Davao Doctors College

General Malvar St. Davao City

BACHELOR OF SCIENCE IN NURSING

Nursing Management of a Patient during

INTRAPARTUM

A Case Study Presented to the Nursing Clinical Instructor

of Davao Doctor College

In Partial Fulfilment of the Requirement in

Mother and Child Nursing 203

Name:
Delos Santos, Japhet P
Devilla, Sarah L.
Dhyani, Sharmaine S.
Diamante, Kia Leanne
Digao, Irene Joy M.
Galan, Abbeygale Joyhn G
Galedo, Melanie A.
Gutierrez, Sheena A.
Haguisan, Aldrich S.
Heje, Marcia Mae E.
Huqueriza, Ninna Alliah A.

October 11, 2019

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 CHAPTER I
INTRODUCTION

BACKGROUND OF THE STUDY

Postpartum period begins immediately after the birth of a child as the mother’s
body, including hormone levels and uterus size, returns to a non-pregnant state. The term
of postpartum lasts a period of four to six week following childbirth. As stated by the
World Health Organization (WHO), postpartum is the period where it is the most critical
and most neglected phase in the lives of mothers and babies due increase to maternal
and newborn deaths occur during this period. The top two leading death toward maternal
and newborn during the postpartum period are postpartum bleeding where maternal may
lose 500ml to 1000ml of blood with the first 24 hour of child birth and complication from
unsafe abortion where a fetus is removed from the embryo before it survives outside the
fetus.
The postpartum period consists of three stages; initial or acute phase, sub-acute
postpartum and delayed postpartum. Acute phase occurs 6 to 12 hours after the child
birth and during this time nurses and midwives typically monitor the mother and the
newborn for any complication that will likely occur and an example of this is postpartum
bleeding. For newborns, it happens after it takes it first breath and is being evaluated by
the use of APGAR scale to quickly determine the health of the newborn against infant
mortality. Sub-acute postpartum period starts and can last for two to six week. This phase
is more about the mother's physical recovery and risk prevention that can lead to high
risk problem. For newborn, at two to four day of postpartum, the mother's milk will come
in and this will be the sign for them to breastfeed their newborn. Delayed postpartum
period last about six months and during this time, the mother's muscles and connective
tissues will return to its pre-pregnancy state. A recovery from childbirth complication in
this period such as urinary and fecal, painful intercourse and pelvic prolapse.

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WHO
The postnatal period is a critical phase in the lives of mothers and newborn babies.
Most maternal and infant deaths occur during this time. Yet, this is the most neglected
period for the provision of quality care. WHO guidelines on postnatal care have been
recently updated based on all the available evidence. The guidelines focus on postnatal
care of mothers and newborns in resource-limited settings in low- and middle-income
countries.
The guidelines address timing, number and place of postnatal contacts, and content
of postnatal care for all mothers and babies during the six weeks after birth. The primary
audience for these guidelines is health professionals who are responsible for providing
postnatal care to women and newborns, primarily in areas where resources are limited.
The guidelines are also expected to be used by policy-makers and managers of maternal
and child health programs, health facilities, and teaching institutions to set up and
maintain maternity and newborn care services.

NATIONAL
The Postpartum Family Planning Supplement to The Philippine Clinical Standards
Manual on Family Planning augments the existing edition to further enhance the quality
of family planning (FP) services delivered by clinic- based providers in both public and
private sector. Critical focus is devoted to the postpartum period as often times, this
represents a missed opportunity to introduce family planning methods that will improve
the health of our women and families. It contains updated information on different family
planning methods that can be used in the postpartum period including timing of initiation,
attributes, risks and benefits. The information presented here is drawn from actual
experiences of family planning experts, and backed up by evidence-based medical
information and effective FP practices recommended by highly credible international
references and organization such as World Health Organization (WHO). This supplement
is a timely and relevant publication that can aid in our target to reach our Millennium
Development Goals (MDGs) of reducing child mortality rates and improving maternal
health. This further contributes to our wider objective of bringing Universal Health Care
(UHC) to all Filipinos.

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LOCAL
After three years of partnership between the Department of Health (DOH) Region
XI, Korea International Cooperation Agency (KOICA) and the World Health Organization
(WHO), the collaborative project closes with improved maternal and newborn health
(MNH) outcomes in the Davao Region.
From baseline figures in 2014, maternal deaths have decreased by 53 percent and infant
deaths have decreased by 32 percent in the whole Davao Region in 2017. Meanwhile,
the maternal deaths reduced by 41 percent and infant deaths reduced by 12 percent in
the 10 project sites from 2014 to 2017.
The 10 project sites are in Santa Maria, Malita and Don Marcelino (Davao Occidental);
New Corella and Tagum City (Davao del Norte); Maco, Mabini and Pantukan
(Compostela Valley); and Caraga and Manay (Davao Oriental).

A.) OBJECTIVE
This case study aims to broaden the knowledge as nursing student for Post-Partum
period by obtaining information, which serves as a guide for us to enhance our skills and
attitudes in application of nursing process and management of Postpartum period for the
mother and the newborn.
At the end of our two day clinical experience at Southern Medical Center in the
Delivery Room, the group was able to conduct a concise case about the patient during
the Post-Partum period.
B.) SPECIFIC OBJECTIVE
 Obtain the client information
a. Biographic date
b. Medical History
c. History of present illness
d. Family History
 Review Anatomy and Physiology of the organ system
 Comprehensive health assessment on the mother and the Neonate
 Obtained from the patient’s chart the following information

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 a. 134 Medical History
b. Laboratory examination and result
c. Pharmacological medication applied
 To formulate the drug study of normal spontaneous delivery
 To develop an effective nursing care plan in which the client may benefit.
 To provide health teaching for the client
 Provide health teaching towards the mother during the stage of labor. \

C.) Glossary of Terms

NSVD- stands for Normal Spontaneous Vaginal Delivery. It is when a woman goes into
labor without the aid of any labor inducing drugs or methods, and is able to deliver the
baby without requiring a doctor's aid through cesarean section, vacuum extraction, or with
forceps. It is a method of childbirth most health experts recommended for women whose
babies have reached full term.

Postpartum - begins immediately after the birth of a child as the mother's body, including
hormone levels and uterus size, returns to a non-pregnant state.
Initial or acute phase- occurs 6 to 12 hours after the child birth and during this time
nurses and midwives typically monitor the mother and the newborn for any complication

Sub-acute postpartum period - starts and can last for two to six week this phase is more
about the mother's physical recovery and risk prevention that can lead to high risk
problem.
Delayed postpartum period = last about six months and during this time, the mother's
muscles and connective tissues will return to its pre-pregnancy state.

APGAR = is a method to quickly summarize the health of newborn children against infant
mortality.

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D.) Significance of the Study

Patients: This study will benefit the patients, particularly the mother because it will help
them on how to take care of themselves after pregnancy so that their baby is alive and
healthy when being born most especially for first-time mothers. This study will help in
educating patients and upcoming mothers in order to decrease mortality rate,
complications in pregnancy, and maternal and fetal death. The care that a woman
received during postpartum can affect the woman herself (physically and emotionally) and
the health of her baby in the short and longer term.

Nursing Students: This study will benefit the nursing students because it serves as one
of their guides on how to take insights on doing postpartum care. It also serves as their
reference in making a Nursing Care Plan and Comprehensive Assessment for Maternal
and Child Nursing. This helps them to understand patients on postpartum and establish
good relationships with their patients. In clinical duty, it may helps them in learning nursing
interventions on postpartum care and determining diagnosis. This helps the nursing
students to fully understand the importance of intrapartum stage because it is one of the
most crucial moments of a woman.

Future Researchers: This study will benefit the future researchers because this serve
as one of their references whenever they conduct a case study mainly about Postpartum.
This can also help them to understand more about Maternal and Child care

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 CHAPTER II
PATIENT’S PROFILE

BIOGRAPHIC DATA
Name: Quinsoy, Elaimie Gunibon
Case Number: 1343147
Date of Birth: February 24, 1999
Place of Birth: Davao Oreintal
Address: Sitio Manacan San Agustin, Santa Maria
Age: 20
Status: Single
Religion: Roman Catholic
Date Admitted: 10/03/2019
Chief Complaint: Labor Pain
Final Diagnosis: G1 P0 Pregnancy uterine Delivered from Cephalic Live Birth to a baby
girl via NSVD with Median Episiotomy and 2nd Degree Laceration

A. Present Medical History

According to our client, she started having pain in her lumbar area and it persisted
on the lower abdomen. She was admitted on October 03, 2019, she was in her 41 weeks
gestation and 6/7 days. She was admitted to the delivery room for normal spontaneous
vaginal delivery; she had undergone median episiotomy to widen the opening of her
vagina and gave birth to a baby girl at 12:40 pm. She is G1P0. After the post-natal and
early post-partum care in the delivery room, she was transferred to OB ward via stretcher.

B. Past Medical History

During the pregnancy of our client, mother always follow on the pre-natal check-up.
Our client remembers that she got her menarche when she was 16 years old. She had
her immunizations such as tetanus toxoid. She never took any medication that can cause
harm to her pregnancy especially to the baby. Patient Q is healthy with no known medical

7
problems such as hypertension, diabetes, seizures, heart disease, cancer. She has only
caught minor disease such cold, fever and cough.

C. Family History

Patient Q’s maternal side is healthy with no known medical problems. Paternal side
has history of HTN and DM, other than this the family history is free; there is no medical
or surgical history or congenital abnormalities.

D. Maternal and Prenatal History

Patient Q’s last menstrual cycle was on December 9, 2018, AOG is 41 weeks and
6/7 days, and EDC was on September 15, 2019. Patient is G1P0. She delivered a baby
girl maturity at term manner of delivery is normal spontaneous vaginal delivery with
episiotomy and laceration at 2nd degree.

E. Development history

The patient was having some symptoms of pregnancy which continue for several
weeks and months due to the many changes that happen to the body as the fetus
continue to grow and develop inside the womb of the patient. Mother started bonding with
her baby during the first, second and third trimester by doing some activities such as
eating healthy foods, doing some exercise like walking and by taking the main
responsibility of care and feeding. Parental attachment appears to be going well. There
is a lot of good eye to eye contact between parents and baby.

F. Nutritional History

Patient Q is able to recognize nutritious food but unable to utilize some of it. She
eats 3 times a day. She weighs 54 kg before she got pregnant and gained 8 kg when she
got pregnant. Patient was taking folic acid and iron supplements during pregnancy. No
known allergy to any kind of food or drug. Patient had nausea and vomiting in the first
trimester. Does not smoke and does not drink alcohol.

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G. Immunization

Patient Q only got 2 shots of her tetanus toxoid although she cannot recall when she
got her first dose.

H. PHYSICAL ASSESSMENT

A thorough cephalocaudal physical assessment was conducted on October 03,

2019 at 12:45pm. This is done systematically using the techniques of inspection,
palpation, percussion and auscultation with the uses of materials and investments such
as thermometer, sphygmomanometer, stethoscope and also senses. Patient’s feelings
were recognizing and were provided comfort measures and senses. Her initial vital signs
are as follows:

VITAL SIGN NORMAL RANGE RESULT

Respiratory Rate 16 – 20 cpm 24 cpm

Temperature 36.5 C – 37.5 C 36.8 C

Pulse Rate 60 – 100 bpm 86 bpm

Blood Pressure 90/60 mm/Hg – 130/80 mmHg

130/90 mm/Hg

General appearance

Patient is a 20-year-old female, stands 5’1 with pulse rate of 86 beats per minute,
respiratory rate of 24 breathe per minute and temperature of 36.8 C. She is conscious
and coherent upon Interaction but answers only those questions she is comfortable with.

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SKIN The patient’s color is uniformly brown but the axilla is slightly darker
in color compared to the surroundings of the skin. Lesions and
ulceration were not noted. The skin is warm to touch with good skin
turgor. Tenderness, masses and edema were not present.

FINGERNAILS Fingernails on both and upper extremities were properly trimmed and
AND TOENAILS with capillary refill time of 2 seconds. Spooning or clubbing of the
fingernails were not present.

EYES Patient’s eyes are symmetrical, black in color, conjunctivas are pink.
Eyelashes are equally distributed and even distributed set of
eyebrows. Lids are symmetrical and is uniform in color with the rest of
the skin with no lesion and no discharges noted upon observation.

EARS The ears of the patient have the same color with her facial skin. Pinna
is aligned with the outer canthus of her eyes and both pinna and
auricles are non-tender as it was palpate. No discharges and redness
noted. The cartilage is intact and no messes and tenderness noted
upon palpation.

NOSE The skin color of the nose is uniform with the rest of the body. Nostrils
were symmetrical and both nares were patent. No swelling of mucus
membrane and presence of nasal naris were seen.

MOUTH Patient’s lips are slightly dry and pale. No lesion and ulcerations are
observed. The tongue is at the midline and is slightly pink in color.
Uvula is in the midline. Hard and soft palates are intact. Tonsils are
non-inflamed. Tongue is able to move when she is asked to.

NECK Muscles are equal in size and no swelling notes upon inspection and
the neck is centered. Jugular vein was not distended. Lymph nodes
were non-palpable. Patient’s showed coordinated, smooth head
movement during assessment.

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THORAX The shape of the patient’s thorax is symmetrical. Dyspnea was not
noted and has respiratory rate of 24cpm within normal range of
between 16-20cpm. Lung expansion is symmetrical upon inhalation.
No wheezing sound noted on both lung fields during auscultations.

HEART The patient's cardiac rate was not assessed. Aortic and pulmonic
sounds were distinct upon auscultation and murmur sounds are
absent.

BREAST The skin in the breast is uniform in color with the rest of the body and
is smooth and intact. Breasts are symmetrical, with the right breast
slightly larger than the left breast and sagging. No dimpling in both of
her breast. The nipples are darker than the areola.

ABDOMEN No masses and tenderness noted in the abdomen upon palpation.

Skin is uniform with the rest of the body but seen with striae
gravidarum and linea nigra. The umbilicus is at the midline. The
abdominal surface has no scars, lesions and rashes.

MUSCULOSKELETAL Patients has a complete set of fingers in each hand and complete toes
in each foot. There were no extra fingers or toes (polydactyl) nor did
webbing (syndactyl) noted. Lesion edema, and tenderness were not
noted on both of her upper and lower extremities.

NEUROLOGIC SYSTEM The patients are good in terms of mental and emotional status. Awake,
aware, active and alert of the environment.

GENITALIA The patients have a minimal amount of pubic hair. 2nd degree
Laceration, tenderness and foul smelling discharges are not present.
Has no problem in urinating

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 CHAPTER III
A. ANATOMY AND PHYSIOLOGY
ANATOMY AND PHYSIOLOGY OF THE REPRODUCTIVE SYSTEM

Our review of the reproductive system begins at the external genital area or vulva
which runs from the pubic area downward to the rectum. Two folds of fatty, fleshy tissue
surround the entrance to the vagina and the urinary opening: the labia majora, or outer
folds, and the labia minora, or inner folds, located under the labia majora. The clitoris, is
a relatively short organ (less than 1 inch long), shielded by a hood of flesh. When
stimulated sexually, the clitoris can become erect like a man’s penis. The hymen, a thin
membrane protecting the entrance of the vagina, stretches when you insert and tampon
or have intercourse. Reproductive system in an organism is for the purpose of sexual
reproduction. It is a system of sex organs within its body which is also called as genital
system. Not only the sex organs but also the various non-living substances within the
body such as hormones, pheromones, body fluids and many more, form an important
accessory to the reproductive system that works together for the purpose of sexual
reproduction.

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 INTERNAL REPRODUCTIVE STRUCTURE

The Vagina
The vagina is an elastic, muscular canal with a soft, flexible lining that provides lubrication
and sensation. The vagina connects the uterus to the outside world. The vulva and labia
form the entrance, and the cervix of the uterus protrudes into the vagina, forming the
interior end. The vagina receives the penis during sexual intercourse and also serves as
a conduit for menstrual flow from the uterus. During childbirth, the baby passes through
the vagina (birth canal). The hymen is a thin membrane of tissue that surrounds and
narrows the vaginal opening. It may be torn or ruptured by sexual activity or by exercise
The Cervix
The cervix is a cylinder-shaped neck of tissue that connects the vagina and uterus.
Located at the lowermost portion of the uterus, the cervix is composed primarily of
fibromuscular tissue. The part of the cervix that can be seen from inside the vagina during
gynecologic examination is known as the ectocervix. An opening in the center of the
ectocervix , known as the external os, opens to allow passage between the uterus and
vagina. The endocervix, or endocervical canal, is a tunnel through the cervix from the
external os into the uterus. The cervix produces cervical mucus that changes in
consistency during the menstrual cycle to prevent or promote pregnancy. During birth the

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cervix dilates widely to allow the baby to pass through. During menstruation the cervix
opens a small amount to permit passage of menstrual flow.
Uterus
Uterus also called womb, an inverted pear-shaped muscular organ of the female
reproductive system, located between the bladder and the rectum. It functions to nourish
and house a fertilized egg until the fetus, or offspring, is ready to be delivered. The uterus
has four major regions: the fundus is the broad curved upper area in which the fallopian
tubes connect to the uterus; the body, the main part of the uterus, starts directly below
the level of the fallopian tubes and continues downward until the uterine walls and cavity
begin to narrow; the isthmus is the lower, narrow neck region; and the lowest section, the
cervix, extends downward from the isthmus until it opens into the vagina. The uterus is 6
to 8 cm (2.4 to 3.1 inches) long; its wall thickness is approximately 2 to 3 cm (0.8 to 1.2
inches). The width of the organ varies; it is generally about 6 cm wide at the fundus and
only half this distance at the isthmus. The uterine cavity opens into the vaginal cavity, and
the two make up what is commonly known as the birth canal.
Oviducts
The fallopian tubes or oviducts are two very fine tubes leading from the ovaries of female
mammals into the uterus. On maturity of an ovum, the follicle and the ovary’s wall rupture,
allowing the ovum to escape and enter the Fallopian tube. There is travels toward the
uterus, pushed along by the movements of cilia on the inner lining of the tubes. This trip
takes hours or days. If the ovum is fertilized while in the Fallopian tube, then it normally
implants in the endometrium when it reaches the uterus, which signals the beginning of
pregnancy. The ovaries are the place inside the female body where ova or eggs are
produced. The process by which the ovum is released is called ovulation. The speed of
ovulation is periodic and impacts directly to the length of a menstrual cycle. After
ovulation, the ovum is captured by the oviduct, where it travelled down the oviduct to the
uterus, occasionally being fertilized on its way by an incoming sperm, leading to
pregnancy and the eventual birth of a new human being. The Fallopian tubes are often
called the oviducts and they have small hairs (cilia) to help the egg cell travel.

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 PATHOPHYSIOLOGY
Postpartum period (Puerperal period)

The postpartum period refers to the six to eight week period after the birth of a
baby in which the body recovers from the changes caused by pregnancy and birth. During
this time, women are susceptible to complications including infection, thrombosis,
insufficient postpartum recovery, and postpartum depression. Based on the fundal height
measurement and the lochia (postpartum vaginal discharge), the examiner can detect
possible pathologies. During the postpartum period, the body also undergoes several
physiological changes, such as the beginning of the lactation process and the discharge
of lochia and uterine involution.
Normal postpartum changes
Low‑grade fever, shivering, and leukocytosis are common findings during the first 24
hours postpartum and do not necessarily indicate an infection.
Uterine involution
* Begins right after birth and the delivery of the placenta
* Afterpains: painful cramps from contractions of the uterus following childbirth
* The uterus returns to its normal size by the 6th–8th week postpartum.
* Fundal height: Method of measuring the size of the uterus, from the fundus to the top of
the symphysis
Lochia (postpartum vaginal discharge)
* Most women pass lochia for about 4 weeks after delivery; in some cases, it lasts for 6–
8 weeks.
* Lochia rubra: blood red; approx. the first 4 days after birth
* Lochia serosa: brown‑red; watery consistency, lasts approx. 2–3 weeks
* Lochia alba: whitish; lasts approx. 1–2 weeks

Lactation and breastfeeding

* Endocrine regulation
* Lactogenesis: increased estrogen and progesterone during pregnancy, resulting in
hypertrophy of the breast

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 * Galactogenesis: After delivery of the placenta, hormone levels decrease and
prolactin activates milk production and milk ejection (let‑down).
* Galactopoiesis: Infant suckling leads to further release of oxytocin and
prolactin. Milk production is maintained in particular by prolactin.
* Prolactin suppresses FSH and LH → no follicle growth → lactational
amenorrhoea
* Galactokinesis: ↑ Oxytocin levels stimulate myoepithelial cell contraction and
milk ejection. Infant suckling maintains oxytocin levels and thus milk flow.
* Breast milk composition
* Proteins
* Fat
* Lactose
* Secretory IgA
* Minerals
* Benefits of breastfeeding
* ↓ Infant allergies
* ↓ Risk of infant respiratory and gastrointestinal tract infections
* Promotes bonding between the mother and child
* Contraindications for breastfeeding
* Maternal HIV
* Active tuberculosis
* Drug abuse
* Certain medication (e.g., tetracycline, chloramphenicol, chemotherapy
agents)
* Baby with galactosemia

* Breast engorgement
* Etiology
* Interstitial edema at the beginning of lactation a few days after birth
* Imbalance of supply and demand of breast milk
* Tight‑fitting bras

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 * Symptoms: tenderness, firmness, and fullness of the breast
* Treatment
* Frequent breast-feeding with optimal nursing techniques
* Warm compresses prior to breast feeding, cold compresses in between breast
feeds
* Analgesics
* Careful expression of breast milk by hand or with a breast pump to alleviate
pressure
Weight loss
* Approx. 13 pounds is the mean weight loss after delivery of the baby, amniotic fluid,
and placenta.
* Lochia discharge and uterine contractions make for an additional weight loss of
approx. 5–15 pounds during the postpartum period.
Postpartum complications
* Subinvolution of the uterus
* Impaired retraction of the uterine muscles
* Can cause severe bleeding
* Retained placenta
* Placental remnants that have not yet been expelled may lead to prolonged or
periodic hemorrhage.
* These remnants also lead to uterine subinvolution.
* Postpartum endometritis
* Definition: inflammation of the endometrium, possibly also including the myo- and
parametrium
* Etiology: Mostly polymicrobial (2–3 ascending organisms, e.g., Gardnerella
vaginalis, Staphylococcus epidermidis, group B Streptococcus and/or Ureaplasma
urealyticum) that are usually found in the normal vaginal flora
* Pathophysiology: lochia retention → ideal breeding ground for infection →
postpartum endometritis/postpartum endomyometritis → postpartum sepsis
* Risk factors
* Cesarean section (C-section)

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 * Prolonged labor
* Multiple cervical examinations
* Retained products of conception after delivery or abortion
* Meconium in amniotic fluid
* Low socioeconomic status
* Clinical findings
* Fever
* Lower abdominal pain, uterine tenderness
* Chills, malaise
* Foul-smelling lochia
* Diagnostics: Primarily a clinical diagnosis; tests may help support and differentiate
the diagnosis
* Gram stain or wet mount of vaginal discharge
* Blood and urine cultures
* Treatment
* Antibiotic treatment: IV clindamycin and gentamicin
* Ampicillin-sulbactam is a reasonable alternative if resistance to clindamycin
is a concern.
* If there are any retained products of conception: curettage to remove retained
products
* Hysterectomy in case of life-threatening complications, no response to
conservative therapeutic measures
* Complications
* Surgical site infection
* Peritonitis
* Intraabdominal abscess
* Postpartum mastitis
* Galactocele
* Deep vein thrombosis
* Ovarian vein thrombosis
* About 90% of cases occur on the right side.

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 * Usually occurs on the 3rd–5th day after birth, often together with endometritis
* Etiology: a combination of hypercoagulability during pregnancy and the postpartum
period, as well as endothelial microlesions during labor and slowed blood flow in the
ovarian veins
* Symptoms: localized pain in the lower abdomen (mostly on the right), possible
fever (septic ovarian vein thrombosis), and headache
* Diagnosis: doppler ultrasound
* Treatment: therapeutic heparin; antibiotics may be necessary
* (Aseptic) sinus vein thrombosis
* Postpartum depression
* Postpartum psychosis

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 CHAPTER IV
RESULT, ANALYSIS, AND JUSTIFICATION

A.) COURSE IN THE WARD

October 03, 2019
A 20 years old female patient arrived in SPMC at 1am in the morning due to labor
pains prior to the admission. The patient was fully effaced at 02:35pm and delivered to
alive baby girl and was transferred at the ward at exactly 04:35pm. The Blood Pressure,
temperature, pulse rate, and respiratory rate must be recorded every shift. The physician
was ordered a Plain Normal Saline Solution 1000ml to be regulated at 15 gtts/min. The
physician was also ordered analgesics and antibiotic for pain relief and prevent infection
due to recent episiorrhaphy.
October 3, 2019
Vital signs of the infant is monitored q15 after EINC.

B.) LABORATORY FINDINGS

URINALYSIS OCTOBER 3, 2019

MICROSCOPIC MUCUS THREADS RARE
COLOR
YELLOW CRYSTALS

TRANSPARENCY TURBID AMORPHOUS URATE RARE

S/PO4
REACTION 5.0 CALCIUM OXALATE
SPECIFIC GRAVITY 1.020 URIC ACID
PROTEIN NEGATIVE TRIPLE PHOSPHATE
GLUCOSE NEGATIVE CAST
OTHERS FINE GRANULAR
COARSE
GRANULAR
MICROSCOPIC WBC
RED BLOOD CELLS 0.2 /HPF
WHITE BLOOD
15.20 /HPF BACTERIA
CELLS

EPITHELIAL CELLS OTHERS

SQUAMOUS MODERATE
RENAL PREGNANCY TEST

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 CHAPTER V
SUMMARY, CONCLUSION, AND RECOMMENDATION
SUMMARY

This chapter contains the summary, conclusion and recommendation base on the
patient’s findings.

SUMMARY

The group 14 of Bachelor of Science in Nursing of second year level section D, aimed to
conduct a holistic evaluation of the patient who had a Normal Spontaneous Vaginal
Delivery and patient’s health status thereby providing the chance to learn and understand
the sequence of pregnancy.

This case study is all about the normal spontaneous vaginal delivery, Vaginal delivery is
the method of childbirth most health experts recommend for women whose babies have
reached full term. 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 (www.healthline.com) . A gravida 1, patient Q, was
admitted on October 3, 2019 at the delivery room of Southern Philippines Medical Center,
Davao City. During pregnancy, the most affected organ of the body is the uterus where
the fetus was developed, Uterus, also called womb is an inverted pear-shaped muscular
organ of the female reproductive system. Located between the bladder and rectum, It’s
functions to nourish and house a fertilized egg until the fetus or offspring is ready to be
delivered. Upon arriving in the area, the patient felt and complained about pain while
contraction occurs, the vital signs was taken every 15 minutes for the whole hour; 30
minutes for an hour, the following results stated, Temperature 36.8 C from the normal
range of 36.5 C – 37.5 C, next is the Pulse rate resulted 86 bpm from normal range of
60-100 bpm, Respiratory rate is 24 cpm from the normal rate of 16-20 cpm, and lastly the

21
Blood pressure is taken 130/80 mmHg from the normal range of 90/60 mm/Hg – 130/90
mm/Hg, by these results noted, it would be monitored until stable vital signs met. During
the delivery the presentation of the baby was in a cephalocaudal phase, which results a
successful delivery of a healthy baby girl. As follows are the medication given by the
physician, Cefuroxime at 50 milligram tablet, taken one tablet, twice a day for seven days,
and Diclofenac, tablet form at 50 milligram, three-times-a-day taken for relief of pain. G1
P0 Pregnancy uterine Delivered from Cephalic Live Birth to a baby girl via NSVD with
Median Episiotomy and 2nd Degree Laceration.As a group we conducted one of our
possible diagnosis as Sleep Deprivation related to pain and discomfort on the perineum
secondary to labor delivery.

CONCLUSION

Every mother wants to have a special, worthwhile experiences. This is true even
though the birth itself is a mostly uncontrollable processes. Their body has done one of
the most exceptional things which is to grow another human being. The birthing
experience of a mother is terrifying but at the end of the day it will result to complete and
utter joy.

A postpartum period begins immediately after the birth of a child as the mother's
body, including hormone levels and uterus size, returns to a non-pregnant state. A woman
giving birth in a normal spontaneous vaginal delivery may leave as soon as she is stable,
which can be as early as a few hours or an average of one to two days. Having a baby is
a trauma for a woman’s body postpartum recovery is not that easy it will last for days, full
recovery from childbirth can even last for months. Though mothers bond with her child
starts as soon as she finds out that she is pregnant, but it expands right after she holds
her baby for the first time.

RECOMMENDATION

Exercise

Doing a regular exercise routine thhroughout pregnancy can help prevent women
stay healthy, improve posture, and relieve stress. Physical activity is important as it helps

22
on relieving common discomforts like fatigue and backache, and it helps prepare the body
for labor and delivery.

Diet

A woman’s health will be a mirror and essential to the health of the baby. Having a
nutritious diet during pregnancy can help develop a good fetal brain, healthy birth weight,
and reduces risk of fetal defects.

Hygiene

Pregnant women are more vulnerable to diseases and infections because they
sweat more and have more vaginal discharge due to hormonal change, thus making
prone to infections by germs and bacteria. The common way to prevent infection is to
wash hands properly, especially before eating and after going to the toilet because
bacteria may build up and are often spread through hands. Thus, pregnant women should
wash her body everyday with clean water, especially in the genital area.

Spiritual

Most of us believe that pregnancy is a gift from God. Prayer is essential for
pregnant women as she creates a bond between God to thank Him about goodness of
life, and a sense of comfort when she experience hardships in her pregnancy journey.
Pregnant women should connect with the nature and its creation in order to reflect about
the new life that she will be creating.

23
 APPENDICX A

Other sources of information

During the study, the members examined many publications, reports, documents and
currents news articles focusing on the Normal Spontaneous Vaginal Delivery. The
following are the said articles:

Buhimschi C.S ,MD and Buhimschi I.A, MD. Advantages of Vaginal Delivery. Department
of Obstetrics, Gnecology and Reproductive Sciences, New Haven, Conneticut.

Cohen, L. MD; Waldron, C. MA, and Brustman, L. MD. Associate of Planned Natural
Childbirth with Spontaneous Vaginal Delivery. (2017)

Fatemeh Mokhtari, Parvin Bahadoran, and Zahra Baghersad Effectiveness of Postpartum

Homecare Program as a New Method on Mothers’ Knowledge about the Health of the
Mother and the Infant, 2018 Iranian Journal of Nursing and Midwifery Research

Journal of Midwifery & Women's Health Noelle Borders, CNM, MSN After the Afterbirth:
A Critical Review of Postpartum Health Relative to Method of Delivery, Journal of
Midwifery & Women's Health

M.J. Saurel-Cubizolles, P. Romito, N. Lelong, P.Y.Ancel Women's health after childbirth

British Journal of Obstetrics & Gynecology, 107 (2014),

Patterson D.A, MD., Winslow M, MD, and Matus C.D, MD. Spontaneous Vaginal Delivery,
(2017)

Prosser S.J, Barnett A.G and Miller Y.D. Factors promoting or inhibiting normal birth,
School of Public Health & Social Work, Institute of Health and Biomedical Innovation,
Queensland University of Technology , Kelvin Grove, Brisbane, QLD2049,
Australia.(2018).

SukheeAhnPhD, RNaJoAnne M.Youngblut PhD, RN, FAANb Predictors of Women's

Postpartum Health Status in the First 3 Months After Childbirth.

24
 APPENDIX A.

Researchers Personal Information

Personal Information

Name: Melanie A. Galedo

Date of Birth: January 18, 2000
Place of Birth: Cavite
Citizenship: Filipino
Gender: Civil Status: Single
Religion: Christian
Educational Attainmen

Level School

Primary Palma Gil, Elementary School

Secondary Davao City National High School
Personal Information

Name: Sheena A. Gutierrez

Date of Birth: July 07, 1999
Place of Birth: Takepan, Pikit, Cotabato
Citizenship: Filipino
Gender: Female
Civil Status: Single
Religion: Roman Catholic
Educational Attainment

Level School

Primary Takepan Central Elementary School

25
Secondary Notre Dame of Midsayap College
Personal Information

Name: Kia Leanne Diamante

Date of Birth: November 28, 1995
Place of Birth: Koronadal City, South Cotabato
Citizenship: Filipino
Gender: Female
Civil Status: Single
Religion: Roman Catholic
Educational Attainmen

Level School

Primary Surallah Central Elementary School

Secondary Notre Dame Surala

Personal Information

Name: Abbeygale Joyhn G. Galan

Date of Birth: August 28, 1999
Place of Birth: Davao City, Davao Del Sur
Citizenship: Filipino
Gender: Female
Civil Status: Single
Religion: Roman Catholic
Educational Attainment

Level School

Primary Holy Child College of Davao

Secondary Catalunan Pequeño National High School

26
 Personal Information

Name: Aldrich S. Haguisan

Date of Birth: September 24, 1997
Place of Birth: Davao City
Citizenship: American
Gender: Male
Civil Status: Single
Religion: Roman Catholic
Educational Attainment

Level School

Primary Jonas E. Salk Elementary School

Secondary Western High School

Personal Information

Name: Marcia Mae E. Heje

Date of Birth: April 12, 1999
Place of Birth: Sto. Tomas, Loreto Agusan Del Sur
Citizenship: Filipino
Gender: Female
Civil Status: Single
Religion: Roman Catholic
Educational Attainment

Level School

Primary Sto, Tomas Elementary School

Secondary Sto. Tomas National High School

27
 Personal Information

Name: Sharmine S. Dhyani

Date of Birth: March 3, 2001
Place of Birth: Kuwait
Citizenship: Filipino
Gender: Female
Civil Status: Single
Religion: Roman Catholic
Educational Attainmen

Level School

Primary Padada Elementary School

Secondary Digos National High School

Personal Information

Name: Japhet Delos Santos

Date of Birth: July 10, 2000
Place of Birth: Buhangin, Davao City
Citizenship: Filipino
Gender: Male
Civil Status: Single
Religion: Roman Catholic
Educational Attainment

Level School

Primary Tibungko Elementary School

Secondary Davao City National High School

28
 Personal Information

Name: Ninna Huqueriza

Date of Birth: January 8, 2000
Place of Birth: Tacurong South Cotabato
Citizenship: Filipino
Gender: Female
Civil Status: Single
Religion: Roman Catholic
Educational Attainment

Level School

Primary Norala Central Elementary School

Secondary Notre Dame of Tacurong, Inc

Personal Information

Name: Irene Joy Digao

Date of Birth: October 26, 2000
Place of Birth: Davao City
Citizenship: Filipino
Gender: Female
Civil Status: Single
Religion: Roman Catholic
Educational Attainment

Level School

Primary MaryKnol Elementary School

Secondary Davao Doctors College

29
 Personal Information

Name: Sarah Devilla

Date of Birth: December 24, 2000
Place of Birth: Davao City
Citizenship: Filipino
Gender: Female
Civil Status: Single
Religion: Islam
Educational Attainment

Level School

Primary Sirawan Elementary School

Secondary Davao Doctors College

30
 BIBLIOGRAPHY

- Classroom Lecture
- Laboratory Test Result
- From the patients chart
- From our observation
- From the internet
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● Intrapartum.(2019).U.S national library of medicine. From:
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● Kluwer, W ( Nursing 2019 Drug Hand Book,)
● National Institute for health and Care Excellence.intrapartum care:care of
healthy women and their babies during childbirth.(clinical guideline
55).2007.www.nice.org.uc/guidance/C655
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Women's health
● Pilleteri (2019)) Maternal and Child health nursing Vol 1.
● Shiel,W.(2018).medical definition of labor.retrieved(12/17/2018).from
● Wilson,D.(2017).Spontaneous Vaginal Delivery.2005-2019 healthline media
(n.d.). WebMD - Better information. Better health.. The Vagina & Vulva (Female
Anatomy): Pictures, Parts, Function, & Problems. Retrieved from
http://www.webmd.com/women/picture-of-the-
vagina?fbclid=IwAR0FoTBbal_aozikHEtEiCJkcSqpJ6lgMgVyyYpHRlR1myVk2ey
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