LABOR AND DELIVERY ASSESSMENT

I. VITAL INFORMATION
Name: LJS Date and Time of Interview:
Age: 20 September 25, 2019 4 AM
Address: Brgy. Sto. Niño, San Miguel, Iloilo
Civil Status: Single (Unwed) Relationship to patient:
Date and Time admitted: 03:22 PM, September 22, 2019 Herself
Chief complaint: Abdominal pain with periodic contractions
Ward: OB
Bed No:
Allergies: None
Religious Affiliation: Catholic
Physician’s Initial: SMC
Impression/Diagnosis: PUFT delivered to a live baby girl via NSVD in cephalic presentation A/S9/10,
G1P1, RMLE repair

II. CLINICAL ASSESSMENT

A. OBTETRICAL DATA
1. Age of menarche: approximately 11-12 years old
2. G1P1(T1P1A0L0)
3. Description of previous pregnancies: N/A

Pregnancy/ies Type of delivery Complications of labor and delivery

_____________N/A____________________ ______________N/A___________

4. LMP (Last Menstrual Period): December 05, 2018

5. EDC (Expected Date of Confinement): September 12, 2019
6. Prenatal check-up: September 20, 2019
7. Description of present pregnancy:
8. Medications taken during pregnancy: None
9. Discomforts on present pregnancy: None
10. Progress of labor: Not assessed because patient came in for emergency deliver

Time Duration Interval Intensity

N/A N/A N/A N/A

11. Description of each stages of labor

II.A Stages of Labor:
a. First Stage
The first stage is divided into three segments:
a.1. Latent phase – starts at the onset of regular perceived uterine contractions and ends
when cervical dilatation begins. Contractions are mild and short, lasting 20 to 40 seconds. Usually
progresses more quickly in multiparous women than a nullipara. Women are encouraged to continue to
walk about and make preparations for birth, such as doing last minute packing for her stay at the hospital
or birthing center, preparing older children for her departure and the upcoming of them while she is away.

a.2. Active phase – cervical dilatation occurs more rapidly in this stage. Contractions grow
stronger, lasting 40 to 60 seconds, and occur approximately 3 to 5 minutes. Show (increased vaginal
secretions) and perhaps spontaneous rupture of membranes of the membranes may occur. In this stage
women are encouraged to be active participants in labor by keeping active and assuming whatever position
is most comfortable for them during this time, except flat on their back. Can be very difficult for them since
contractions grow so much stronger and last so much longer than they did in the latent phase that she
begins to experience true discomfort.

a.3. Transition phase – in this phase contractions reach their peak of intensity, occurring every
2 to 3 minutes with a duration of 60 to 70 seconds and a maximum dilation of 8 to 10 cm occurs. Show will
occur as the last of the mucus plug from the cervix is released and rupture of membranes will occur if it did
not rupture before due to full dilatation (10cm). during this phase a woman, may experience intense
discomfort that is so strong, it might be accompanied by nausea and vomiting. May experience a feeling of
loss of control, anxiety, panic and/or irritability. The irresistible urge to push, usually begins.

b. Second stage – is the time span from full dilatation and cervical effacement to birth of the
infant. An uncontrollable urge to push or bear down with each contraction as if to move her bowels. She
may experience momentary nausea and vomiting because pressure is no longer exerted on her stomach
as the fetus descends into the pelvis. She pushes with such force that she perspires and the blood vessels
in her neck become distended. Anus may become everted and stool may be expelled. Crowning is noted.
Pain may disappear as all of her energy and thoughts are directed toward giving birth. Fetus is exerted and
pushed out of the birth canal. The baby is born.

c. Third stage – also known as the placental stage, begins with the birth of the infant and
ends with the delivery of the placenta. Two separate phases are involved:

c.1. Placental separation - as the uterus contracts down on an almost empty interior, there is such
a disproportion between the placenta and the contracting wall of the uterus that folding and separation of
the placenta occur. Active bleeding on the maternal surface of the placenta begins with separation, which
helps to separate it by pushing it away from the attachment. As it completes, the placenta sinks to the lower
uterine segment or the upper vagina.

c.2. Placental Expulsion/Delivery – the placenta has loosened and ready to deliver when, there is
lengthening of the umbilical cord, a sudden gush of vaginal blood occurs, the placenta is visible at the
vaginal bleeding and the uterus contracts and feels firm again. It is either delivered by the natural bearing
down of the mother or by gentle pressure on the contracted uterine fundus by the primary health care
provider (a Credé maneuver). Pressure should never be applied to noncontracted uterus because doing so
could cause the uterus to evert, accompanied by massive hemorrhage. Remaining placental fragments
should always be evacuated to prevent pospartal bleeding.

d. Fourth stage – this stage expands from the delivery of the placenta to the first 2 hours
postpartum. In this stage the mother and the fetus is closely monitored for any signs postpartum
complication. The mother and the baby is monitored every 15 minutes for the first hour and every 30 minutes
for the next hour. Administration of Vitamin K and Hepatitis B are administered during this time and
erythromycin is administered as prophylaxis. The mother is monitored for signs of bleeding or shock.

II.B Schematic diagram

Ovum Fertilization occurs Sperm
after the union of
the sperm and
ovum

Zygote is
formed after
fertilization

Zygote
implants itself
to the uterine
endometrium
 Enlargement
 Frequent of breasts
urination  Thickening of
the fundus
 Increased
appetite
 Nausea/
 v Embryo is formed
until 8th week

 Linea nigra Fetus continues to grow from

 Uterine
9th week until delivery
 Melisma enlargement
 Striae  Quickening
gravidarum (kick counts)
 Fatigue
 Braxton Hicks
contractions

Estimated Birth Date calculated

after 280 days after the last
menstrual period.

 Periodic
contractions
Labor
 Show
 Rupture of
membranes
PUFT delivered to a live baby girl via NSVD in cephalic
presentation A/S9/10, G1P1, RMLE repair

II.C Management
a. Nursing
Initial interview and physical examination is done to gain information about the
woman’s pregnancy, through her prenatal record upon admission. Questions might
include her Expected Date of Birth (EDB), when her contractions began, amount and
character of show whether rupture of membranes have occurred, any known drug
allergies and history of pregnancies and her birth plan. Assess for the vital signs,
nature of contractions, her pain rating on a 10 – point scale, urine specimen, position
and presentation of her fetus.
Leopold’s maneuver is a systematic method of observation and palpation to
determine fetal presentation and position, done as part of the physical examination.
Auscultation of fetal heart sounds is also performed every 30 minutes during
latent labor, every 15 minutes during active first stage labor and every 5 minutes
during second stage of labor. A Doppler unit (which uses ultrasound waves that
bounce off the fetal heart to produce echoes or clicking noises, which reflect the fetal
heartbeat), a Pinard stethoscope (a hollow tube that direct sounds directly into the
ear) or a fetoscope (a modified stethoscope attached to a headpiece).
The woman is also taught about deep breathing exercises and they are told to
assume whatever position that is comfortable for them.

b. Medical
Determine

c. Surgical
Episiotomy is a cut (incision) through the area between your vaginal opening and your anus. This
area is called the perineum. This procedure is done to make your vaginal opening larger for childbirth.
Normally, once the baby’s head is seen, your healthcare provider will ease your baby’s head and
chin out of your vagina. Once the baby’s head is out, the shoulders and the rest of the body follow.
Sometimes the vaginal opening does not stretch enough for the baby’s head. In this case, an
episiotomy aids your healthcare provider in delivering your baby. It’s important to make a surgical incision
rather than letting the tissue tear. Your provider will usually do an episiotomy when the baby’s head has
stretched your vaginal opening to several centimeters.
 Once you deliver the placenta, your healthcare provider will stitch the cut. If you don’t have an
epidural, your provider may inject a numbing medicine into the perineum. This will numb it before the
provider repairs the episiotomy.
An episiotomy may be classified into two types:

 Midline or median. This refers to a vertical incision that is made from the lower opening of the vagina
toward the rectum. This type of episiotomy usually heals well but may be more likely to tear and
extend into the rectal area, called a third or fourth degree laceration.

 Mediolateral . This refers to an incision that is made at a 45-degree angle from the lower opening of
the vagina to either side. This type of episiotomy does not tend to tear or extend, but is associated
with greater blood loss and may not heal as well.

[Flagg, J and Pillitteri, A. (2018) Maternal and Child Health Nursing: Care of the Childbearing and
Childbaring Family 8th Edition “Nursing Care during Normal Pregnancy and Care of the Developing
Fetus”; pp. 173-189; Vol.1]

[Stanford Children’s Health (2019) “Episiotomy” retrieved from:

https://www.stanfordchildrens.org/en/topic/default?id=episiotomy-92-P07775; retrieval date: September 28,
2019]

[John Hopkins Medicine (2019) “episiotomy” retrieved from:

https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/episiotomy; retrieval date: September
29, 2019]

12. Type of anesthetic used: Lidocaine HCl (local)

13. Type of episiotomy and description: right mediolateral (RML)
14. Type of delivery: Normal Spontaneous Vaginal Delivery
15. Type of BOW (bag of water) ruptured: clear
16. Description of placental delivery: Schultze presentation

B. GYNECOLOGIC HISTORY

Not assessed

C. FAMILY PLANNING PRACTICES

None

D. PAST HEALTH PROBLEMS/STATUS

a. Childhood illness
None as claimed
b. Childhood immunizations
complete as claimed
c. Allergies
None as claimed
d. Accidents and injuries
None as claimed
e. Hospitalizations for serious illness
None as claimed
f. Medications
Iron and Folic Acid Supplements – during pregnancy
Amoxicillin (500 mg) – UTI during pregnancy (frequency unrecalled)

E. FAMILY HISTORY OF ILLNESS

None as claimed

F. PATIENT’S EXPECTATIONS
Towards hospitalization: “Nga makabata ako tani nga wala man sang komplikasyon.” as
verbalized by LJS.
Towards nursing care: “Tani mabuligan lang nila ko na maayo lang ko kag ang bata ko.”
as verbalized.

G. PATTERNS OF FUNCTIONING
a. Breathing Patterns
Respiratory Problems: None
Usual Remedy: N/A
 Manner of Breathing: relaxed, effortless
b. Circulation
Usual Blood Pressure: 110 – 120 mmHg
70 -80
Any history of chest pains, palpitations, coldness of extremities, etc. None
c. Sleeping Patterns
Usual bedtime: 7-9 PM
No. of Pillows: 2 – under the head, 1 – below the abdomen
Bedtime Rituals: “Gapanibin eh, kag galantaw Cardo.” As verbalized
Problems regarding sleep: None
Usual Remedy: N/A
d. Drinking Patterns
Total amount of fluid intake/day: 2000 – 2500 mL
Kinds of fluids usually taken: water, coffee, juice
e. Eating Patterns
Usual food taken Time
Breakfast Not assessed
Lunch Not assessed
Dinner Not assessed
Snacks Not assessed

Food likes: Not assessed

Food Dislikes: Not assessed

f. Elimination Patterns: Not assessed

1. Bowel Movement:
Frequency:
Problems/Difficulties
Usual Remedy
2. Urination: Not assessed
Frequency
Problems/Difficulties
Usual Remedy
g. Exercise: “Manlimpyo sa balay, lakat lakat.” as verbalized.

h. Personal Hygiene: Not assessed

1. Bath
Type:
Frequency:
Time of Day
2. Oral
Frequency of Brushing
Care of dentures
i. Recreation: Not assessed
j. Health Supervision: Not assessed

III. A. CLINICAL INSPECTION

1. Vital Signs Date and Time Taken:
September 23, 2019,
04:00 AM

T= 35.8 oC PR=81 bpm RR=16 cpm B/P=110/80 mmHg

2. Height: approx..149 cm
3. Weight: not assessed
4. Physical Assessment:
General Appearance:
Conscious, but appears drowsy, on low fowler's position; appearance appropriate
with age; body build, height, and weight are proportionate; clothing appropriate for
weather; maintains eye contact when talking; Protruding stomach noted.
a. Integumentary System
Skin: fair and uniform in color; moisture in skin folds; skin return to original state in less
than 2 seconds; areas of pigmentation present in cheeks lips: symmetric, smooth,
pink, and moist, no lesions or masses; Hair: Black; evenly distributed; thick and silky;
body hair distributed evenly; no infestation, no sparse areas; Nails: Nail plate
colorless, convex curvature, 160º angle; smooth; intact surrounding epidermis; uniform
in thickness.

b. Neuro-Sensory System
 Not Assessed

c. Respiratory System
Thorax and Back: RR= 16 cycles per minute, effortless, relaxed and even; equal
chest movement; symmetric chest expansion; tactile fremitus equal bilaterally;
resonance sounds heard over all lung fields; diaphragmatic excursion 5 cm and equal
bilaterally; vesicular breath sounds clear over all lung bases.

d. Cardiovascular System
Heart rate: 64 beats per minute (apical), +2 bilaterally; S1 and S2 heard at all sites
(aortic, pulmonic, tricuspid, apical); capillary refill on finger nail beds are less than 2
seconds; Positive Allen’s test, Temporal, Brachial, and Radial pulses: +2 bilaterally.

e. Gastrointestinal System
Not assessed

f. Genito-Urinary System
Not Assessed

g. Reproductive System
Breast: symmetric with left breast slightly larger than the right, skin color consistent
with overall tone, venous patterns same bilaterally, falls freely and evenly from the
chest, smooth, no rash, lesions or tenderness; areolae: brown, round, nearly equal in
size; nipples: almost equal in size and shape, same color as the areolae, everted,
points slightly upward, no discharge; External Genitalia: pubic hair: distributed
heavily at the mons pubis in an inverted-triangle pattern, thins out towards umbilicus;
clitoris: midline, 1cm, fuller, smooth; urethral orifice: midline, pink, smooth, slit like;
vagina: introitus pink, round, smooth, swelling noted, RMLE repair noted.

h. Endocrine System

i. Musculoskeletal System
Not assessed

j. Lymphatic System
Not assessed

k. Hematopoietic System
Not assessed

B. PSYCHOLOGICAL ASSESSMENT
1. Lifestyle Information:
Not assessed
2. Normal Coping Patterns:
Not assessed
3. Understanding of Current Illness:
Not Assessed
4. Personality Style:

5. History of Psychiatric Disorder:

None as claimed
6. Recent Life Changes or Stressors:
None as claimed
7. Major Issues Raised by Current Illness:

8. Mental Status Examination (Circle the correct words. Include a

short description of client for each area assessed.)

Appearance
Neat Clean Disheveled Poor grooming Erect posture

Good eye contact Inappropriate make-up

Description: Maintains good eye contact when conversing.

Behavior
Calm Appropriate Restless Agitated Compulsions

Unusual actions
 Description: Responds calmly with “Okay lang ako, sakit lang ang tahi” when asked
how is she feeling. ____________________________

Speech
Appropriate Pressured Loose association Loud Soft Mute
Description: Mother converses with her baby in a soft and soothing tone
________________________________________________________

Mood/Affect
Appropriate Labile Flat Depressed Worrie Anxious
d

Angry Hopeless
Description: mother constantly checks baby’s position, breathing, and sucking of
nipple.

Thoughts

Not Assessed
Appropriate Low Self-esteem Suicidal ideations Hallucinations

Delusions Phobias
Description:

Ability to abstract: NO
Not assessed
Impaired: YES
Description:

Memory
Not Assessed
Impaired recent mem