TABLE OF CONTENTS

Title Page
I. Table of Contents 1
II. Objectives 2
III. Introduction 3-8
IV. Patient’s Profile 9
V. Nursing Health History 10-11
VI. Gordon’s Functional Patterns 12-16
VII. Course In The Ward 17-22
VIII. Physical Assessment 23-41
IX. Anatomy And Physiology 42-66
X. Laboratory Results 67-69
XI. Drug Study 70-75
XII. Nursing Care Plan 76-83
References
Books:
 Maternal and Child Health Nursing 6th edition by Adele Pillitteri
Websites:
 https://www.healthline.com/health/pregnancy/spontaneous-vaginal-delivery
 https://www.mobapbaby.org/Labor-Delivery/Types-of-Birth
 https://www.medicinenet.com/early_signs_and_symptoms_of_labor/article.ht
m
 https://nurseslabs.com/stages-of-labor/
 https://www.medicalnewstoday.com/articles/307462.php
 https://courses.lumenlearning.com/boundless-ap/chapter/the-female-
reproductive-system/
 https://www.parent24.com/Pregnant/Birth/Different-pelvic-shapes-and-what-
they-mean-for-your-birth-experience-20150826

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 OBJECTIVES

GENERAL OBJECTIVES:
 This case study aims to assess and gather information about Normal Spontaneous
Delivery.

SPECIFIC OBJECTIVES:
Knowledge:
 To be able to define Normal Spontaneous Delivery
 To be able to deepen and broaden our knowledge regarding Normal Spontaneous
Delivery
 To be able to familiarize with the concept of anatomy and physiology and the
changes after delivery
Skills:
 To be able to deal and handle patient who had a normal spontaneous delivery
 To be able to monitor effectiveness of nursing interventions
 To be able to promote safety, comfort and patient’s privacy
 To be able to develop a SMART (specific, measurable, attainable, realistic and time
bound) nursing care plan.

Attitude:
 To be able to maintain therapeutic relationship with the patient
 To be able to promote holistic nursing care

INTRODUCTION
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 NSD (Normal Spontaneous Delivery) is a method that refers to a vaginal delivery that
happens on its own, without requiring using tools to help pull the baby out. This occurs
after a pregnant woman goes through labor. Labor opens, or dilates, her cervix to at least
10 centimeters.
For women experiencing pregnancy for the first time, NSD might be a little more
difficult since the pelvis is not yet wide enough to accommodate a child. This is extremely
painful especially if no anesthesia is use.

Types of Delivery
 Vaginal Birth- Is the natural method of childbirth. In this method, the baby is born
down the birth canal and through the vagina of the mother.
 Cesarean Birth (C- Section) - Is the delivery of a baby through incisions mode in the
mother’s abdomen and uterus when a vaginal is not optional.
 Vaginal Birth (After caesarean delivery) - Some women who have had a cesarean
after cesarean birth before may be given the option delivery (VBAC) to give birth
vaginally.
 Assisted Delivery- Will use forceps or a vacuum extractor to help deliver the baby.

THEORIES OF LABOR
1. Uterine Stretch Theory- The idea is based on the concept that any hollow muscular
organ when stretched to capacity will contract and empty as pregnancy advanced by
the growing fetus, placenta and amniotic fluid distension of the uterus creates
pressure on the nerve endings which stimulates contraction.
2. Oxytocin Theory- Believed to increase just before the pregnancy comes to term and
initiates labor due to its contractile activity on the myometrium.
- Oxytocin stimulates contractions thus facilitating sealing of ruptured capillaries
which then stop bleeding.
- Known to be a patent uterotoxin (uterine contractant)
3. Progesterone Deprivation Theory- Progesterone produced by the placenta relaxes
uterine smooth muscle by interfering with conduction of the impulses from once cell
to next.
- Decreased amount of progesterone inhibits the relaxation effect on the uterus.
4. Prostaglandin Initiation Theory- Amnion and source of prostaglandin.
- Rising fetal cortisol level increases the formation of prostaglandin which stimulates
contraction.
- Prostaglandin causes smooth muscle contract.

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 5. Theory of the Aging Placenta- As the placenta “ages” it becomes less efficient as a
result, it produce less amount of progesterone of prostaglandin and allows
concentration of prostaglandin and estrogen to rise steadily with result to rhythmic,
regular and strong uterine.

SIGNS & SYMPTOMS

1. The baby drops (lightening)
2. An increased urge to urinate (urinary reflux)
3. The mucus plug passes (bloody show)
4. The cervix dilates
5. Thinning of the cervix (effacement)
6. Back pain
7. Contraction
8. A burst of energy (nesting)
9. Feeling the urge to have a bowel movement (bowel reflux)
10. Your water breaks (bag of water)

STAGES OF LABOR
Table 1: Stages of labor and their descriptions
Duration
Stages of Labor Start End
Nullipara Multipara
First stage True labor Full cervical 10-12 hrs. 6-8 hrs. but
contractions dilatation but 6-20 hrs. 2-12 hrs. is
(progressive cervical is the normal the normal
dilatation) limit limit
False labor (absence
of cervical
dilatation)

Latent phase Onset of regularly 0-3 cm cervical 6 hrs. 4-5 hrs.

perceived uterine dilatation
contractions (mild
contractions lasting
20-40 sec)
Active Phase Stronger uterine 3-7 cm cervical 3 hrs. 2 hrs.
contractions lasting dilatation
40-60 seconds
Transitional Phase Uterine contractions 7-10 cm dilatation 3 hrs. 1.5-2 hrs.
reaching their peak,

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 occurring every 2-3
minutes for 60-90
sec.
Second Stage Full cervical Infant birth < 2 hrs. 3 0.5- 1 hr. 2
dilatation hrs. with hrs. with
epidurals epidurals
Third Stage Infant Birth Placental Delivery Maximum of Maximum of
30 mins. 30 mins.
Fourth Stage Immediate Postpartum 2-4 hours 2-4 hours
postpartum period management

1. First stage of labor (cervical stage) is divided into three sub phases;

 Latent (Preparatory) Phase (from onset of true labor contractions to 0-3 cm cervical
dilatation)
Nursing responsibilities:
1. Assess patient’s psychological readiness. Provide continuous maternal
support (compared to usual care).
2. Allow patient to be assume continually to comfort. 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.
3. Conduct interviews and filling in of forms a (e.g. birth certificate) at this
phase while the patient experiences minimal discomfort and has control over
contraction pains.
4. Conduct health teaching on breastfeeding, newborn care, educate patient
on different relaxation techniques, and effective bearing down because
during this time, patient’s anxiety is controlled and she is able to focus on
nurses instructions.
5. Ensure that the total number of internal examinations the woman receives
in the entire course of labor is limited to 5.

 Active Phase (start from 4 cm cervical dilatation to 3-7 cm cervical dilatation)

Nursing responsibilities:
1. Inform patient on the progress of her labor.
2. Start monitoring progress of labor.
3. Encourage patient to be continually active to maximize the effect of
uterine contractions.
4. Assist patient in assuming her position of comfort.

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 5. Monitor maternal vital signs and fetal heart rate every 2 hours.
6. Anticipate patient needs (e.g. sponging face with cool cloth, keeping bed
clean and dry) to promote comfort.
7. Determine when patient last voided.
8. Institute non-pharmacological pain measures (e.g. breathing exercises,
distraction method, imagery, music therapy, etc.)

 Transition Phase (starts from 8 cm cervical dilatation to 7-10 cm cervical dilatation

and full cervical effacement)
Nursing responsibilities:
1. Inform patient on progress of her labor.
2. Assist patient with pant-blow breathing.
3. Monitor maternal vital signs and fetal heart rate. Contraction monitoring is
also continued.
4. Notify staff and prepare necessary supplies and equipment, including
resuscitation machine. Lastly perform hand washing and double gloving.

2. Second stage of labor (expulsive stage) (starts when cervical dilatation reaches 10
cm and ends when the baby is delivered.)
Nursing responsibilities:
1. Instruct patient on quality pushing.
2. Provide a quite environment.
3. Provide positive feedback as the patient pushes.
4. Repeat doctor’s instructions.
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.

3. Third stage of labor or (the placental stage) (starts from birth of infant to delivery
of placenta.)
Nursing responsibilities:
1. Coach in relaxation for delivery of placenta.
2. Congratulate on delivery of the baby.
3. Encourage skin-to-skin contact to facilitate bonding and early
breastfeeding.
4. Administer prophylactic oxytocin as ordered.
5. Utilize controlled cord traction technique for placental expulsion.

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 6. Utilize absorbable synthetic suture materials (over chromic catgut) for
primary repair of episiotomy or perineal lacerations.

4. Fourth stage (immediate postpartum period) (No more expulsions of conception

products for this stage as this generally accepted as POST PARTUM juncture. This phase is
from the placental delivery to full recovery of the mother.)

COMPLICATIONS
Maternal
 Premature rupture of the membranes (the mother’s water breaks too soon)
 Post-term pregnancy and post-maturity (a pregnancy continues longer than normal,
sometimes causing problems with the baby)
 Labor that progresses too slowly
 Uterine rupture
 Excessive uterine bleeding delivery
 Inverted uterus (a uterus that is turned inside out

Fetal
 Abnormal position and presentation of the fetus (the fetus is in the wrong position
for the safest delivery)
 Amniotic fluid embolism
 Shoulder dystocia
 Prolapsed umbilical cord (the umbilical cord comes out of the birth canal before the
baby)
 Nuchal cord (the umbilical cord is wrapped around the baby’s neck)
 Fetopelvic disproportion (a fetus that is too large to pass through the birth canal
 Fetal distress, respiratory distress

EPIDEMIOLOGY
 There were 103,526 (37%) women who delivered in United States during the study
period who had normal term pregnancies and entered labor spontaneously. Overall,
96% of these women had vaginal deliveries, and adverse neonatal outcomes were
rare. For example, perinatal deaths occurred in 0.3 of every 1,000 women.
 The National Birth Center Study involved 11, 814 women admitted for labor and
delivery to 84 freestanding birth centers in the United States. CNMs provided care
during 78.6% of the labors and attended 80.6% of the births.
 Birth-center care deviated from hospital-based medical management care in that
women were much less likely to receive narcotics, anesthesia, continous electronic
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 fetal monitoring, induction of labor, augmentation of labor, intravenous infusion,
amniotimies, and episiotomies.
 In addition, relatively few vaginal examination were performed, and the patients
were more likely to be permitted to use a variety of birthing position, to each solid
or clear food, and to take showers or baths during labor.
 The rate of the ceasarean was 4.4%. there were no maternal deaths. The overall
intrapartum and neonatal mortality rate was 1.3 per 1000 births. The rates of low
Apgar and infant mortality were comparable to those reported in large studies of
low-riskhospital births.

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

PATIENT’S PROFILE

Name: Patient A.L

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Age: 38 years old
Gender: Female
Address: Dodan, Aparri, Cagayan
Birth Date: November 08, 1980
Place of Birth: Aparri, Cagayan
Civil Status: Single
Religion: Roman Catholic
Nationality/Ethnicity: Filipino
Occupation: Farmer

ADMISSION PROFILE
Date and time of admission: 07 – 15 – 19 @ 01:40pm
Chief complaint/s: Labor pain
Admitting diagnosis: G4 P3 (3003) Pregnancy Uterine 39 5/7 weeks
Cephalic in beginning labor
Final diagnosis: G4 P4 (4004)
Pregnancy uterine, term, cephalic delivered
Advanced Maternal AGA A/S 8/9
Normal Spontaneous Delivery
Admitting physician: Dr. P

ADMITTING VITAL SIGNS

Blood Pressure: 110/80 mmHg LMP: 10/10/18
Temperature: 37°C AOG: 39 5/7 weeks
Pulse rate: 82 bpm FH: 36 cm
Respiratory rate: 20 cpm

Date and time handled: 07 – 16 – 19 @ 8:00 AM

Source of information: Patient and Patient’s chart

NURSING HEALTH HISTORY

PRESENT HEALTH HISTORY

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 1 day prior to admission, the patient started to have vaginal discharge (white
discharge with some blood) accompanied by intermittent painful contractions at home on
day prior to admission. Patient immediately reported it to her live in partner. Thus,
prompted them to consult at Aparri Provincial Hospital. Hence referred and advised them to
go to the Cagayan Valley Medical Center (CVMC) for further management. Thus, patient
admitted at LR-DR and had underwent abdominal ultrasound on July 15, 2019 at 1:40 pm
and was diagnosed of G4P3 (3003), pregnancy uterine 39 5/7 weeks, cephalic in beginning
labor.

PAST HEALTH HISTORY

The patient is not a sickly person. She experienced mumps, chicken pox, common
colds and cough. To manage these diseases she uses OTC drugs such as paracetamol and
neozep. Patient has no allergies to food and medicines. This is her first time to admit in the
hospital. “Jay gamin tallu nga anak ku ading, jay balay nayyanak iti tulung ti paltera ngem
madi met mabalin tattan ta masapul da ti papel nga lisensya” she added.

FAMILY HEALTH HISTORY

 (+) Hypertension (both side)  (-) Cancer
 (-) Diabetes mellitus  (-) Allergy
 (-) Heart disease  (-) Kidney disease

SOCIAL HEALTH HISTORY

She’s not been married yet, she lives in Aparri, Cagayan at Dodan as a farmer. Their
children were at home and taking care by her mother. She is a friendly person, she use to
communicate with their neighbors whenever she has no work. The patient is a Roman
Catholic by religion. She said that her family always attends the holy mass on most Sunday.
She firmly believes that God is the provider of needs and he never left her in her problems.

OBSTETRIC HISTORY
On 2013, she had a full term normal pregnancy and delivered a baby boy via
spontaneous vaginal delivery (NSD) at home and the weight of the baby was 2.5 kg and is
alive and well. She had her check-up during 2nd month of pregnancy.

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 On 2015, she had a full term normal pregnancy and delivered a baby girl via
spontaneous vaginal delivery (NSD) at home and the weight of the baby was 2.4 kg and is
alive and well.
On 2017, she had a full term normal pregnancy and delivered a baby boy via
spontaneous vaginal delivery (NSD) at home and the weight of the baby was 2.7 kg and is
alive and well.
On 2019, she had a full term normal pregnancy with an OB Score of G4P4 (4004)
and delivered a baby boy via spontaneous vaginal delivery (NSD) at Cagayan Valley Medical
Center and the weight of the baby was 3.5 kg and is alive and well. She had her check-up
during the 3rd month of her pregnancy.
Their children stay with her mother.

GYNECOLOGY HISTORY
She attained her menarche at the age of 16 years old with 28 days regular cycle with
5 days of duration. Consumed 3 pads a day and used soap (safeguard) for cleaning with
regular shave. Her LMP was October 10, 2018 and the AOG is 39 5/7 weeks.

As for contraception, she was then on oral contraceptive pills for 1 month after she
gave birth for her first baby and had stopped immediately.

GORDON’S FUNCTIONAL PATTERN

BEFORE
PATTERN
HOSPITALIZATION
1. HEALTH According to pt. A.L she
defined health as “Iti health
PERCEPTION/ HEALTH
ket napateg iti pigsa ti tau,
MANAGEMENT ken alalagaak ti bagbagik
PATTERN lalu daytuy kalusugak para
ka daytuy anak ku” she also
DURING
HOSPITALIZATION
“Nangina gayam iti may
confine, ken ipa-apuk ti
health ku tatta” as
verbalized by the patient.

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 stated that, to manage her
diseases she immediately
took over the counter drugs
such as paracetamol and
neozep.
2.NUTRITIONAL The patient weight 45 kg.
According to the pt. She ate 3
METABOLLIC
times a day with the snack in
PATTERN between. Typically, her meal
is composed of rice with fish
and vegetable dish. She
approximately drinks 7-9
glasses of water a day.
Furthermore, the patient
stated that she has no
allergies on foods and
medications.
3. ELIMINATION According to the pt. She
doesn’t have any problem in
PATTERN
urinating and defecating. She
urinates every after meal,
yellow in color. She defecates
every day with semi-form
and brown stool.
4. ACTIVITY EXERCISE According to the pt. she is a
farmer and considered it as
PATTERN
her exercise every day.
5. SLEEP – REST According to the pt. she
usually sleeps for 7-8 hours.
PATTERN
Her earliest time to sleep is
7:00 pm and wakes up at
12
According to the patient, she
was instructed by the nurses
and doctor to have a DAT-
NPO. “Innapuy,sabaw ken
saba met iti kanayun da
ipakan kanniyami ading ”
she added. Moreover she
already consumed 500 ml of
water during the shift. Her
current IVF is PNSS 1L x 8hrs.
“Kasjay met latta ading,
awan met problemak
pinagisbuk ken panagtakkik,
namin duwa nak ummisbun
ken adda bassit nga dara
nga rumwar ken sabali ti
angut na kumpara dijay
regla, hannak pay tummakki
manipud idi nay confine
nak” as verbalized by the
patient
“Agpagnapagna nak lang
dituy uneg ti hospital ading
tapnu maexercise tuy
bagbagik” as verbalized by
the patient.
According to the patient,
most of the time, she only
stays on her bed to rest. But
her sleep is usually disturbed
 4:00 am. According to her,
she doesn’t usually take a
nap in the afternoon because
she is busy working at farm.
Moreover, she doesn’t
experience any sleep onset
difficulties and only wakes up
at night to urinate.
6. COGNITIVE According to the pt. she
doesn’t have any problem to
PERCEPTUAL
her 5 senses, she listen
PATTERN attentively and answer
question coherently.
7. SELF – PERCEPTION According to the pt. she is a
very supportive and
PATTERN
responsible mother to her
live in partner and 3 children.
8. ROLE – Patient A.L is a high school
graduate at AENHS and she is
RELATIONSHIP
currently living in Dodan,
PATTERN Aparri, Cagayan together
with her live in partner and
children. She stated that she
is comfortable and happy
with her family. Whenever
there is misunderstanding,
they manage to talk things
through and be alright again.
9. SEXUALITY – According to the pt. she had
her menarche when she was
REPRODUCTIVE
16 years old. Her
PATTERN menstruation period usually
last for 5 days. It occurs
regularly, once a month. She
stated that she started to get
sexually active at the age of
21 and expressed her
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because of interruptions like
routine check-up and
monitoring. “Sabali dituy
ading haan nak unay
makaturug, hannak sanay”,
she added. Furthermore, she
still feels rested in the
hospital despite the sleep
interruptions.
Patient A.L is cooperative
during the assessment and
interview. She is oriented to
person, time and place.
Patient A.L notices physical
changes on her body during
her pregnancy like stretch
marks and dark lining (linea
nigra) on her abdomen.
The patient said that she is
unable to take care of her
family because she is inside
the hospital. Her live in
partner was always beside
her and always ready to carry
her whenever she needs
something.
This is her 4th pregnancy with
a baby boy.
Her first child is a boy who is
now 6 years old.
Her second child is a girl who
is now 4 years old.
Her first child is a boy who is
now 2 years old.
 satisfaction with her sex life.
As for contraception, she was
then on oral contraceptive
pills for 1 month after she
gave birth for her first baby
and had stopped
immediately.
Her LMP was October 10,
2018 and the AOG is 39 5/7
weeks.
10. COPING STRESS According to the pt. she feels The patient stated that she’s
stressed out when she gets thankful for having her family
PATTERN
into a fight with her husband. and being supportive
Furthermore, her stresses are throughout her delivery.
usually relieved when talks to
her family and friends and
finds comfort and assurance
from them “Agdait- dait nak
nukwa jay balay, ken
aglutu-lutu tapnu maikkat ti
bannug ku” she added.
11. VALUE – BELIEF According to the pt. she is a She believes that having faith
Roman Catholic by religion. in God will help her get
PATTERN
She said that her family through situations like this.
always attends the holy mass “Amin nga santo ket
on most Sundays. She firmly awawagak nukwa tapnu
believes that God is the lumaing naklang para iti
provider of needs and he anak ku ken pamilyak” as
never left her in her verbalized by the patient.
problems. Furthermore, she
believe on supertitions,
“Hilot ken Lihi, jay inuna
nga anak ku saba ti
naglihiak ilemmeng ku
inggana malungksut, jay
met mekadduwa
sabunganay ti kaykayatak
na lutuwen ken kanen, jay

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 met mekatlu tinunu nga
tarong, kadetuy met naudi
nga anak ku jay puraw ti
itlug lang ti kayatak na
kanen ” she added.

COURSE IN THE WARD

DATE / NURSING
DOCTOR’S ORDER RATIONALE
TIME RESPONSIBILITY
07 – 15 – 19  Please admit to LR-  To provide  Admit patient as

15
1:40 pm DR under the environmental ordered
service of Dr. P convenience for  Prepare and fill out
therapeutic all necessary
purposes documents
 Obtain initial V/S
 Notify the
designated
department
regarding admission
 Prepare and assist
the patient
 Secure consent for  For documentation  Serve as witness in
the admission and and records consent signing
management keeping  Secure consent on
chart
 TPR q shift and  To monitor  Obtain VS as
record patient’s condition ordered
 Refer relevant
findings accordingly
 Soft diet  To aid in patient’s  Instruct the
nutritional/therape patient/SO about
utical needs the diet
 Dx: CBC  For diagnosis and  Facilitate lab
determination of any request
abnormality in the
blood
 UA  For determination  Facilitate lab
of any components request
such as protein or
microorganisms in
the urine
 Tx: IVF D5LRS 1L x  For hydration and  Ensure proper
8hrs balance fluid and regulation
electrolytes    Monitor IV site for
swelling or signs of
infection
 Check patency
 Hook to baseline  To monitor fetal  Monitor and record
IPM then q2 condition and fatal heart tone

16
 activity inside the  Refer relevant
womb while labor findings
 Monitor V/S q 10  For baseline data  Monitored patient’s
and FHT q 15 mins  To monitor fetal vital signs as
condition inside the ordered. Report
womb immediately if
there is any
abnormal findings
 Monitor and record
fetal heart tone
 Refer relevant
findings
 Labor watch  To monitor  Refer relevant
progress of labor findings
 Routine perineal  To reduce  Prepare perineum
preparation bacteria/flora aseptically
around the
perineum
 Refer  For continuous  Refer accordingly
monitoring
4:14 pm  HN BB 1 amp/IV  To relieve spasms  Ensure proper drug
now then q2 of female uterine administration
wall  Monitor for any
adverse effect of
drug to the patient
07 – 16 – 19  Change IVF to  To hasten  Ensure proper drug
1:15 am D5LRS 1L + 10 units contractions administration and
oxytocin x 10 regulation
 Monitor for any
gtts/min
adverse effect of
drug to the patient
 Hook to baseline  To monitor fetal  Monitor and record
IPM, FHT q 10 condition and fatal heart tone
activity inside the  Refer relevant
womb while labor findings
 Refer  For continuous  Refer accordingly
monitoring
2:48 am  PPO: To OB ward  For appropriate  Monitor patient

17
 care and treatment and provide nursing
care
 Dat once fully  To maintain  Informed and
awake then NPO patient’s nutritional explained to the
status patient and
significant others
about the ordered
diet
 Informed the
dietary department
regarding the diet
of the patient
 Incorporate 20  To hasten  Ensure proper drug
units oxytocin x IVF contractions administration and
to run at 30 regulation
 Monitor for any
gtts/min
adverse effect of
drug to the patient
 Med: FeSO4 tab  To treat iron  Ensure proper drug
BID deficiency anemia administration
 Monitor for any
adverse effect of
drug to the patient
 Mefenamic acid  To decrease pain  Ensure proper drug
500mg/TID and blood loss administration
 Monitor for any
adverse effect of
drug to the patient
 VS q 15mins x 1  For baseline data  Monitored patient’s
then q 10 then q 4 vital signs as
ordered. Report
immediately if
there is any
abnormal findings
 Watch for profuse  To monitor  Monitor the patient
bleeding and abnormal low blood
contraction pressure

 For postpartum  Consent is  Make sure the

BTL: Secure necessary to patient/SO

18
 consent protect healthcare understand the
providers as well as purpose, benefits
the patient and possible, risk
upon admission
 Serve as witness in
the signing of
consent
 Send OR request  To inform OR of the  Coordinate with the
procedure to be OR
done
 Inform OR/AROD  For the procedure  Coordinate with the
to be done OR and AROD
 Abdominal perineal  To reduce  Prepare perineum
preparation bacteria/flora aseptically
around the
perineum
 Refer  For continuous  Refer accordingly
monitoring

07 – 16 – 19  IE  To determine  Prepare and assist

8:00 am dilation and the patient
possibly the
position of the
baby, which can
help define when
labor actually does
or did start
 NPO  To prepare patient  Ensure the patient
to surgery; to maintained NPO
prevent aspiration
 Follow up CBC  To note for any  Facilitate lab
deviations request
or abnormalities in the
blood components
 Follow up labs  To note for any  Facilitate lab
deviations request

19
 or abnormalities
 Repeat VS q1 and  For baseline data  Monitored patient’s
record vital signs as
ordered. Report
immediately if
there is any
abnormal findings
 Refer  For continuous  Refer accordingly
monitoring

PHYSICAL ASSESSMENT

GENERAL SURVEY:
The patient was assessed on July 17, 2019 @ 1:30 pm in her bed, with ongoing IVF
PNSS 900 ml X 20 gtts/min via left metacarpal vein patent and infusing well. She has an
Endomorphic body figure. She has a body temperature of 36.4 degree Celsius which is
normal, a respiration of 24 cycles per minute, and her pulse rate was assessed to be 70
beats per minute. She is 5’1 in height and she has well-developed muscles.

BODY PART METHOD USE NORMALFINDINGS ACTUAL FINDINGS ANALYSIS

THE SKIN
Color Inspection Varies from light to Brown Normal
deep brown; from physiologic
ruddy pink to light change
pink; from yellow during
overtunes to olive. pregnancy
due to

20
 increased
production of
Melanin s/t
increased
estrogen
level
Uniformity of Inspection Generally uniform Uniform except in Normal
color except in areas areas (under arms, physiologic
exposed to the sun; neck) change
areas of lighter during
pigmentation in dark pregnancy
skinned people due to
(palms, lips, nail increased
beds) production of
Melanin s/t
increased
estrogen
level
Skin turgor Inspection When pinched, skin Skin springs back to Normal
springs back to previous state physiologic
previous state (elastic) except on change
(elastic); maybe lower extremities during
slower in older pregnancy
adults. due to
increased
fluid
retention
Presence of Inspection/ No edema (+) Edema on both Normal
Edema Palpation feet physiologic
change
during
pregnancy
due to
increased
fluid
retention
Skin lesions Inspection/ Freckles, some Dark patches on Normal
palpation birthmark, some flat cheeks physiologic
raised nevi, (+) Melasma change
no abrasions or other during

21
 lesions pregnancy
due to
increased
production of
Melanin s/t
increased
estrogen
level
Skin moisture Inspection/palp Moisture in skin folds Slightly dry Normal
ation and the axillae
(varies with
environmental
temperature and
humidity, body
temperature and
activity)
Skin Palpation Uniform within Temp: 36.4˚C Normal
temperature normal range
(depending on the
route)
HAIR
Color Inspection Varies depending on Black Normal
race
Distribution Inspection Evenly distributed Evenly distributed Normal
(evenness of hair hair
growth over
the scalp)
Thickness Inspection Thick hair Thick hair Normal
Texture and Inspection/ Silky, resilient hair Silky, resilient hair Normal
oiliness Palpation
NOSE
Color Inspection Uniform in color with Uniform in color with Normal
other facial features other facial features
Shape and size Inspection Symmetric and Symmetric and Normal
straight straight but slightly physiologic
larger than usual change
during
pregnancy
due to

22
 increase of
estrogen
leve;
Outer Lip
Color Inspection Uniform pink color Dark brown Normal
(darker, bluish hue in
Mediterranean
groups and dark
skinned client)
Symmetry of Inspection Symmetry of contour Uniform pink color Normal
contour
Texture Inspection/ Soft, moist, smooth Normal Normal
palpation texture
INNER LIPS AND BUCCAL MUCOSA
Color Inspection Uniform pink color Uniform pink color Normal
(freckled brown
pigmentation in dark
skinned clients)
Moisture and Inspection/ Moist, smooth, soft. Moist, smooth, soft. Normal
texture Palpation Glistening and elastic Glistening and elastic
texture (drier oral texture
mucosa in elderly
due to decreased
salivation)
Number of Inspection 32 adult teeth 29 teeth Normal
teeth
Color and Inspection/ Smooth, white, shiny Smooth, white, shiny Normal
texture palpation tooth enamel tooth enamel

HEART
Apical pulse/ Auscultation Regular heart sounds Regular heart sounds Normal
Heart sounds and rhythm (within rhythm
(aortic, normal range in rate)
pulmonic,
tricuspid, S1: Usually heart at
mitral) all sites, louder at the
apical area
S2: Usually heard at

23
 all sites, usually
louder at base of the
heart
S3: Present in
children and young
adults
S4: Present in many
older adults
Apical pulse/ Auscultation Systole: silent 72 bpm Normal
Heart sounds interval, slightly
(aortic, shorter duration than
pulmonic, diastole at normal
tricuspid, heart rate (60-90
mitral) bpm)

Diastole: silent
interval, slightly
longer duration than
systole at normal
heart rates.
BREAST
Size symmetry, Inspection Females: Rounded Tingling sensation in Normal
contour/shape( shape”; slightly breast physiologic
sitting position) unequal in size, change
generally symmetric during
pregnancy
d/t breast
milk
production
Localized Inspection Skin uniform in color Skin uniform in color Normal
discoloration or (same in appearance (same in appearance
hyperpigment as skin of abdomen as skin of abdomen
action, or back) or back)
retraction or
dimpling Skin smooth and Skin smooth and
intact intact

Diffuse symmetric
horizontal or vertical

24
Areola area Inspection Round or oval and Round and bilateral Normal
(size,shape, bilateral the same the same physiologic
symmetric,colo Color varies widely, Color dark brown change
r, surface from light pink to during
characteristics, dark brown pregnancy
masses/lesion) due to
Irregular placement
hormones
of sebaceous glands
caused the
on the surface of the
cells that give
areola
our skin its
pigmentation
to become
more active
Nipples for size, Inspection Rounded, everted Rounded, everted Normal
shape, position, and equal in size, and equal in size,
color, discharge similar in color, soft similar in color,
and lesions and smooth, both slightly dry, both
nipples point in the nipples point in the
same direction same direction
Inversion of one or
both nipples may be
present from puberty
Axillary, Palpation No tenderness, No tenderness, Normal
subclavicular masses or nodules masses or nodules
and lymph
nodes
Masses, Palpation No tenderness, Tender, nipple Normal
tenderness and masses, nodules. No discharge physiologic
discharge from nipple discharge change
the areola and except from during
nipples pregnant or breast- pregnancy
feeding females d/t breast
milk
production
ABDOMEN
Skin Integrity Inspection Unblemished skin, Presence of stretch Normal
uniform in color marks physiologic
Silver-white change
striae(Stretch marks during
or surgical scars) pregnancy

25
 due to
rupture and
atrophy of
small
segments of
the
connective
layer of the
skin

Due to
increased
And dark lining (linea
production of
nigra)
melanin s/t
increased
estrogen
level
Contour and Inspection Flat rounded(convex Protuberant Normal in
symmetry or scaphoid FH: 19 cm pregnancy
(concave)
Abdominal Inspection Symmetric Symmetric Normal
movements movements caused movements caused
by respirations by respirations
Visible peristalsis in Visible peristalsis in
very lean people very lean people
Aortic pulsations in Aortic pulsations in
thin persons at thin persons at
epigastric area epigastric area
Vascular Inspection No visible vascular No visible vascular Normal
patterns problem problem
Level of Inspection Glasgow coma score Glasgow coma score Normal
consciousness of 15 indicates of 15 indicates
alertness and alertness and
complete orientation complete orientation

26
 ANATOMY AND PHYSIOLOGY
Anatomy of the Male Reproductive System

The organs of the male reproductive system are specialized for three primary functions:

1. To produce, maintain, transport, and nourish sperm, and protective fluid (semen).
2. To discharge sperm within the female reproductive tract.
3. To produce and secrete male sex hormones.

FIGURE 1: Male external and internal reproductive system

 Penis: This is the male organ used in sexual intercourse. This skin is sometimes
removed in a procedure called circumcision. The opening of the urethra, the tube that
transports semen and urine, is at the tip of the penis. The glans of the penis also contains a
number of sensitive nerve endings.

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

 Scrotum: This is the loose pouch-like sac of skin that hangs behind and below the
penis. It contains the testicles (also called testes), as well as many nerves and blood vessels.
The scrotum acts as a "climate control system" for the testes.
 Testicles (testes): These are oval organs about the size of large olives that lie in the
scrotum, secured at either end by a structure called the spermatic cord. Most men have two

27
 testes. The testes are responsible for making testosterone, the primary male sex hormone,
and for generating sperm. Within the testes are coiled masses of tubes called seminiferous
tubules. These tubes are responsible for producing sperm cells.
 Epididymis: The epididymis is a long, coiled tube that rests on the backside of each
testicle. It transports and stores sperm cells that are produced in the testes. It also is the job
of the epididymis to bring the sperm to maturity, since the sperm that emerge from the
testes are immature and incapable of fertilization. During sexual arousal, contractions force
the sperm into the vas deferens.
 Vas deferens: The vas deferens is a long, muscular tube that travels from the
epididymis into the pelvic cavity, to just behind the bladder. The vas deferens transports
mature sperm to the urethra, the tube that carries urine or sperm to outside of the body, in
preparation for ejaculation.

 Ejaculatory ducts: These are formed by the fusion of the vas deferens and the
seminal vesicles (see below). The ejaculatory ducts empty into the urethra.
 Urethra: The urethra is the tube that carries urine from the bladder to outside of the
body. In males, it has the additional function of ejaculating semen when the man reaches
orgasm. When the penis is erect during sex, the flow of urine is blocked from the urethra,
allowing only semen to be ejaculated at orgasm.
 Seminal vesicles: The seminal vesicles are sac-like pouches that attach to the vas
deferens near the base of the bladder. The seminal vesicles produce a sugar-rich fluid
(fructose) that provides sperm with a source of energy to help them move. The fluid of the
seminal vesicles makes up most of the volume of a man's ejaculatory fluid, or ejaculate.
 Prostate gland: The prostate gland is a walnut-sized structure that is located below
the urinary bladder in front of the rectum. The prostate gland contributes additional fluid to
the ejaculate. Prostate fluids also help to nourish the sperm. The urethra, which carries the
ejaculate to be expelled during orgasm, runs through the center of the prostate gland.
 Bulbourethral glands: Also called Cowper's glands, these are pea-sized structures
located on the sides of the urethra just below the prostate gland. These glands produce a
clear, slippery fluid that empties directly into the urethra. This fluid serves to lubricate the
urethra and to neutralize any acidity that may be present due to residual drops of urine in
the urethra.

Female Reproductive System

28
 The structures that form the female external genitalia are termed the vulva (from the Latin
word for “covering”)

FIGURE 2. Female external genitalia

 Mons Veneris: The mons veneris is a pad of adipose tissue located over the
symphysis pubis, the pubic bone joint. It is covered by a triangle of coarse, curly hairs. The
purpose of the mons veneris is to protect the junction of the pubic bone from trauma.
 Labia Minora: Just posterior to the mons veneris spread two hairless folds of
connective tissue, the labia minora. Before menarche, these folds are fairly small; by
childbearing age, they are firm and full; after menopause, they atrophy and again become
much smaller. Normally the folds of the labia minora are pink; the internal surface is
covered with mucous membrane, and the external surface with skin.
 Labia Majora: The labia majora are two folds of adipose tissue covered by loose
connective tissue ad epithelium that are positioned lateral to the labia minora. Covered by
pubic hair, the labia majora serve as protection for the external genitalia and the distal
urethra and vagina.
 Other External Organs. The vestibule is the flattened, smooth surface inside the
labia. The openings to the bladder (the urethra) and the uterus (the vagina) both arise from
the vestibule. The clitoris is a small (approximately 1 to 2 cm), rounded organ of erectile
tissue at the forward junction of the labia minora.clitoris is sensitive to touch. It is covered
by a fold of skin, the prepuce. Arterial blood supply for the clitoris is plentiful. When the
ischiocavernous muscle surrounding it contracts with sexual arousal, the venous outflow for
the clitoris is blocked, leading to clitoris erection.
 Two Skene’s glands (parurethral glands) are located just lateral to the urinary
meatus, one on each side. Bartholin’s glands (vulvovaginal glands) are located just lateral to

29
 the vagina opening of both sides. Their ducts open into the distal vagina. Secretions from
both of these glands help to lubricate the external genitalia during coitus.
 The fourchette is the ridge of tissue formed by the posterior joining of the two labia
minora and labia majora. This is the structure that is sometimes cut (episiotomy) during
childbirth to enlarge the vaginal opening.
 Posterior to the fourchette is the perineal muscle or the perineal body. Because this
is a muscular area, it is easily stretched during childbirth to allow foe enlargement of the
vagina and passage of the fetal head. Many exercises suggested for pregnancy (such as
Kegel’s, squatting, tailor-sitting) are aimed at making the perineal muscle more flexible to
allow easier expansion during birth without tearing of this tissue.
 The hymen is a tough but elastic semicircle of tissue that covers the opening to the
vagina in childhood. It is often torn during the time of first sexual intercourse. However,
because of the use of tampons and active sports participation, many girls who have not had
sexual relations do not have intact hymens at the time of their first pelvis examination.

Female Internal Structures

Female internal reproductive organs are the ovaries, the fallopian tubes, the uterus, and the
vagina.

FIGURE 2.1: Female internal

 Ovaries. The ovaries are approximately 4 cm long by 2 cm in diameter and

approximately 1.5 cm thick, or the size and shape of almonds. They are grayish white and
appear pitted, or with minute indentations on the surface. Ovaries are located close to and
on both sides of the uterus in the lower abdomen. It is difficult to locate them by abdominal
palpation because they are situated so low in the abdomen.
Ovarian have three principal divisions:

30
 1. Protective layer of surface epithelium

2. Cortex, where the immature (primordial) oocytes mature into ova and large amounts of
estrogen and progesterone are produced

3. Central medulla, which contains the nerve, blood vessels, lymphatic tissue, and some
smooth muscle tissue

Division of Reproductive Cells (Gametes): At birth, each ovary contains approximately 2

million immature ova (oocytes), which were formed during the first 5 months of
intrauterine life. Although these cells have the unique ability to produce a new individual,
they basically contain the usual components of cell: a cell membrane, an area of clear
cytoplasm, and a nucleus containing chromosomes. The oocytes, like sperm, differ from all
other body cells in the number of chromosomes they contain in the nucleus. The nucleus of
all other human body cells contains 46 chromosomes, consisting of 22 pairs of autosomes
Reproductive cells (both ova and spermatozoa) have only half the usual number of
chromosomes, so that, when they combine (fertilization), the new individual formed from
them will have the normal number of 46 chromosomes.

Maturation of Oocytes: Each oocyte lies in the ovary surrounded by a protective sac, or thin
layer of cells, called a primordial follicle. Between 5 and 7 million ova form in utero. The
majority never develop beyond the primitive state and actually atrophy, so that by birth
only 2 million are present in each ovary; by 22 years, there are approximately 300,00; and
by menopause, none are left (all have either matured or atrophied).

 Fallopian Tubes: Fallopian tubes approximately 10 cm long in mature woman. Their

function is to convey the ovum from the ovaries to the uterus and to the uterus and to
provide a place for fertilization of the ovum by sperm. Although a fallopian tube is a
smooth, hollow tunnel, it is anatomically divided into four separate parts.

FIGURE 2.2:
Anterior view of female reproductive organs showing relationship of fallopian tubes and body the

31
 The most proximal division, the interstitial portion, is that part of the tube that lies within
the uterine wall. This portion is only about 1 cm length; the lumen of the tube is only 1 mm
in diameter at this point. The isthmus is the next distal portion. It is approximately 2 cm in
length and like the interstitial tube, is extremely narrow. This is the portion of the tube that
is cut or sealed in a tubal ligation, or tubal sterilization procedure. The ampulla is the third
and also the longest portion of the tube. It is approximately 5 cm in length. It is in this
portion that fertilization of an ovum usually occurs.
The infundibular portion is the most distal segment of the tube. It is approximately 2 cm
long and is funnel shaped. The rim of the tunnel is covered by fimbria (small hairs) that help
to guide the ovum into the fallopian tube.
The mucus produced may also act as a source of nourishment for the fertilized egg, because
it contains protein, water, and salts. Because the fallopian tubes are open at their distal
ends, a direct pathway exists from the external organs, through the vagina to the uterus
and tubes, to the peritoneum. It can also lead to infection of the peritoneum (peritonitis) if
disease spreads from the perineum through the tubes to the pelvic cavity. For this reaction,
careful, clean technique must be used during pelvic examinations r treatment. Vaginal
examinations during labor and birth are done with sterile technique to ensure that no
organisms can enter.

 Uterus: The uterus is a hollow, muscular, pear-shaped organ located in the lower
pelvis, posterior to the bladder and anterior to the rectum. The function of the uterus is to
receive the ovum from the fallopian tube; provide a place for implantation and
nourishment; furnish protection to a growing fetus; and at maturity of the fetus, expel it
from a woman’s body. After a pregnancy, the uterus never returns to its non-pregnant size
but remains approximately 9 cm long, 6 cm wide, 3 cm thick, and 80 g in weight.
 The cervix is the lowest portion of the uterus. The opening of the canal at the
junction of the cervix and isthmus is the internal cervical os; the distal opening to the vagina
is the external cervical os. The level of the external os is at the level of the ischial spines (an
important relationship in estimating the level of the fetus in the birth canal).
 Uterine and Cervical coats: The uterine wall consists of three separate coats or
layers of tissue: an inner one of muscle fibers (the endometrium), a middle one of muscle
fibers 9 the myometrium), and an outer one of the connective tissue (the perimetrium).
 Uterine Blood Supply: The large descending abdominal aorta divides to form two
iliac arteries; main divisions of the iliac arteries are the hypogastric arteries. These further
divide to form the uterine arteries and supply the uterus. Because the uterine blood supply
is not far removed from the aorta, it is copious and adequate to supply the growing needs
of a fetus.

32
 FIGURE 2.3: Blood supply to the uterus

 Uterine Nerve supply: The uterus is a supplied by both efferent (motor) and afferent
(sensory) nerves. The efferent nerves arise for the T5 through T10 spinal ganglia. The
afferent nerves join the hypogastric plexus and enter the spinal column at T11 and T12. The
fact that sensory innervation from the uterus registers lower in the spinal column than does
motor control has implications in controlling pain in labor. An anesthetic solution can be
injected near the spinal column to stop the pain of uterine contractions at the T11 and the
T12 levels without stopping motor control or contractions (registered higher, at the T5 to
T10 level). This is the principle of epidural and spinal anesthesia.
 Uterine Supports: The uterus is suspended in the pelvic cavity by several ligaments
that also help support the bladder and is further supported by a combination of fascia and
muscle. If its ligaments become overstretched during pregnancy, they may not support the
bladder well afterward, and the bladder can then herniate into the anterior wall, a
rectocele.
 Uterine Deviations: Several uterine deviations (shape and position) may interfere
with fertility or pregnancy. In the fetus, the uterus first forms with a septum or a fibrous
division, longitudinally separating it into two portions. As the fetus matures, this septum
dissolves, so that typically at birth no remnant of the division remains. In some women, the
septum never atrophies, and so the uterus remains as two separate compartments. In
others, half of the septum is still present, still other women have oddly shaped “horns” at
the junction of the fallopian tubes, termed a bicornuate uterus. Any of these malformations
may decrease the ability to conceive or to carry a pregnancy to term (Krantz, 2007). Some

33
 variations of uterine formation are shown. The specific effects of these deviations on
fertility and pregnancy are discussed in later chapters.
FIG
URE 2.4:
(A)

Cystocele. The bladder has herniated into the anterior wall of the vagina.

(B) Rectocele. The rectum has herniated into the posterior vaginal wall.

 Ordinarily, the body of the uterus is tipped slightly forward. Positional deviations of
the uterus commonly seen are:
 Anteversion, a condition in which the entire uterus is tipped far forwad
 Retroversion, a condition in which the entire uterus is tipped backward
 Anteflexion, a condition in which the body of the uterus is bent sharply
forward at the junction with the cervix.
 Retroflexion, a condition in which the body is bent sharply back just above
the cervix.

 Vagina: The vagina is a hollow, musculomembranous canal located posterior to the

bladder and anterior to the rectum. It extends from the cervix of the uterus to the external
vulva. Its function is to act as the organ of intercourse an to convey sperm to the cervix so
that sperm can meet with the ovum in the fallopian tube. With childbirth, it expands to
serve as the birth canal.

34
 FIGURE 2.5: Uterine flexion and version

(A) Anterversion. (B) Anteflexion. (C) Retroversion.(D) Retroflexion.

 When a woman is lying on her back, as she does for a pelvic examination, the
course of the vagina is inward and downward. Because of this downward slant and the
angle of the uterine cervix, the length of the anterior wall of the vagina is approximately 6-7
cm; the posterior wall is 8 to 9 cm. At the cervical end of the structure, there are recesses
on all sides of the cervix, termed fornices. Behind the cervix is the posterior fornix; at the
front, the anterior fornix; and at the sides, the lateral fornices. The posterior posterior
fornix serves as a place for the pooling of semen after coitus; this allows a large number of
sperm to remain close to the cervix and encourages sperm migration into cervix.
 The vaginal wall is so thin at the fornices that the bladder can be palpated through
the anterior fornix, the ovaries through the lateral fornices, and the rectum through the
posterior fornix. The vagina is lined with stratified squamous epithelium similar to that
covering the cervix. It has a middle connective tissue layer and a strong muscular wall.
 Normally, the walls contain many folds or rugae that lie in close approximation to
each other. These folds make the vagina very elastic and able to expand at the end of
pregnancy to allow a full-term baby to pass through without tearing.
 The blood supply to the vagina is furnished by the vaginal artery, a branch of the
internal iliac artery. Vaginal tears at childbirth tend to bleed profusely because of this rich
blood supply. The same rich blood supply is also the reason that any vaginal trauma at birth
heals rapidly.
 The vagina has both sympathetic and parasympathetic nerve innervations
originating at the S1 to S3 levels. The vagina is not an extremely sensitive organ, however.
Sexual excitement, often attributed to vaginal stimulation, is influenced mainly by clitoral
stimulation.
 The mucus produced by the vaginal lining has a rich glycogen content. When this
glycogen is broken down by the lactose-fermenting bacteria that frequent the vagina
(Doderlein’s bacillus), lactic acid is formed. This makes the usual pH of the vagina acid, a
condition detrimental to the growth of pathologic bacteria, so that even though the vagina
connects directly to the external surface, infection does not readily occur.
 Instruct women not to use vaginal douches or sprays as a daily hygiene measure
because they may clean away this natural acid medium of the vagina, inviting vaginal
infections. After menopause, the pH of the vagina becomes closer to 7.5 or slightly alkaline,
a reason that vulvovaginitis infections occur more frequently in women in this age group
(Selby, 2007).

35
 Different pelvic shapes and what they mean for your birth experience:
The shape of your pelvic cradle is an important component in determining the outcome of
your birth experience. Here are the four basic types these are classified according to the
shape of the brim or inlet.

Although the shape of the pelvis varies, it is not a rigid, fixed structure, but an elastic
system of bones that can widen and stretch, and which is very flexible at the joints so that it
can open wide during labour.

The shape of your pelvic cradle is an important component in determining the outcome of
your birth experience. The size and shape of this bony canal determines whether a baby of
average size and shape and lying in a normal position would be able to negotiate its way out
into the world.

The four types of female pelvis:

FIGURE 3: The Gynaecoid or genuine female pelvis

 Gynecoid pelvis-It has an almost round brim and will permit the passage of an

average-sized baby with the least amount of trauma to the mother and baby in normal
circumstances. The pelvic cavity (the inside of the pelvis) is usually shallow, with straight
side walls and with the ischial spines not so prominent as to cause a problem as the baby
moves through. 

 Android pelvis- It has a heart-shaped brim and is quite narrow in front. This type of

pelvis is likely to occur in tall women with narrow hips and is also found in African women.
The pelvic cavity and outlet is often narrow, straight and long. The ischial spines are
prominent. Women with this shape pelvis may have babies that lie with their backs against
their mothers’ backs and may experience longer labours. It is important that these women
take an active role during their labour and need to squat and move aroundas much as
possible. 
36
 Anthropoid pelvis- It has an oval brim and a slightly narrow pelvic cavity. The outlet
is large, although some of the other diameters may be reduced. If the baby engages in the
pelvis in an anterior position, labour would be expected to be straightforward in most
cases. 
 Platypelloid pelvis- It has a kidney-shaped brim and the pelvic cavity is usually
shallow and may be narrow in the antero-posterior (front to back) diameter. The outlet is
usually roomy. During labour the baby may have difficulty entering the pelvis, but once in,
there should be no further difficulty.
 Many women are concerned that their pelvic capacity may be limited and that they
will therefore have difficulty in giving birth. The true capacity of the pelvis will only be
realised during labour. Only the forces created by mother and baby during birth will allow
the pelvis to open to its full potential. This may take some time, but it is the only true way of
exploring the “fit” between the mother and baby during birth.

Breasts
The mammary glands, or breasts, form from ectodermic tissue early in utero. They
then remain in a halted stage of development until a rise in estrogen at puberty produces a
marked increase in their size. The size increase occurs mainly because of an increase of
connective tissue plus deposition of fat. The glandular tissue of the breasts, necessary for
successful breastfeeding, remains undeveloped until first pregnancy begins. Boys may
notice a temporary increase in breast size at puberty, termed gynecomastia. Breasts are
located anterior to the pectoral muscle and in many women breast tissue extends into the
axilla.

FIGURE 4: Anatomy of the breast (A) NonPregnant (B) Pregnant (C) During lactation

37
 Milk glands of the breasts are divided by connective tissue partitions into
approximately 20 lobes. All of the glands in each lobe produce milk by acinar cells and
deliver it to the nipple via a lactiferous duct. The nipple has approximately 20 small
openings through which is secreted. An ampulla portion of the duct, located just posterior
to the nipple, serves as a reservoir for milk before breastfeeding.

A nipple is composed of smooth muscle that is capable of erection on manual or

sucking stimulation. On stimulation, it transmits sensations to the posterior pituitary gland
to release oxytocin. Oxytocin acts to constrict milk gland cells and push milk forward into
the ducts that lead to the nipple. The skin surrounding the nipples is darkly pigmented out
to approximately 4 cm and is termed the areola. The area appears rough on the surface
because it contains many sebaceous glands, called Montgomery’s tubercles.

Menstruation

A menstrual cycle (a female reproductive cycle) is episodic uterine bleeding in

response to cyclic hormonal changes. The purpose of a menstrual cycle is to bring an ovum
to maturity and renew a uterine tissue bed that will be responsible for the ova’s growth
should it be fertilized. It is the process that allows for conception and implantation of a new
life. Because menarche may occur as early as 9 years of age, it is good to include health
teaching information on menstruation to both school age children and their parents as early
as fourth grade as part of routine care. The length of menstrual cycle differs from woman to
woman, but the average length is 28 days (from the beginning of one menstrual flow to the
beginning of the next). It is not unusual for cycles to be as short as 23 days or as long as 35
days. The length of the average menstrual flow (termed menses) is 4 to 6 days, although
women may have periods as 2 days or as longs as 7 days.

TABLE 1: Characteristics of Normal Menstrual Cycles

Characteristic
Beginning (menarche)
Interval between cycles
Duration of menstrual flow
Amount of menstrual flow
Color of menstrual flow
Description
Average age at onset, 12.4 years; average range, 9-17 years
Average, 28 days; cycles of 23-35 days not unsual
Average flow, 2-7 days; ranges of 1-9 days not abnormal
Difficult to estimate; average 30-80 mL per menstrual period;
saturating pad or tampon
Dark red; a combination of blood, mucus, and endometrial
cells

38
 Odor Similar to that of marigolds

Physiology of Menstruation
Four body structures are involved in the physiology of the menstrual cycle: the
hypothalamus, the pituitary gland, the ovaries, and the uterus. For a menstrual cycle to be
complete, all four structures must contribute their part; inactivity of any part results in an
incomplete or ineffective cycle.

FIGURE 5: The interaction of pituitary-uterine-

ovarian functions in a menstrual cycle

Fertilization: The Beginning of Pregnancy

Fertilization (also referred to as conception and impregnation) is the union of an

ovum and a spermatozoon. This usually occurs in the outer third of a fallopian tube, the
ampullar portion (Crombleholme, 2009).

Usually only one of a woman’s ova will reach maturity each month. Once the mature
ovum is released, fertilization must occur fairly quickly because an ovum is capable of
fertilization for only 24 hours (48 hours at the most). After that time, it atrophies and

39
becomes nonfunctional. Because the functional life of a spermatozoon is also about 48
hours, possibly as long as 72 hours, the total critical time span during which sexual relations
must occur for fertilization to be successful is about 72 hours (48 hours before ovulation
plus 24 hours afterward).

As the ovum is extruded from the graafian follicle of an ovary with ovulation, it is
surrounded by a ring of mucopolysaccharide fluid (the zona pellucida) and a circle of cells
(the corona radiata). The ovum and these surrounding cells (which increase the bulk of the
ovum and serve as protective buffers against injury) are propelled into a nearby fallopian
tube by currents initiated by the fimbriae- the fine, hair like structures that line the
openings of the fallopian tubes. Normally, an ejaculation of semen averages 2.5mL of fluid
containing 50 to 200 million spermatozoa per milliliter, or an average of 400 million sperm
per ejaculation. At the time of ovulation, there is a reduction in the viscosity (thickness) of
the cervical mucus, which makes it easy for spermatozoa to penetrate it. Sperm transport is
so efficient close to ovulation that spermatozoa deposited in the vagina generally reach the
cervix within 90 seconds and the outer end of a fallopian tube within 5 minutes after
deposition. This is one reason why douching is not an effective contraceptive measure
(Burkman, 2007).

Spermatozoa move through the cervix and the body of the uterus and into the
fallopian tubes, toward the waiting ovum by the combination of movement by their flagella
(tails) and the uterine contractions. Capacitation is a final process that sperm must undergo
to be ready for fertilization. This process, which happens as the sperm move to the ovum,
consists of changes in the plasma membrane of the sperm head, which reveal the sperm-
binding receptor sites.

All of the spermatozoa that achieve capacitation reach the ovum and cluster around
the protective layer of corona cells. Hyaluronidase (a proteolytic enzyme) is released by the
spermatozoa and dissolves the layer of cells protecting the ovum. One reason than an
ejaculation contains such a large number of sperm is probably to provide sufficient enzymes
to dissolve the corona cells. Under ordinary circumstances, only one spermatozoon is able
to penetrate the cell membrane of the ovum. Once it penetrates the cell, the cell
membrane changes composition to become impervious to other spermatozoa. An exception
to this is the formation of hydatidiform mole, in which multiple sperm enter an ovum; this
leads to abnormal zygote formation.

Immediately after penetration of the ovum, the chromosomal material of the ovum
and spermatozoon fuse to form a zygote. Because the spermatozoon and ovum each
carried 23 chromosomes (22 autosomes and 1 sex chromosome), the fertilized ovum has 46
chromosomes. If an X-carrying spermatozoon entered the ovum, the resulting child will
have two X chromosomes and will be female (XX). If a Y-carrying spermatozoon fertilized
the ovum, the resulting child will have an X and Y chromosome and will be male (XY).

40
 Fertilization is never a certain occurance because it depends on at least three separate
factors; equal maturation of both sperm and ovum, the ability of the sperm to penetrate
the zona pellucida and cell membrane and achieve fertilization.

From the fertilized ovum (zygote), both the future child and the accessory structure needed
for support during intrauterine life (e.g, placenta, fetal membranes, amniotic fluid, and
umbilical cord) are formed.

IMPLANTATION

Once fertilization is complete, a zygote migrates over the next 3 to 4 days toward
the body of the uterus, aided by the currents initiated by the muscular contractions of the
fallopian tubes. During this time, mitotic cell division, or cleavage, begins. The first occurs
at about 24 hours; cleavage divisions continue to occur at a rate of about one every 22
hours. By the time the zygote reaches the body of the uterus, it consists of 16 to 50 cells. At
this stage, because of its bumpy outward appearance, it is termed a morula (from the Latin
word morus, meaning “mulberry”).

The morula continues to multiply as it floats free in the uterine cavity for 3 or 4 additional
days. Large cells tend to collect at the periphery of the ball, leaving a fluid space
surrounding an inner cell mass. At this stage, the structure becomes a blastocyst. It is this
structure that attaches to the uterine endometrium. The cells in the outer ring are
trophoblast.9

PHYSIOLOGY OF POST-PARTUM

Primary responsibilities of nurses in postpartum settings are to assess postpartum

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

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 Breasts
Assess the breasts for:
 Signs of engorgement, including fullness, around postpartum days 3 and 4
 Hot, red, painful, and edematous areas, which could indicate mastitis
 Nipple condition and latch-on technique of women who are breastfeeding
Breastfeeding women should wear a comfortable, well-fitted support bra. Instruct them to
gently rub colostrum or breast milk into their nipples and allow the nipples to air dry after
each feeding to “condition” the nipples. Mothers can prevent drying by avoiding soap when
washing the nipples.
It is also extremely important to teach patients proper breastfeeding techniques to ensure
a positive experience for mothers and their infants. Teaching proper latch-on techniques
and how to break the infant’s suction after feeding can have a positive and lasting effect
upon mothers’ breastfeeding experiences. Otherwise, mothers may develop sore, cracked,
and sometimes bleeding nipples, which can discourage the continuation of breastfeeding.
According to the Joanna Briggs Institute (2009), “Among the options of applying warm-
water compresses, breast milk, or teabags, the placement of a warm-water compress was
found to be the most effective intervention in controlling nipple pain and trauma.”
Instruct bottle-feeding patients to wear a well-fitting support bra and to avoid any type of
nipple stimulation until lactation is discontinued.

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

Bowel Function

42
 Assessment of the bowel is important in all postpartum patients. It is especially vital for
patients following C-sections. Assess for the following:
 Bowel sounds
 Return of bowel function
 Flatus
 Color and consistency of stool
Administer prescribed stool softeners or laxatives as needed to treat constipation and ease
perineal discomfort during defecation.
Encourage patients to ambulate soon after delivery. Teach the need to eat fruits,
vegetables, and other high-fiber foods daily. Postpartum patients should consume at least
2,000 mL/day of fluid. While patients may consider 2,000 mL a lot to drink in one day,
consumption can be spread out throughout the day.

Bladder
Assess urination and bladder function for the following:
 Return of urination, which should occur within 6 to 8 hours of delivery
 For approximately 8 hours after delivery, amount of urine at each void. Patients
should void a minimum of 150 mL per void; less than 150 mL per void could indicate urinary
retention due to decreased bladder tone post-delivery (in the absence of preeclampsia or
other significant health problems).
 Signs and symptoms of a urinary tract infection (UTI)
The bladder should be non-palpable above the symphysis pubis.
Encourage patients to drink adequate fluid each day and to report signs and symptoms of a
urinary tract infection, including frequency, urgency, painful urination, and hematuria.

Lochia
Assess lochia during the postpartum period:
 Saturating one pad in less than an hour, a constant trickle of lochia, or the presence
of large (i.e., golf-ball sized) blood clots is indicative of more serious complications (e.g.,
retained placenta fragments, haemorrhage) and should be investigated immediately. A
significant amount of lochia despite a firm fundus may indicate a laceration in the birth
canal, which should be addressed immediately.
 Foul-smelling lochia typically indicates an infection and needs to be addressed as
soon as possible.

43
 Lochia should progress from rubra to serosa to alba. Any changes in this progression
could be considered abnormal and should be reported. Lochia rubra is present on days 1–3,
lochia serosa on days 4–10, and lochia alba on days 11–21.
It is important to note that patients who had a C-section will typically have less lochia than
patients who delivered vaginally; however, some lochia should be present.
After discharge, patients should report any abnormal progressions of lochia, excessive
bleeding, foul-smelling lochia, or large blood clots to their physician immediately. Instruct
patients to avoid sexual activity until lochial flow has ceased.

Episiotomy/Perineum
The acronym REEDA is often used to assess an episiotomy or laceration of the perineum.
REEDA stands for:
 Redness
 Edema
 Ecchymosis
 Discharge
 Approximation
Redness is considered normal with episiotomies and lacerations; however, if there is
significant pain present, further assessment is necessary. Furthermore, excessive edema can
delay wound healing. The use of ice packs during the immediate postpartum period is
generally indicated.
There should be an absence of discharge from the episiotomy or laceration, and the wound
edges should be well approximated. Perineal pain must be assessed and treated. Nurses are
encouraged to assess the rectal area for haemorrhoids and, if present, should instruct
patients to discuss haemorrhoidal treatments (e.g., witch hazel pads or other over-the-
counter hemorrhoid medications) with their certified nurse-midwife or physician.
Various actions can aid in perineal healing. To avoid infection, teach patients to pat from
front to back and to use a peri-bottle for gentle cleansing of the perineum after a bowel
movement or urination. Many certified nurse-midwives and physicians prescribe topical
ointments and sprays to ease the discomfort of a sore perineum. If one of these has been
prescribed, instruct patients to use a sitz bath and then apply the suggested topical agent
for best results.
Analgesics are often prescribed for pain. Patients are generally instructed to apply ice packs
to the perineum immediately after delivery. Inform patients with lacerations and
episiotomies that, as sutures dissolve, the perineum may itch and that this is normal in the

44
absence of any other perineal abnormalities. Instruct patients to avoid tampons and sexual
activity until the perineum has healed.
Performing Kegel exercises are an important component of strengthening the perineal
muscles after delivery and may be begun as soon as it is comfortable to do so.
Lower Extremities
To assess for deep vein thrombosis (DVT), the lower extremities should be examined for
the presence of hot, red, painful, and/or edematous areas.
Assess the legs for adequate circulation by checking the pedal pulses and noting
temperature and color. In addition, the lower extremities should be assessed for edema.
Pedal edema is normally present for several days after delivery as fluids in the body shift.
However, lasting edema should be reported for further assessment.
To improve circulation and prevent the development of thrombi, encourage patients to
ambulate shortly after delivery. Also teach them to avoid crossing the legs for long periods
of time and to keep the legs elevated while sitting. Many certified nurse-midwives and
physicians seek to combat the development of thrombi by encouraging patients to wear
TED hose and/or sequential compression devices (SCDs) after delivery.
ASSESSING FOR DVT
In the past, postpartum nurses assessed for DVTs by eliciting a Homan’s sign (dorsiflexion of
the foot). The presence of pain when eliciting the Homan’s sign indicated the probable
presence of a DVT. However, it is now contraindicated to use the Homan’s sign to assess for
DVTs, as this action may dislodge a clot. Massage of the legs should also be avoided.
Emotions
Emotions are an essential element of the postpartum assessment. Postpartum patients
typically exhibit symptoms of the “baby blues” or “postpartum blues,” demonstrated by
tearfulness, irritability, and sometimes insomnia. The postpartum blues are caused by a
multitude of factors, including hormonal fluctuations, physical exhaustion, and maternal
role adjustment. This is a normal part of the postpartum experience.If symptoms last longer
than a few weeks or if the postpartum patient becomes non-functional or expresses a
desire to harm herself or her infant, she should be instructed to report this to her certified
nurse-midwife or physician immediately. Appropriate interventions should be implemented
to protect the mother and her infant; this behaviour is indicative of postpartum depression
(discussed below under “Postpartum Complications”).Postpartum mothers and their
families should be taught to understand that the baby blues are a normal part of the
postpartum experience. Encourage patients to rest regularly and to allow family members
to care for them as needed. Instruct patients to get plenty of fresh air and gentle exercise.
Acquaint patients with groups for new mothers that provide the support of others

45
experiencing postpartum blues. Finally, teach postpartum mothers and their families about
the signs and symptoms of postpartum depression.
LABORATORY RESULT
COMPLETE BLOOD COUNT
DATE/TIME: 7/15/19 @ 12:07pm
TEST DONE NORMAL VALUES ACTUAL VALUES ANALYSIS
Hemoglobin 120-60 108 g/L Normal
Hematocrit 0.380-0.470 0.347 Lower value; due to
excessive amount of
blood the body
produces to help
provide the
nutrients for the
body
Erythrocytes 4.50-6.00 4.62 10^12/L Normal
RBC count 150-400 275 10^9/L Normal
Platelet count 80.0-100.00 75.1 fL Lower value; due to
iron deficiency
anemia
MCV 26.0-32.0 23.5 pg Lower value; due to
iron deficiency
anemia
MCH 320-360 313 g/L Lower value; due to
iron deficiency
anemia
WBC count 4.50-11.00 12.97 10^9/L Elevated; due to
physiologic stress
during pregnancy
state
Neutrophils 35.0-65.0 74.1 % Elevated; due to
bone marrow’s
response
Lymphocytes 20.0-40.0 14.7 % Lower value; due to
changes
suppressions of
activity during
pregnancy
46
Monocytes 2.0-8.0 8.0 % Normal
Eosinophils 0.0-5.0 3.0 % Normal
Basophils 0.0-1.0 0.2 % Normal

URINALYSIS
DATE/TIME: 7/15/19 @ 2:29pm
TEST DONE NORMAL VALUES ACTUAL VALUES ANALYSIS
Physical
examination:
Color Yellow Normal
Transparency Hazy Due to presence of
blood
Chemical Analysis
pH 7.5 (acidic) Normal
Specific gravity 1.020 Normal
Protein Trace Normal
Glucose Negative Normal
Ketones Negative Normal
Blood Negative Normal
Bilirubin Negative Normal
Urobilinogen Normal Normal
Nitrite Negative Normal
Leucocyte Negative Normal

URINE FLOW CYTOMETRY

TEST DONE NORMAL VALUES ACTUAL VALUES ANALYSIS
White blood cell 0-17 12 /uL Lower value; due to
body fight infection
Red blood cell 0-11 5 /uL Lower value; due to
growth of
development baby
Epithelial cells 0-17 19 /uL Elevated; due to
presence of
contamination in
the specimen with
skin flora
Hyaline cast 0-1 0 /uL Normal
Bacteria 0-278 81 /uL Normal

47
 DRUG STUDY

DOCTOR’S ORDER: HN BB 1 amp/IV now then q2

GENERIC NAME: Hyoscine-N-butylbromide
BRAND NAME: Buscopan
CLASSIFICATION: Antispasmodic,
PREGNANCY CLASSIFICATION: C

MECHANISM OF ACTION:
 The mechanism of action of Buscopan is that it blocks the muscarinic receptors
found on the smooth muscle walls which means its blocks the action of acetylcholine
on the receptors found within the smooth muscle of the gastrointestinal and urinary
tract and thus reduces the spasms and contractions. This relaxes the muscle and
thus reduced the pain from the cramps and spasms.

INDICATIONS:
 To relieve spasm on genitourinary tract.

CONTRAINDICATIONS AND CAUTIONS:

48
  Myasthenia gravies, megacolon, hypersensitivity to drug contents, narrow angle
glaucoma, prostate hypertrophy with urinary retention, mechanical stenosis in the
GI tract, tachycardia.

ADVERSE EFFECTS:
 Constipation, decreased sweating, mouth, skin, eye dryness, blurred feeling,
bloating, dysuria, nausea or vomiting, lightheadedness, headache, weakness.

NURSING RESPONSIBILITIES:
 Take this drug 30 minutes to 1 hour before meals.
 Buscopan will potentiate the effect of alcohol and other CNS depressants.
 Do not take antacids and antidiarrheal 2 to 3 hours prior to raking this drug.
 It is not necessary to take the medication if you are not in pain.
 Avoid driving or operating machinery after parenteral dose.

49
DOCTOR’S ORDER: FeSO4 tab BID
GENERIC NAME: Ferrous sulfate
BRAND NAME: Ferrous sulfate
CLASSIFICATION: Enzymatic mineral and iron preparation
PREGNANCY CLASSIFICATION: A

MECHANISM OF ACTION:
 Ferrous sulfate is an essential component in the formation of hemoglobin,
myoglobin and enzymes. It is necessary for effective erythropoiesis and transport or
utilization of oxygen.

INDICATIONS:
 The prevention or treatment of iron deficiency anemia due to inadequate diet,
malabsorption pregnancy, and blood loss.

CONTRAINDICATIONS AND CAUTIONS:

 Patient receiving repeated blood transfusions; anemia not due to iron deficiency.

ADVERSE EFFECTS:
 Large doses may aggravate peptic ulcer, regional enteritis, and ulcerative colitis.
 Severe Iron poisoning: Vomiting, severe abdominal pain, diarrhea, dehydration,
hyperventilation, pallor or cyanosis, cardiovascular collapse.

NURSING RESPONSIBILITIES:
 Store all forms at room temperature.
 Give between meals with water but may give with meals if gastrointestinal discofort
occur.

DOCTOR’S ORDER: Mefenamic acid 500mg/TID

50
GENERIC NAME: Mefenamic acid
BRAND NAME: Ponstel
CLASSIFICATION: Nonsteroidal anti-inflammatory
PREGNANCY CLASSIFICATION: C

MECHANISM OF ACTION:
 Anthranilic acid derivative. Like ibuprofen inhibits prostaglandin synthesis and affect
platelet function. No evidence that it is superior to aspirin.

INDICATIONS:
 For the short-term treatment of mild to moderate pain from various conditions. It is
also used to decrease pain and blood loss from menstrual period.

CONTRAINDICATIONS AND CAUTIONS:

 Hypersensitivity to drug; GI inflammation, or ulceration. Safety in children <1/t y,
during pregnancy (category C), or lactation is not established.

ADVERSE EFFECTS:
 CNS: Drowsiness, insomnia, dizziness, nervousness, confusion, headache.
 GI: Severe diarrhea, ulceration, and bleeding; nausea, vomiting, abdominal cramps,
flatus, constipation, hepatic toxicity.

NURSING RESPONSIBILITIES:
 Assess patient who develop severe diarrhea and vomiting for dehydration and
electrolyte imbalance.

51
DOCTOR’S ORDER: Change IVF to D5LRS 1L + 10 units oxytocin x 10 gtts/min
GENERIC NAME: Pitocin
BRAND NAME: Oxytocin
CLASSIFICATION: Oxytoin, lactation stimulant
PREGNANCY CLASSIFICATION: C

MECHANISM OF ACTION:
 Oxytocin promotes contractions by increasing the intracellular Ca2+, which in turn
actives myosin’s light chain kinase. Oxytocin has specific receptors in the muscle
lining of the uterus and the receptors concentration increases greatly during
pregnancy, reaching a maximum in early labor at term.

INDICATIONS:
 Used for labor induction, augmentation of labor, postpartum abbreviation of third
stage of labor, postpartum control of uterine bleeding, termination of pregnancy
and for the evaluation of fetal respiratory capability.

CONTRAINDICATIONS AND CAUTIONS:

 Contraindicated in patients hypersensitive to drugs and in those with severe
toxemia, hypertonic uterine patterns, total placental Previa, and vasoprevia. Also
contraindicated when cephalopelvic disproportion is present.
 Use cautiously during first and second stage of labor and in patients with history of
cervical or uterine surgery.

ADVERSE EFFECTS:
 MATERNAL: CNS: Subarachnoid hemorrhage (from hypertension), seizures or coma
(from water intoxication)
CV: hypertension, increased heart rate, systemic venous return, and
cardiac output, arrhythmias
GI: nausea vomiting
GU: tetanic uterine contractions, absorption placentae, impaired
uterine blood flow, pelvic hematoma, increased uterine motility, uterine rupture
postpartum hemorrhage.
Hematologic: afibrinogenemia ( may be related to postpartum bleeding)
 FETAL: CNS: Infant brain damage
EENT: Retinal hemorrhage
CV: bradycardia, PVCS, arrhythmias
Hepatic: jaundice

52
 Respiratory: anoxia, asphyxia

NURSING RESPONSIBILITIES:
 Continuously monitor contractions, fetal and maternal heart rate, and maternal
blood pressure and ECG. Discontinue infusion if uterine hyperactivity occurs.
 Monitor patient extremely closely during first and second stages of labor because of
risk of cervical laceration, uterine rupture and maternal and fetal dead.
 Assess fluid intake and output. Watch for sign and symptoms of water intoxication.

53