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I. II. III. Introduction Patient’s Profile 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
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.
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 : PULSE : BP : RESPIRATION : 36.8 oC 71 bpm 120/70 mmHg 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. j. l.
Avoid empty or overloaded stomach. Maintain good posture – give stomach ample room. Avoid fried, odorous, spicy, greasy, or gas-forming foods.
k. Stop smoking. 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, lowheeled 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. 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. g. Monitor maternal vital signs.
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. j. Continue to monitor maternal vital signs, FHR, vaginal secretions, fetal lie and position using Leopold’s maneuver. 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. g. Reposition delivery table. 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
At the end of one day, Ritchelr will report improvement in sleep rest. 2.
Sleep pattern disturbance related to inability to maintain comfort as evidenced by difficulty in falling asleep.
On the next day of visit, Ritchel reported to have slept well in side-lying position.
“Galisud gyud ko ug katulog sa gabii. Ambut ngano pirme ko dili kumportable” as verbalized by Ritchel.
Objectives : 1. dark circles under the eyes 2. constant yawning irritability
Independent : 1. Overindulgence 1. Evaluate use of caffeine interferes with REM and alcoholic beverages. (Rapid Eye Movement) sleep. Suggest side-lying position with pillow between legs for support, or place bed board under mattress. 1. Back discomfort may necessitate change in position, use of multiple pillows /body pillow, or firmer mattress. 3. .Excess anxiety, excitement, physical discomforts, nocturia, and fetal activity all may contribute to sleeping difficulties.
3. Suggest aids to sleep, such as relaxation techniques/tapes, reading, warm bath, and reduced activity just before retiring.
4. Note reports of positional breathing difficulties. Suggest sleeping in a semi-Fowler’s position. INTERVENTION
. 4. Use of semi-Fowler’s position allows the diaphragm to descend, fostering RATIONALE optimal lung expansion.
5. Encourage participation in regular exercise program during day to aid in stress control/release of energy.
. 5. Exercise at bedtime may stimulate rather than relax patient and actually interfere with sleep.
Drinking a glass of milk maybe recommended.
1. To reduce sleep interference from hunger.
ACTUAL NURSING CARE PLAN
( Intrapartum Stage )
OBJECTIVE INTERVENTION CUES NURSING RATIONALE EVALUATION
Subjective : “Sakit kaayu ang akong balat-ang ug mura ko ug kalibangon”, as verbalized by Ritchel. Objectives : 1. Facial grimaces 2. Expressive behavior – crying Bloody show Comfort, Alteration in : Pain related to uterine contractions At the end of ten minutes, Ritchel will verbalize perceived or actual reduction of pain. Independent :
1. Provide Ritchel need for physical touch during contractions.
1. Provides supportive reassurance and encouragement and may aid in maintaining control/reducing pain. 2. To provide comfort by not occluding the vena cava. 3. To minimize pain during contractions and to prevent hypoxia. 4. To control pain and stimulate cervical dilatation and fetal descent.
At the end of ten minutes, Ritchel verbalized decreased in pain and discomfort. She was able to relax for a while.
2. Encourage position changes like the left lateral position. 3. Assist the woman with breathing and relaxation techniques. 4. Encourage ambulation as tolerated if membranes are not yet ruptured and presenting part is not yet engaged. 5. Provide back, leg and shoulder massage as needed.
5. To minimize pain by improving blood circulation.
ACTUAL NURSNG CARE PLAN
( Postpartum Stage )
Subjective : “sakit akong tahi sa akong kinatao” as verbalized by Ritchel. Objectives : 1. gravida 3 para 3 2. as verbalized by client 3. Facial grimaces during walking
Alteration in comfort: Pain related to perinial incision done
At the end of the day, client will be able to reduce or eliminates factors that precipitate pain.
1. instructed the proper perineal care or the proper way to clean the vagina 2. instructed to do sitz bath or clean the vagina with warm water. 3.administer pain medication like aspirin. 4. divert clients attention like talking to the client
1.to prevent infection that precipitate pain
2. for faster healing of the episiotomy 3. to relieve pain. 4. diverting clients attention will help in alleviating the pain of the client.
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 selfcare 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.
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 At birth 6 weeks 6 weeks 10 weeks
IMMUNIZATION BCG DPT and OPV Hepatitis B DPT and OPV
REMARKS BCG given at the earliest possible age protects against the possibility of infection from other family members An early start with DPT reduces the chance of pertusis An early start of Hepatitis B reduces the chance of being infected and becoming a carrier The extent of protection against polio is increased the earlier OPV is given
14 weeks 9 months
DPT and OPV Measles
-------At least 80% of measles can be prevented by immunization at this stage
Moreover, instructions had been made to immediately contact the pediatrician for any abnormalities observed.
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.
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 (check-up) there are any problem that she encounter after 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.
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.
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