepartal stage, which is
divided into 3 trimesters, the intrapartal stage with its 4 phases, postpartum and the
immediate newborn care.

THE ANTEPARTAL STAGE

FIRST TRIMESTER
1. Breast changes, new sensations: pain, tingling
a. Wear supportive maternity brassiere with pads to absorb discharge may
be worn at night, wash with warm water and keep dry.
2. Urgency and frequency of urination
a. Encourage woman to do Kegel’s exercises.
b. Encourage to void before going to bed.
c. Encourage to void after meals.
d. Instruct the woman to limit fluid intake in the evening.
e. Provide reassurance that this is just a normal process.
f. Wear perineal pad.
g. Refer to physician for pain or burning sensation.
3. Languor and malaise; fatigue (early pregnancy usually)
a. Provide reassurance.
b. Rest as needed.
c. Well-balanced diet to prevent anemia.
4. Nausea and vomiting, “morning sickness”
a. Encourage the woman to eat low-fat protein foods and dry carbohydrates,
such as toast and crackers.
b. Encourage the woman to eat small, frequent meals.
c. Instruct the woman to avoid brushing her teeth soon after eating.
d. Instruct her to get out of bed slowly.
e. Encourage to drink soups and liquids between meals to avoid stomach
distention.
f. Instruct the woman in the use of antacids; caution against the use of
sodium bicarbonate because it results in the absorption of excess sodium
and fluid retention.
g. Teach her the importance of good nutrition for herself and her fetus.
Review the basic food groups with appropriate daily servings.
h. Advice to limit the use of caffeine.
i. Avoid empty or overloaded stomach.
j. Maintain good posture – give stomach ample room.
k. Stop smoking.
l. Avoid fried, odorous, spicy, greasy, or gas-forming foods.
m. Consult physician if intractable vomiting occurs.
5. Ptyalism – may occur starting 2 to 3 weeks after first missed period
Use of astringent mouthwash, chewing gum, support.
6. Psychological dynamics – mood swings, mixed feelings
a. Treatment same as prevention.
b. Both partners need reassurance and support.
c. Support significant other who can reassure woman about her
attractiveness, etc.
d. Improved communication with her partner, family, and others.

SECOND TRIMESTER
1. Pigmentation deepens (striae gravidarum, chloasma, linea nigra, finger nails,
hair, nipples and areolae); acne, oily skin
a. Not preventable.
b. Usually resolved during puerperium.
c. Reassurance given to women and their families about these
manifestations of pregnant state.
2. Spider nevi – appear during trimesters 2 or 3 over neck, thorax, face, and arms
a. Not preventable.
b. Reassurance that they fade slowly during late puerperium.
c. Rarely disappear completely.
3. Palmar erythema occurs in 50% of pregnant women; may accompany spider
nevi
a. Not preventable.
b. Reassurance that condition will fade within 1 week after giving birth.
4. Pruritus (itching)
a. Keep fingernails short and clean.
b. Not preventable; symptomatic: Keri baths; mild sedation.
c. Distraction; tepid baths with sodium bicarbonate or oatmeal added to
water; lotions and oils; change of soaps or reduction in use of soap;
loose clothing.
5. Supine hypotension
a. Side-lying position or semi-sitting posture, with knees slightly flexed.

6. Faintness and, rarely, syncope: may persist throughout pregnancy
a. Moderate exercise, deep breathing, and vigorous leg movement.
b. Avoid sudden change in position and warm crowded areas.
c. Move slowly and deliberately.
d. Keep environment cool.
e. Sit down as necessary.
7. Food cravings
a. Satisfy craving unless it interferes with well-balanced diet
8. Heartburn
a. Limit or avoid gas-forming or fatty foods and large meals.
b. Maintain good posture.
c. Keep torso upright.
d. Bend down at knees to reach below the waist.
e. Sips of milk, hot tea, chewing gum for temporary relief.
9. Constipation
a. Instruct the woman to increase fluid intake to at least eight glasses of
water a day. One to two quarts of fluid a day is desirable.
b. Teach the woman that food high in fiber should be eaten daily.
c. Encourage to establish regalar patterns of elimination.
d. Encourage daily exercise, such as walking.
e. Inform her that over-the-counter laxatives should be avoided and that
bulk-forming agent may be prescribed if indicated.
10. Flatulence with bloating and belching
a. Chew solid foods slowly and thoroughly.
b. Avoid gas-forming foods, fatty foods, large meals.
c. Exercise and regular bowel habits.
11. Varicose veins; hemorrhoids
a. Avoidance of obesity, lengthy standing or sitting, constrictive clothing,
and constipation and bearing down with bowel movements.
b. Moderate exercises. Rest with legs and waist elevated.
c. Support stockings applied before rising.
d. Relieve swelling and pain with hot sitz baths, local application of
astringent compresses.

12. Leukorrhea
a. Do not douche.
b. Hygiene, perineal pads, reassurance.
13. Headaches
a. Emotional support; prenatal teaching; conscious relaxation.
14. Periodic numbness
a. Maintain good posture.
b. Wear good supportive maternity brassiere.
c. Reassurance that condition will disappear if lifting and carrying baby
does not aggravate it.
15. Joint pain, backache, and pelvic pressure; hypermobility of joints
a. Teach the woman to use good body mechanics-wear comfortable, low-
heeled shoes with good arch support, try the use of a maternity girdle.
b. Instruct the woman in the technique for pelvic rocking exercises.
c. Encourage to take rst periods with her legs elevated.
d. Instruct the woman to dorsoflex the foot while applying pressure to the
knee to straighten the leg for immediate relief of leg cramps.
e. Local heat and back rubs.

THIRD TRIMESTER
1. Shortness of breath
a. Good posture.
b. Flying exercise.
c. Sleep with extra pillows.
d. Avoid overloading stomach.
e. Stop smoking.
2. Insomnia
a. Reassurance.
b. Conscious relaxation.
c. Back massage or effleurage.
d. Support of body parts with pillows.
e. Warm milk or warm shower before retiring.
3. Psychosocial responses: mood swings, mixed feelings, increased anxiety
a. Reassurance and support from significant other and nurse.
b. Improved communication with partner, family, and others.
4. Gingivitis and epulis
a. Well-balanced diet with adequate protein and fresh fruits and vegetables.
b. Gentle brushing and good dental hygiene; avoid infection.
5. Urinary frequency and urgency returns
a. Limit fluid intake before bedtime.
b. Reassurance.
c. Wear perineal pad.
6. Perineal discomfort and pressure
a. Rest, conscious relaxation and good posture.
b. Maternity girdle.
7. Braxton Hicks’ contractions
a. Reassurances, rest, change of position.
b. Practice breathing techniques when contractions are bothersome.
c. Effleurage; rule out labor.
8. Leg cramps
a. Use massage and heat over affected area.
b. Stretch affected muscle until spasm relaxes.
c. Stand on cold surface.
d. Oral supplementation with calcium carbonate or calcium lactate tablets.
9. Ankle edema
a. Ample fluid intake for “natural” diuretic effect.
b. Put on support stockings before arising.
c. Rest periodically with legs and hips elevated.
d. Exercise moderately.
THE INTRAPARTUM STAGE

CONDUCT OF THE FIRST STAGE
1. Anxiety, excitement of onset of labor and fear of the unknown
a. Establish a relationship with the woman or couple.
b. Provide information on the health care facility’s policies and procedures.
c. Inform the woman or couple of maternal status and fetal status and labor
progress.
d. Explain all procedures and equipment used during labor.
e. Answer any questions the woman/couple have.
f. Review the birth plan and make appropriate revisions.
g. Monitor maternal vital signs.
 Temperature every 4 hours, unless elevated or membranes
ruptured, then every 2 hours.
 Pulse and respirations every hour unless receiving pain
medication, then every 15-30 minutes or as indicated.
 Blood pressure every hour unless hypertension or hypotension
exist or woman has received pain medication or anaesthesia.
Then evaluate more frequently based on findings or as
indicated.
h. Monitor FHR
 Evaluate once every hour for 15-30 minutes for intermittent
monitoring.
 Evaluate the monitor strip at least hourly with continues
monitoring.
 Evaluate immediately and after each of the next 5 contractions
on rupture of the membranes.
2. Fluid volume deficit.
a. Explain to woman and support person why oral fluids are restricted or
stopped at this time.
b. Start and maintain an IV infusion.
c. Provide ice chips or sips of clear fluids if allowed.
d. Provide mouth care as needed.
3. Injury: contamination, infection, prolapsed cord and abnormal fetal position.
a. Take the woman temperature and record every 2 hours.
b. Maintain asepsis during vaginal examination.
c. Change the pads and linens when wet or soiled.
d. Provide perineal care after voiding and as needed.
e. Discourage the use of perineal pads, because they create a warm, moist
and environment for bacteria.
f. Minimize vaginal exams.
g. Observe for fetal tachycardia.
h. Assess complete blood count as indicated.
i. Continue to monitor maternal vital signs, FHR, vaginal secretions, fetal
lie and position using Leopold’s maneuver.
j. Reposition client to left lateral position or other positions as necessary.
k. Provide oxygen by nasal cannula or mask.
4. Pain: increasing intensity and frequency of uterine contractions.
a. Encourage position changes for comfort.
b. Assist the woman with breathing and relaxation techniques as needed.
c. Provide back, leg, and shoulder massage as needed.
d. Provide pain relief as assessing woman’s verbal and nonverbal
communication.
e. Assess vital signs, including BP, FHR, frequency and intensity of uterine
contractions.
5. Bladder fullness
a. Encourage the woman to void every two hours at least 100ml.
b. Palpate the lower abdomen and evaluate for a distended bladder.
c. Assist with enabling the woman to void by providing time and privacy,
running the sink water gently, providing the perineal bottle of warm water
for the woman to squirt against her perineum.
d. Catheterize (in and out) when necessary.
e. Monitor intake and output.

THE SECOND STAGE OF LABOR
1. Impaired gas exchange
a. Coach woman to reestablish appropriate breathing pattern.
b. Help woman focus attention by doing the breathing with her and making
eye contact.
c. Side-lying position or left lateral position for oxygenation.
d. Encourage using open epiglottis technique when pushing.
2. Physiologic response to contractions; low self-esteem
a. Provide information.
b. Coach woman through contractions giving her verbal and nonverbal
approval and reassurance.
3. Experiences contractions as overwhelming in intensity. Reports ring of fire as
head crowns.
a. Encourage slow gentle pushing.
b. Explain that “blowing away a contraction” facilitates a slower birth of the
head.
c. Coach relaxations of the mouth, throat, and neck to relax pelvic floor.
d. Apply warm compress to perineum to aid relaxation.

THE THIRD AND FOURTH STAGES OF LABOR
1. Delivery of the placenta
a. Assist the mother in delivery of placenta.
b. Massage the uterus immediately but gently.
c. Check for intactness of placenta
d. Check BP.
e. Administer oxytocin if ordered.
2. Episiotomy and hemmorhoids
a. Suture any tearing.
b. Cleansed vulvar area with sterile water.
c. Ice caps wrapped in gauze may be placed over the episiotomy to numb
the area and minimize the edema.
d. Apply a sterile perineal pad.
e. Remove drapes and place dry linen under buttocks.
f. Reposition delivery table.
g. Lower the mother’s legs simultaneously from the stirrups.
3. Tremors that resemble chilling.
a. Dress woman in a clean gown and cover her with a warm blanket. Explain
that tremors are commonly seen after delivery and are not related to
infection. Warm blankets also provide a means of “mothering the mother”.
This helps in restoring her energy so she can move from a focus on
herself to a focus on her baby.
b. Assists the woman onto her bed if transferred from the delivery room to
the recovery room.
c. Raise side rail of bed when transferred.
4. Fluid balance (hydration)
a. Give clear fluids, such as apple juice or tea, and toast can be given unless
the mother’s condition does not allow this.
b. The nurse records the type of fluids and foods taken, the time, the
amount, and the mother’s tolerance of the fluids or foods ingested.
c. In the event of hemorrhage, IV medications are given by the physician.
THE POSTPARTUM STAGE
Immediately after the delivery, or perhaps later, the parents, particularly
the mother may relieve tension by giving way to some emotional displays like laughing,
crying, incessant chattering, and anger. These emotions often are quite unexpected and
shock and embarrass those involved. A calm, accepting, nonjudgmental attitude in the
part of the nurse is very effective in allaying any embarrassment and in helping the
patient to gain control.

Several comfort measures can be employed to restore calm and to help the
mother to relax enough to get some much needed rest and sleep. A soothing backrub,
change of gown and linen, a quiet conversation with the nurse or the husband in which
the patient is allowed to ventilate her feelings, an environment conducive for resting, are
all helpful (Bobac,1989).

The first hour following the delivery is a most critical one for the mother. It is at
this time that the postpartal hemorrhage is most likely to occur as the result of uterine
relaxation. Thus, it is mandatory that the uterus be watched constantly throughout this
period by a competent nurse who keeps her hand more or less constantly on the fundus
and at the slightest sign of diminishing contraction massages it, to make sure that it does
not relapse and balloon with blood. It is important for the nurse to be alert not only to the
condition of the mother’s uterus but also to any abnormal symptoms related to her
general condition. Checking of the maternal vital signs is usually included in the nursing
observations. These signs are checked as often as necessary until they become stable
(Reeder, et. al.,1966).

Certain observations should be made and recorded daily. These would include
such findings as temperature, pulse and respiration; urinary and intestinal elimination;
the physical changes which occur normally in the puerperium. The nurse should take
note the changes in the breasts, the height and consistency of the fundus, the character,
the amount and the color of the lochial discharge and the condition of the episiotomy.
Temperature, Pulse, Respiration
• A slight rise in the temperature may occur without apparent cause following the
delivery, but in general the mother’s temperature should remain within normal
limits during the puerperium which is below 38 C.
• In the early puerperium, the pulse rate is somewhat slower. The rate is usually
between 60 and 70 but may even become a little slower than this in 1 or 2 days
after the delivery. By the end of the 1st week or 10 days it will return to its normal
rate. On the other hand, a rapid pulse after labor may indicate shock or
hemorrhage.

After-Pains
Normally after the delivery of the first chills, the uterine muscle tends to remain in
a state of tonic contraction and retraction. In multiparas a certain amount of the initial
tonicity of the uterine muscle has been lost, and these contractions and retractions
cannot be sustained. Consequently, the muscle contracts and relaxes at intervals, and
these contractions give rise to the sensation of pain, the so-called “after-pains”(Reeder,
et. al., 1966).
Several nursing interventions that can be applied in this discomfort would be the
application of ice cap on affected area, administration of analgesics and encourage the
mother of early ambulation.

Nutrition
After delivery the mother is given small amounts of easily digested foods, such
as milk or tea and toast, for the first meal if it is not contraindicated. Thereafter she
enjoys a normal diet.
The daily diet of the lactating mother should be like that taken during pregnancy,
with the addition of 1,000 calories and amounts of the various nutrients such as protein,
calcium, vitamin A, iron, etc. These increased demands in the diet during lactation can
be supplied with the addition of a pint of milk, 1 serving of vegetables and 1 citrus fruit,
an egg and 1 large serving of meat. Often, these mothers become hungry in between
meals. For this reason it is advisable to see that they receive immediate nourishment
consisting of a nourishing beverage or a snack 3 times a day.

Rest and Sleep
The mother in the puerperium should be encouraged to relax and sleep
whenever possible. To accomplish this she must be comfortable and free from any
worries and anxiety-producing situations must be avoided. Especially if she is
breastfeeding, the need for rest is more significant for it will inhibit her milk supply.
Urinary and Intestinal Elimination
The mother should be encouraged to void within the first 6 to 8 hours following
the delivery. It is not prudent, however, to adhere to a designated lapse of time to
indicate when the mother should empty her bladder, but rather on evidence indicating
the degree of bladder distension. It should be kept in mind that there is an increased
urinary output during the early puerperium. Moreover, mothers who have received
intravenous fluids, or who are having them are very likely to develop a full bladder.
Intestinal elimination in the early puerperium may be somewhat a problem
because the bowel tends to remain relaxed. Constipation can be anticipated unless
certain measures are instituted to prevent it. It is common to give a stool softener each
night after the delivery and/or a laxative or mild cathartic on the evening of the 2 nd day
following a delivery. If a bowel evacuation has not occurred by the morning of the 3rd
day, a cleansing enema or a suppository may be prescribed.
BREAST CARE
This routine care is directed to maintain cleanliness and adequate breast support
necessary for the normal function of the breasts and the comfort of the mother.
Precautions should always be exercised to handle the breast gently, and above all to
avoid rough rubbing, massage or pressure on these organs.
The mother who is bottle-feeding her infant should bathe her breasts daily with
mild soap and water; this is done most conveniently at the time of the daily shower or
bath (Reeder, et. al., 1966).
IMMEDIATE CARE OF THE INFANT

As soon as the infant is born, measures should be taken to promote a clear air
passage before the onset of respiration. As the head is delivered, it is necessary to wipe
the mucus and the fluid from the infant’s nose and mouth before he has the chance to
gasp and aspirate with the first breath. From the moment of delivery the infant should be
kept in the head-down position until his upper respiratory passage is cleared of mucus,
an amniotic fluid, etc. a small rubber bulb syringe, or a soft rubber suction catheter
attached to a mechanical suction or mouth aspirator, should be used promptly to suction
the oropharynx and to remove fluids which may be obstructing the airway.

Assess respiratory status and do Apgar scoring 1 and 5 minutes after delivery of
the baby. Look for meconium staining. Wrap the newborn baby in a warm blanket and
place in heated crib or give to mother and/or father to hold. Avoid excessive exposure as
body temperature is variable. Place infant on side or modified Trendelenburg’s to
facilitate drainage of mucus or blood. Suction mucus as needed with the bulb. The nurse
is to clamp the cord if the physician has not done so. The baby is then identified with
bands.

When the baby is passed to the nursery, another set of care is implemented.
After receiving the baby into the unit, the nurse will check the axillary temperature and
take the vital measurements such as the weight, length, head and chest circumference.
The baby is bathe and afterwards placed in the crib where his cord is to be cut and
dressed. The cord is to be applied with alcohol daily or as necessary. It must likewise be
kept dry. Palm and sole prints are done for identification purposes. The infant is then
dressed and Vitamin K is administered as ordered to facilitate blood coagulation. The
Crede’s prophylaxis is the application of an eye ointment, like the silver nitrate, to the
eyes to prevent the development of the ophthalmia neonatorum. Lastly, the infant is then
bundled and placed into crib. The bulb syringe is placed at the crib.

Vital signs of the infant such as his heart rate, respiration and temperature are to
be checked every hour for 2 to 3 hours and when necessary(prn).
CONTINUING CARE
The daily cleansing of the infant affords the nurse an excellent opportunity for
making the observations that are necessary during the immediate postpartal period.
Several decades ago the daily soap and water and oil baths were replaced with merely
wiping off excess vernix with dry or slightly moist cotton balls. The diaper area was
cleansed as necessary. However, babies do not receive a tub bath until the cord has
separated and until the umbilicus has healed. If the cord is left exposed to the air, some
physicians prefer that the based of the cord be wiped with alcohol daily to encourage
drying further and to discourage the possibility of infection.
ACTUAL NURSING CARE PLAN
Antepartum Period
NURSING
CUES OBJECTIVE INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective : Sleep pattern At the end of one Independent : 1. Overindulgence On the next day
disturbance day, Ritchelr will 1. Evaluate use of caffeine interferes with REM of visit, Ritchel
“Galisud gyud ko related to inability report and alcoholic beverages. (Rapid Eye Movement) reported to have
ug katulog sa to maintain improvement in sleep.
slept well in
gabii. Ambut comfort as sleep rest.
evidenced by
side-lying
ngano pirme ko dili 2. Suggest side-lying 1. Back discomfort may
difficulty in falling position with pillow between necessitate change position.
kumportable” as
asleep. legs for support, or place in position, use of
verbalized by
bed board under mattress. multiple pillows /body
Ritchel. pillow, or firmer
mattress.
Objectives :
1. dark circles 3. Suggest aids to sleep, 3. .Excess anxiety,
under the such as relaxation excitement, physical
eyes techniques/tapes, reading, discomforts, nocturia,
2. constant warm bath, and reduced and fetal activity all
yawning activity just before retiring. may contribute to
irritability sleeping difficulties.
.
4. Note reports of positional 4. Use of semi-Fowler’s
breathing difficulties. position allows the
Suggest sleeping in a diaphragm to
NURSING semi-Fowler’s position. descend, fostering
CUES OBJECTIVE INTERVENTION RATIONALE EVALUATION
DIAGNOSIS optimal lung
expansion.

.
5. Encourage participation in 5. Exercise at bedtime
regular exercise program may stimulate rather
during day to aid in stress than relax patient and
control/release of energy. actually interfere with
sleep.

6. Drinking a glass of milk 1. To reduce sleep
maybe recommended. interference from
hunger.

ACTUAL NURSING CARE PLAN
( Intrapartum Stage )
CUES NURSING OBJECTIVE INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective : Comfort, At the end of ten Independent : 1. Provides supportive At the end of ten
Alteration in : minutes, Ritchel 1. Provide Ritchel need for reassurance and minutes, Ritchel
“Sakit kaayu ang Pain related to will verbalize physical touch during encouragement and verbalized
akong balat-ang ug uterine perceived or contractions. may aid in decreased in pain
mura ko ug contractions actual reduction maintaining and discomfort.
kalibangon”, as of pain. control/reducing pain. She was able to
verbalized by relax for a while.
Ritchel. 2. Encourage position 2. To provide comfort by
changes like the left not occluding the
Objectives : lateral position. vena cava.
3. Assist the woman with 3. To minimize pain
1. Facial grimaces breathing and relaxation during contractions
2. Expressive techniques. and to prevent
behavior – crying hypoxia.
Bloody show
4. Encourage ambulation as 4. To control pain
tolerated if membranes and stimulate cervical
are not yet ruptured and dilatation and fetal
presenting part is not yet descent.
engaged.
5. 5. Provide back, leg 5. To minimize pain by
and shoulder massage as improving blood
needed. circulation.

ACTUAL NURSNG CARE PLAN
( Postpartum Stage )
NURSING
OBJECTIVE INTERVENTION RATIONALE EVALUATION
CUES DIAGNOSIS

Subjective : Alteration in At the end of the 1. instructed the proper 1.to prevent infection that
“sakit akong tahi sa comfort: Pain day, client will be perineal care or the precipitate pain
akong kinatao” as related to able to reduce or proper way to clean the
verbalized by perinial incision eliminates vagina
Ritchel. done factors that
precipitate pain. 2. instructed to do sitz bath 2. for faster healing of the
Objectives : or clean the vagina with episiotomy
warm water.
1. gravida 3 para 3
2. as verbalized by 3.administer pain 3. to relieve pain.
client medication like aspirin.
3. Facial grimaces
during walking 4. divert clients attention 4. diverting clients attention
like talking to the client will help in alleviating the
pain of the client.
SUMMARY
The knowledge about Ritchel’s pregnancy was not a shock to her family because this was her 3rd baby. For

she has 2 daughters she and her partner wanted to have a baby boy but as she was on her labor they found out

that it was again a baby girl. Though they wanted a boy, they accepted and love the new member of their family.

They named the baby “Roxanne”.

It was gathered from the interview and physical assessment that Ritchel had undergone a positive childbearing experience

during this pregnancy. Except for some minor discomforts normally experienced by most pregnant women, it could be said that

Ritchel had a healthy and uncomplicated pregnancy. Her prenatal care included proper nutrition, exercise and adequate rest and self-

care measures which all significantly contributed to the safe passage of her baby and her safety, as well. Being a multigravida, she

reported to have an easy and short labor. Her records at the center showed us that she has no any signs of fetal distress. Inspection of

the neonate did not also show molding which would evidence ineffective bearing down.
REFERRAL

Pediatric primary care involves all the health promotion and disease prevention needs of the child. To obtain the highest level
of wellness attainable, referrals as to immunization/vaccinations had been made as follows:

AGE IMMUNIZATION REMARKS

BCG given at the earliest possible age protects
At birth BCG against the possibility of infection from other
family members
An early start with DPT reduces the chance of
6 weeks DPT and OPV
pertusis
An early start of Hepatitis B reduces the chance
6 weeks Hepatitis B
of being infected and becoming a carrier
The extent of protection against polio is
10 weeks DPT and OPV
increased the earlier OPV is given
14 weeks DPT and OPV --------
At least 80% of measles can be prevented by
9 months Measles
immunization at this stage

Moreover, instructions had been made to immediately contact the pediatrician for any abnormalities observed.

Bibliography

 Pilliteri, Adelle. Maternal and Child Health Nursing (3rd Edition ). Lippincott Williams and Wilkins, Inc. 1999.

 Taylor. Fundamentals in Nursing (4th Edition ). J.B. Lippincott Company. 2001.
 Kozier. Erb. Blais. Wilkinson. Fundamentals in Nursing (5th Edition). Addison esley Longman Inc. 1998.

 Nettina, Sandra. The Lippincott Manual of Nursing Practice (6th Edition). J.B. Lippincott Company. 1996.

 Childcraft. Guide to Parents (Volume 15). World Book – Childcraft International, Inc. 1981.

 Timelife. Raising a Happy Child. Time-Life Books, Inc. 1986.

HEALTH TEACHINGS
Name of patient: Ritchel Canaugon
 Instructed the client to take vitamins that’s rich

MEDICATION in iron to revive the blood loss during her labor.

 Take mefanamic acid if pain persist, to lessen
the pain that she felt.

 Instruct the patient to do the postpartum

EXERCISE exercise to promote muscle tone.

 Do the proper breast care to have the baby’s

TREATMENT safety when doing breastfeeding.

 Instructed to have proper perineal care for fast
healing of the episioraphy.

 Instruct the patient to go to the nearest center if

OUTPATIENT there are any problem that she encounter after

(check-up) giving birth, like if there is a problem about the
baby’s health or about her episioraphy.
 To eat vegetables that’s high in iron to regain

DIET the blood loss.

 To eat foods that is rich in vitamins to have her
energy back.

HEALTH TEACHING

NAME OF PATIENT: x

During our fourth visit to our client, we taught her about proper hygiene, nutritions that she needed and the
post-partum exercise.

We emphasize our teaching to the proper hygiene because as we observed our client, we found out that she
does not care about herself or to her children. We could see that they have a dirty surroundings. If she continuous
to take for granted about proper hygiene this could affect her health and her children and mostly to her new baby.
We also taught her about the proper nutrition that she should take so that she would regain her energy and
could return to her lifestyle before she got pregnant and also to regain her blood loss.

And lastly we taught her about the 10 post-partum exercise that she could apply after giving birth. We
instructed her on how to do it for ten days and on what exercise it is about.