ABSTRACT

Pregnancy (gestation) is the physiologic process of a developing fetus within the

maternal body. In obstetrics there are developmental stage of human conception and the

duration of pregnancy determine (Bernstein, 2019).

This study is about patient F. B., 39 years old female from Barangay Sabang, Baybay

City, Leyte admitted at Western Leyte Provincial Hospital with a chief complaint of onset of

uterine contraction; P4 39 2/7 weeks AOG; cephalic G4P3.

The methods used in this study are determining the condition of the breast, uterus,

bladder, bowel, lochia, episiotomy, cardio, hooman’s sign, emotion and respiration of the patient

after the delivery. Nursing interventions were also conducted in order for the patient to feel

comfortable while waiting for discharge.

This study aims to understand the condition of the patient and identify the significant

physiological and psychological needs to provide appropriate care. This will also enable the

students to have a better understanding about a normal pregnancy.

Based on the actual management of the patient’s condition, the health care team

focused on the management for prevention of infection and promote wellness of the patient

before discharge.

The prognosis of the patient is good because the baby is normal and the patient is

recovering from her recent delivery.

 CHAPTER I

INTRODUCTION
 Pregnancy (gestation) is the physiologic process of a developing fetus within the

maternal body. In obstetrics there are developmental stage of human conception and the

duration of pregnancy determine (Bernstein, 2019). The start of the gestation is based on the

last menstrual period (LMP) it is usually 2 weeks before ovulation, assuming a 28-day regular

menstrual cycle. The developmental or fetal age is the age of the conception calculated from the

time of implantation, which is 4 to 6 days after ovulation is completed. The menstrual gestational

age of pregnancy is calculated at 280 days or 40 completed weeks. The estimated due date

(EDD) may be estimated by adding 7 days to the first day of the last menstrual period and

subtracting 3 months plus 1 year using the Naegele's rule (Bernstein, 2019).

According to Silbert-Flagg (2018) Medical diagnosis of pregnancy serves to date when

the birth will occur and also predict the existence of a high-risk status. There are presumptive,

probable and positive indications of pregnancy. There are 10 presumptive signs determine by

the woman during pregnancy, during the 2nd weeks from the time of implementation, the woman

can feel breast enlargement and darkening of nipples, nausea, vomiting and amenorrhea. A

week after is diuresis, these may include the increase of urine output and the urge to urinate.

During 12th weeks, the woman may feel fatigue and uterine enlargement is observable. In its 18th

weeks, quickening or fetal movements can be felt by the mother. During 24 th weeks there will be

changes in the mother that can be notice such as the appearance of linea negra and striae

gravidarum evident in the abdomen of the woman and melasma in the face and different part of

the mother.

Probable signs of pregnancy, during the 1st week are the positive result of maternal

serum test, this test determine the presence of human chorionic gonadotropin (Hcg), a hormone

created by the chorionic villi of the placenta, in these test are only accurate 95-98% of the time,

positive results from these test are considered probable rather than positive. In its 6 th weeks,

there are changes in the perineum area of the mother that can be noticed such as Chadwick’s
sign, the change of color of the vagina from pink to violet. Goodell’s sign, the softening of the

cervix and Hegar’s sign softening of the lower uterine segment. Another is the sonographic

evidence of gestational sac. During the 16th weeks ballottement test can be done, the lower

uterine segment is tapped on bimanual examination. The fetus can be felt to rise against the

abdominal wall. As it progress to its 20 th weeks, Braxton Hicks contractions may fell the mother

it is a periodic uterine tightening occurs. Another is the fetal outline felt by the examiner in the

abdomen of the mother (Silbert-Flagg, 2018).

To validate pregnancy of the mother, there are positive signs that may confirm that the

mother is pregnant. During the 8th weeks there is a sonographic evidence of fetal outline and the

fetal heart is audible using fetal doppler, these indicates that there is developing fetus in the

uterus of the mother. Another sign is fetal movement felt by the examiner; it is usually during the

20th weeks of pregnancy (Silbert-Flagg, 2018).

According to World Health Organization (1997), normal birth is an onset, low-risk at the

start of labor and remaining so throughout labor and delivery. The infant is born spontaneously

in the vertex position between 37 and 40 completed weeks of pregnancy. Both mother and the

baby are in good condition after birth.

Vaginal delivery is the simplest kind of delivery process among all the methods of child

childbirth such as cesarean delivery and induced labor. In addition, 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. Labor makes

the cervix opens or dilates for at least 10 centimeters. This usually begins with the passing of a

woman’s mucous plug. Mucous plug is a clot of mucous that protects the uterus from the

bacteria during pregnancy. Soon after, woman’s amniotic sac may breaks; this is also called the

“rupture of membrane”. Amniotic sac may just breaks when labor is established well even right
before delivery. Strong contractions help push the baby into the birth canal as the labor

progresses however every pregnant women differs to the length of labor. Like for instance,

women giving birth for the first time tend to go through labor for approximately 12-24 hours while

women who have previously delivered a child may only go through labor for 6 to 8 hours.

Hereunder are the three stages of labor that signal spontaneous vaginal delivery may about to

occur: (1) Contractions soften and dilate the cervix until it’s flexible and wide enough for the

baby to exit the mother’s uterus. (2)The mother must push to move her baby down her birth

canal until it’s born. (3)Within an hour, the mother pushes out her placenta, the organ

connecting the mother and the baby through the umbilical cord and providing nutrition and

oxygen.
 CHAPTER II

COMPREHENSIVE NURSING HEALTH HISTORY

I. PERSONAL DATA

A. Personal Data

Flora Joson Bulfa is the nameof the patient, she is 25 years and was born on

Febuary 11, 1980. She lives in Brgy. Sabang Baybay Leyte and was married, having 4

children. The patient has no occupation however her husband Rolando Bulfa is a

construction laborer and a elementary graduate. Both of them are Roman Catholic. She

is the wife of the head of the family. Patient had her LMP on Jan. 16, 2019. The number

of conception the patient had was 4, Preterm 0, Term 0, Abortion 0, Living 4, Miscarriage

0. She was admitted on November 6, 2019 Wednesday around 2:10 pm in the afternoon

with a chief complaint of Labor Pain. Her vital signs are: T= 36.6℃ P= 84 bpm R= 24

cpm BP= 130/90 mmHg, she weighed 59 kg. and a height of 151 cm. Her attending

physician is Dr. Verano.

B. Reason for Admission

The reason for admission is onset of uterine contractions. P4 39 2/7 weeks AOG;

Cephalic G4P3.

C. Obstetric History

The client’s menstruation started when she was 12 years old in the year 1993

for 3 days. She does not menstruate every month, usually every another month with a
 duration of 3 days, moderate flow on the first day that consume 4 sanitary napkin.

The patient does not experience dysmenorrhea. The patient and her partner does not

use any synthetic family planning method.

Year Pregnancy Duration Mode of Live Birth/ Sex / Place of Status of

of Labor Delivery Still Birth Birth Delivery TT
weight Immuniza
tion
2002 1 Less than NSVD Live Birth M / N/A Abuyog 2 DOSE
an hour District
Hospital
2004 2 Less than NSVD Live Birth F / N/A Western 1 DOSE
an hour Leyte
Provincial
Hospital
2011 3 Less than NSVD Live Birth M / N/A Western 1 DOSE
an hour Leyte
Provincial
Hospital
2019 4 Less than NSVD Live Birth M / 2.8 Western 1 DOSE
an hour kg Leyte
Provincial
Hospital

D. History of Present Illness

The patient was doing some house-hold chores when she experienced pain on her lower pelvic

pain radiating at the back. Pain felt started by the patient around 1:30 pm in the afternoon and

was rushed by her husband in the hospital. She was waiting for her delivery to come and was

abruptly felt by the mother. Relaxation and breathing technique was performed to somehow

alleviate the pain. Upon arrival in the hospital the patient was immediately rushed in the delivery

room and delivered her baby.

E. Past Medical History

The patient has no any childhood disease nor allergies. The patient cant recall

what immunization that she received when she was a child. No accident or injuries and

maintenance medication noted. She was only hospitalized due to past delivery of her 1 st,

2nd and 3rd child. Regarding on mental health history, no mental illnesses reported.
 F. Family History

The patient’s father is still alive with no illness noted. However, her mother died

last June due to liver disease, the patient can’t remember what specific liver disease that

cause her mother’s death. The type of family they have is nuclear. Her husband’s name

is Rodolfo Bulfa, 44 years old and they have now 4 children including the newly born

child. On husband’s family sides have heredofamilial illness of hypertension.

G. Environmental History

The patients house is owned and the housing structure is mixed materials. Their

drainage system is open with a water-sealed toilet. The family’s source of water is from

the water district and their way of garbage disposal is by city collection and also they

practice garbage segregation.

II. REVIEW OF FUNCTIONAL HEALTH PATTERN

A. Health Perception and Health Maintenance Management Pattern

The patients general health is stable. She experienced colds in the past but only

lasted for days. The patients view on how to keep the body healthy is keeping the body

moving by doing household chores or “trabaho sa balay” as verbalized by the patient

and drinking alot of water. The patient never use tobacco and drugs in the past. She

perform breast self examination whenever she remembers it, in order to check if there is

any abnormalities in her breast. In following nurses/doctors orders is easy for her to

follow because it is for her own good. It is important whenever she’s in the hospital is to

stay positive and follow what the doctor’s advises.

B. Nutritional and Metabolic Pattern

 The patients typical food intake is 1 cup of vegetables,1 piece of fish and 1 cup

of rice in every meal with 8 and more glasses a day Gain weight is noted due to

pregnancy. Appetite is good and increased due to food cravings with no food

restrictions. The patient can heal well. There are no signs of abnormalities in her

integument. However, presences of dental cavity noted and also teeth that needs to be

teeth filling on the right lower second molar.

C. Elimination Pattern

The patient usually defecate everyday and every morning with consistency of soft

and colored brown and urinate every 1 to 2 hours with yellowish in color and varies if the

patient keeps on drinking water with no discomfort noted. No excessive perspiration and

odor problems noted.

D. Activity- Exercise Pattern

The patients does not have proper exercise, the only physical activities done is

by doing household chores and can perform full self-care on daily life activities.

E. Sleep-Rest Pattern

Normally patients hours of sleep is 8 to 9 hours. No difficulty in falling asleep and

does not take any sleep medications. Continuous but she does not feel tired upon

waking up. She doesn’t take a nap. For relaxation, she watches television shows and

spending time up her children and relatives.

F. Cognitive- Perceptual Pattern

 No difficulty in hearing and discomforts noted. The patient doesn’t use

eyeglasses. Sometimes she easily forget things. In order to remember things easily is by

repeating the phrases until she already memorized it.

G. Self- Perception and Self-Concept Pattern

She usually see herself as normal, healthy and very confident. During her

pregnancy she became more happier but sometimes emotional. Changes in her body

noted is the enlargement of the uterus and the increase body weight. The client

frequently angry is due to her child who is misbehaving and unorganized things in the

house.

H. Role Relationship Pattern

Legend:

Male

Female

The patient lives with her husband and 3 children. No recent family problems that

occur, whenever they have it is only caused by the misunderstanding. They usually

handle problems by sharing and seeking for advice in order to solve the problem. The

family feel about the recent hospitalization is excited and happy for the new member of

the family. Sometimes, the children are not listening and misbehaving but it is being
 handled well by the patient and her husband. In their neighborhood, their relatives is only

around the family’s house.

I. Sexuality- Reproductive Pattern

No problem regarding to the patient’s sexual relation. The patient only had one

sexual partner and is sexually active. She had her first sexual contact at the age of 20

and uses natural family planning method.

J. Coping-Stress Pattern

In order to relieve stress or problems the patient watched T.V, spend time with

the family and relatives, and to stay calm and look for possible solutions with the help of

our Almighty God. When stressed she talks or share with her husband and some

cousins and they are all available everytime she needed them. The big changed in her

life is the new member of the family and they are excited about it. Most of the time this

method is successful.

K. Value-Belief Pattern

The things that is important for the patient is her family and the well-being of the

family. Religion is important to the patient because through God every thing is possible.

Every difficulty God will be there and help.

L. Others

III. NURSING HEALTH ASSESSMENT

 A. Nursing Review of Symptoms

 EENT

No abnormalities noted.

 Cardio-respiration

The patient noted that she is easily tired while walking.

 Gastrointestinal

The patient had constipation.

 Genito-urinary

Frequent urination in the past months.

 Musculo-skeletal

No abnormalities noted.

 Nervous system

No abnormalities noted.

 Endocrine

No abnormalities noted.

 Emotional

Frequent change of moods or mood swings.

B. Physical Assessment

A. General Survey

The patient is clean and can answer the questions appropriately. Active and

aware of what is happening.

B. Vital signs

The patient’s blood pressure is 120/70 mmHg, body temperature of 35.0 c, pulse

rate of 89 bpm and respiratory rate of 19 cpm.

C. Organ System Assessment

i. The Integument

The patient has a dark brown skin tone, intact, smooth with no lesion

palpated, elasticity and recoil immediately, warm to touch and presence of

perspiration. Presences of dark pigments on both cheeks and forehead. No

edema noted. Surgical wound on the perineum due to the delivery. Hair is balck,

midlength, and no dandruff noted. Hair is equally distributed but vary on location

like armpit. Dark colored armpit and back of the neck. Nails are well-trimmed but

presence of dirt on sides, hard and immobile. Pink tone returns less than 2

seconds as the pressure is released.

ii. The Head

The face is symmetric and the head is proportion to the body. No lesions no

ted. Head is round, still and upright. Temporal artery is not tender and can perform

mastication easily. The patient was able to do all facial movement without

difficulty. The eyes is brown with no redness or swelling.The vision acuity is 20/20.
 The patient can perform easily the visual field test. Light reflex and pupil

accommodation noted. The ears are symmetric and smooth. No lesion noted.

Presences of cerumen (moist consistence and yellowish color) and tympanic

membrane is gray.The nose is midline and symmetric, No palpable sinuses and

can sniff to every nostrils. The gums and tongue are pinkish in color. Presence of

dental cavities noted. Tonsils are not red or there are no signs of inflammation.

iii. The Neck

The neck is symmetric. No bulging masses and lymph nodes are noted.

Thyroid cartilage and cricoid move upward symmetrically. Trachea is midline.

iv. The Thorax and Lungs

Fast breathing was noted. It is symmetric and no tenderness or pain and also

free from lesions. Upon auscultating, clear sounds was heard. The patient does

not use any accessory muscle while breathing.

v. The Cardiovascular and Peripheral Vascular System

Arms and also legs are symmetric and no edema noted on both lower and

upper extremities. No edema noted and color are bilaterally same but differ on

parts that constantly exposed to the sun. The extremities are warm to touch.

Capillary refill returns in 2 seconds or less. Radial pulses on both extremities are

strong and brachial pulse have equal strength bilaterally. No palpable nodes

noted. Allen test was conducted and pink tone returns with 3-5 seconds. The

patient was able to perform ROM easily. The breast is symmetric and no pain or

discomfort noted. 3 inches wide areola and half an inch nipples. Left breast is

smaller than the right breast.

vi. The Abdomen

Upon Inspection, linea negra and presences of striae gravidarum. Warm to

touch. The fundus is still on the lower part of the abdomen about 2 to 3 inches

below the navel.

vii. The Musculoskeletal System

The patient was able to perform every ROM easily with no difficulty. Both

extremities are symmetric. No snapping or clicking sound on temporomandibular

joint.

viii. The Neurologic System

The patient was able to identify the scent (alcohol and perfume). Visual acuity

of 20/20 both eyes. Eye movement was smooth and coordinated. The pupil

constrict as it accommodate light. Temporal and masseter muscles contract

bilaterraly. The patient was able to correctly identify the sharp, dull and ticklish

sensation on both lower and upper extremities. Facial movements are coordinated

and symmetric. The patient was able to hear properly and efficiently. Uvula is

midline and no signs of redness in the oral mucosa.

ix. The Genito-Urinary System

The patient refuses to be assessed on this area.

x. The rectum and Anus

The patient refuses to be assessed on this area.

 CHAPTER III

COMPLETE DIAGNOSIS

REPRODUCTIVE SYSTEM

Anatomic and Physiologic Overview

I. Organs of the Female Reproductive System

II. Histology of Ovaries

a) Ovulation

b) Fertilization

c) Follicular Development

III. Physiology

a) Menstrual Cycle

b) Pregnancy

c) Lactation

ORGANS OF THE FEMALE REPRODUCTIVE SYSTEM

Ovaries

The ovaries are a pair of small glands about the size and shape of almonds, located on

the left and right sides of the pelvic body cavity lateral to the superior portion of the uterus. Each

ovary is suspended in the pelvic cavity by two ligaments, namely the suspensory and broad

ligaments. The ovaries produce female sex hormones such as estrogen and progesterone as

well as ova (eggs).

Fallopian Tubes
 The fallopian tubes are a pair of muscular tubes that extend from the left and right

superior corners of the uterus to the edge of the ovaries. It ends in a funnel-shaped structure

called the infundibulum, which is covered with small finger-like projections called fimbriae. The

fimbriae swipe over the outside of the ovaries to pick up the released ova and carry them into

the infundibulum for transport to the uterus. Each insides of the fallopian tube is covered in cilia

that work with the smooth muscle of the tube to carry the ovum to the uterus.

Uterus

The uterus is a hollow, muscular, pear-shaped organ located posterior and superior to

the urinary bladder. It is also known as the womb, as it surrounds and supports the developing

fetus during pregnancy. The inner lining of the uterus, known as the endometrium, provides

support to the embryo during early development. The visceral muscles of the uterus contract

during childbirth to push the fetus through the birth canal.

Vagina

The vagina is the female organ of copulation as it receives the penis during intercourse.

It also allows menstrual flow and childbirth. The wall of the vagina consists of an outer muscle

layer and an inner mucous membrane. The muscle layer is smooth muscles and contains many

elastic fibers. Thus, the vagina can increase in size in order to accommodate the penis during

intercourse. Also, it can stretch greatly during childbirth.

Vulva
 The vulva, also called the pudendum, is the collective name for the external female

genitalia located in the pubic region of the body. The vulva surrounds the external ends of the

urethral opening and the vagina, which includes the mons pubis, labia majora, labia minora, and

clitoris. The mons pubis is a raised layer of adipose tissue between the skin and the pubic bone

that provides cushioning to the vulva. The inferior portion of the mons pubis splits into left and

right halves called the labia majora. The space between the labia majora is called the pudendal

cleft. Inside the labia majora are smaller, hairless

folds of skin called the labia minora that surround

the vaginal and urethral opening. Uniting the two

labia minora over the clitoris called to form a fold

of skin called prepuce. On the superior end of the labia minora is a small mass of erectle tissue

known as the clitoris that contains many nerve

endings for sensing sexual pressure.

Breast and Mammary Glands

The breasts are specialized organs of the female body that contain mammary glands,

milk ducts, and adipose tissue. The two breasts are located on the left and right sides of the

thoracic region of the body. The mammary glands are the organs of milk production and are

modified with sweat glands. Externally, each of the breasts of both males and females has

raised nipple surrounded by a circular, pigmented area called the aerola. Each adult female

breast contains mammary glands consisting of usually 15-20 glandular lobes covered by

adipose tissue, which gives the breast its form. Each lobe possesses a single lactiferous duct

that opens independently to the surface of the nipple. The duct of each lobe is formed as

several smaller ducts, which originate from lobules, converge. Within a lobule, the ducts branch

and become even smaller. In lactating breasts,

the ends of these small ducts expand to form

secretor sacs called alveoli.

OVARIAN STRUCTURE AND HISTOLOGY

The ovary is divided anatomically into the cortex and medulla. The cortical aspect of the ovary is

covered by cuboidal epithelium during the development that converts to squamous epithelium

with age. The cortical parenchyma is composed of follicles (oocytes and follicular cells),

interstitial cells and collagenous connective tissue stroma. The ovarian medulla contains large

arteries and veins, lymphatics, nerves embedded in a loose collagenous matrix. The rete ovarii

are also present in the medulla, which are cords of cells found in the medulla, which are cords

of cells found in the medulla homologous to the rete testis.

Ovulation

It is the release of an oocyte from an ovary. Just before ovulation, the primary oocyte

completes the first meiotic division to produce a secondary oocyte and a polar body. Unlike

meiosis in males, cytoplasm of the primary oocyte remains with the secondary oocyte. The polar

body either degenerates or divides to form two polar bodies. The secondary oocyte begins the

second meiotic division but stops in metaphase II.

Fertilization

After ovulation, the secondary oocyte may be fertilized by a sperm cell. Fertilization

begins when a sperm cell penetrates the cytoplasm of a secondary oocyte. Subsequently, the

secondary oocyte completes the second meiotic division to form 2 cells, each containing 23

chromosomes. One of these cells has very little cytoplasm and is another polar body that

degenerates. In the other, larger cell, the 23 chromosomes from the sperm join with the 23 from

the female gamete to form a zygote and complete fertilization. The zygote has 23 pairs of

chromosomes (a total of 46 chromosomes). All cells of the human body contain 23 pairs of

chromosomes, except for the male and female gametes. The zygote divides to form 4 cells, and

so on. The mass of cells formed may eventually implant in, or attach to, the uterine wall and

develop into a new individual.

Follicular Development

Development of the ovarian follicle is a sequential process which is primarily directed by the

influence of gonadotrophins (follicle stimulating hormones and luteinizing hormone) and can be

variable between species. Its sequence is primordial follicle, primary follicle, secondary follicle,

and tertiary follicles. Primordial follicle is a primary oocyte surrounded by a single layer of flat

cells, called granulosa cells. Once puberty begins, some of the primordial follicles become

primary follicles. The oocyte enlarges and the single layer of granulosa cells becomes enlarged

and cuboidal. Subsequently forms into a layer of clear material called zona pellucida. The

secondary follicles start develops spaces between granulosa cells that coalesce to eventually

form a large space called the follicular antrum. The granulosa cells secretes PAS positive

material into these spaces. Graafian (mature) follicles are large preovulatory follicles which

bulge from the surface of the ovary. Once the follicular antrum is formed, the oocyte is
surrounded by a remnant of granulosa cells called the cumulus oophorus. The cells of the

cumulus oophorus immediately adjacent to the oocyte are known as corona radiata.

PHYSIOLOGY

Menstrual Cycle

It refers to the series of changes that occur in sexually mature, non-pregnant females

and the result in menses. Menses is a period of mild hemorrhage, during which part of the

endometrium is sloughed and expelled from the uterus. Typically, the menstrual cycle is about

28 days long, although it can be as short as 18 days or as long as 40 days. The menstrual cycle

results from the cyclical changes that occur in the endometrium of the uterus. These changes, in

turn, result from the cyclical changes that occur in the ovary and are controlled by the secretions

of FSH AND LH from the anterior pituitary gland.

Pregnancy
 If the ovum is fertilized by a sperm cell, the fertilized embryo will implant itself into the

endometrium and begin to form an amniotic cavity, umbilical cord, and placenta. For the first 8

weeks, the embryo will develop almost all of the tissues and organs present in the adult before

entering the fetal period of development during weeks 9 through 38. During the fetal period, the

fetus grows larger and more complex until it is ready to be born.

Lactation

Lactation is the production and release of milk to

feed an infant. The production of milk begins prior to

birth under the control of the hormone prolactin.

Prolactin is produced in response to the suckling of an

infant on the nipple, so milk is produced as long as

active breastfeeding occurs. As soon as an infant is

weaned, prolactin and milk production end soon after.

The release of milk by the nipples is known as the “milk-letdown reflex” and is controlled by the

hormone oxytocin. Oxytocin is also produced in response to infant suckling so that milk is only

released when an infant is actively feeding.

NARRATIVE PATHOPHYSIOLOGY

The perception of acute pain during labor originates with the transmission of noxious

sensory input to the central nervous system (CNS). The stimuli that give rise to pain generally

are those associated with actual or potential tissue damage, and the response to these stimuli

involves reflex and cognition. The neurophysiology of pain can be briefly summarized as

follows: (a) Noxious impulses originate in nociceptive receptors distributed throughout the skin,

subcutaneous tissue, periosteum, joints, muscles, and viscera; (b) nociceptive stimuli are

transmitted via primary afferent neurons that almost always are myelinated A delta or

unmyelinated C fibers to the dorsal horn of the spinal cord; (c) the stimuli are processed

primarily in the substantia gelatinosa (laminae II) of the dorsal horn and transmitted by

interneurons of the spinothalamic tract to the thalamus and cerebral cortex, where spatial and

temporal analysis occurs, and to the hypothalamic and limbic systems, where emotional and

autonomic responses originate; (d) transmission by the spinoreticular tract to the reticular

formation of the brain mediates motor, autonomic, and sensory functions associated with pain

perception and discrimination and triggers arousal and the affective dimension of pain; and (e)

at the level of the substantia gelatinosa, modulation of nociceptive impulse transmission occurs

through several complex inhibitory systems that are activated at many supraspinal levels of the

CNS (Bonica,1990).
 In the reproductive system, both mechanical and chemical nociceptors have been found

in the ovaries, uterus, and broad ligaments (Bonica, 1990). The high-threshold

mechanoreceptors are stimulated by intense pressure, such as that associated with uterine

contractions. The increasing intensity of perceived pain commonly observed with the

progression of labor may be attributable in part to a lowered response threshold in the

mechanoreceptors produced by the repeated stimulation of uterine contractions. In addition, a

number of substances released by myometrial cellular breakdown during repeated uterine

contractions may lead to chemo- receptor stimulation. These liberated “pain-producing

substances” include bradykinin, histamine, serotonin, acetylcholine, and, potassium ions. One

mechanism involved in these cellular responses may be a relative myometrial ischemia caused

by constriction and contraction of the arteries supplying the uterine muscle.

During the first stage of labor, visceral pain usually predominates, with the transmission

of nociceptive stimuli from the uterus, cervix, adnexa, and pelvic ligaments. These stimuli are

transmitted primarily via sympathetic fibers to the posterior nerve root ganglia at T10 through LI.

As fetal descent increases during late first stage and early second stage labor, distention and

traction on the pelvic structures surrounding the vaginal vault become the predominant source

of noxious sensory input. Finally, second stage labor is dominated by stimuli arising from

distention of the perineal structures. These stimuli are transmitted primarily by the pudendal

nerves through the sacral plexus to the posterior nerve root ganglia at spinal levels S2 through

S4. (Lowe,1996)

Throughout labor, additional noxious stimuli may be transmitted because of traction and

pressure on the adnexa and parietal peritoneum; pressure on and stretch of the bladder,

urethra, and rectum; pressure on one or more roots of the lumbosacral plexus; and reflex
skeletal muscle spasm in structures supplied by the same spinal cord segments that supply the

uterus and cervix. Referred pain from the anterior abdominal wall, iliac crests, gluteal area,

thighs, and lumbosacral regions also may be experience because of the stimulation of neurons

from these regions by afferent stimuli from the pelvic organs according to the dermatomal rule.

The last few hours of human pregnancy are characterize by forceful and painful uterine

contractions that effect cervical dilatation and cause the fetus to descend through the birth

canal. There are extensive preparations in both the uterus and cervix long before this. During

the first 36 to 38 weeks of normal gestation, the myometrium is in a preparatory yet

unresponsive state.“Access Medicine” (2018). Concurrently, the cervix begins an early stage of

remodeling termed softening yet maintains structural integrity. Following this prolonged uterine

quiescence, there is a transitional phase during which myometrial unresponsiveness is

suspended, and the cervix undergoes ripening, effacement, and loss of structural integrity.

CHAPTER IV

LABORATORY RESULT

URINALYSIS
MACROSCOPIC MICROSCOPIC
Color: yellow RBC: 10- 15/ hpt
Transparency: Cloudy Puss Cell: 2-3/ hpt
Specific Gravity: 1-030 Epithelial cell: few
PH: 6.0 Mucus: Abundant
 Chemical: Amorphous Waste: few
Sugar Amorphous Phosphate
Albumin Uric acid
Blood: + Calcium oxalate
Ketone Triple phosphate
Urobilinogen

CAST
Hyaline
Fine Granular
Coarse Granular
Waxy
Other
Bacteria- None

Jeffany C. Padrique Jennifer B. Abieras

Med Technologist Pathologist

NO. UNITS REFERENCE

GLU 3.56 L mmol/L 3.89-6.1
TC 6.61 H mmol/L 0.5-2
TG 3.13 H mmol/L 0.4-1.81
CRE 62.0 mmol/L 50-120
BUN 3.12 mmol/L 2.5-6.5
 HEMATOLOGY
CBC
HEMATOCRIT 0.40
WBC 11.80 x10/ L
Different Counts
Tabs .01 Blood type: B /ph
Seamus .75 Positive
Lympo .24

DRUG STUDY LIST

DRUG NAME PRESCRIPTION DATE DATE

PRESCRIBE DISCONTINUED
Cephalexin
Cephalexin 500mg NOV. 6,2019
1cap TID x7 days

Mefenamic Acid
 Mefenamic Acid 500 NOV. 6,2019
mg1Cap TID

Methyldopamine NOV. 7,2019

Methyldopamine
250mg 1tab now
then TID

Atorvastatin
Atorvastatin 40 mg NOV. 6,2019
1 tab OD

Magnesium Sulfate NOV. 6,2019 November 7,2019

MgSO4 40g IVTT
now

Hydralazine
Hydralazine 5U NOV. 6,2019
IVTT now then x9
doses per BP >140
 Nifedipine
Nifedipine 5mg 1cap NOV. 6,2019
q 6’

IVF FLOW SHEET

IV TYPE: REGULATION: DATE PRESCRIBED:

1. PLR 1L 20 GTTS/MIN 11-06-19
2. PLR 1L + 20 U 20 GTTS/MIN 11-07-19

OXYTOCIN
3. PLR 30GTTS/MIN 11-08-19
4. PLR 1L 20 GTTS/ MIN 11-08-19

ACTUAL MANAGEMENT

THE LABOR PROCESS

The phases of pregnancy, labor, and birth are normal physiologic processes. A pregnant

women typically approaches the birth process with possible concerns of personal well-being,

that of her unborn child, and fear of labor pain. Adressing these concerns, minimizing her

discomforts, and optimizing patient safety should be of paramount importance to all participants

involved in the care of the mother and her fetus during the intrapartum period.
Nursing Considerations:

First Stage of Labor

 Latent Phase

Latent (Preparatory) Phase starts from the onset of true labor contractions to 3 cm cervical

dilatation. Here are nursing responsibilities during this phase:

1. Assess patient’s psychological readiness. Provide continuous maternal support

(compared to usual care).

2. Measure duration of latent phase. For nulliparas, it should not be more than 6 hours.

On the other hand, for multiparas, it should be within 4.5 hours. Determine if patient

received anesthesia because it can prolong latent phase. One of the most common

cause of prolonged latent phase is cephalopelvic disproportion (CPD) and it

requires cesarean birth.

3. Allow patient to be continually active. Upright maternal positions are recommended

for women on the first stage of labor. Patients without pregnancy complications can

still walk around and make necessary birth preparations.

4. Conduct interviews and filling in of forms (e.g. birth certificate) at this phase while the

patient experiences minimal discomfort and has control over contraction pains.

5. Conduct health teaching on breastfeeding, newborn care, and effective bearing down

because during this time, patient’s anxiety is controlled and she is able to focus on

nurse’s instructions.

6. Educate patient on different relaxation techniques. As early as this phase, encourage

patient to begin alternative therapy of pain relief.

 7. Ensure that the total number of internal examinations the woman receives in the

entire course of labor is limited to 5 only.

8. Ensure that birthing companion of choice is present all throughout the course of

labor.

 Active Phase

Active Phase starts from 4 cm cervical dilatation to 7 cm cervical dilatation. During this phase,

contraction intensity is stronger, interval shortens, and duration lengthens. This is where true

discomfort is first felt by the patient so she is dependent and her focus is on herself. Here are

nursing responsibilities in this phase:

1. Inform patient on the progress of her labor to lessen her anxiety and obtain her

trust and cooperation.

2. Start monitoring progress of labor with the use of WHO partograph, 2-hour action

line.

3. Encourage patient to be continually active to maximize the effect of uterine

contractions. Upright maternal positions are recommended if tolerated.

4. Assist patient in assuming her position of comfort. For those who can’t stay

upright, left-side lying is recommended to avoid disruption in fetal oxygenation.

5. Monitor maternal vital signs and fetal heart rate every 2 hours, or depending on

the doctor’s order.

6. Anticipate patient needs (e.g. sponging face with cool cloth, keeping bed clean and

dry, providing ice chips or lip balm) to promote comfort.

7. Determine when patient last voided because a full bladder can hinder fast labor

progress.
 8. Institute non-pharmacological pain measures (e.g. breathing exercises, distraction

method, imagery, music therapy, etc.)

 Transition Phase

Transition Phase starts from 8 cm cervical dilatation to 10 cm (full) cervical dilatation and full

cervical effacement. During this time, patient may be exhausted and withdrawn or aggressive

and restless. Patient’s urge to push is noticeable. Here are nursing responsibilities in this

phase:

1. Inform patient on progress of her labor.

2. Assist patient with pant-blow breathing.

3. Monitor maternal vital signs and fetal heart rate every 30 minutes -1 hour, or

depending on the doctor’s order. Contraction monitoring is also continued.

4. When perineal bulging is noticeable, prepare for delivery. Check room temperature

(25-280C and free of air drafts). The nurse should also notify staff and prepare

necessary supplies and equipment, including resuscitation machine. Lastly,

perform handwashing and double gloving.

WHO do not recommend the following nursing interventions during labor because they have

low quality of evidence:

1. Routine perineal shaving

 2. Routine use of enema

3. Admission cardiotocography (CTG) for low-risk women

4. Vaginal douching

5. Routine amniotomy for patients in spontaneous labor

6. Massage and reflexology

Second Stage of Labor

Second Stage of Labor starts when cervical dilatation reaches 10 cm and ends when the baby

is delivered. At this stage, the patient feels an uncontrollable urge to push. The patient may also

experience temporary nausea together with increased restlessness and shaking of extremities.

The nurse at this stage must coach quality pushing and support delivery.

Here are nursing care tips for this stage:

1. Instruct patient on quality pushing. The abdominal muscles must aid the involuntary

uterine contractions to deliver the baby out.

2. Provide a quiet environment for the patient to concentrate on bearing down.

3. Provide positive feedback as the patient pushes.

4. Repeat doctor’s instructions. At this phase, the patient barely hears the conversation

around the room because all her energy and thoughts are being directed toward

giving birth.

5. Take note of the time of delivery and proceed to initiate essential newborn care.

Delayed cord clamping is recommended.

6. Assist in restrictive episiotomy for patients who had vaginal births.

WHO do not recommend the following interventions during delivery because they provide low

quality of evidence:

1. Perineal massage

2. Use of fundal pressure

Third Stage of Labor

Third Stage of Labor or the placental stage starts from birth of infant to delivery of placenta. It

is divided into two separate phases: placental separation and placental expulsion. Five minutes

after delivery of baby, the uterus begins to contract again, and placenta starts to separate from

the contracting wall. Blood loss of 300-500 mL occurs as a normal consequence of placental

separation. Placenta sinks to the lower uterine segment or upper vagina. The placenta is then

expelled using gentle traction on the cord.

Here are the signs of placental separation:

1. Lengthening of umbilical cord

2. Sudden gush of vaginal blood

3. Change in the shape of uterus (globular in shape)

4. Firm uterine contractions

5. Appearance of placenta in vaginal opening

At this stage, here are the nursing care tips:

1. Coach in relaxation for delivery of placenta.

 2. Congratulate on delivery of baby.

3. Encourage skin-to-skin contact to facilitate bonding and early breastfeeding.

4. Ask patient whether placenta is important to them before it is destroyed. For those

who want to take it home, ensure that they understand and follow

standard infection precautions and hospital policy.

5. Administer prophylactic oxytocin as ordered.

6. Utilize controlled cord traction technique for placental expulsion.

7. Utilize absorbable synthetic suture materials (over chromic catgut) for primary repair

of episiotomy or perineal lacerations.

For immediate postpartum, the nurse checks the vital signs and monitors for

excessive bleeding. The first four hours after birth is sometimes referred to as the fourth

stage of labor because this is the most critical period for the mother. The nurse is set to

perform nursing interventions that would prevent the patient from infection and hemorrhage.

Also, they are being reminded of the importance of breastfeeding, ambulation, and newborn

care.

Here are WHO recommendations for immediate postpartum:

1. Early (<6 hours) resumption of feeding for patients who have vaginal birth

2. Prophylactic antibiotics for women who sustained third to fourth degree of perineal

tear during delivery

3. In healthy women who delivered vaginally to term infants, early postpartum discharge

is recommended.

On the other hand, here are interventions not recommended during immediate postpartum:

 1. Routine use of ice packs

2. Oral methylergometrine for patients who delivered vaginally

Nursing care for women in labor is a routine that takes a while to fall into. After all, it is

overwhelming for beginner nurses to do their responsibilities in front of a woman writhing in

pain. However, the opportunity to protect women and the privilege of being a part of their

positive pregnancy experience is rewarding. Read and share this to your nurse friends because

women’s and children’s lives deserve only the best care.

Tubal Ligation

Tubal ligation prevents an egg from traveling from the ovaries through the fallopian tubes and
blocks sperm from traveling up the fallopian tubes to the egg. The procedure doesn't affect your
menstrual cycle. Tubal ligation can be done at any time, including after childbirth or in combination with
another abdominal surgery, such as a C-section. Most tubal ligation procedures cannot be reversed. If
reversal is attempted, it requires major surgery and isn't always effective. Tubal ligation is one of the
most commonly used surgical sterilization procedures for women. Tubal ligation permanently prevents
pregnancy, so you no longer need any type of birth control. However, it does not protect against
sexually transmitted infections.

Risks

Tubal ligation is an operation that involves making incisions in your abdomen. It requires anesthesia.
Risks associated with tubal ligation include:

Damage to the bowel, bladder or major blood vessels

Reaction to anesthesia

Improper wound healing or infection

Continued pelvic or abdominal pain

Failure of the procedure, resulting in a future unwanted pregnancy

NURSING CONSIDERATION:

Before the procedure

Before the procedure, ask the patient what drugs they are taking, even drugs, herbs, or supplements
they bought without a prescription.

During the procedure

Intake of aspirin, ibuprofen (Advil,Motrin), warfarin(Coumadin), and any other drugs that make it hard
for blood to clot must be stopped. Patient smoking also should be stopped.

After the procedure

Tell the patient not to drink or eat anything after midnight-the night before the procedure, or 8 hours
before the time of the surgery. Doctor prescribed could be taken with a small sip of water. Tell the
patient when to arrive at the hospital or clinic.

DISCHARGE PLAN

 Advice patient to wear a well-fitting

bra.

 Recommend to wash breasts with

water daily for cleanliness.

 Instruct patient to air dry nipples after

BREAST each feeding.

 Advice patient to apply a few drops of

breast milk after a feeding and let air

dry if nipples are sore.

 If breasts are engorged, tell patient to

apply warm compress.

UTERUS  Let patient understand that

postpartum 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.
 Advice patient to consume diet high in

fiber and fluids to help avoid

constipation.

 Recommend walking, this promotes

BOWELS bowel movements, passing gas, and

increased general circulation.

 Suggest patient to raise feet onto a

stool during a bowel movement, this

helps decrease straining.

 Educate patient that pregnancy, labor,

and vaginal delivery causes stretch or

injury to pelvic floor muscles which

supports the uterus, bladder, small

intestine and rectum. This might

cause to leak a few drops of urine

BLADDER
while sneezing, laughing or coughing.

Let patient understand that this

problem usually improves within

weeks.

 Advice patient to rinse and clean

perineal area every time of voiding.

LOCHIA  Educate patient that vaginal discharge
 usually lasts about 10 days to 4

weeks. The color will change from

bright red (1-3 days) to pinkish brown

(4-10 days) to tan (11 days onwards)

and will become less in amount and

finally disappear.

 Advice patient to visit clinic / physician

if bright red lochia lasts more than 4

days.
 Teach patient how to perform Sitz

bath: sitting in a tub of water for 15

minutes, 2-3 times per day, this will

help relieve the discomfort.

 Let patient understand that perineal

EPISIOTOMY / LACERATION stitches will dissolve in 1-3 weeks.

 Teach patient to rinse from front to

back with warm water until the

bleeding stops.

 Advice patient to cool the wound with

an ice pack to lessen pain.

 Explain to patient that elevating feet

when sitting or lying down and making

HOMAN’S SIGN
sure to drink a lot of fluids will help

body to get rid of excess fluid.

SKIN  Educate patient that stretch marks will

not disappear after delivery, but

eventually fades from red to silver.

  Advice patient to provide adequate

moisture to skin to avoid dryness.

Apply lotion.
 Educate patient and significant others

that one may get “baby blues” after

delivery. There may be presence of

feeling let down, anxious, and crying.

This is normal. These feelings can

begin 2-3 days after delivery and

usually disappear in about a week or

two. Prolonged sadness may indicate

postpartum depression.

 Encourage patient to verbalize

feelings to trusted support persons

EMOTIONAL SUPPORT
from time to time.

 Encourage patient to seek God’s

guidance over healing.

 Psychological treatment can also be

advised if client has suffered clinical

depression which includes counseling

or therapy. Types of treatment may

include antidepressant medication,

psychotherapy or both. Client may

also be referred to a local support

group.
 CHAPTER V

APPENDICES

Physician’s Orders/ Progress notes

Date Notes

11/6/19; 2:10 pm > 2 OB Gyne

> TPR every shift

> NPO

> Laboratories – CBC, BT, U/A, PLR at 30

gtts/min

> Nifedipine 10 mg 1 tab now

> Hydralazine 5 units IVTT now x 3 doses if

SBP > 140 mmHg

> Magnesium Sulfate 4 g start IVTT now

> Magnesium Sulfate 20 units to 1 L D5W at

15 gtts/min

> FBC F#16 attach to Urobag

> Monitor Vital signs

> Refer accordingly.

11/6/19; 2:30 pm Don’t Post Order > Oxytocin 10 units IM

> Oxytocin 20 units to present IVF and

 regulate to 20 gtts/min

> IVF to follow PLR ii C + 20 units Oxytocin

per bottle at 20 gtts/min

> Cefalexin 500 mg TID x 7 days

> Mefenamic Acid 500 g TID

> Ferus Sulfate 1 tab OD

> Methyldopa 250 mg 1 tab TID to start now

>Refer to ROD.

11/7/19; AM > Monitor Vital signs

>Refer to OB-Gyne for Family Planning

Counseling.

11/7/19; 8:20 am > Continue IVF and meds

11/7/19; 9:50 pm > NPO temporarily except med for BTL this

pm

> Inform OR and Family Planning of

schedule

> Abdominal Pain

> Nifedipine 5 mg 1 cap every 6 hours if still

on NPO

> monitor Vital signs

> Refer accordingly.

11/7/19; 3 pm
11/7/19; 3:05 pm > May give Nifedipine 5 g SL now.

> For BTL now

> Pre-operative med now

a. Diazepam 10 mg slow IVTT

b. Tramadol SD of IVTT

> Oxygen inhalation 2-3 L/hour

> monitor Vital signs every 15 minutes.

11/7/19; 3:18 pm

11/7/19; 4:12 pm > May give another Tramadol 50 mg IVTT.

> Post BTL order

11/7/19; 4:20 pm BP: 120/70 mmHg > IVF to follow mainline PLR 1 L at 30

gtts/min.

> May discontinue Magnesium Sulfate drip

> Low salt low fat diet when fully awake –

NPO post-midnight for blood chemistry

> For FMS, BUA creatinine; HDL, LDL, total

cholesterol, triglyceride, AST

> Remove diet once blood chemistry is

taken

> Remove FBC

> Resume PO meds

 > discontinue Nifedipine sublingual

> Shift to Nifedipine 5 mg1 cap sublingual

11/8/19; 9:30 am Afebrile, no profuse every 12 hours at least 2 hours apart from

vaginal bleeding, BP: Methyldopa.

140/80

11/8/19; 1:46 pm > May change dressing

> monitor Vital signs

> Refer accordingly.

> Atrovastatin 40 g 1 tab OP

> IVF to follow PLR 2 L at 20 gtts/min.

Recommendations
 The proponents of this case analysis recommend that further study will be made for the

different diagnosis and problems of the patient. In order for the health care providers including

nurses and student nurses will be equipped with knowledge , skills and attitude in rendering

care for patients having this condition. Further study about the health condition of the patient will

help the family better understand this condition, in order that they could better take care of their

family member.

This study is also recommended for nursing students who will conduct case presentation

that that will have a flow on the proponents needed for a case presentation. They will be

equipped with knowledge, skills and attitude in conducting a case presentation especially in

making thorough assessment of their patient.

It is also of high consideration that further evaluation be done to determine the progress

and compliance of the patient to the out-patient treatment regimen. Aside from this, the sources

of data for this case presentation is only limited to the assessments, laboratory results, patient’s

chart and personal interview with the patient, as well as on her significant others. Progression of

the patient’s recovery must also be monitored and documented regularly to determine the

necessary changes and improvement of patient’s care.

CHAPTER VI
REFERENCES

Sources:

Women’s Care Center, Kent Hospital

http://www.kentri.org/services/pregnancy/postpartum-discharge-instructions.cfm

Howard County General Hospital, Johns Hopkins Medicine

https://www.hopkinsmedicine.org/howard_county_general_hospital/services/mothers_and_babi

es/taking_baby_home/postpartum-discharge-instructions.html

Labor and delivery – Postpartum Care, Mayo Clinic

https://www.mayoclinic.org/healthy-lifestyle/labor-and-delivery/in-depth/postpartum-care/art-

20047233