Republic of the Philippines

Tarlac State University

College of Science
Department of Nursing
Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300
Level 1 accredited by AACCUP

A Clinical Case Study Presented to the faculty of the

Department of Nursing
In Partial Fulfillment
Of the requirement of the Subject
NCM 101 RLE (OB-Ward)

Normal Spontaneous Delivery

(Post-Partum)
S.Y 2016-2017

May D. Reyes
Patricia Ann D. Almosa
Sherilyn A. Daysor
Kimberly M. Diza
Christia Jane C. Estabillo
Joan D. Juliano
Ana Veronica M. Padilla
Franklin R. Reyes
BSN- 2A A4
November 2016
Submitted to:
Mrs. Merlie Q Espiritu
Clinical Instructor

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I.Introduction

A normal spontaneous vaginal delivery (SVD) occurs when a pregnant female goes into labor
without the use of drugs or techniques to induce labor, and delivers her baby in the normal manner,
without forceps, vacuum extraction, or a cesarean section. A vaginal delivery is the recommended
method of childbirth for women whose babies have reached full term. However, vaginal deliveries are
not recommended for women who have had cesarean deliveries before, or who have infections that
can be transferred to their baby through vaginal delivery.

A cesarean delivery is the alternative to a vaginal delivery. Vaginal delivery is the method of childbirth
most health experts recommend for women whose babies have reached full term, or at least 37 weeks.
Compared to other methods of childbirth, such as a cesarean delivery and induced labor, it’s the
simplest kind of delivery process.

A spontaneous vaginal delivery is a vaginal delivery that happens on its own, without requiring doctors
to use tools to help pull the baby out. This occurs after a pregnant woman goes through labor, which
opens, or dilates, her cervix to at least 10 centimeters.

Labor usually begins with the passing of a woman’s mucous plug. This is a clot of mucous that protects
the uterus from bacteria during pregnancy. Soon after, a woman’s water may break. This is also called
a rupture of membranes. As labor progresses, strong contractions help push the baby into the birth
canal.

The length of the labor process varies from woman to woman. Women giving birth for the first time tend
to go through labor for 12 to 24 hours, while women who have previously delivered a child may only go
through labor from six to eight hours.

When gestation has completed, it goes through a process called delivery, where the developed fetus is
expelled from the mother’s womb. There are two options of delivery: caesarean section and NSVD

A postpartum period or postnatal period is the period beginning immediately after the birth of a child
and extending for about six weeks. Less frequently used are the terms puerperium or puerperal period.
The World Health Organization (WHO) describes the postnatal period as the most critical and yet the
most neglected phase in the lives of mothers and babies; most deaths occur during the postnatal
period.[1] It is the time after birth, a time in which the mother's body, including hormone levels and
uterus size, returns to a non-pregnant state. Lochia is postpartum vaginal discharge, containing blood,
mucus, and uterine tissue.

STAGE 1:
It is usually the longest part of labor. It begins with regular uterine contractions and ends with complete
cervical dilatation at10 centimeters. This stage is broken down into three (3) phases: the Early phase,
where the contractions are usually very light and maybe approximately 20 minutes or more apart from
the beginning, gradually becoming closer, possibly up to five minutes apart; the Active phase, where

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contractions are generally four or five times apart, and may last up to 60 seconds long. Cervix dilates
with 4-7 cm and initiates a more rapid dilatation. It is known that to get through active labor, mobility
and relaxations are done to increase contractions; and the Transition phase, where it is definitely
known as the shortest phase but the hardest, contractions maybe two or three times apart, lasting up to
a minute and a half, about approximately 8-10 cm of cervical dilatation. Some women will shake and
may vomit during this stage, and this is regarded as normal. Most of the time, women would find a
comfortable position to acquire complete dilatation.

STAGE II
: This stage lasts for three or more hours. However, the length of this stage depends upon the mother’s
position (e.g.; upright position yields faster delivery). Once the cervix has completely dilated, the
second stage had begun. This stage ends with the expulsion of the fetus.

STAGE III
:This stage focuses on the expulsion of the placenta from the mother. Placenta exclusion is much more
easier than the delivery of the baby because it includes no bones, and this is during this stage that the
baby is placed on top of the mother’s womb.

STAGE IV
: No more expulsions of conception products for this stage as this is generally accepted as POST
PARTUM juncture. This phaseis from the placental delivery to full recovery of the mother.

Labor and delivery of the fetus entails physiological effects both on the mother and the fetus. In the
cardiovascular system, the mother’s cardiac output increases because of the increase in the needed
amount of blood in the uterine area. Blood pressure may also rise due to the effort exerted by the
mother in order expel the fetus. There could also be a development of leukocytes or a sharp increase in
the number of circulating white blood cells possibly as a result of stress and heavy exertion. Increased
respiratory may also occur. This happens as a response to the increase in blood supply in order to
increase also the oxygen intake. Braxton Hicks contractions, or also known as false labor or practice
contractions

. Braxton Hicks are sporadic uterine contractions that actually start at about 6 weeks, although one will
not feel them that early. Most women start feeling them during the second or third trimester of
pregnancy. True labor is felt in the upper and mid abdomen and leads to the cervical changes that
define true labor. With delivery imminent, the mother is usually placed supine withher knees bent (ie,
the dorsal lithotomy position). An episiotomy (anincision continuous with the vaginal introitus) may be
performed at this time. Episiotomy may ease delivery of the fetal head and allow some control over
what may otherwise be an uncontrolled perineal laceration. However, many providers no longer
perform routine episiotomy, since it may increase the risk of rectal injury and are larger than the
spontaneous laceration.

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The labor and birth process is always accompanied by pain. Several options for pain control are
available, ranging from intramuscular or intravenous doses of narcotics, such as Meperidine (Demerol),
to general anesthesia. Regional nerve blocks, such as a pudendal block or local infiltration of the
perineal area can also be used. Further options include epidural blocks and spinal anesthetics.

Maternal, Newborn, and Child Health and Nutrition Situation in the Country

The Department of Health (DOH) is committed to achieve the Millennium Development Goals (MDGs)
of reducing child mortality and improving maternal health by 2015. Although significant gains in
maternal and child mortality have been realized in the past four decades, pregnancy and childbirth still
pose the greatest risk to Filipino women of reproductive age, with 1:120 lifetime risk of dying from
maternal causes.1 Maternal deaths account for 14percent of deaths among women of reproductive
age. The Maternal Mortality Ratio (MMR) in the country remains high and decreased very slowly at
162/100,000 live births (LB) in 2006 from 209/100,000 LB in 1990.2 Although the Under-Five Mortality
Rate (UFMR) and Infant Mortality Rate (IMR) have considerably declined (UFMR from 61/1,000 LB in
1990 to 32/1,000 LB in 2008; IMR 42percent in 1990 to 26percent in 2006)3 , the rates of decline have
decelerated over the last ten years. The deceleration is driven largely by the high neonatal deaths and
slow decline of infant deaths.4 Neonatal Mortality Rate (NMR) is still high, with 17 infants dying per
1,000 LB within the first 28 days of life. In 2000-2003, newborn deaths accounted for 37 percent of all
Under- 5 mortalities.5Most neonatal deaths occur within the first week after birth, half of which occur in
the first two days of life. With the slow decline in MMR for the past two decades and the loss of
momentum in rate of decrease in newborn, infant, and child deaths, the Philippines is at risk of not
attaining its MDG targets of lowering maternal deaths to 52/100,000 LB and child deaths to 20/1,000 LB
in the next five years.

This case were given to us, to have a broader knowledge regarding the Postpartum care
for Normal spontaneous vaginal delivery case which we are handling. By this, we are able to discover
its process, how it is being managed, the physiology and clinical manifestations, which are being,
experience by our patient. By doing so, we are able to fructify our knowledge, enabling us to know the
appropriate nursing care for our patient. This study will help us as a student nurse to comprehend not
only the procedure and management mentioned but also for the commonalities and differences among
other cases for the betterment of this study.

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General Objective

This group case study aimed to broaden our knowledge as a student nurse for Normal
Spontaneous Vaginal Delivery by obtaining sufficient information, which could serve as a guide for us to
enhance our skills and attitudes in the application of nursing process and management of Post-partum
care for Normal Spontaneous Delivery patient.

Specific Objective

 To know the client’s personal data, family profile, past health history, current health history, and
physical assessment using 13 areas of assessment.
 To review the anatomy and physiology of the female reproductive system and the changes
after the delivery.
 To correlate the results of the diagnostic procedures to its normal values.
 To formulate the drug study of normal spontaneous delivery.
 To develop an effective nursing care plan in which the client may benefit.
 To formulate a post-partum discharge plan for the continuity of care.

II. Nursing process

A. Assessment
1. PERSONAL DATA:
NAME: Patient X
CASE NUMBER: 327255
DATE OF BIRTH: December 11, 1994
PLACE OF BIRTH: Tarlac City
ADDRESS: Aquino Street, Ligtasan, Tarlac City
AGE: 21 yrs. old
STATUS: Married
RELIGION: Roman Catholic
DATE ADMITTED: November 8, 2016 5:46 am
CHIEF COMPLAINT: Watery vaginal discharge for 12 hours, Labor pain
FINAL DIAGNOSIS: G1P1, Pregnancy uterine delivered
spontaneously to a term cephalic live baby by APGAR score: 8.9
Baby’s weight 2.6 kg
Environmental Status: She lived in an urban area wherein pollution is very common. They live
in a concrete house with 6 occupants. In her hospitalization, she felt some discomfort because
of the setting, two person sharing in a single bed. According to her, the room is too crowded for

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 her to have some quality time to rest but she was aware the time she was interviewed in the
emergency room.

Lifestyle: Patient X described her habits by watching TV all the time and using her smartphone
for social medias. She was very lazy all the time as she stated. She didn’t even tried to engaged
herself to pre-natal exercises but she clearly states that she had a regular check-ups. “Lagi lang
ako sa bahay, nakahiga nanunuod, cellphone,ganun kaya siguro nahirapan ako sa
panganganak”, as verbalized.

2. Family history of health and illness

MOTHER SIDE FATHER SIDE

Patient X

- Asthma

- Hypertension -Female

- Congenital Heart disease -Male

Patient X has two siblings she is the eldest in their family, she is married to Mr. Y for 1 year. They stay
on patient X’s parents for a while since they don’t have enough money on their own to avail their own
house. She has a younger sister with congenital heart disease she is now 15 years old. Her father had
an history of hypertension he is currently taking his maintenance and her mother and youngest sister
had an asthma but now controlled.

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 3. History of past illness

Patient X experienced some common colds before she got pregnant. She has no allergy to any
medications or foods. She completed her pre-natal check-ups and she is regularly taking her ferrous
sulfate supplement. During her 7 months of conception, she experienced UTI and she immediately
went to her doctor and gave her cefalexin. She completed the prescribed dose and she felt better on
the following days. She has a regular menstruation, and she also experienced dysmenorrhea. She has
no history of bleeding and any discomfort on her pregnancy until she begun to labor and delivered her
first baby.

4. Present health history

Few hours prior to admission patient X had watery vaginal discharge for 12 hours. She was
admitted with a chief complaint of labor pain with watery vaginal discharge. Her second stage of labor
lasted for 20 minutes and the third stage lasted for 5 minutes. At 8:27 am she delivered an alive baby
boy via Normal spontaneous delivery. She had to undergo episiotomy to widen the opening of her
vagina (primigravida) with 200cc blood loss based on her chart. After the post-natal and early post-
partum care in the delivery room, she was transferred to OB- service ward via stretcher. She was
conscious and had no complications throughout the delivery.

5. 13 AREAS OF ASSESSMENT

1.SOCIAL STATUS
Mrs. S is 21 years old, born on December 11, 1994 at Tarlac City. She resides at Aquino St.
Ligtasan Tarlac City together with her husband and their family. They are Roman Catholic. Mr. S her
husband is 23 years old and working at the canteen. Their savings supported the hospitalization of Mrs.
S. Mrs. S became lazy during her conception. However, before she works at the canteen together with
her husband. They planned for having a baby. Mrs. S admitted on November 8,2016 at 5:46:28 AM
(G1P1).
NORMS:
Social status includes family relationships that state the patient’s support system in time of stress
and in time of need. It meets a fundamental human need for social ties, making life less stressful and
social support buffers the negative effects of stress, thus indicating indirectly contributing to good health
outcomes.(Fundamentals of nursing, Barbara Kozier,s eventh edition)
ANALYSIS:
Because they were extended family, Mrs. S has a good relationship with her family. Mrs. S and his
husband have a savings to sustain the hospitalization of Mrs. S yet it’s not enough.

II.MENTAL STATUS
Mrs. S is oriented in time, place and person. She can identify things and answers the questions
being asked. She can recall recent and remote memories she experienced. She is able to read and
write and she can speak different language like kapampangan, tagalog and English. She is very
responsive and collaborative.

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NORMS:
The patient should be oriented to time, place, can identify past and recent memories and should
be able to verbalized concrete messages. The patient’s ability to read and write should match her
educational level. The patient should be able to respond to questions and identify all the objects
presented to him. The patient should be able to evaluate and act appropriately in situation.
(source: estez health assessment and physical examination third edition.)
ANALYSIS:
The patient was able to evaluate and act appropriately in situations requiring her judgment.

III.EMOTIONAL STATUS
Mrs. S is cooperative while performing the interview. As stated by her husband they are very
happy for having their first baby. She also states her feelings about the delivery she felt mad first on
herself in the delivery room for not being compliant to the proper pushing of the baby that cause her to
undergo episiotomy. But when she saw her baby she begun to felt self-worth because she is now a
mother a and she has a responsibility to deal with.
NORMS:
Young adult is a time of separation and independence from the family and a new commitments,
responsibilities and accountability in social, work, and home relationships and roles.(Health
Assessment and Physical Examination, Mary Ellen Zator Estez)
ANALYSIS:
Mrs.S is aware regarding her condition. According to them, they are both willing to bear a child
that is why they are very happy to have blessings. Erickson’s industry vs. inferiority reflects on Mrs. S
experienced because she learns self-worth as she gains mastery of psychosocial and physiological
changes.

IV.SENSORY STATUS
Mrs. S has a clear vision no history of eye checkups. Her hearing ability is normal using whisper
test with the distance of two feet away. Her sense of smell is normal and she can distinguish foul from
fresh odor. Her lips is pink in color and she can taste whatever food she eats. She feels pain
“Kumikirot” as stated according to the pain scale rate of 10/10 during the delivery but subsides to 6/10
afterwards.
NORMS:
The normal visual acuity is 20/20 as considered normal. The eyes must be symmetrical during the
six cardinal gazes test. The sclera should be white with some small blood vessels. Papillary constriction
should occur when struck by light. The skin contains receptors for pain, touch, pressure and
temperature. Sensory signals are transmitted along rapid sensory pathways, and less distinct signals
such as pressure of localized touch are sent via slower sensory pathways. Nose must be symmetrical
and align of the face. Each nostril must be patent and recognize the smell of an object. (Health
Assessment and Physical Examination, Mary Ellen Zator Estez.)
ANALYSIS:
Her sensory transmission functions as well as manifested by the data presented is normal. 12 Cranial
Nerves are functioning well but in minimal movement due to pain.

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V.MOTOR STATUS
Mrs. S is not comfortable with her condition because of the perineal incision. She had trouble in
walking, sitting and changing in position. She needs assistance when performing vigorous activities of
daily living. She tried to perform things alone if she can, but admitted that she needs help.
NORMS:
In standing position, the torso and head are upright. The head is midline and perpendicular to the
horizontal line of the shoulders and the pelvis. The shoulders and hips are level, symmetry of the
scapulae and iliac crests. The arms are freely from the shoulders. The feet are aligned and the toes
point forward. Walking initiated in one smooth rhythmic fashion. The foot is lifted 2.5 to 5cm to the floor
and propelled 30 to 45cm forward in a straight path. The patient remains erect and balance during all
stages of gait. The patient should be able to transfer easily to various position. There should absence of
discomfort during range of motion exercises.(Health assessment and physical examination, Mary ellen
zator estez)
ANALYSIS:
Her range of motion is altered but normal with certain activities performed with assistance. On the
second day, the patient demonstrated independent range of motion movements.

VI.BODY TEMPERATURE
The table below shows the body temperature of Mrs.S
Date Time Temperature Analysis
11/08/16 6:00 am 36.3ᵒ C Normal
7:00am 36.4ᵒ C Normal
10:00am 36.5ᵒ C Normal
NORMS:
Normal axillary body temperature is within 36.5 C to 37.4C
ANALYSIS:
In Mrs. S confinement her body temperature ranges in normal values.

VII.RESPIRATORY STATUS
The table below shows the respiratory rate of Mrs.S
Date Time Respiratory rate Analysis
11/08/16 6:00 am 20bpm Normal
7:00 am 15bpm Normal
10:00 am 24bpm Normal
NORMS:
Respiratory quality or character refers to those aspects of breathing that are different from normal.
Normal breathing sounds are:
a.Vesicular- soft,low pitched,heard over periphery of lungs
b.Brocho- vesicular-soft,medium-pitched heard over major bronchi.

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 c.Bronchial- loud,high pitched,heard over trachea.(G and N notes-Gregory N.Yalma, M.D)
A normal respiratory rate ranges from 12-20 cpm. (Kozier,Fundamentals of Nursing 7th edition)
ANALYSIS:
Mrs. S had a normal breath sounds via auscultation no abnormal sounds noted .Mrs. S respiratory
rate is in normal range. Elevated at 10am to 24bpm due to transfer from delivery room.

VIII.CIRCULATORY STATUS
The circulatory status of Mrs. S as well as the blood pressure noted below:
Date Time Blood pressure Pulse rate Analysis
11/08/16 6:00am 110/70 85 Normal
7:00am 10/70 86 Normal
10:00am 100/80 82 Normal
During the assessment of her capillary refill, it returned to its original color after 2 seconds.
NORMS:
The normal cardiac rate or pulse rate is 60-100 bpm. The average blood pressure of a healthy adult
is 120/80 mmHg. The normal capillary refill test is 2-3 seconds and upon capillary refill test was done it
returns to normal state within 2-3 seconds. (Kozier, Fundamentals of Nursing 7th edition)
ANALYSIS:
The data given above shows that Mrs. S pulse rate is in normal range. She also had a normal blood
pressure. Her capillary refill is normal.

IX.NUTRITIONAL STATUS
Mrs. S is able to recognized nutritious food but unable to utilized some of it. She eats 3 times a day
with some interval of snacks. Her husband bought her fruits during her pregnancy. She weighs 48 kg.
before she got pregnant and gained 4kilos when she got pregnant. She eats variety of vegetables but
mostly meats during lunch. She has no allergy to foods.

NORMS:
According to the Health Asian Diet Pyramid ,there should be a daily intake of rice, grains, bread, fruit
and vegetables: optional daily for fish, shellfish, and dairy products: weekly for sweets, eggs, and
poultry and monthly for meat. There should be an increase intake of a wide variety of fruits and
vegetables. Include in the diet foods higher in vitamin C, and E, and omega-3 fatty acids rich
foods.(www.webmd.com)

ANALYSIS:
She has a normal eating pattern.

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X.ELIMINATION
Mrs. S defecated once during the delivery. She voided once before the delivery, with pinkish color
because of blood present in urine. She had a past history of Urinary Tract Infection(UTI). Every time
she voids she’s in pain because of the perineal incision.

NORMS:
Normal bowel movement of a person must be 1 to 2 times a day and voiding in 3 to 4 times a day
with an output of 1200 to 1500 ml a day. A normal stool is brown in color and well formed, urine is clear
to yellowish in color.(Fundamentals of Nursing,Kozier 2007)

ANALYSIS:
Mrs. S had delayed bowel movement due to slow peristalsis movement after the delivery, after 24
hours the patient should demonstrate timely bowel movement.

XI.REPRODUCTIVE STATUS
Some of her reproductive organ is altered especially the external areas (Episiotomy and
Episioraphy) but it is considered normal due to the process of delivery. Her menstrual period was
regular. She is viable to get pregnant again because there was no birth control procedures noted upon
the interview.
NORMS
Pregnancy is a normal physiologic process that affect all body systems and results in both subjective
and objective changes, it is stressful time requiring many adaptations and may lead to minor
discomforts. (Lectures from NCM 101)
Analysis
Mrs. S marked the physiologic changes of pregnancy hence, reproductive status is altered but
expected to return to normal status after 1 month (approximately)

XII.STATE OF PHYSICAL REST AND COMFORT:

Mrs. S usually sleep 6-8 hours at night, she stated that sometimes her sleep is interrupted because
of the discomfort due to her perinial incision. By the help of her cousin and her husband they
simultaneously taking care of the baby as Mrs. S take her rest periods.

NORMS:
Adults average amount of sleep per day is 7 to 8 hours.(Wikipedia.org)

ANALYSIS:
She consumed the 7 to 8 hours sleep, but the only thing is she felt irritated because of her perineal
incision.

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XIII.STATE OF SKIN APPENDEGES

Mrs. S has a tan skin. Her hair is evenly distributed in a dark brown color. She has a stretch mark over
her abdomen area considered striae gravidarum .Her finger nails was dirty and has a long nailbeds. We
tested her capillary refill .And her skin turgor normally back into 2 seconds when we pinched at the right
arm. No skin rashes and allergies noted upon inspection.

NORMS:
Capillary refill 0-2 seconds. Hair varies from dark to pale blonde based on the amount of melanin
present. The body is covered in villus hair. Terminal hair is found in the eyebrows, eyelashes and scalp,
and in the axilla and pubic areas after puberty. Native Americas, Asians, and those from the Pacific Rim
may have a light distribution of hair. Skin is dry with minimum perspiration. Skin surfaces should be no
tender. It should normally feel smooth, even and firm.(Health Assessment and Physical Examination,
Mary Ellen Zator Estez)

ANALYSIS:
Mrs. S has normal texture, distribution, color and temperature. Localized or systematic tenderness
is absent. Her skin turgor is normal. Noted excessive sweating consider normal after the delivery and
so as presence of striae gravidarum over her abdomen.

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6.DIAGNOSTICS AND LABORATORY PROCEDURE

 Pelvic Ultrasound Report (Biophysical Profile)

Date: 11/7/2016
Name: Patient X
Age:21
Pertinent data: 39 weeks by LMP (+) watery vaginal discharge
BIOPHYSICAL PARAMETERS
No. of Fetus: Singleton Fetal Breathing: 2
Presentation: Cephalic Fetal Movement: 2
Fetal Heart Rate: 142 bpm Fetal Tone: 2
Amniotic Fluid Volume: 7.8 cm Amniotic Fluid Index: 2
Placenta-Location: Anterior Non-Stress Test: 2
Grade-3 Total score= 10/10
Distance from the OS- no previa
BIOMETRY NON- BIOMETRIC PARAMETERS

BPD: 85 mm = 34 2/7 wks Cerebellum: 5.1 cm- 37 weeks

HC: 305 mm = 34 wks Colonic Grade: 2

AC: 316 mm = 35 4/7 Distal Femoral Epiphysis: (+)

FL: 68 mm = 35 wks Proximal Humeral Epiphysis: (-)

Mean Ultrasonic Age: 35 4/7

Estimated Fetal Weight: 2598 grams ( 5 lb 12 oz)

Ultrasonic EDD: 12/14/16
4 QUADRANT AFI: 2.7 cm, 0. 2.8 cm, 2.2 cm

IMPRESSION:
PREGNANCY UTERINE, 34 WEEKS 5 DAYS AOG BY FETAL BIOMETRY.
LIVE, SINGLETON FETUS IN CEPHALIC PRESENTATION, MALE.
ANTERIOR PLACENTA GRADE 3, NO PREVIA.
RELATIVELY LOW AMNIOTIC FLUID VOLUME.
GOOD FETAL TONE. ACTIVE FETAL BREATHING AND MOVEMENT.
REACTIVE NON-STRESS TEST. BIOPHYSICAL PROFILE SCORE:10/10
Please correlate clinically and with earliest scan.

CHRISTINE ROSE ARENZANA-TEJADA,MD,FPOGS,FPSUOG

OB-GYN Sonologist

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 HEMATOLOGY
PARAMETERS RESULTS REFERENCE RANGE

Unit
Hemoglobin 126 gl 123-153
Hematocrit 0.344 vol% 0.359-0.446
RBC 4.46 x10^12L 3.50-4.70
MCV 77.1 % 80.0-96.0
MCHC 36.6 % 33.4-33.5
MCH 28.3 pg 27.5-33.2
WBC 21.6 x10^9L 4.5-11.0
POLYS 0.890 % 0.55-0.63
LYMPHOCYTES 0.090 % 0.230-0.350
MXD 0.020 %
PLATELET 276 x10^9L 150-450

PARAMETERS RESULTS REFERENCE RANGE

Unit
Platelet 276 x10^9L 150-450
Bloodtype O
RYType Rh(+)
Others: HBsAG:Nonreactive

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7.Anatomy and Physiology of female and male reproductive system

Female Internal Reproductive system

Ovaries
 The ovaries are the ultimate life-maker for the females.
 For its physical structure, it has an estimated length of 4 cm and width of 2 cm and is 1.5 cm
thick. It appears to be shaped like an almond. It looks pitted, like a raisin, but is grayish white in
color.
 It is located proximal to both sides of the uterus at the lower abdomen.
 For its function, the ovaries produce, mature, and discharge the egg cells or ova.
 Ovarian function is for the maturation and maintenance of the secondary sex characteristics in
females.
 It also has three divisions: the protective layer of epithelium, the cortex, and the central medulla.
Fallopian Tubes
 The fallopian tubes serve as the pathway of the egg cells towards the uterus.
 It is a smooth, hollow tunnel that is divided into four parts: the interstitial, which is 1 cm in length;
the isthmus, which is2 cm in length; the ampulla, which is 5 cm in length; and the infundibular,
which is 2 cm long and shaped like a funnel.
 The funnel has small hairs called the fimbria that propel the ovum into the fallopian tube.
 The fallopian tube is lined with mucous membrane, and underneath is the connective tissue and
the muscle layer.
 The muscle layer is responsible for the peristaltic movements that propel the ovum forward.
 The distal ends of the fallopian tubes are open, making a pathway for conception to occur.

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 An overview of external reproductive system, The mons pubis is a rounded mound of fatty
tissue that covers the pubic bone. During puberty, it becomes covered with hair. The mons pubis
contains oil-secreting (sebaceous) glands that release substances that are involved in sexual attraction
(pheromones). The labia majora (literally, large lips) are relatively large, fleshy folds of tissue that
enclose and protect the other external genital organs. They are comparable to the scrotum in males. ---
The labia majora contain sweat and sebaceous glands, which produce lubricating secretions. -During
puberty, hair appears on the labia majora.
The labia minora (literally, small lips) can be very small or up to 2 inches wide. The labia minora lie just
inside the labia majora and surround the openings to the vagina and urethra. A rich supply of blood
vessels gives the labia minora a pink color. During sexual stimulation, these blood vessels become
engorged with blood, causing the labia minora to swell and become more sensitive to stimulation. The
area between the opening of the vagina and the anus, below the labia majora, is called the perineum. It
varies in length from almost 1 to more than 2 inches (2 to 5 centimeters). The labia majora and the
perineum are covered with skin similar to that on the rest of the body. In contrast, the labia minora are
lined with a mucous membrane, whose surface is kept moist by fluid secreted by specialized cells. The
opening to the vagina is called the introitus. The vaginal opening is the entryway for the penis during
sexual intercourse and the exit for blood during menstruation and for the baby during birth.
When stimulated, Bartholin glands (located beside the vaginal opening) secrete a thick fluid that
supplies lubrication for intercourse. The opening to the urethra, which carries urine from the bladder to

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 the outside, is located above and in front of the vaginal opening. The clitoris, located between the labia
minora at their upper end, is a small protrusion that corresponds to the penis in the male. The clitoris,
like the penis, is very sensitive to sexual stimulation and can become erect. Stimulating the clitoris can
result in an orgasm.

Male external and internal reproductive system

 Penis: This is the male organ used in sexual intercourse. It has three parts: the root, which attaches to
the wall of the abdomen; the body, or shaft; and the glans, which is the cone-shaped part at the end of
the penis. The glans, also called the head of the penis, is covered with a loose layer of skin called
foreskin. This skin is sometimes removed in a procedure called circumcision. The opening of the
urethra, the tube that transports semen and urine, is at the tip of the penis. The glans of the penis also
contains a number of sensitive nerve endings.

The body of the penis is cylindrical in shape and consists of three circular shaped chambers. These
chambers are made up of special, sponge-like tissue. This tissue contains thousands of large spaces
that fill with blood when the man is sexually aroused. As the penis fills with blood, it becomes rigid and
erect, which allows for penetration during sexual intercourse. The skin of the penis is loose and elastic
to accommodate changes in penis size during an erection.

Semen, which contains sperm (reproductive cells), is expelled (ejaculated) through the end of the penis
when the man reaches sexual climax (orgasm). When the penis is erect, the flow of urine is blocked
from the urethra, allowing only semen to be ejaculated at orgasm.

Page 17
 Scrotum: This is the loose pouch-like sac of skin that hangs behind and below the penis. It contains
the testicles (also called testes), as well as many nerves and blood vessels. The scrotum acts as a
"climate control system" for the testes. For normal sperm development, the testes must be at a
temperature slightly cooler than body temperature. Special muscles in the wall of the scrotum allow it to
contract and relax, moving the testicles closer to the body for warmth or farther away from the body to
cool the temperature.

 Testicles (testes): These are oval organs about the size of large olives that lie in the scrotum, secured
at either end by a structure called the spermatic cord. Most men have two testes. The testes are
responsible for making testosterone, the primary male sex hormone, and for generating sperm. Within
the testes are coiled masses of tubes called seminiferous tubules. These tubes are responsible for
producing sperm cells.
 Epididymis: The epididymis is a long, coiled tube that rests on the backside of each testicle. It
transports and stores sperm cells that are produced in the testes. It also is the job of the epididymis to
bring the sperm to maturity, since the sperm that emerge from the testes are immature and incapable of
fertilization. During sexual arousal, contractions force the sperm into the vas deferens.

 Vas deferens: The vas deferens is a long, muscular tube that travels from the epididymis into the
pelvic cavity, to just behind the bladder. The vas deferens transports mature sperm to the urethra, the
tube that carries urine or sperm to outside of the body, in preparation for ejaculation.

 Ejaculatory ducts: These are formed by the fusion of the vas deferens and the seminal vesicles (see
below). The ejaculatory ducts empty into the urethra.

 Urethra: The urethra is the tube that carries urine from the bladder to outside of the body. In males, it
has the additional function of ejaculating semen when the man reaches orgasm. When the penis is
erect during sex, the flow of urine is blocked from the urethra, allowing only semen to be ejaculated at
orgasm.

 Seminal vesicles: The seminal vesicles are sac-like pouches that attach to the vas deferens near the
base of the bladder. The seminal vesicles produce a sugar-rich fluid (fructose) that provides sperm with
a source of energy to help them move. The fluid of the seminal vesicles makes up most of the volume
of a man's ejaculatory fluid, or ejaculate.

 Prostate gland: The prostate gland is a walnut-sized structure that is located below the urinary bladder
in front of the rectum. The prostate gland contributes additional fluid to the ejaculate. Prostate fluids
also help to nourish the sperm. The urethra, which carries the ejaculate to be expelled during orgasm,
runs through the center of the prostate gland.

Page 18
 Bulbourethral glands: Also called Cowper's glands, these are pea-sized structures located on the
sides of the urethra just below the prostate gland. These glands produce a clear, slippery fluid that
empties directly into the urethra. This fluid serves to lubricate the urethra and to neutralize any acidity
that may be present due to residual drops of urine in the urethra.

8.Physiology

 Skin Discoloration
Some women develop what's called the "mask of pregnancy." That tan-colored area around
your eyes will start to fade. Women who suffered from severe acne during pregnancy should see their
skin start to clear up. However, other women will begin to experience a red rash that around their
mouth and chin or suffer from extremely dry skin. Both of these conditions should be gone within
weeks.

 Breast Changes
Your breasts will probably become flushed, swollen, sore, and engorged with milk for a day or
two after the birth. Once this swelling goes down, in about three to four days (or until you stop
breastfeeding), your breasts will probably begin to sag as a result of the stretched skin. You may also
experience milk leakage for several weeks, even if you don't breastfeed.

Page 19
  Stomach Changes
Just after giving birth, your uterus is still hard and round (weighing about 2 1/2 pounds) and can
be felt just by touching your naval. In about six weeks, it will weigh only 2 ounces and will no longer be
felt by pressing on your abdomen. That mysterious brown line that you may have had down the center
of your lower abdomen during pregnancy will disappear. But, unfortunately, those stretch marks you
developed aren't going anywhere in the near future. Stretch marks tend to be bright red during and
shortly after pregnancy, but they will eventually become more of a silver color and begin to blend in with
your skin. Also, even the fittest moms will experience some flabbiness in the midsection after giving
birth. Sit-ups, certain yoga poses, and other abdominal exercises can get your tummy as flat as it once
was.

 Back Pain
Because it will take some time for the stretched abdomen muscles to become strong again, your
body is putting extra weight on the muscles of your back. This can lead to a backache until the
abdominal muscles tighten up again. A new mom can also be suffering from back pain due to poor
posture during pregnancy. Generally, these problems should clear up in the first six weeks after giving
birth. If not, you may want to see a chiropractor.

Page 20
  Incontinence
Without the baby pressing on your bladder any more, you're not urinating as frequently. But
pressure on the urethra during delivery can make urination difficult postpartum. New moms may also
suffer from incontinence or a urinary tract infection, which can cause a burning sensation during
urination.

 Vaginal pain and discharge

Your vagina may feel stretched and tender after the delivery. If you had an episiotomy, using
cold packs right after delivery can help ease discomfort. Shortly after delivery, you will start to have a
vaginal discharge made mostly of blood and what is left of the uterine lining from your pregnancy. This
is called lochia and can last for several weeks. You can usually start having sex again about three to
four weeks after giving birth. If you're breastfeeding at that point, you may experience vaginal dryness,
which can make intercourse very uncomfortable. Look for a water-soluble vaginal lubricant to ease the
pain. If you're not breastfeeding, expect your period to return about seven to nine weeks after delivery.
If you are breastfeeding, your periods may not return for several months -- or possibly not until you stop
breastfeeding altogether.

 Swollen legs and varicose veins

The swelling and puffiness in your legs that you may have experienced during pregnancy will
lessen very quickly after you give birth. However, some women begin experiencing twitchiness in their
legs postpartum. If this happens to you, walking can provide some relief. Spider veins and varicose
veins will probably improve with postpartum weight loss, but they will never go away completely.

 Sweating
You may start experiencing excessive sweating at night after giving birth. This is because your
body needs to get rid of all the extra fluids it accumulated during your pregnancy.

Page 21
  Ephysiotomy
Ephisiotomy is a minor surgery that widens the opening of the vagina during childbirth. It is the
cut to the perineum- the skin and muscle between the vaginal opening and anus.
There are some risk in having an ephisiotomy. Because of risks, ephisiotomies are not
as common as they used to be. The risks nclude:
 The cut may tear and become larger during the delivery. The tear may reach into the
muscle around the rectum, or even into the rectum itself
 There may be more bloodloss
 The cut and the stitches may get infected
 Sex may be painful for the first few months after birth.
Sometimes, an ephisiotomy can be helpful even with the risks.
Times when an ephisiotomy is often performed include:
 If you are pushing as the baby’s head is dose to coming out, and you tear up toward the
urethral area
 If labor is stressful for the baby and the pushing phase needs to be shortened to
decrease problems for the baby
 If the baby’s head or shoulders are too big for the mother’s vaginal opening
 If the baby in a breech position (feet or buttocks coming first) and there is a problem
during delivery
 If instruments ( forcep or vacuum extractor) are needed to help the baby out

Not every woman will need an ephisiotomy during childbirth. Many women get through childbirth
without tearing on their own, and without needing a cut.

Ephisiotomies don’t heal better than tears. They often take longer to heal since the cut is usually
deeper than a natural tear. In both cases, the cut or tear must be stitched and properly cared for after
childbirth.

Just before your baby is born, and as the head is about to crown, your doctor or midwife will give you a
shot to numb the area(if you haven’t had an epidural).

Next, a small incision (cut) is made. There are two types of cuts: median and medio-lateral.

Page 22
  The median incision is the most common type. It is a straight cut in the middle of the
perineum.
 The medio-lateral incision is made at an angle . it is less likely to tear through the anus,
but it takes longer to heal than a median cut.
Your Doctor will then deliver the baby through the enlarged opening.

 Next, your doctor will deliver the placenta(afterbirth)

 The cut will be stitched closed.

PHYSIOLOGY OF POST-PARTUM
Primary responsibilities of nurses in postpartum settings are to assess postpartum patients, provide
care and teaching, and if necessary, report any significant findings. Postpartum nurses are essentially
detectives searching for findings that might lead to negative outcomes for patients if left unattended.
Thus, it is imperative for nurses to distinguish between normal and abnormal findings and to have a
clear understanding of the nursing care necessary to promote patients’ health and well-being.
Many nurses find it useful to use the acronym BUBBLE-LE to remember the necessary components of
the postpartum assessment and teaching topics. These include:
 Breasts
 Uterus
 Bowel function
 Bladder
 Lochia
 Episiotomy/perineum
 Lower extremities, and
 Emotions

Breasts
Assess the breasts for:
 Signs of engorgement, including fullness, around postpartum days 3 and 4
 Hot, red, painful, and edematous areas, which could indicate mastitis
 Nipple condition and latch-on technique of women who are breastfeeding
Breastfeeding women should wear a comfortable, well-fitted support bra. Instruct them to gently rub
colostrum or breast milk into their nipples and allow the nipples to air dry after each feeding to
“condition” the nipples. Mothers can prevent drying by avoiding soap when washing the nipples.
It is also extremely important to teach patients proper breastfeeding techniques to ensure a positive
experience for mothers and their infants. Teaching proper latch-on techniques and how to break the
infant’s suction after feeding can have a positive and lasting effect upon mothers’ breastfeeding

Page 23
 experiences. Otherwise, mothers may develop sore, cracked, and sometimes bleeding nipples, which
can discourage the continuation of breastfeeding.
According to the Joanna Briggs Institute (2009), “Among the options of applying warm-water
compresses, breast milk, or teabags, the placement of a warm-water compress was found to be the
most effective intervention in controlling nipple pain and trauma.”
Instruct bottle-feeding patients to wear a well-fitting support bra and to avoid any type of nipple
stimulation until lactation is discontinued.

Uterus
Assess the fundus:
 By approximately one hour post delivery, the fundus is firm and at the level of the umbilicus.
 The fundus continues to descend into the pelvis at the rate of approximately 1 cm or finger-breadth per
day and should be nonpalpable by 10 days postpartum.
In addition, assess patients for uterine cramping and treat for pain as needed.
Patients or a family member can be taught to assess the firmness of the fundus and to provide
massage in the event of a boggy uterus or excessive bleeding. Encourage patients to void before
palpation of the uterine fundus because a full bladder displaces the uterus and can lead to excessive
bleeding.

Bowel Function
Assessment of the bowel is important in all postpartum patients. It is especially vital for patients
following C-sections. Assess for the following:
 Bowel sounds
 Return of bowel function
 Flatus
 Color and consistency of stool
Administer prescribed stool softeners or laxatives as needed to treat constipation and ease perineal
discomfort during defecation.
Encourage patients to ambulate soon after delivery. Teach the need to eat fruits, vegetables, and other
high-fiber foods daily. Postpartum patients should consume at least 2,000 mL/day of fluid. While
patients may consider 2,000 mL a lot to drink in one day, consumption can be spread out throughout
the day.

Bladder
Assess urination and bladder function for the following:
 Return of urination, which should occur within 6 to 8 hours of delivery

Page 24
 For approximately 8 hours after delivery, amount of urine at each void. Patients should void a minimum
of 150 mL per void; less than 150 mL per void could indicate urinary retention due to decreased bladder
tone post delivery (in the absence of preeclampsia or other significant health problems).
 Signs and symptoms of a urinary tract infection (UTI)
The bladder should be nonpalpable above the symphysis pubis.
Encourage patients to drink adequate fluid each day and to report signs and symptoms of a urinary
tract infection, including frequency, urgency, painful urination, and hematuria.

Lochia
Assess lochia during the postpartum period:
 Saturating one pad in less than an hour, a constant trickle of lochia, or the presence of large (i.e., golf-
ball sized) blood clots is indicative of more serious complications (e.g., retained placenta fragments,
hemorrhage) and should be investigated immediately. A significant amount of lochia despite a firm
fundus may indicate a laceration in the birth canal, which should be addressed immediately.
 Foul-smelling lochia typically indicates an infection and needs to be addressed as soon as possible.
 Lochia should progress from rubra to serosa to alba. Any changes in this progression could be
considered abnormal and should be reported. Lochia rubra is present on days 1–3, lochia serosa on
days 4–10, and lochia alba on days 11–21.
It is important to note that patients who had a C-section will typically have less lochia than patients who
delivered vaginally; however, some lochia should be present.
After discharge, patients should report any abnormal progressions of lochia, excessive bleeding, foul-
smelling lochia, or large blood clots to their physician immediately. Instruct patients to avoid sexual
activity until lochial flow has ceased.

Episiotomy/Perineum
The acronym REEDA is often used to assess an episiotomy or laceration of the perineum. REEDA
stands for:
 Redness
 Edema
 Ecchymosis
 Discharge
 Approximation
Redness is considered normal with episiotomies and lacerations; however, if there is significant pain
present, further assessment is necessary. Furthermore, excessive edema can delay wound healing.
The use of ice packs during the immediate postpartum period is generally indicated.
There should be an absence of discharge from the episiotomy or laceration, and the wound edges
should be well approximated. Perineal pain must be assessed and treated. Nurses are encouraged to

Page 25
assess the rectal area for hemorrhoids and, if present, should instruct patients to discuss hemorrhoidal
treatments (e.g., witch hazel pads or other over-the-counter hemorrhoid medications) with their certified
nurse-midwife or physician.
Various actions can aid in perineal healing. To avoid infection, teach patients to pat from front to back
and to use a peri-bottle for gentle cleansing of the perineum after a bowel movement or urination. Many
certified nurse-midwives and physicians prescribe topical ointments and sprays to ease the discomfort
of a sore perineum. If one of these has been prescribed, instruct patients to use a sitz bath and then
apply the suggested topical agent for best results.
Analgesics are often prescribed for pain. Patients are generally instructed to apply ice packs to the
perineum immediately after delivery. Inform patients with lacerations and episiotomies that, as sutures
dissolve, the perineum may itch and that this is normal in the absence of any other perineal
abnormalities. Instruct patients to avoid tampons and sexual activity until the perineum has healed.
Performing Kegel exercises are an important component of strengthening the perineal muscles after
delivery and may be begun as soon as it is comfortable to do so.

Lower Extremities
To assess for deep vein thrombosis (DVT), the lower extremities should be examined for the
presence of hot, red, painful, and/or edematous areas.
Assess the legs for adequate circulation by checking the pedal pulses and noting temperature and
color. In addition, the lower extremities should be assessed for edema. Pedal edema is normally
present for several days after delivery as fluids in the body shift. However, lasting edema should be
reported for further assessment.
To improve circulation and prevent the development of thrombi, encourage patients to ambulate shortly
after delivery. Also teach them to avoid crossing the legs for long periods of time and to keep the legs
elevated while sitting. Many certified nurse-midwives and physicians seek to combat the development
of thrombi by encouraging patients to wear TED hose and/or sequential compression
devices (SCDs) after delivery.

ASSESSING FOR DVT

In the past, postpartum nurses assessed for DVTs by eliciting a Homan’s sign (dorsiflexion of the foot).
The presence of pain when eliciting the Homan’s sign indicated the probable presence of a DVT.
However, it is now contraindicated to use the Homan’s sign to assess for DVTs, as this action may
dislodge a clot. Massage of the legs should also be avoided.
Emotions
Emotions are an essential element of the postpartum assessment. Postpartum patients typically exhibit
symptoms of the “baby blues” or “postpartum blues,” demonstrated by tearfulness, irritability, and
sometimes insomnia. The postpartum blues are caused by a multitude of factors, including hormonal

Page 26
fluctuations, physical exhaustion, and maternal role adjustment. This is a normal part of the postpartum
experience.
If symptoms last longer than a few weeks or if the postpartum patient becomes nonfunctional or
expresses a desire to harm herself or her infant, she should be instructed to report this to her certified
nurse-midwife or physician immediately. Appropriate interventions should be implemented to protect
the mother and her infant; this behavior is indicative of postpartum depression (discussed below under
“Postpartum Complications”).
Postpartum mothers and their families should be taught to understand that the baby blues are a normal
part of the postpartum experience. Encourage patients to rest regularly and to allow family members to
care for them as needed. Instruct patients to get plenty of fresh air and gentle exercise. Acquaint
patients with groups for new mothers that provide the support of others experiencing postpartum blues.
Finally, teach postpartum mothers and their families about the signs and symptoms of postpartum
depression.

OTHER ASSESSMENTS
Vital Signs
During the postpartum period, women may exhibit a slight temperature elevation due to dehydration
following delivery or as a result of breast milk coming in around day 3 or 4. Immediately after delivery,
the blood pressure should remain the same as during delivery. An increase in blood pressure could
indicate gestational hypertension (previously referred to as pregnancy-induced hypertension), while a
decrease could indicate shock or orthostatic hypotension. Slight bradycardia is normal immediately
after delivery; however, tachycardia could indicate hemorrhage or infection and should be monitored
carefully. Respirations are usually within the normal range for an adult.
Pain
During the postpartum period, it is very important that healthcare providers continually assess a patient
for pain, taking into account the patient’s acceptable pain levels. They should look for pain in all areas
of the body, including the head, chest, breast, back, limbs, abdomen, uterus, perineum, and
extremities. Positioning during labor may cause muscular discomfort, and headaches can indicate
gestational hypertension. Patients should also be assessed for emotional pain and treated accordingly.
Mild analgesics or narcotics may be prescribed. Providers can also teach nonpharmacologic methods
of pain relief to the patient and her family. Some of these methods include the application of hot or cold
packs, massage, progressive relaxation, and meditation.

Page 27
 Primary Follicle in ovary containing
immature ovum

Secretes
progesterone Corpus
luteum
(and
formed
Follicle matures
estrogen)which
support any in ovary
subsequent
pregnancy

Ovulation:
Ovum release

Ovum
fertilized
Ovum not fertilized

Secretes human
chorionic secr Embeds in Uterine
gonadotropin walls
ete menstruation
s

Pregnancy
New cycle begin

(www. Eurocytology.eu)

Physiology of Conception and Menstruation

Page 28
B. Planning
Name: Patient X
Age: 21 years old
Date admitted: November 8, 2016
Diagnosis: Risk for Infection

Assessment Diagnosis Planning Intervention Rationale Evaluation

 Subjective:  risks of  After 4 hrs of  Encouraged  To maintain After 4 hrs. of
“May tinahi po infection proper the client to clean perineal proper nursing
yung doctor sa related to nursing perform area free from intervention the
akin dahil traumatized intervention proper infection patient identified
kailangan daw skin tissue the patient perineal care intervention to
lakihan para secondary to will identify  Advised to  To reduce prevent risks of
mabilis lumabas episiotomy interventions use warm discomfort and infection and
yung baby.”-as to prevent water during to keep it clean achieved timely
verbalize by the risk of perineal wound healing
client infection and washing and free from
achieved  Instructed to  For immediate infection.
 Objective: timely wound keep the area healing of Demonstrated
-poor hygiene healing free clean and dry stitches proper techniques
-unable to perform from to promote safe
proper perineal infection by  Facilitated  To improve and clean
care due to demonstratin kegel’s circulation and environment.
discomfort g proper exercise to speed up the
-improper techniques to healing time
environmental promote safe -GOAL MET-
sanitation and clean  Instructed the  Too long of
environment client to using pads may
 Vital signs as change her contaminate
follows: pad regularly the wound area
T- 36.5C
P- 82bpm  Emphasized  To eliminate the
R- 24 the presence of
BP-100/80 importance of rodents and
clean microorganisms
environment that may cause
eradicating contamination
things that is to mother and
not important child
throughout
the
confinement
such as used
clothes,
waste
products and
plastics and
bottles

Page 29
Name: Patient X
Age: 21 years old
Date admitted: November 8, 2016
Diagnosis: Ineffective breastfeeding
Assessment Diagnosis Planning Intervention Rationale Evaluation
 Subjective  Ineffective  After 4 hrs. of  Recommended  Proper  After 4 hours
“Madam dahil breastfeeding proper nursing and positioning
of proper
nga first time ko related to intervention, demonstrated will provide
hindi pa ako knowledge the patient will
use of variety comfort for nursing
of nursing the mother intervention
masyadong deficit demonstrate positioning in and the infant
marunong mag proper breastfeeding the patient
pa dede”, as techniques to such as cradle demonstrated
verbalized. improve hold, football proper
breastfeeding hold, underarm
techniques to
 Objective experience. and back
-noted an support In a improved
quiet and breastfeeding
improper comfortable
positioning of the environment  Early
experience
baby  Inform the recognition of
mother about infant hunger -GOAL MET-
-unable to early promotes
identify feeding intervention more
cues feeding cues rewarding
such as feeding
rooting, licking, promotion for
-curiosity about
mouthing, mother and
proper sucking and lip infant
breastfeeding smacking.

-weak in  Demonstratred  To stimulate

appearance early milk
management production
-primigravida of and to
breastfeeding enhance let-
problem such down reflex
Vital Signs as inhibited let-
taken: down- apply
T- 36.7C warm towel to
P- 82 bpm the breast area
R-23  Demonstrated  To prevent
BP-100/80 proper breast contamination
and nipple upon
care before breastfeeding
latching on
 Encourage  To limit
frequent rest fatigue and
period facilitate
relaxation of
feeding times

 Encourage to  To promote
eat high breastfeeding
protein and production
proper diet and optimize
such as lean infants growth
meat, egg and
white, milk and development
green leafy
vegetables

Page 30
 C.IMPLEMENTATION
1. DRUGS
Name of Drugs Date Route, General action Indication/Purpos Client’s Nursing
Administer dosage, e
ed and
response responsibilities
frequency
 Ampicillin  11/8/16  IV  Bactericidal  Treatment of  Anti-  Contraindicat
push, action infections
250- against caused by
negative e d with
500mg sensitive susceptible skin allergies to
q6 hrs. organisms, strains of testing(-) penicillins,
inhibits shigella, caphalosporin
synthesis of salmonella,
bacterial cell E.coli,  no s, or other
wall, H.influenza, adverse allergens.
causing cell P.mirabilis, effect
death. N.gonorrhea,
enterococci, noted to
gram-postive the
organism. patient

 Mefenamic acid 11/8/16  Oral,  Anti-  Relief of  Contraindicat

500mg inflammator moderate pain ed with
1 cap., y, when therapy
TID analgesics, will not exceed hypersensitivit
and 1wk and y to
antihyperten treatment of mefenamic
sic activities primary
related to dysmenorrhea
acid and ASA
inhibition of allergy. Use
prostaglandi cautiously
n synthesis: with asthma,
exact
mechanism renal or liver
s of action dysfunction,
are not peptic ulcer
known.
disease, GI
bleeding,
hypertension,
CHF,
pregnancy,
and lactation.

 Ferrous Sulfate 11/8/16  Oral, 1  Elevates the  Prevention and  Contraindicat
cap, serum iron treatment of ed with
TID concentratio iron deficiency allergy to any
n, which anemias .
then helps Dietary ingredient;
to form supplement for sulfate allergy;
hemoglobin iron. hemochromat
or trapped
in the
osis,
reticuloendo hemosiderosis
thelial cells

Page 31
 for storage , hemolytic
and
eventual
anemias. Use
conversion cautiously
to a usable with normal
form of iron iron balance;
peptic ulcer
regional
enteritis,
.
ulcerative
colitis.
 Cortisone  Oral, 1  Enters  Replacement  Contraindicat
acetate  11/8/16 tab a target cells theraphy in
ed with
day where it has adrenal cortical
antiinflamm insufficiency. infections,
atory and Hypercalemia especially
immunosup related with tuberculosis,
pressive cancer. Short-
(glucocortic term fungal
oid) and management infections,
salt- of various amebiasis,
retaining inflammatory
(mineralocor and allergic
vaccinia, and
ticoid) disorders: varicella, and
effects. Rheumatoid antibiotic-
arthiritis, resistant
collagen
disease (SLE), infections,
dermatologic pregnancy,
disease(pemp lactation. Use
higus), status
asthmaticus, cautiously
and with renal or
autoimmune hepatic
disorders.
Ulcerative
disease;
colitis, acute diabetes
exacerbations mellitus,
of multiple pregnancy,
sclerosis, and
palliation in lactation.
some
leukamias and
lymphomas.

 Cephalexin  Oral,1  For  Respiratory

 11/8/16 cap, bactericidal: tract infections  Contraindicat
500mg, inhibits caused by
TID synthesis of streptococcus
ed with
bacterial cell pneumoniae, allergy to
wall, group A beta cephalosporin
causing cell hemolytic s or
death. streptococci.
Dermatologic penicillins.
infections Use cautiously
caused by with renal
staphylococcu
s,
failure,
lactation,
pregnancy.

Page 32
2.MEDICAL MANAGEMENT

Medical Date performed/ General Description Indication/ Client’s

management/ Date Purpose reaction to

Treatment discontinued treatment

Intravenous Fluid Performed: Hypertonic, Treatment for Client was able to

of 5% Dextrose in 11/8/16 nonpyrogenic,parenteral persons needing tolerate the

Lactated Ringer’s Discontinued: fluid, electrolyte and extra calories who treatment well,

Solution 1L x 30 11/9/16 nutrient replenisher cannot tolerate with no signs of

gtts/min Administered fluid overload. distress or adverse

intravenously , has a value It helps to prevent reactions

as a source of water, dehydration to the

electrolytes and calories patient

or as an alkalinizing agent.

3. SURGICAL MANAGEMENT

Name of Date Brief Indication/Purpose Client’s Nursing

procedure performe descripti s response to Responsibilities
d on operation
Episiotomy 11/8/16 Episiotomy -If you are pushing as -client stated 1. Apply an icepack on
and repair is minor the baby’s head is at first she perineum to help
surgery close to coming out, didn’t felt the reduce swelling and
that widens and you tear up pain upon ease the pain.
the toward the urethral cutting the area
opening of area. due to severe 2. Instructed to tighten
the vagina labor pain but buttocks upon sitting
during -If labor is stressful for when the baby to prevent from
childbirth. It the baby and the is out she felt stretching and pulling
is a cut to pushing phase needs the pain upon at the stitches.
the to be shortened to stitching the
perineum- decrease problems for tear. 3. Intstructed to pour
the skin the baby. water over the wound
and during urination to
muscles reduce discomfort and
between to keep it clean.
the vaginal
opening 4. Instructed to keep
and anus. the area clean and dry
to encourage the
stitches to heal.

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 5. Instructed to
perform Kegels
exercise to improved
circulation and speed
up the healing time.

6. Drink plenty of
water to reduce
constipation upon
bowel movement.

4.DIET

TYPE OF DIET DATE INDICATIONS NURSING RESPONSIBILTY

For post-partum: 11/8/2016 -aiding in muscle relaxation , -Listed and encouraged to eat
High Calcium blood coagulation, transmission the following:
of nerve impulses, and 1.Dairyproducts(milk,butter)
enzymes reactions, as well as 2. Fish
promoting tooth and bone 3. Green-leafy vegetables
health and preventing (malunggay, beans, kale, okra,
osteoporosis. ampalaya, sweet potatoes)

- Dietary requirements for iron -Oysters, beef liver, and lean

High-Iron return to pre-pregnancy levels beef are excellent sources of
in the postpartum period— iron.
15mg/day. Postpartum iron
supplementation may be
indicated when blood loss is
higher than usual during vaginal
delivery or the interval between
pregnancies is less than two
years.

What to eat
For Breastfeeding -protein is an important  Include protein foods 2-
-High Protein component of breast milk, 3 times per day such as
consuming plenty of protein can meat, poultry, fish, eggs,
help maximize your milk supply, dairy, beans, nuts and
which will help optimize your seeds.
infant’s growth and
 Eat three servings of
development.
vegetables, including dark
green and yellow vegetables
per day.
 Eat two servings of fruit
per day.
 Include whole grains
such as whole wheat
breads, pasta, cereal and
oatmeal in your daily diet.

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  Drink water to satisfy
your thirst. Many women
find they are thirsty while
breastfeeding; however,
forcing yourself to drink
fluids does not increase your
supply.

5. ACTIVITY/EXERCISE

Type of exercise GENERAL INDICATIONS/PURPOSE CLIENT’S

DESCRIPTION RESPONSE

1. Early  Performs  For normal functioning  The patient

ambulation physical activity and circulation of the maintained muscle

independently cardiovascular and strength and

musculoskeletal systems. improves circulation.

2. Kegel’s  Tighten the  Improves muscle  The patient will

Exercise perinial circulation and speed up relieve from pain and

muscles. healing process in improves muscle

patients with episiotomy. strength in the

perinial floor.

3. Deep breathing  Respiratory  Essential for vasodilation  It promotes comfort

exercise and tissue and improves circulation and relaxation to the

circulaton patient to prevent

fatigue.

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6.NURSING MANAGEMENT (SOAPIE)
Date performed: November 9, 2016
Age: 21
Dx:NSD
Date admitted: November 8, 2016

 S- “Hanggang ngayon masakit padin yung tahi ko”, as verbalized.

 O- Facial grimace upon moving
- limited movement
- Pain scale of 6/10
- Lochia: Moderate
- Vital signs as follows:
BP: 100/80
T: 36.5C
P: 82 bpm
R: 24/ min
- with ongoing Intravenous fluid of 5% Dextrose in Lactated Ringer’s Solution 1L at 700mL on
the right arm regulated at 20 gtts/min infusing well.
 A- Acute pain related to perineal incision
 P- After 4 hours of proper nursing intervention, the patient will report pain is relieved and will
able to demonstrate use of relaxation skills and diversional activities.
 I- Demonstrated proper breathing exercise
 Encouraged to use lukewarm water in perineal washing to promote comfort.
 Instructed proper body mechanics in breastfeeding and rest periods to minimize the pain.
 Encouraged to increase fluid intake to replenish the needs of the body.
 Encouraged to take high-protein and high-iron diet to gain energy and to speed up the healing
process of the wound.
 E- After 4 hours of proper nursing intervention, the patient was relieved and demonstrated the
use of relaxation exercise and diversional activities.

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D. EVALUATION
DISCHARGE PLANNING

POST PARTUM DISCHARGE PLAN

Breastfeeding:

 Wash breast with lukewarm water daily for cleanliness.

 Air dry nipples after each feeding.
 If breasts are engorged, apply warm packs and express milk.
 Practiced feeding per demand.
Uterine Changes:

 After pains, or cramping are normal. This cramping means that the uterus is contracting to
return to its non-pregnant size. The uterus takes 5-6 weeks to return to its non-pregnant size.
Vaginal Discharge

 Usually lasts about 10 days t0 4 weeks. The color will change from bright red to brownish to tan
and will become in approximately 6-8 weeks, unless breastfeeding.
 Maintain good perinial and personal hygiene by taking a bath every day.
 Menstruation : Periods will resume in approximately 6-8 weeks, unless breastfeeding.
Care of Episiotomy

 Sitz Bath: sitting in a tub of warm water for 15 minutes, 2-3 times per day will help relieved the
discomfort.
 Keep the area clean and dry to speed up the healing process.
 Stitches will dissolve in 1-3 weeks.
Diet and Nutrition

 Continue taking prenatal iron and vitamin pills until the post-partum visit.
 It is important to eat well-balanced diet and drink plenty of fluids. Drink two quarts of fluid per
day if you are breastfeeding.
Post-partum Visit

 Follow the allotted date of post-partum visit thus the post-natal check-ups.

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III.CONCLUSION
For at least 2 days of gathering data on our proposed case study about post-partum of normal
spontaneous delivery, we encountered memorable learning experienced in the implementation and
interventions of the post-partum cases in the OB ward. At first we were very excited and nervous, but
as the days passed by we were able to conquer our fears and able to perform nursing procedures in
the best of our knowledge. The exposure in OB ward taught us on how to handle post-partum women
and newborn care. We performed cord care to newborn and demonstrated it to their mothers. It was
fulfilling to be able to impart some health teaching and necessary management during their
confinement. Seeing our patients cooperating with our nursing care makes us more productive and
confident with our nursing practice. We had a short period of time gathering all the data but, we didn’t
lose hope and we conducted research about the case we were handling. We applied the outline that
was given to us and with the good cooperation of our chosen client, we were able to assemble and
performed assessment to evaluate the patient. We learned from this case the importance of post-
partum care and the Physiology of Normal Spontaneous Delivery. From this learned experienced it will
served as a stepping-stone for us to strive more. With the help of our very supportive and kind-hearted
instructor Ma’am Merlie Espiritu we were able to conquer day by day challenges. We are so blessed
because she is not just a clinical instructor to us but also a mother who guides and correct our
mistakes, that is why we also dedicate this case study to her, and we hope we made her happy.

IV.RECOMMENDATION

Care in Preparation for Discharge

Before the woman is discharged, she must be educated properly regarding the care of the newbornand
herself at home.

 Assess first the ability of the mother to absorb new instructions and to listen.
 Conducting group classes regarding newborn care could greatly help mothers learn not only
what the instructors teach but also from the experiences that some mothers could share to
the group.
 It is also recommended for fathers to attend such classes so the mother would have
someone she can rely on with the newborn care.
 Individual instruction is also sought after postpartum, as the family will need to know how to
care for the woman and the newborn after discharge.
 Teaching should not always be formal; it may come in the form of comments during classes
or procedures.

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  Instruct the woman to avoid lifting heavy objects for the first three weeks after birth.
 Advise the woman to allot a rest period every day, or to rest and sleep while her newborn is
also asleep so she can regain her energy.
 Be certain that the woman is aware that she must return to the healthcare facility after 4 to 6
weeks for examination and that she must arrange an appointment for her baby to be
examined by a pediatrician at 2 to 4 weeks of age.
 Make sure that the woman and the family understood the discharge instructions amidst all
the frenzy of the new baby; review instructions with parents before they leave.
 Calling or visiting 24 hours after discharge is the best way to evaluate whether the family has
been able to grasp all instructions and integrate the newborn into the family.

Care after Discharge

Discharge from the healthcare facility usually occurs after 2 to 3 days after birth.

 The woman can rest better at home and may eat better if she has cultural preferences
regarding food.
 The newborn can also be exposed earlier to the routines of the family, and make it easier for
her to adjust to extrauterine environment.
 A home visit after the discharge is usually recommended to check on how the family is doing
now that they have a newborn in the house.
 High-risk newborns, newborns born to adolescent mothers, and newborns with mothers who
have abused drugs during pregnancy need to have a specially planned discharge and home
visit.
 Pregnancy history is assessed during the postpartum visit and if there are any difficulty with
the bonding between the mother and the baby, and allow the woman to relate her labor and
birth experiences.
 Assess the newborn history and if there are any concerns about the newborn that the
woman has noticed.
 Assess the woman’s future plans, whether she is going back to work outside home and if
she had already arranged the care of her newborn while she is away.
 Conduct a family assessment and ask if other members of the family are adapting well with
a newborn in the house.

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  Examine both the mother and the newborn physically to note any signs of postpartum
complications or defects.
 Remind the mother about the health maintenance visit of the newborn once she reaches 2 to
4 weeks old, and her return checkup 4 to 6 weeks after birth.

V.REVIEW OF RELATED LITERATURES/STUDIES

Systematic review of the literature on postpartum care: methodology and literature search results.

Abstract
BACKGROUND:
The postpartum period is a time for multiple clinical interventions. To date, no critical review of these
interventions exists. This systematic review examined evidence for the effectiveness of postpartum
interventions that have been reported in the literature.

METHODS:
MEDLINE, Cinahl, PsycINFO, and the Cochrane Library were searched for randomized controlled trials
of interventions initiated from immediately after birth to 1 year in postnatal women that were conducted
in North America, Europe, Australia, or New Zealand. The initial literature search was done in 1999,
using postpartum content search terms, and was enhanced in 2003. In both years, bibliographic
databases were searched from their inception. Studies were categorized into key topic areas. Data
extraction forms were developed and completed for each study, and the quality of each study was
systematically reviewed. Groups of studies in a topic area were reviewed together, and clinically
relevant questions emanating from the studies were identified to determine whether the studies, alone
or together, provided evidence to support the clinical intervention.

RESULTS:
In the 1999 search, of 671 studies identified, 140 studies were randomized controlled trials that met the
selection criteria: 41 studies related to breastfeeding, 33 to postpartum perineal pain management, and
63 to 11 other key topic areas (Papanicolaou test, rubella immunization, contraception, postpartum
support, early discharge, postpartum depression and anxiety, postpartum medical disorders, smoking
cessation, nutrition supplements other than breastfeeding, effects of pelvic floor exercise, and effects of
early newborn contact). The results of the systematic review of each topic will be summarized in
separate papers as they are completed.

CONCLUSIONS:
This systematic search has identified key topic areas in postpartum care for which randomized
controlled trials have been conducted. Our ultimate goal is to provide evidence-based guidelines on the
use of routine postpartum interventions.

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VI. BIBLIOGRAPHY/REFERENCES
 From our observation
 From client
 From clinical instructor
 Client’s chart
 Lectures

Internet References

 http://msdoctor.net/wp-content/uploads/2015/08/Post-Pregnancy-Back-Pain-e1391623990668.jpg
 http://www.slideshare.net/pinoynurze/case-studynsvd
 http://www.parents.com/pregnancy/my-body/postpartum/common-postpartum-body-
changes/?slideId=50757
 https://www.google.com.ph/search?q=skin+discoloration+post+pregnancy&biw=1366&bih=662&sourc
e=lnms&tbm=isch&sa=X&sqi=2&ved=0ahUKEwiM9pKEy6LQAhVBxGMKHa3_CtUQ_AUIBigB#tbm=isch&
q=stomach+changes+in+post+pregnancy&imgrc=2tZS3UZNLsLhhM%3A
 http://assets.babycenter.com/ims/2015/06/531415043_wide.jpg?width=600
 http://www.slideshare.net/homeworkping2/189787229-casestudynsdprimi
 http://www.arhp.org/publications-and-resources/quick-reference-guide-for-clinicians/postpartum-
counseling/diet
 http://www.chop.edu/pages/diet-breastfeeding-mothers
 http://www.doh.gov.ph/sites/default/files/publications/MNCHNMOPMay4withECJ.pdf

Book reference
 Lippincott’s Nursing Drug guide
 Pediatric Nursing Nicki L. Potts
 Nursing Pocket Guide Edition 11

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