MCN Case

ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City
NCM 107 RLE

Case Study 1:
Pre-natal Visit
Mae Arra G. Lecobu-an

BSN 2-G
Group 3
Mrs. Dolly Mia S. Argel

Clinical Instructor
I. INTRODUCTION
Pregnancy is described as the period in which fetus develops inside a woman’s womb or
uterus. It usually lasts for about 40 weeks or over 9 months, measures from the last menstrual
period up to delivery.
Prenatal is a care that a pregnant woman receives from health care services, it is also a
care provided by the family and relatives and also the partner of the pregnant mother. It is done
to keep the pregnant mother and the future baby healthy. It starts by planning of pregnancy and
should be recognized by those who take part in the pregnancy process and should continue
throughout the labor, delivery, and to neonatal period. It aims to maintain and improve the health
of the childbearing mother and the infant as well as to provide right education, nutrition, periodic
surveillance, laboratory assessment and risk factors of pregnancy including genetic disease and
birth defects.
Nausea and dizziness early in the morning is common during early pregnancy. This
happens because of the hormonal changes that happens in the body and also because of the
increasing blood volume. It is also best known as morning sickness.
Amenorrhea is the absence of menstruation. Primary amenorrhea is the absence of
menstruation by someone who doesn’t have a period by the age of 15. Secondary refers to the
absence of three or more periods by someone who had periods in the past. The most common
cause of secondary amenorrhea is pregnancy.
II. OBJECTIVES
At the end of this case presentation, the participants and the audience will be educated about the
signs of early pregnancy and its nursing management and acquire proper knowledge, skills and
attitude in providing nursing care to the patient.
Specific Objectives:
Knowledge:
1. Recognize the signs and symptoms of patient’s condition.
2. Identify other participating factors of patient’s condition.
3. Discuss health teachings about prenatal care.
Skills:
1. Make accurate and attainable nursing care plan.
2. Implement proper nursing interventions depending the patient’s condition signs and
symptoms.
3. Document correct nursing interventions and evaluation.
Attitude:
1. Establish rapport with the patient and the patient’s partner.
2. Recognize the patient’s needs using a holistic approach.
3. Show an outmost confidence when with the patient.
III. NURSING HEALTH HISTORY

A. BIOGRAPHIC DATA
Patient’s Name: Belle
Address:
Age: 21 years old
Sex: Female
Marital status: Single
Occupation: None
Religion:
Source of Information: The patient herself
Attending Physician:
Date Admission: 10-04-2021
Time of Admission: 7:45 AM
Chief Complaint: Nausea and dizziness upon rising in the
morning.
Admitting Impression: Morning sickness
B. CHIEF COMPLAINTS:
Belle sought consultation to the health center complaining of nausea and dizziness
upon rising in the morning.
C. HISTORY OF PRESENT ILLNESS

None
D. PAST MEDICAL HISTORY
Bella had chicken pox at the age of 12 years old. She has not been admitted
before and no history of any respiratory illnesses, negative for tuberculosis, heart
disease, diabetes mellitus and hypertension.
E. FAMILY HISTORY
Belle’s father has asthma and her mother has hypertension. Belle’s family is
negative for both mental illness and cancer.
F. LIFESTYLE AND HEALTH PRACTICES

Menarche: 12 years old. 28 days cycle. Duration of 5 days. Used 2 pads a day.
Dysmenorrhea tolerated. Takes 3 square meals a day. Diet would consist of
vegetables, fish and fruits like banana. Chicken and meat not on a daily basis.
Non-smoker and does not drink alcohol. Drinks 1 cup of coffee during breakfast.
IV. PHYSICAL EXAMINATION

Vital Signs: T = 36.8°C
PR = 83bpm
RR = 20cpm
BP = 110/70mmHg
Weight = 42 kgs.
Last Menstrual Period: June 16, 2021
Gravida: 1 Para: 0
V. ANATOMY AND PHYSIOLOGY

Nausea and vomiting are most common symptoms and most severe during 1st trimester.
Pathophysiology of nausea and vomiting during early pregnancy is unknown, although
metabolic, endocrine, gastrointestinal, and psychologic factors probably all play a role. Estrogen
may contribute because estrogen levels are elevated in patients with hyperemesis gravidarum.
Dizziness Several factors may contribute to dizziness in the first trimester. Changing
hormones and lowering blood pressure. As soon as you become pregnant, your hormone levels
change to help increase the blood flow in your body. This helps the baby develop in utero.
Increased blood flow can cause your blood pressure to change. Often, your blood pressure will
drop during pregnancy, also known as hypotension or low blood pressure. Low blood pressure
can cause you to feel dizzy, especially when moving from lying down or sitting to standing.
The Uterus, the endometrium, myometrium and perimetrium becomes clearly defined
over the course of pregnancy. The uterus grows steady, predictable rate during pregnancy with
this expansion first becoming detectable at approximately 5 weeks of gestation. Where the initial
uterine growth occurs in the anteroposterior diameter, while isthmus or lower segment of the
uterus can become very soft.
Hormones of Pregnancy:
The placenta is the primary physiologic interface between the maternal and fetal
compartments and is a central mediator for chemical messages between the fetus and the
pregnant woman.
The primary hormones of pregnancy produced by the placenta are estrogen, progesterone, and
human chorionic gonadotropin (hCG).
Human chorionic gonadotropin (hCG) (Source Syncytiotrophoblast and Placenta):
 Stimulates the production of progesterone from corpus luteum
 Prevents degeneration of the corpus luteum, by ensuring on going estrogen
and progesterone production.
 Stimulates thyroid production of thyroxine in the first trimester
Human Placental Lactogen (hPL) (Source: Placenta):
 Stimulates production of growth hormones
Progesterone (Source: Corpus Luteum and Placenta)
 Promotes systemic vasodiliation
 Support mammary growth for lactation
 Inhibits uterine productions of prostaglandins
Estrogen (Source: Ovaries, Corpus Luteum, Placenta and Fetus):
 Increase uterine blood floe
 Promotes growth of uterus and breast glandular tissues.
 Increases myometrial sensitivity to oxytocin, may upregulate oxytocin
receptors.
VI. Diagnostic and Laboratory

Belle’s pregnancy test is confirmed positive requested for the following laboratory work
up:
 CBC
 Blood Typing and Rh factor
 RPR
 HIV Screening
 HbsAg
 Urinalysis
VII. Drug Study
Drug Name Classification Mechanism of action Indication Contraindication Adverse Reaction Nursing responsibility
Generic Iron supplement Iron combines with Treat iron Iron metabolism Gastrointestinal Check doctor’s order
name: porphyrin and globin deficiency anemia disorder causing (stomach and Assess for allergy to any
Ferrous chains to form (a lack of red blood increased iron bowel) problems ingredient.
sulfate hemoglobin which is cells caused by storage. An like constipation, Monitor blood studies.
critical for oxygen having too little overload of iron in nausea, vomiting, Administer the right drug
Trade name/s: delivery from the lungs iron in the body) the blood. A type of and diarrhea. in the right dose and route
Femiron, to other tissues. Iron blood disorder When taken in at the right time.
Hemocyte, deficiency causes a where the red blood empty stomach Assess for skin lesions,
Iron microcytic anemia due cells burst called they can damage color, gums, teeth color.
to the formation of hemolytic anemia. the lining of the
Dosage: small erythrocytes with An ulcer from too stomach.
Route: insufficient hemoglobin. much stomach acid,
Per orem and a type of
stomach irritation
Frequency: called gastritis.
1 tab q.d.
Timing:
VIII. Nursing Care Plan
Assessment Diagnosis Outcome Intervention Rationale Evaluation
Subjective: Nausea and vomiting Short term: Independent: Alleviate nausea and Short term:
complaining of nausea related to early To reduce the severity Recommend patient to nausea and dizziness Nausea and dizziness
and vomiting symptoms of of nausea and dizziness avoid aversive odor or during early pregnancy. reduced.
pregnancy known as foods. Maintain a healthy life
morning sickness Long term: style and nutrition on Long term:
Reduce the risk for Advice patient to eat early pregnancy. Lower risk of
hyperemesis foods with higher hyperemesis
gravidarum protein and gravidarum
carbohydrate and lower
fat content are helpful.
Such as:
Drinking smaller
volumes of liquids at
multiple times
IX. Discharge Plan/Health Teaching
Evaluation
The patient sought consultation to the health center accompanied by her boyfriend
complaining of nausea and dizziness upon rising in the morning. The Goal is not
yet met.
Discharge Plan:
Prescribed ferrous supplement to be taken one tablet daily.
Health Teachings:
1. Get plenty of rest.
2. Drink plenty of fluids, especially water, throughout the day.
3. Avoid odors and flickering lights that could trigger nausea and dizziness
4. Keep the rooms well ventilated and at right room temperature.
1. Eat a few crackers or toast in the morning to help settle your
stomach. Keep a few crackers at bedside and eat a couple before
getting up.
5. Eat 5 or 6 small meals a day instead of 3 large meals.
6. Eliminate alcohol and limit caffeine
7. Visit your dentist
8. Wear sunscreen
Know when to call the doctor
If you have any of the following symptoms, the Center for Disease Control
recommends contacting your doctor:
1. Vaginal bleeding or leaking of fluid
2. Contractions that are 20 minutes apart or less
3. Pain of any kind
4. Strong cramps
5. Heart palpitations
6. Dizziness or fainting
7. Decreased activity of the baby
8. Shortness of breath
QUESTIONS:
1. Determine the EDC and AOG of Belle.
Estimated Date of Delivery: March 23, 2022
Age Of Gestation: 15 5/7 days
2. Define Para, Gravida, Nullipara, Multipara.
 Para- the number of completed pregnancies beyond 20 weeks gestation
(whether viable or nonviable).
 Gravida- the number of times that a woman has been pregnant. Parity is
defined as the number of times that she has given birth to a fetus with a
gestational age of 24 weeks or more, regardless of whether the child was
born alive or was stillborn.
 Nullipara- A woman who has not given birth to a viable child.
 Multipara- A woman who has had two or more pregnancies resulting in
potentially viable offspring.
3. What is Bell’s obstetric score?
G1P0.
4. What are the psychological response of Belle in her journey during her first
trimester of pregnancy.
Belle was shocked upon confirmation of her pregnancy and doctor’s states
that Belle is not yet ready for pregnancy.
5. Differentiate the presumptive, probable and positive signs of pregnancy in
the first trimester.
 Presumptive signs those which, when taken as single entities, could easily
indicate other conditions. This includes: Breast changes, Nausea and
vomiting, amenorrhea, frequent urination, fatigue, uterine enlargement,
quickening linea Negra, melasma and striae gravidarum.
 Probable signs are objective and so can be verified by an examiner.
Although they are more reliable than presumptive symptoms, they still do
not positively diagnosis a pregnancy. This includes: Chadwick’s sign,
Goodell’s sign, Hegar’s sign, sonographic evidence of gestational sac,
ballottement,
 Positive sign There are only three documented or positive signs of
pregnancy: Demonstration of a fetal heart separate from the mother’s Fetal
movements felt by an examiner and Visualization of the fetus by ultrasound
6. Identify and discuss the physiological and psychological changes that Belle
may experience during her state.
Physiologic changes:
The platelet count tends to fall progressively during normal pregnancy. In a
proportion of women (5–10%), the count will reach levels of 100–150 × 109
cells/l by term. Despite this hemodilution, there is usually no change in
corpuscular volume or hemoglobin concentration.
Changes in the cardiovascular system in pregnancy are profound and begin
early in pregnancy. Peripheral vasodilation leads to a 25–30% fall in
systemic vascular resistance. To compensate for this, cardiac output
increases by around 40% during pregnancy. Maximum cardiac output is
found at about 20–28 weeks' gestation.
Psychological changes:
First trimester- During this time, there may be emotional fluctuations
between positive feelings (such as excitement, happiness, and joy) and rather
negative ones (such as disbelief, anticipation, worry, and tearfulness.
Second trimester- Although the mood fluctuations continue even during the
second trimester, the negative feelings could sometimes lessen. This is due
to reduced nausea/ vomiting, more adaptation to changes.
Third trimester- Negative emotional feelings could come back more again
during this time. This could be due to increasing discomfort (such as due to
pelvic girdle pain/ a backache), insomnia,
7. Identify at least 5 discomforts that she might experience during the first
trimester and discuss
independent nursing intervention for each.
1. Nausea and vomiting
Advice patient to eating small meals several times a day may help lessen the
symptoms. A diet high in protein and complex carbohydrates (like whole-
wheat bread, pasta, bananas, and green, leafy vegetables) may also help
reduce the severity of the nausea.
2. Fatigue
Recommend patient to have exercise, pamper herself and take a nap.
3. Heartburn and indigestion
Advice patient to prevent or reduce by eating smaller meals throughout the
day and by not lying down shortly after eating.
4. Constipation
Recommend patient to drink plenty of fluids and include fibers in her diet.
5. Headache
Recommend patient to have rest, proper nutrition, and adequate fluid intake
may help ease headache symptoms.
8. What is the significance of proper diet and nutrition to a pregnant woman?
Discuss healthy eating habits and vitamins needed for her and her growing
fetus.
Eating proper diet during pregnancy is important because the pregnant
mother’s diet during her pregnancy is linked to the development of good
brain, healthy birth weight of the baby and also to reduce birth defects.
Taking vitamins in addition to a healthy diet ensures that the pregnant
mother and the baby gets enough important nutrients like folic acid and iron.
9. What are the expected discomforts of pregnancy on the first trimester that
should be discussed to Belle so she would understand better? Include
independent nursing interventions for each.
Nausea and vomiting
Nursing intervention:
Advice Belle to have diet high in protein and complex carbohydrates (like
whole-wheat bread, pasta, bananas, and green, leafy vegetables) may also
help reduce the severity of the nausea.
Headache
Recommend Belle to have rest, proper nutrition, and adequate fluid intake
may help ease headache symptoms.
Fatigue
Recommend Belle to have exercise, pamper herself and take a nap.
10. Formulate Nursing Diagnosis – based on identified problem of Belle at the
present. How the present status would affect Belle?
Nausea and dizziness related to early symptoms of pregnancy know as
morning sickness.
Undergoing to different changes and symptoms of pregnancy can cause
anxiety and discomfort to the mother. As stated by the doctor Belle is also
not ready for pregnancy which could cause difficulty in accepting the
pregnancy.
11. Discuss the significance of every prenatal visits
Prenatal visit is important to the health of the baby and the mother during
pregnancy. Regular visits can allow your doctor to determine complications
that may arise and treat it as soon as possible. Through this knowledge given
by pre-natal visits the pregnant mother and the doctor could get appropriate
nutritional advice and be given appropriate immunization.
12. How important is the support of a significant others?
The support of the significant other during pregnancy strengthens the bond
and the sense of teamwork on both partners. With the partner’s support the
pregnant mother would be happier and less
stressed during the time of pregnancy. This could also reduce the worries
and a supportive partner will be able to provide the needs and wants of a
pregnant partner.

COLLEGE OF NURSING
NCM 107 RLE

Case Study 2:
Third Trimester
BSN 2-G
Group 3

Clinical Instructor
I. INTRODUCTION
Pregnancy is described as the period in which fetus develops inside a woman’s
womb or uterus. It usually lasts for about 40 weeks or over 9 months, measures
from the last menstrual period up to delivery.
Each week there are different developments and changes a pregnant mother
encounter. Each week of pregnancy includes description of the baby’s
development, as well as changes that takes place in the body.
Most of the babies were born between 38 to 42 weeks from the first day of the
mother’s last menstrual period. Pregnancy is divided into trimesters. The first week
is from week 1 to the end of the week 12. The second trimester is from week 13 to
the end of week 26 and the third trimester is from week 27 to the end pregnancy.
II. OBJECTIVES
General Objectives:
At the end of this case presentation, the participants and the audience will be
educated about the physiological changes during the middle of the second
trimester, approaching the last trimester and also assessing the psychological state
of the pregnant mother and each corresponding nursing management and acquire
proper knowledge, skills and attitude in providing care to the patient.
Knowledge
1. Recognize the changes that happens during the middle of second trimester.
2. Identify the participating factors that could happen with the patient’s
conditions.
3. Discuss health teachings about prenatal care
Skills
1. Make accurate and attainable nursing care plan for the pregnant mother.
2. Implement proper during interventions that could alleviate the condition of
the patient.
3. Document correct nursing interventions and proper evaluations.
Attitude
1. Establish rapport with the patient and the family.
3. Show an outmost confidence when managing patient’s bedside care.
III. NURSING HEALTH HISTORY

A. Biographic Data
Address:
Age: 21 years old
Sex: Female
Marital Status: Single
Occupation: None
Religion:
Source of Information: The patient herself.
Date of Admission: 10-11-2021
Chief Complaint: Prenatal Visit
Admitting Impression:
B. Chief Complaint
C. History of Present Illness
Complains of backache, painless contractions and times experiences
constipation. She also experiences increase in vaginal discharge.
D. Past Medical History:
E. Family Health History
F. Lifestyle and Health Practices
IV. PHYSICAL EXAMINATION
Vital Signs: BP: 130/70mmHg
Pulse: 87 b/min
Respiratory Rate: 224cpm
Temperature: 36.5°C
Weight: 137lbs.
Fetal Heart Rate: Audible by stethoscope 145bpm
Done Leopold’s maneuver: cephalic presentation
Fetal position: Right Occiput anterior (ROA)
Nervous System Respiratory System
Immune System Cardiovascular System
Mammary System Hematological System
Liver Spleen
Digestive Tract Renal System
Bone
Pancreas
Skeletal Muscle
Nervous System Adipose Tissue
 Increased prefrontal cortex
activation.
 Increased oligodendrocyte proliferation.
 Forebrain olfactory neurogenesis.
 Decrease brain size and volume, gray matter regions subserving social
cognition.
Immune System
 Involution of the thymus.
 Hyperplasia of the uterine-draining lymph nodes.
 Activation of monocytes and granulocytes.
 Suppression of the pro-inflammatory Th1immune state.
 Activation of the anti-inflammatory Th2immune state.
 Decrease circulation of the Natural Killer cells and decrease IFN-gamma
and increase in T cells.
Mammary gland
 Increase in breast volume, ductal branching and vascular remodeling.
 Formation of secretory lobuloalveolar units
 Epithelial cell proliferation and hypertrophy of areola glands.
 Secretory differentiation; synthesis and accumulation of cytoplasmic lipid
droplets and milk proteins in alveolar cells.
Liver
 Increased size
 Increased fasted gallbladder volume & residual volume after contraction.
 Normal hepatic blood flow, decrease in percentage of cardiac output to the
liver
 Early pregnancy; Increased insulin sensitivity: increased glycogen content.
 Late pregnancy: Increased insulin resistance: increased gluconeogenesis.
Digestive Tract
 Decreased gastrointestinal motility.
 Decreased gastroesophageal sphincter tone.
 Increased intestinal calcium absorption.
Bone
 Increased bone turnover
 Decreased bone mineral density,
 Increased bone resorption,
 Trabecular thickness: decrease in early pregnancy and increase in late
pregnancy.
Skeletal muscle
 Increase pelvic floor muscle stiffness.
 Increased intramuscular extracellular matrix.
 Elongation of muscle fibers
 Early pregnancy: increase insulin sensitivity: increased glycogen content
 Late pregnancy: increase insulin resistance; increased gluconeogenesis.
Respiratory system
 Increased in vascularization of the mucosa, edema and glandular secretion.
 Increase thorax diameter, diaphragm elevation.
 Increase in tidal volume (hyperventilation)
 Increase in oxygen consumption, decrease oxygen reserves and increased
carbon dioxide production
 Respiratory alkalosis
Cardiovascular System
 Increased heartrate, stroke volume and cardiac output.
 Decrease in arterial compliance.
 Decrease in mean arterial pressure.
 Decrease total vascular resistance
 Heart enlargement (increase left ventricle and relative wall) thickness;
physiological eccentric hypertrophy growth
Hematological System
 Increase blood volume (plasma is greater than red cell expansion; relative
anemia
 Increase platelet width and volume
 Decrease albumin concentration and colloid osmotic pressure
 Decrease plasma osmolality
 Prothrombotic state (increase pro-coagulant and decrease in fibrinolysis
factors.
Spleen
 Increase size and cellularity, expansion of splenic red pulp

 Increase erythropoiesis
 Increase lymphoid nodules
 Increase mononuclear cell number
Renal System
 Increase size (pelvic and calyceal systems dilation)

 Increase blood flow
 Decrease vascular resistance
 Increase glomerular filtration rate
 Increase renin-angiotensin-aldosterone system
 Increase retention of water and electrolytes
Pancreas
 Increase pancreas vascularization and size

 Beta-cell mass expansion (hyperplasia and hypertrophy)
 Increase insulin synthesis, glucose-stimulated insulin secretion
Adipose tissue
 Expandability of adipose tissue: adipocyte diameter and volume

 Adipocytokines: increase leptin and normal adiponectin synthesis.
 Early pregnancy: increase insulin sensitivity: lipid accumulation
 Late pregnancy: decrease insulin sensitivity; lipid accumulation/release.
Changes in Mammary Tissue

Enlargement of the breasts is typical and may complicate use
of a conventional laryngoscope during induction of general
anesthesia. A short-handled laryngoscope may facilitate easier
instrumentation of the airway.
Changes in the Dermatological System
Hyperpigmentation of certain parts of the body such as the face, neck, and
midline of the abdomen is not uncommon during pregnancy. Melanocyte-
stimulating hormone is responsible for this change
Anatomical changes:
Breast:
 Engorgement and venous prominence.

 Mazodynia (breast tenderness): tingling to frank pain caused by hormonal
responses of the mammary ducts and alveolar system.
 Montgomery’s tubercles: enlargement of circumlacteal sebaceous glands of
the areola
 Colostrum secretion.
 Montgomery’s tubercles
Uterus:
 The uterus undergoes an enormous increase in weight from the 50g- 70g
nonpregnant size to approximately 950g at term, primarily through
hypertrophy of existing myometrial cells.
 Also, the uterine cavity, which in the nongravid state has a volume of less
than 10 ml, increases up to as much as 5 liters.
 The uterine blood vessels also undergo hypertrophy and become
increasingly coiled in the first half of pregnancy but no further growth after
that.
 The lower uterine segment is that part of the lower uterus and upper cervix
lying between the line of attachment of the peritoneum of the uterovesical
pouch superiorly and the
 histological internal os interiorly
Cervix:
 Becomes softer and swollen in pregnancy (doesn’t change in size only

becomes more swollen), with the result that columnar epithelium lining the
cervical canal becomes exposed to the vaginal secretions.
 Prostaglandins act on the collagen fibers, especially in the last week of
pregnancy. At the sometime collagenase is released from leucocytes, which
also helps in breaking down collagen. The cervix becomes softer and more
easily dilatable the so-called ripening of the cervix.
VAGINA
-The vaginal mucosa becomes thickness, the vaginal muscle hypertrophins.
-There is alteration in the composition of the connective tissue, with the result that
the vagina dilates more easily to accommodate the fetus during labor.
By second trimester to 3rd , the fetus will be about 13 to 16 inches long and weigh
about 2 to 3 pounds. Fetal development during the second trimester includes the
following:
 The fetus kicks, moves and can turn from side to side.
 The eyes have been gradually moving to the front of the face, and the ears
have moved from the neck to the sides of the head. The fetus can hear your
voice.
 A creamy white substance (called vernix caseosa, or simply vernix) begins
to appear on the fetus and helps to protect the thin fetal skin. Vernix is
gradually absorbed by the skin, but some may be seen on babies even after
birth.
 The fetus is developing reflexes, like swallowing and sucking.
 The fetus can respond to certain stimuli.
 The placenta is fully developed.
 The brain will undergo its most important period of growth from the fifth
month on.
 Fingernails have grown on the tips of the fingers and toes, and the fingers
and toes are fully separated.
 The fetus goes through cycles of sleep and wakefulness.
 Skin is wrinkly and red, covered with soft, downy hair (called lanugo).
 Hair is growing on the head of the fetus.
 Fat begins to accumulate in the fetus.
 Eyelids are beginning to open, and the eyebrows and eyelashes are visible.
 Fingerprints and toeprints have formed.
 Rapid growth is continuing in fetal size and weight.
 The 20th week marks the halfway point of the pregnancy.
VI. DIAGNOSTIC AND LABORATORY

Blood pressure 130/70mmHg.
Fetal heart rate audibles by stethoscope 145 bpm.
Leopold’s maneuver cephalic presentation: fatal position. Right occiput
anterior
VII. DRUG STUDY

VIII. NURSING CARE PLAN
ASSESSMENT NURSING OUTCOME INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Readiness for Short term: Independent This will create a safe Short term:
“I am already a single enhanced parenting: Verbalize realistic Teach patient positive parenting skills environment and enhance The patient is able to
mother, and I accept my expresses willingness information and expectations such as: the relationship of the verbalize realistic
fate with my live-in to enhance parenting of parenting role and identify  Talk to your baby. mother and child. information and expectations
partner that we won’t skills. her own strengths, needs,  Sing to your baby and play of parenting role. The patient
work out.” As verbalized methods and resources to music. is able to identify and meet
by the patient. meet them.  Breastfeed your baby her own, strengths, needs,
 Give her a massage. methods and resources.
Long term:
After birth the patient is able To provide safe and Long term:
Teach parent skills to care for adequate care for the infant
Objective: to participate in activities to newborn. Goal met
The patient’s face shows enhance parenting skills and to be healthy. The patient is able to
excitement and demonstrate improved Attachment promotion such as: participate in activities
confidence that she will parenting behaviors. Facilitate development of enhance parenting skills and
 Assist parent in infant care. parent-infant relationship.
be able to take care of her demonstrate improved
 Let the parent, see hold and
family without her parenting behaviors.
examine her newborn after
partner.
birth.
ASSESSMENT NURSING OUTCOME INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Readiness for Short term: Independent: Short term:
“What are the things enhanced Patient will learn how Recommend patient to follow Dietary Dietary guidelines are written The patient understands
and substances that nutrition: desire to eat according to Guidelines to determine what foods to by professionals, healthcare how to eat according to
may be harmful to my for knowledge of Dietary Guidelines. eat such as: providers and nutrition Dietary guidelines.
growing fetus?” as appropriate  Green leafy vegetables educators to promote proper
verbalized by the nutrition during Verbalize and  Dairy products health nutrition. Long term:
patient. pregnancy. understand nutritional  Whole grains Patient identify and alter
needs.  Beans Help determine caloric needs, behavior that impedes
Objective: set weight goal and evaluate enhanced nutritional
 Citrus fruits
Patient’s face seems to adequacy of nutrition plan. status.
 Salmon
be anxious about her
Advice patient to consult to a dietitian to It is helpful to examine the usual
growing fetus.
provide nutritionally balanced meals and foods eaten and patterns of
supplements. eating.
Ask patient to keep track of her
nutritional intake and analyze the quality, To avoid threat to the mother
Long term: quantity and pattern of food intake. and baby.
The patient will be able
to identify and alter Educate patient to not use unprescribed To avoid the risk for
behavior that impedes medications. developmental disabilities and
enhanced nutritional disorders.
status. Advice patients not to engage in
recreational vices such as:
 Smoking
 Illegal Drugs
 Alcohol
ASSESSMENT NURSING OUTCOMES INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Risk for infection Short term; Independent: Short term:
“I have increased related to alteration in After 30 mins of Advice patient to take This will provide Patient is
whitish vaginal pH of secretion nursing intervention shower or bath, avoid comfort to the patient knowledgeable of
secretions and makes patient is able to know the use of vaginal and avoid the risk of proper perineal care.
me uncomfortable. proper perineal care. INTERVENTION
scented products and infection and also
ASSESSMENT NURSING OUTCOMES RATIONALE
promotes cleanliness LongEVALUATION
term:
DIAGNOSIS when using the toilet
Long term: wipe from front to and healthy well- Patient attains comfort
Subjective: Impaired comfort Short term:
The patient will beIndependent: Short term: nursing
Tobeing.
back. and perform
“I experienced related to back pain. After 30 maximize
able to perform things measures to relieve
mins of Provide Patient is able
interventions toto
avoid
backpain and nursingtointervention pain opportunities for self-
provide comfort andbefore
Wearit becomes
cotton=lined Cotton absorbs know how
infections. to
sometimes I also feel the patient will be severe such as: control everand
moisture painkeeps alleviate pain.
reduce risk of infection under pants.
painless contractions able to know what Proper sleeping position manifestations.
you cooler and drier.
and relaxes again” things to do to Practice good posture Long term:
complained by the alleviate pain. Lift properly Patient performs and
patient. Heat or cold massages able to manage her
lower back pain.
Long term: Encourage adequate rest.
Patient is able to
perform pain Demonstrate and encourage
To prevent fatigue.
management to breathing exercises and
reduce and relieve provide comfort measures, To promote
NURSING back pain.
OUTCOME quiet environment and calm
INTERVENTION RRATIONALE
nonpharmalogical EVELUATION
DIAGNOSIS activities. measures.
ASSESSMENT
Subjective: Readiness for enhanced Short term: Teach patients the The patient will not be Short term:
knowledge: expresses Patient will be able to difference of true and falsely alarmed to go to Patient knows the signs
“What would be the on interest in learning know indications of false labor, the hospital. of true labor and false
indications that I am true labor. labor,
going on a labor?” Advice patient to be In order to not shock
asked by the client. Long term: mentally and the patient to the things Long term:
Patient is able to physically prepared for she might experience Patient is prepared
perform necessary labor is a very during labor, before and during labor
Objective: preparation before and dangerous and painful
Patient’s face shows during labor, process. In order for the patient
excitement and to know when to go to
confidence. Educate patient of the the hospital and seek
symptoms of labor for care.
such as:
Strong and regular
contractions
Water breaks
Excessive lower back
pain
Bloody or brownish
discharge
IX. DISCHARGE PLAN/HEALTH TEACHINGS
Evaluation
The patient belle was complacent with her monthly scheduled prenatal visit
with complaints of back ache, contractions and vaginal secretions. She is currently
in her middle or 2nd trimester.
All laboratory tests were normal and the patient was very positive and
attentive during assessment.
Discharge Plan
 Advice patient to exercise regularly
 Work out pelvic floor by doing Kegel exercise
 Drink lots of water
 Eat enough calories
 Keep teeth and gums healthy.
 Avoid strenuous activities and exercises that could cause injury to stomach
 Avoid alcohol and illegal drugs
 Take parenting classes on breastfeeding’s, infant CPR and first aids
QUESTIONS
1. Describe Ms. Belle’s emotional state based on the case presented.
Belle is anxious but very excited about her pregnancy. She is also confident
that she is able to take care of her family without her partner. Belle is very
much concerned about the health of the fetus.
2. How valuable is a woman’s state of mind in accepting her pregnancy and
how does it affect her entire pregnancy.
It is important that the pregnant mother is in her healthy mental state because
mothers who are depressed, anxious, or have other issues might not be able
to get the medical care they need. There is also a chance that they might not
be able to take care of themselves and their baby.
3. As physical assessment was done, the nurse found out that her breast is full
and tender upon inspection and palpation. What does a full/tender breast
indicate?
Sore nipples and tender breasts can be one of the earliest signs of pregnancy.
It is because of the pregnancy hormones progesterone and estrogen. As you
near the end of the third trimester, your body kicks into high gear to get ready
for your baby’s imminent arrival. You might feel breast pain and tenderness
again at this point since colostrum production is beginning.
4. Leopold’s Maneuver, Fundic Height and Heart Rate was taken as a part of
the assessment. Why is it included?
Leopold’s maneuvers are important because they help determine the position
and lie of the fetus, which in conjunction with correct assessment of the
shape of the maternal pelvis can indicate whether the delivery is going to be
complicated, or whether a caesarean section is necessary. A fundal height
measurement is typically done to determine if a baby is small for its
gestational age. The main purpose of fetal heart rate monitoring is to alert us
if your baby is not getting enough oxygen.
5. Why is there an increase of vaginal secretions as pregnancy progresses?
As the cervix and vaginal wall soften, the body produces excess discharge to
help prevent infections. Your baby's head may also press against the cervix
as you near the end of your pregnancy, which often leads to increased
vaginal discharge.
6. Constipation can be prevented through what health teachings? How do you
manage constipation?
Drink plenty of fluids. Water is a good choice. Prune juice also can help.
Include physical activity in your daily routine. Being active can help prevent
pregnancy constipation.
Include more fiber in your diet. Choose high-fiber foods, such as fruits,
vegetables, beans and whole grains. With your health care provider's OK,
consider a fiber supplement, such as Metamucil.
7. Why is it important for the nurse to include health teachings and self-care
needs; such as bathing, breast care, perineal hygiene, wearing comfortable
clothes and supportive bras to Ms. Belle
It will lead toward a better balance among dimensions of overall health and
wellness. It assists in determining what is most essential to the patients. It
also significantly decreases stress and improves clarity of their thought. It
also helps her avoid infectious diseases and keep her at a comfortable state.
8. Discuss the reason why Ms. Belle complained of backache. Explain nursing
management.
 Back pain is due to gaining of weight as the center of the gravity changes
and the hormones are relaxing the ligaments in the joints of the pelvis.
 Stand up straight and tall.
 Hold your chest high.
 Keep your shoulders back and relaxed.
 Don't lock your knees.
 Get the right gear
 Lift properly
 Sleep on your side
 Heat or cold massages
 Consider complementary therapies
9. When does the nurse consider Ankle Edema as a danger sign?
If you experience sudden or gradually worsening swelling in your face,
around your eyes, or in your hands accompanied by high blood pressure, call
your doctor immediately
10. What are the preliminary signs of labor?
 The baby drops.
 An increased urge to urinate.
 The mucus plug passes.
 The cervix dilates.
 Thinning of the cervix.
 Back pain.
 Contractions.
 A burst of energy.
11. Ms. Belle is interested to know what are the beginning signs of labor that
pregnant woman like her should be alert. Discuss each sign.
1. The baby drops
Medically known as "lightening," this is when the baby "drops." The baby's head
descends deeper into the pelvis.
2. An increased urge to urinate
An increased urge to urinate can be a result of the baby's head dropping into the
pelvis.
3. The mucus plug passes
Passage of the mucus plug is a known sign that labor is near. Thick mucus
produced by the cervical glands normally keeps the cervical opening closed during
pregnancy.
4. The cervix dilates
Dilation of the cervix is a sign that labor is approaching, although this is detected
by the health-care professional during a pelvic examination.
5. Thinning of the cervix
In addition to dilation, thinning (effacement) of the cervix also occurs. This occurs
in the weeks prior to labor, since a thinned cervix dilates more easily.
6. Contractions
Contractions, which can vary among women and can be described as pounding,
tightening, stabbing, or similar to menstrual cramps, increase in strength and
frequency as labor approaches.
12. Ms. Belle is complaining of shortness of breath as she increases her
activity. Give the rationale why pregnant women as their pregnancy
progresses complain of such.
As a normal part of pregnancy, your breathing may be affected by the increase in
the hormone progesterone, which causes you to breathe in more deeply. This might
make you feel as if you're working harder to get air. The uterus is expanding and
pushing up into the abdomen. This squeezes the lungs a bit, reducing the space
they have for oxygen exchange.
13. Identify true and false labor using the 5 parameters.
FALSE LABOR:
 Contractions don’t come regularly and they don’t get closer together
 They stop with walking or resting or with changes in position
 They are usually weak and don’t get stronger, or start strong and get weaker
 The pain is only felt in the front
TRUE LABOR:
 Contractions come and get closer together over time, lasting about 30-70
seconds each
 They continue regardless of movement or resting
 They progressively get stronger
 They start in the back and move to the front
The 5-1-1 Rule: The contractions come every 5 minutes, lasting 1 minute each,
for at least 1 hour.
14. Formulate nursing diagnosis. Identify any problem in the case presented
using the nursing care plan.
 Deficit knowledge to primiparity
 Risk for constipation: risk factor pregnancy
 Readiness for enhanced parenting: expresses willingness to enhance
parenting skills.
COLLEGE OF NURSING
NCM 107 RLE

CASE STUDY 3:
LABOR AND DELIVERY

BSN 2-G
Group 3

Clinical Instructor
I. Introduction
Labor is a term for the changes in anatomy and physiology in the female
reproductive tract that prepare the fetus and the placenta for delivery. Labor is a
series of continuous, progressive contractions of the uterus that help the cervix
dilate and efface. This allows the fetus to move through the birth canal.
In majority of cases, this happens when the baby is fully developed at full term,
between 37-40 weeks gestation. Labor heralds the end of the baby’s time in the
uterus and the beginning of adaption to life outside the mother.
Delivery can occur in two ways, vaginally through the birth canal or by a cesarean
which is a surgical delivery. It takes nine months to grow a full-term baby, labor
and delivery occurs in a matter of days or even hours.
Labor and delivery are divided into three stages. The first stage of labor
incorporates the onset of labor through a complete dilation of the cervix. This is
further subdivided in three stages. Early labor, the longest and least intense phase
of labor it is also called the latent phase of labor and this includes the thinning and
dilation of the cervix to 3-4 cm. Contractions ranges from mild t strong. Active
labor is when the cervix dilated from 3-4 cm to 7cm and contractions become
stronger and other symptoms may include backache and blood. Transitional labor
is the most intense phase of labor with a sharp and increase in contractions. They
became stronger at an average of 60-90 secs and the last 3 cm dilations usually
occur in a very short period of time.
During the second stage occurs the delivery, the cervix becomes fully dilated and
the pregnant mother may feel the urge to push right away after they’re fully
dilated. The baby may still be high up in the pelvis for other women.
It may take some time for the baby to descend with the contractions so that it’s low
enough for the mother to start pushing.
The third stage the delivery of placenta, the placenta will be delivered after the
baby has been born. Mild contractions will help separate the placenta from the
uterine wall and move it down towards the vagina. Stitching to mend a tear or
surgical cut (episiotomy) will occur after the placenta is delivered
II. Objectives
General Objectives:
educated about the stages of labor and delivery and the signs and symptoms of a
laboring mother. Also assess the physiological and physical state of the pregnant
mother and each corresponding nursing management and acquire proper
knowledge, skills and attitude in provident care to the childbearing mother,
Knowledge
1. Recognize changes that happens during labor and delivery.
2. Describe how to manage common post-partum issues.
3. Identify participating factors that could happen with the patient’s condition.
4. Discuss health teaching about newborn and post-partum care.
Skills
1. Make accurate and attainable nursing care plan for the mother and the
newborn.
2. Implement proper nursing interventions after labor and delivery.
3. Perform appropriate evaluation and documentation from admission through
childbirth and discharge, of a woman with a term singleton pregnancy who
presents to labor and delivery in labor.
4. Provide encouragement to and support for woman to during the postpartum
period.
Attitude
1. Provide culturally competent care to the mother and her family,
2. Utilize support systems, including consultations, in the hospital and the
family to provide existing optimal care and follow-up of woman and their
newborn.
5. Show an outmost respect and confidence when managing the patient’s
bedside care.
III. Nursing Health History

A. Biographic Data
Address:
Age: 21 years old
Sex: Female
Occupation: None
Religion:
Date of Admission: 10-18-2021
Chief Complaint: Labor and delivery
B. Chief Complaint
Ms. Belle came to the hospital because of labor pain.
C. History of present illness
D. Past Medical History
IV. Physical Examination

Upon arrival to the hospital:
Cervix dilated 3cm 50% effaced
Membranes intact
Fetal Heart Tone 140 beats per minute.
Fetus – cephalic presentation as revealed in ultrasound
Bladder distended
Vital signs:
Temperature 37.1°C
Pulse Rate 88bpm
Respiratory Rate 20 cpm
Blood pressure 130/80 mmHg
FHB 140 bpm
After 3-4 hours from admission:
Membranes raptured

The cervix is the area of the lower segment of the uterus that sits between the
lower abdominal wall and the uterine cavity. During labour, the cervix begins to
dilate - this is known as cervical dilatation. It then gradually widens - a diameter of
10cm is called fully dilated.
Estrogen makes the myometrium (the uterine smooth muscle) more sensitive to
stimuli that promote contractions. Some women may feel the result of decreasing
levels of progesterone as weak and irregular peristaltic Braxton-Hicks contractions,
also called false labor.
The anterior pituitary has been boosting its secretion of oxytocin, a hormone that
stimulates the contractions of labor. The myometrium has been expressing more
receptors for this hormone as labor nears. Oxytocin stimulates stronger, more
painful uterine contractions; prostaglandins from fetal membranes enhance uterine
strength.
Stretching of the myometrium and cervix by a full-term fetus in the head-down
position is regarded as a stimulant to uterine contractions. The sum of these
changes initiates the regular contractions known as true labor, which become more
powerful and more frequent with time.
Cervical changes include effacement and dilatation. For an average-sized fetal
head to pass through the cervix, its canal must dilate to a diameter of
approximately 10 cm. During second-stage labor in nulliparas, the presenting part
typically descends slowly and steadily.
VI. DIAGNOSTIC AND LABORATORY

Laboratory results:
CBC
A. HgB 142g/L
B. Hct 0.41 Vol. Fr
C. RBC 4.41 x 10ͮ^12/L
D. WBC 6.4 x 10^g/L
Urinalysis
Physical Properties
Color Straw
Transparency Hazy
Reaction 5.0 (acidity)
Specific Gravity 1.025
Chemical Tests
Sugar Negative
Albumin Negative
Microscopic Findings
Pus Cells Occasional 0-3
RBC Occasional 2-4
Ultrasound
Cephalic presentation of fetus.
VII. DRUG STUDY
VIII. NURSING CARE PLAN
Defining Characteristics Diagnosis Outcome Intervention Rationale Evaluation
Subjective: Impaired comfort Short term: Independent: Helps identify abnormal At the end of each nursing
Patient complains of labor related to labor Patient will be able to Monitor uterine activity with contractile pattern, allowing interventions,
pain. verbalize reduction of pain. each contraction. prompt assessment and Patient verbalized reduction
intervention, of pain and is able to relax
Objective: (Reference: Ladwig. The patient will be able to Identify degree of discomforts between contractions. Also,
Started 5 hours ago. Nursing Diagnosis relax between contractions and its sources. Clarify client’s needs and Managed and understood
Cervix dilated 3cm 50% Handbook : an allows for appropriate labor and delivery process.
effaced membranes intact. Evidence-Based Guide Long term: Observe perineal and rectal intervention. Also, used techniques to
Uterine contractions to Planning Care. 11th Understand the labor and bulging, opening of vaginal maintain control.
moderate to strong with 45 edition) delivery process and comfort introitus, and changes in fetal Anal eversion and perineal
seconds in an interval of 3 Labor, Normal measures to manage labor station. bulging occur as fetal vertex
mins. Page 72 pain. descends, indicating need to
Encourage client to relax all prepare for delivery.
Patient will be able to use muscles and rest between
appropriate techniques to contractions. Complete relaxation
maintain control. between contractions
Provide comfort measures, such promotes rest and helps
as mouth care; perineal limit muscle strain/fatigue
care/massage; clean, dry linen
and under pads; cool
environment (68°F–72°F [20°C–
22.1°C]), cool, moist cloths to
face and neck; or hot
compresses to perineum,
abdomen, or back, as desired.
Defining characteristics Diagnosis Outcomes Interventions Rationale Evaluation
Subjective: Labor pain related to Short term: Independent; To not shock and confuse At the end of each nursing
“My uterine contractions uterine contractions, The client is able to Inform patient what to the patient. interventions, the patient
increased” stretching of cervix and understand measure on expect during delivery understood measures on
birth canal how to deliver a safely and such as: how to deliver safely and
Objective: through NSVD. Stronger contractions through NVSD. Also,
Intensity occurring every Water breaks To avoid and prevent performed proper bearing
2-3 min. and with a (Reference: Ladwig. Long term: Increase pressure on the further tissue trauma. down technique and
duration of 60-70sec. Nursing Diagnosis The patient is able to back. delivery tolerated NSVD.
Bloody show and rupture Handbook: an Evidence- perform proper bearing
of the Based Guide to Planning down and demonstrate Advise and coach patient For client to determine
membranes noted. Internal Care. 11th edition) proper behavior to to push only during reality based and to avoid
examination done revealed Labor pain facilitate labor via NSVD. contractions. perineal or vaginal
10 cm. cervical dilatation. Page 72 laceration.
She complaints the urge of Inform patient of possible
bearing down. episiotomy. For patient to be aware of
The patient holds her ongoing delivery.
abdomen, screams and Inform the patient
regarding the progress of Encourage continuous and
shouts.
delivery cooperation to the process
of delivery.
Provide positive regard
regarding the process of
delivery.
Defining characteristics Diagnosis Outcome Interventions Rationale Evaluation
Subjective: Anxiety related to Short term: Independent: To implement early At the end of each nursing
unknown future, After 30 mins of nursing Assess anxiety level and implement interventions to decrease interventions, the patient
“Why does this hurst so threat to self- intervention patient will measures to reduce anxiety as anxiety level. makes decisions regarding
badly” as verbalized by the secondary to pain of be able to make informed needed such as: pain control and obtain
client. Labor decision regarding pain Shutting down negative stories and The patient will be more knowledge about the pain
control options she would beliefs. attentive will help and discomfort. The patient
like to use and obtain Relaxation techniques such as internalize information also able to express relief
Objective: ((Reference: Ladwig. knowledge what causes meditation when not in pain. and make use of techniques
Holds her abdomen, Nursing Diagnosis pain and discomfort. to provide
screams and shouts. Handbook: an Provide teaching between uterine Allows the patient to be
Evidence-Based informed and make
Long term: contractions
Guide to Planning
Patient will express relief informed decisions
Care. 11th edition on
2018-2020) obtained from labor pain Inform patient that the pain is regarding pain control.
Pregnancy normal by the use of childbirth associated to labor and approaching
techniques learned or delivery. To help the client relieve
Page 97
comfort measures. anxiety.
Teach patients techniques to relive
pain.
Blowing out breathing
Apply hot or cold packs
Walking
Squatting
Massage
Relaxed environment
Defining Characteristics Nursing Diagnosis Outcomes Interventions Rationale Evaluation
Objective: Risk for Infection: Risk Short term: Monitor patient’s vital Alternation of vital signs After each nursing
factors: tissue trauma, After nursing interventions, signs may be a sign of infection. interventions, the patient is
blood loss. the patient will be able to able to
Successfully delivered verbalize understanding of Proper perineal care and Reduces that risk of Verbalize and understand
alive baby girl via NSVD. risk factors. hygiene. bacterial invasion. risk factors after NSVD
and is able to demonstrate
(Reference: Ladwig. Nursing Long term: Discuss and encourage the Circulations of blood is techniques to prevent risk
Diagnosis Handbook: an Demonstrate techniques to patient to the importance of promoted and helps healing for infection.
Evidence-Based Guide to early ambulation and process.
prevent the risk for
Planning Care. 11th edition beginning of early
infections.
Postpartum, normal care postpartum exercises and Vit C is the best for
Page 96 activities as tolerated. preventing infections and
protein is for tissue repair
Encourage to eat foods that and regeneration.
are rich in proteins and vit.
C such as:
Meat
Dairy products
Eggs
Nuts
Citrus fruits
Broccoli
Potatoes.
IX. Discharge Plan/Health Teachings
Discharge plan/Health Teachings
 Avoid heavy lifting, strenuous exercise and excessive stair climbing.
 Start Kegel exercises immediately after delivery.
 Try got get as much rest as you can.
 Shower as often as you like but avoid tubs or swimming until after your
postpartum check-up.
 There should be nothing place in the vaginal after your postpartum check-up
 Good nutrition and adequate fluids are necessary for tissue repair, healing,
breast feeding and general health.
 Concern about the ability to have a bowel movement is common after
having a baby.
 uterus should feel firm after delivery. You will feel contractions (afterbirth
pains) after delivery as your uterus works to get back to a non-pregnant size.
 Wear a well-fitting bra. Nurse the baby as frequently as possible. Make sure
your baby is latched properly to avoid sore or cracked nipples.
 Mild feelings of sadness, depression and anxiety are common and are due to
hormonal changes, lack of sleep and the demanding job of caring for a
newborn. These are frequently referred to as the “baby blues.” These
feelings are usually temporary and self-limiting.
Other ways you and your family can adjust to a new baby are:
 Rest/sleep when the baby sleeps.
 Eat a well-balanced diet. Now is not the time for dieting or junk food.
 Be flexible. It takes time to get to know your baby.Talk to other parents who
are going through some of the same experiences.
When to call the doctor
 Frequent urgency or burning upon urination
 Temperature of 100.4°F or above
 No bowel movement for four days or longer
 Bleeding stays heavy despite rest
 Saturating a pad an hour
 Passing many clots or passing clots larger than an egg
 Foul-smelling bleeding
 Severe headache that is not relieved by a snack, nap and
acetaminophen or visual disturbances like blurred vision or tunnel
vision
 Social withdrawal or persistent baby blues/depression
 Hot, firm, red area in the breast
QUESTIONS:
1. Interpret the vaginal examination done to Belle when she came in the lying
in clinic based on the record presented in the scenario (3cm, 50%effaced).
Cervical examination
2. Ultrasound of Belle revealed cephalic presentation. Explain cephalic
presentation?
The baby is positioned head-down, facing your back, with the chin tucked to
its chest and the back of the head ready to enter the pelvis. This is called
cephalic presentation. Most babies settle into this position with the 32nd and
36th week of pregnancy.
3. Belle’s duration of uterine contraction lasted 45 seconds with an interval of
3 minutes. Discuss the stages and phases of labor she experienced.
Three stages of labor:
Labor: This includes early, active and transitional labor.
Pushing and delivery of the baby: This phase of labor begins with pushing
and ends with the delivery and birth of your baby.
Delivery of the placenta: Your placenta will either naturally be expelled or
need to be removed by your doctor after your baby is born.
Three phases:
Early labor: The cervix dilates (opens) and effaces (thins) to 4 to 6
centimeters. Contractions last for about 30 to 45 seconds and gradually
increase in intensity and frequency, from around 20 minutes to five minutes
apart.
Active labor: The cervix dilates anywhere from 4 to 6 centimeters to to 7 to
8 centimeters. Contractions last around 40 to 60 seconds and come about
three to four minutes apart.
Transitional labor: The cervix fully dilates to 10 centimeters. Contractions
are around 60 to 90 seconds long and occur about every two to three
minutes.
4. Why do we advise the mother on NPO during labor?
Nothing by Mouth” policy is to ensure that laboring people have an empty
stomach should they need emergency surgery with general anesthesia.
5. FHR was checked and revealed 140 beats per minute. What is a normal
fetal heart rate during labor?
120-160 bpm,
6. Ms. Belle presented her laboratories. What is the normal reference value?
Discuss the significance if it is elevated and decreased result during
pregnancy.
Color Straw Turbidity Clear pH 5-9
Specific Gravity 1.003-1.030 Protein Negative
Glucose Negative Ketone Negative
Bile Negative Urobilinogen Trace to 1 mg/dL
Blood Negative Leukocyte Esterase Negative
Nitrite Negative
MICROSCOPIC
WBC Male: 0-2/hpf Female: 0-5/hpf
RBC Male: 0-3/hpf Female: 0-4/hpf
Casts 0-1 Hyaline/lpf
Epithelial, Squamous Varies with Method of Collection
Epithelial, Transitional 0-2 Bacteria: Clean Catch Occasional
Bacteria: Catharized None seen
7. State and discuss psychological behavior presented in the scenario as

verbalized by Ms. Belle.
“Why does this hurt so badly”, I wish my boyfriend is here. Belle wants the
support of her boyfriend during her pregnancy because she is in so much
pain and needs the support of her loved ones to surpass delivery.
8. Identify and discuss the stage of labor in the progress of uterine
contractions of Ms. Belle presented in the case scenario.
Contractions in second-stage labour are powerful, coming every two to three
minutes and lasting 60 to 90 seconds. You may feel a strong urge to push or
go through a short time with no contractions and no urge to push.
9. As crowning occur, is episiotomy applicable to Ms. Belle? Why?
It was recommended to perform episiotomy before crowning, i.e. when the
fetal head recedes into the pelvis in between the contractions and the
delivery of the fetus is expected within the next three to four contractions 15,
or once 3–4 cm in diameter of the fetal head is visible during a contraction.
10. What is Ritgen Maneuver? Explain the indication in performing Rirgen
Manuever?
Ritgen´s maneuver means that the fetal chin is reached for between the anus
and the coccyx and pulled anteriorly, while using the fingers of the other
hand on the fetal occiput to control speed of delivery and keep flexion of the
fetal neck. Ritgen's maneuver denotes extracting the fetal head, using one
hand to pull the fetal chin from between the maternal anus and the coccyx,
and the other on the fetal occiput to control speed of delivery.
11. Enumerate and briefly discuss the 2 types of episiotomies
There are two types of episiotomy incisions:
Midline (median) incision. A midline incision is done vertically. A midline
incision is easier to repair, but it has a higher risk of extending into the anal
area.
Mediolateral incision. A mediolateral incision is done at an angle. A
mediolateral incision offers the best protection from an extended tear
affecting the anal area, but it is often more painful and is more difficult to
repair.
12. Explain are the mechanisms of labor?
The mechanisms of labor, also known as the cardinal movements, involve
changes in the position of the fetus's head during its passage in labor. These
are described in relation to a vertex presentation.
The 7 mechanisms of labor namely engagement, descent, flexion, internal
rotation, extension, external rotation, and expulsion.
13. Enumerate and explain the signs of placental separation.
The main symptom of placental abruption is vaginal bleeding. However,
sometimes blood can become trapped behind the placenta, and 20 percent of
women do not experience vaginal bleeding. Other symptoms that can occur
with placental abruption include:
 discomfort
 sudden stomach or back pain
 tenderness
 Vaginal bleeding, although there might not be any.
 Abdominal pain.
 Back pain.
 Uterine tenderness or rigidity.
 Uterine contractions, often coming one right after another
14.Formulate a nursing care plan base on Ms. Belle
Assessment Diagnosis Outcomes Interventions Rationale Evaluation
Subjective: Labor pain related to Short term: Independent; To not shock and confuse Short term:
“My uterine contractions uterine contractions, The client is able to Inform patient what to expect the patient. Understood measures on
increased” stretching of cervix and understand measure on how during delivery such as: how to deliver safely and
birth canal to deliver a safely and Stronger contractions To avoid and prevent through NVSD.
Objective: through NSVD. Water breaks further tissue trauma.
Intensity occurring every 2- Increase pressure on the back. Long term:
3 min. and with a duration Long term: For client to determine Performed proper bearing
of 60-70sec. Bloody show The patient is able to Advise and coach patient to push reality based and to avoid down technique and
and rupture of the perform proper bearing only during contractions. perineal or vaginal delivery tolerated NSVD.
membranes noted. Internal down and demonstrate laceration.
examination done revealed proper behavior to facilitate Inform patient of possible
10 cm. cervical dilatation. labor via NSVD. episiotomy. For patient to be aware of
She complaints the urge of ongoing delivery.
bearing down. Inform the patient regarding the
progress of delivery Encourage continuous and
cooperation to the process
Provide positive regard regarding of delivery.
the process of delivery.
15. Base on this finding formulate 2 nursing diagnosis

 Labor pain related to uterine contractions, stretching of cervix and birth canal
 Anxiety related to the fear of the unknown, situational crisis and impaired comfort related to labor
COLLEGE OF NURSING
NCM 107 RLE

CASE STUDY 4:
DELIVERY

BSN 2-G
Group 3

Clinical Instructor
I. Introduction
Postpartum period also takes place after the delivery and this
period involves again many changes the mother will be moving
through after the birth, both emotionally and physically.
Postpartum also means the time after birth, during the first
weeks after giving birth the body begins to heal and adjust to the
state of non-pregnant. The body recovers and goes through many
changes. Every woman experiences different changes. The first
weeks after childbirth also are the time to bond with your newborn
baby and make routines for caring of baby and yourself as well.
During postpartum period the pregnant woman will likely fell
soreness and tiredness after several weeks and this make take about
4-6 weeks to get back from the normal state. Over few days and
weeks, the woman will have some bleeding and afterpains as the
uterus shrinks.
Postpartum also affects the emotional state of the pregnant
woman first few weeks after the baby is born can be a time of
excitement—and of being very tired. Woman may feel exhausted
from a lack of sleep and your new responsibilities.
Many women get the "baby blues" during the first few days after
childbirth. The "baby blues" usually peak around the fourth day and
then ease up in less than 2 weeks. If you have the blues for more
than a few days, or if you have thoughts of hurting yourself or your
baby, call your doctor right away. You may have postpartum
depression. This needs to be treated. Support groups and counseling
can help. During this period the pregnant mother also needs to be
educated about newborn care.
II. Objectives
General Objectives:
At the end of this case presentation, the participants and the
audience will be educated about the process of postpartum period.
Also be able to assess the physiological state of the patient during
this time as well as to understand the role of the health care providers in giving a
complete care for the patient and apply corresponding nursing interventions and
management. Acquire proper knowledge, skills and attitude in providing care to
the mother
after childbirth and during postpartum period.
Knowledge:
1. Recognize and identify major events that may happen during postpartum
period.
2. Describe how to manage common post-partum issues and complications.
3. Discuss health teachings about post-partum care.
Skills:
1. Make accurate and attainable nursing care plans for the mother.
2. Implement proper nursing interventions to postpartum care.
3. Perform proper evaluation and documentations after delivery.
4. Provide encouragement and support for the mother to breastfeed during the post-
partum period.
Attitude:
1. Provide culturally competent care to the patient
2. Utilize support systems, consultations and follow up care for the patient.
4. Recognize the needs of the patient using a holistic approach.
5. Show an outmost respect and confidence when managing patient’s bedside care.

A. Biographic Data
Address:
Age: 21 years old
Sex: Female
Occupation: None
Religion:
Date of Admission:
Time of Admission:
Chief Complaint:
B. Chief Complaint
After Delivery:
Lengthening of the cord as placenta was expelled
Complete cotyledons
Blood pressure
Vital signs after an hour:
Temperature 36.7°C
Pulse Rate 90 beats/min
Respiratory Rate 18cpm
Blood pressure 110/80mmHg
IV. ANATOMY AND PHYSIOLOGY

General Physiologic changes:
The temperature is slightly elevated up to 37.2C (99F) along with increased
shivering, sweating, or diaphoresis in the first 24 hours and normalizes within 12
hours. There is a weight loss of 5 to 6 kg due to the expulsion of products of
gestation and accompanying blood loss.
Post-partum Physiology, also referred to as the puerperium Last on an average of
about 6 weeks Reproductive System and Associated Structures: Uterus Involution-
the return of the uterus to a nonpregnant state after birth Fundus descends 1 to 2
cm every 24 hours Subinvolution- is the failure of the uterus to return to a
nonpregnant state. Most common causes are retained placenta fragments and
infection Contractions Oxytocin- strengthens and coordinates uterine contractions,
which compress the blood vessels and thereby promotes hemostasis Postpartum
hemostasis- is achieved primarily by compression of intra-myometrial blood
vessels as the uterine muscle contracts, rather than platelet aggregation and clot
formation Afterpains Intermittent uterine contractions. Oxytocin causes
contractions of the lateral ducts in the breast which cause contractions of the
uterine muscles Lochia Rubra, last 3 to 4 days. Cervix Remains edematous, thin,
and fragile for several days after birth.
Constitutes an optimal condition for development of an infection Vagina and
Perineum Vagina returns to its pre pregnancy size by 6 to 10 weeks after
childbirth. Normal estrogen levels and lubrication return by 6 to 10 weeks.
Lowest levels 1 week into the postpartum period. Abdomen During the first days
after birth, woman`s abdominal muscles protrude and give her a still-pregnant look
and 6 weeks for the abdominal wall to return almost to it pre pregnancy state.
Breasts Breastfeeding Mothers Colostrum-before lactation begins and is
yellowish in color. Breast milk (true)- after lactation begins and is bluish white in
color, breast may feel warm and firm. Non-breastfeeding Mothers Prolactin levels
decrease rapidly. Colostrum is excreted for the first few days after childbirth and
on the 3rd or 4th postpartum day, engorgement may occur and the breast become
swollen, firm, tender, and warm to touch.
VII. Drug Study
DRUG NAME CLASSIFIC MECHANISMS INDICATIONS CONTRAINDICA ADVERSE REACTION NURSING RESPONSIBILITY
ATION OF ACTION TIONS
Generic Name: Pharmacother Increases tone, Prevention/ Hypersensitivity to Side effects:  Nurses must do baseline assessment and
Methylergonov apeutic: rate, amplitude Treatment of methylergonovine. Frequent: Nausea, uterine determine the baseline serum calcium
ine Ergot of contraction of postpartum, Hypertension, cramping, vomiting. kevel, B/P, pulse and assess for any
alkaloid uterine smooth Postabortion pregnancy, Occasional: evidence of bleeding before
Trade name/s: muscle. Hemorrhage toxemia. Abdominal pain, diarrhea, administration.
Methergine Clinical: Therapeutic dizziness, diaphoresis, tinnitus,  Monitor uterine tone, bleeding, B/P,
maleate Oxytoxic effect: shortens bradycardia, chest pain. pulse q15min until stable (about 1-2hrs).
agent, uterine third stage of Rare:  Assess extremities for color, warmth,
Dosage: stimulant. labor, reduces Allergic reaction, (rash, pruritus), movement, pain. Report chest pain
0.2mg/Ml. blood loss. dyspnea, severe or sudden promptly.
hypertension. Severe hypertensive  Provide support with ambulation if
Injection episodes mat result in CVA, serious dizziness occurs.
solution: arrhythmias, seizures. Hypertensive  Give patient/family teachings such as:
effects are more frequent with pt  Avoid smoking: causes increased
Route: susceptibility, rapid IV
Intramuscular vasoconstriction.
administration, concurrent use of
 Report increased cramping, bleeding,
regional anesthesia,
Frequency: foul-smelling lochia.
vasoconstrictors. Peripheral
Report pale, cold hands/feet (possibility of
ischemia may lead to gangrene.
Timing: diminished circulation).
Source: Saunders Nursing Handbook
Drug Name Classification Mechanism of Indication Contraindication Adverse Reaction Nursing Responsibility
action
Generic name: Penicillins, It acts through the Treatment of Hypersensitivity to Abdominal or stomach Check doctor’s order
Amoxicillin Amino inhibition of cell susceptible amoxicillin, other cramps or tenderness. Assess for allergy to any ingredient. (esp.
wall biosynthesis infections due to beta-lactams. back, leg, or stomach penicillins, cephalosporins)
Trade name/s: that leads to the streptococci, E. coli, pains. Administer the right drug in the right
Amoxil, death of the E. faecalis, black, tarry stools. dose and route at the right time.
Biomox, and bacteria. P.mirabilis, H. blistering, peeling, or Assess for rash, diarrhea (fever,
Polymox influenzae, N. loosening of the skin. abdominal pain, mucus and blood in stool
gonorrhoeae, bloating. may indicate antibiotic-associated
Dosage: including ear, nose, blood in the urine. colitis).
500 mg and throat; lower bloody nose.
respiratory tract; chest pain. Be alert for superinfection: fever,
Route: skin and skin vomiting, diarrhea, anal/genital pruritus,
Per orem structure; UTIs; black "hairy" tongue, oral mucosal
acute uncomplicated changes (ulceration, pain, erythema).
Frequency: gonorrhea;H. Monitor renal/hepatic function test
1 tablet q8h pylori.)
Drug Name Classification Mechanism of action Indication Contraindication Adverse Reaction Nursing Responsibility
Generic Name: Pharmacologic: Anti-inflammatory, Relief for Hypersensitivity to CNS: Headache, dizziness, Check doctor’s order.
Mefenamic acid NSAID analgesic, and moderate pain mefenamic acid, insomnia Assess pain score.
antipyretic activities when therapy aspirin allergy and as Assess for history of allergies to NSAIDs
Trade name/s Therapeutic: related to inhibition of will not exceed treatment of Dermatologic: rash, pruritus, Educate patient regarding desired and
Ponstel Analgesic prostaglandin synthesis; 1 week preoperative pain sweating adverse effect.
Antipyretic exact mechanisms of Treatment of with coronary artery Educate patient that prolonged used of
Dosage: action are not known. primary bypass grafting. GI: nausea, GI pain, diarrhea, drug may damage the liver.
500mg/capsule Pregnancy dysmenorrhea. constipation Give drug with food, milk or antacids.
category risk: Onset: varies Do not increase or double the dose, follow
Route: C Hematologic: bleeding, platelet as prescribed.
PO Peak: 2-4 hrs inhibition with higher doses, Administer with a full glass of water.
neutropenia Do not break, chew or crush capsule and
Frequency: Duration: 6hrs tablet.
1 capsule q4h then Do not administer with anticoagulants and
prn for pain Metabolism: hepatic, 2- Respiratory: other drugs that causes GI upset.
4 hrs Dyspnea, hemoptysis Document accordingly.
pharyngitis Monitor for adverse effects.
Distribution: crosses Instruct discontinuation of medication if
placenta, enters Other: perineal edema, adverse effect occurs.
breastmilk anaphylactoid reactions to Assess for occurrence of GI ulcers after
anaphylactic shock. taking.
Excretion: feces urine

DEFINING NURSING OUTCOMES INTERVENTIONS RATIONALE EVALUATION
CHARCTERISTIC DIAGNOSIS
S
Impaired skin Short term: Independent:
integrity related to Patient will be able to Render perineal flushing, place sanitary Perineal care will help the perineum heal faster, fell better and After each nursing
Objective: perineal incisions verbalize relief and pads and keep the perineal area warm prevent infections. interventions the patient’s
Repair of comfort after 30 mins of and dry. wound will be healed
episiotomy was Reference: nursing interventions. To detect early sighs of potential-life threatening without experiencing major
done completely Ladwig. Nursing complications. complications and is able to
after the delivery of Diagnosis Handbook: Long term: Monitor patient’s vital signs every 15 perform proper healing
the baby. an Evidenced-based Patient will be able to mins until stable. In order to maintain good hydration and lower the risk of process and understands the
Guide to Planning have a timely would contracting urinary tract infections. importance of self-care.
Care 11th edition healing/repair by
(Episiotomy, page understanding the Encourage the patient to eat nutritious To be able to give interventions and prevent further heavy
96) importance of self-care food and increase fluid intake. bleeding and prevent postpartum hemorrhage.
activities.
Able to identify possible
signs of the wound and Refer if unable to void for 4-6 hrs, Postpartum voiding
Assess patient and watch out for any
informed of proper dysfunction may occur and can potentially cause permanent
untoward signs and symptoms of
perineal care and routine, damage to the detrusor muscle and long-term complications.
profuse vaginal bleeding.
The compressions help prevent bleeding and if the muscles of

the uterus don’t contract strongly enough, the blood vessels
Advice patient to void for 4-6 hours. can bleed freely.
Provide comfort measures such as

massaging the uterus until firm and Prevention/Treatment of postpartum, Postabortion
contracted. Hemorrhage
Relief for moderate pain when therapy will not exceed 1 week.
Relief of pain and muscle spasms, increases blood stimulation

and reduces enema and soreness.
Dependent:
Administer medications as ordered used to replace lost fluid
such as:
Methergine maleate 0.2 mg/ml 1
ampule injected intramuscularly at the
left deltoid muscle
Mefenamic acid 500 mg/capsule, 1
capsule q4h then prn for pain, as
ordered
Perform perilite exposure to the

perineal area for 15 mins bid.
IVF od D5LRS 1L to run at 30

gtts/minute.
CHARACTERISTIC DIAGNOSIS
S
Objective: Risk for infection: Short term: Independent: After the implementation of
Episiotomy was done risk factor tissue Patient will be able to Observe for local signs of infections in Will establish presence of infection. each nursing interventions the
after the baby was trauma. know and understand the the perineal area. patient will be free from any
bon. risk of infections caused signs and symptoms of
Reference: by episiotomy. Maintain sterile technique for invasive Sterile and clean technique prevent the introduction of infections. The patient
Ladwig. Nursing procedures and cleaning of the incision potentially pathogenic infections. understands the proper use of
Diagnosis Long term: site. peri-bottle, handwashing and
Handbook: an Identify and perform Regular wound dressing promotes fast healing and medications.
Evidenced-based interventions to reduce Maintain aseptic technique when drying of wounds.
Guide to Planning the risks of infections changing, dressing /caring wound.
Care 11th edition and demonstrate Premature discontinuation of treatment when client
(Episiotomy, page techniques and lifestyle Emphasize necessity of taking begins to feel well may result in return or risk of
96) changes. antibiotics as ordered. infection.
Cleaning the site of the wound after using the bathroom

will help prevent infections.
Encourage use of peri-bottle after
using the bathroom.
For mobilization of respiratory secretions.
Encourage early ambulation, deep
breathing, coughing and position
changes
Treatment of susceptible infections.
Dependent:
Administer medications as ordered
such as: Hand hygiene is a first line of defense against
Amoxicillin 500mg/tab q8h infections.
Collaborative:
Stress proper hand hygiene for both
patient and caregivers/nurses
Advice patient to take medications such as:
 Amoxicillin 500mg/tablet, 1 tablet every 8 hours
 Mefenamic Acid 500mg/capsule. 1 capsule every 4 hours then prn for pain.
Discharge plan/health teachings:
1. Encourage breastfeeding her baby.
2. Perilite exposure to the perineal area 15 mins BID.
3. Take medications as ordered by the doctor.
4. Watch out for any untoward signs and symptoms of profuse vaginal
bleeding.
5. Encourage eating nutritious food and increasing fluid intake.
6. Massage uterus.
7. Avoid heavy lifting and start kegel exercises after delivery.
8. Rest well when the baby sleeps.
9. Maintain aseptic technique when changing, dressing /caring wound.
10. Mild feelings of sadness, depression and anxiety are common and are due to
hormonal changes, lack of sleep and the demanding job of caring for a
newborn.
11. Watch out for any untoward signs and symptoms of profuse vaginal
bleeding.
12. Good nutrition and adequate fluids are necessary for tissue repair, healing,
breast feeding and general health.
When to call the doctor:
1. Frequent urgency or burning up upon urination.
2. Foul-smelling bleeding
3. If one leg is much more swollen than the other; you have pain in your leg
when walking; or there is a red, hot area, especially in the back of your leg.
QUESTIONS:
1.Two types of Placenta and its Functions:
 The choriovitelline or yolk sac placenta- is formed when the yolk sac wall
(splanchnopleure) combines with the chorion and then contacts the
endometrium It may be fully or partially vascularized by the vitelline plexus,
which connects with the omphalomesenteric vein leading to the developing
heart. Blood returns from the embryo to the vitelline circulation in the yolk
sac via the omphalomesenteric artery, which branches from the dorsal aorta.
 The chorioallantoic placenta- is when the allantois fuses with the chorion,
an allantochorion is formed. The allantochorion contacts the endometrium,
resulting in a chorioallantoic placenta.
2.How long does it take for the placenta to expel?
The placenta should be expelled carefully and as soon as possible within 30
minutes. It is because placenta has already served its function and leaving the
placenta inside the mother’s womb may lead to infection or blood loss.
3.What do you think are the cord. What do you think are the earliest signs of
placental separation?
SIGNS OF PLACENTA SEPARATION
1.The uterus become globular and firmer (this sign is the earliest to appear)
2.A sudden gush of blood from vagina
3.The uterus rises in the abdomen.
4.The umbilical cord lengthens out of the vagina indicating that the placenta has
descended.
4.What is Brandt-Andrew’s maneuver
A method of expressing the placenta by grasping the umbilical cord with one hand
and placing the other hand on the abdomen.
5. What is the importance of skin-to-skin contact?
Skin-to-skin contact helps the baby's body self-regulate, which stabilizes the
heartbeat and breathing patterns. It makes the baby became calm and relaxes both
mother and baby.
6.What are the benefits of breastfeeding for her and baby
Breast milk provides the ideal nutrition for infants. It has a nearly perfect mix of
vitamins, protein, and fat everything your baby needs to grow. And it's all provided
in a form more easily digested than infant formula. Breast milk contains antibodies
that help your baby fight off viruses and bacteria. Breastfeeding lowers your baby's
risk of having asthma or allergies. Breastfed infants are more likely to gain the
right amount of weight as they grow rather than become overweight children.
7. Identify the proper positioning for breastfeeding
The cradle hold is a classic. It’s the OG of breastfeeding holds. To do this hold
comfortably, you should sit in a chair with armrests or an area with lots of pillows
to support your arms. Babies may be tiny, but holding them in one position for a
long time can be hard on your arms and back.
8. What is perilite exposure?
Perilite Exposure is the application of dry heat to the perineal area to provide
comfort. It increases blood circulation and hasten wound healing. The application
of heat to open wounds of lesions may rapture demands a sterile technique.
Importance of Perilite Exposure
1. Relief of pain and muscular spasm
2. Provides comfort by relief pain
3. It relaxes muscles and capillaries making pain tolerable
4. Increases blood circulation
5. Hastens wound healing following an episiotomy repair
6. Increases circulation of blood
7. Increases supply of oxygen and nutrient which promotes wound healing
8. It releases dry heat and thus help reduce edema and soreness
9. Alleviated by relax muscles and capillaries
9.What is the significance if rooming in?
Rooming-in allows you to develop confidence in caring for your baby. It also
allows you to be able to read baby's cues so you know if your infant is sleepy or
hungry. This will be a huge help when you leave the hospital. If you decide to
breastfeed, studies show that rooming-in helps improve the experience.
10. what is latching on?
Latch refers to how the baby fastens onto the breast while breastfeeding. Aim the
nipple toward the baby's upper lip/nose, not the middle of the mouth. You might
need to rub the nipple across the top lip to get your baby to open his/her mouth.
The baby's head should be tilted slightly back. You do not want his chin to his
chest.
11.Why do we have to close monitor Belle's condition 1-2 hours after delivery?
What are the important things to be assessed during this stage?
Postnatal care (PNC) for the mother should respond to her special needs, starting
within an hour after the delivery of the placenta and extending through the
following six weeks. The care includes the prevention, early detection and
treatment of complications, and the provision of counselling on breastfeeding, birth
spacing, immunization and maternal nutrition.
The routine care provided to the mother during the postnatal period is mainly
preventive measures targeted towards the early detection of the common causes of
maternal morbidity and mortality in rural communities.
THE IMPORTANT THINGS TO BE ASSESSED DURING THIS STAGE
ARE THE FOLLOWING..
Check the mother’s vital signs, i.e. her temperature, pulse rate, and blood pressure,
and make sure they are within the normal range. Straight after the birth, check her
pulse and blood pressure at least once every hour, and her temperature at least once
in the first six hours.
Check if her uterus is contracting normally. Palpate (feel) her abdomen to check
contraction of the uterus to make sure it is firm. Immediately after the birth, you
should be able to feel it contracting near the mother’s umbilicus (belly button), and
it gradually moves lower in her pelvis over the next two weeks. Check her uterus
every 15 minutes for the first two hours after birth and every 30 minutes for the
third hour. If possible, check every hour for the following three hours. If the uterus
is hard, leave it alone between checks. If it feels soft, rub the abdomen at the top of
the uterus to help it to contract.
Clean the mother’s belly, genitals and legs. Help the mother clean herself after the
birth. Change any dirty bedding and wash blood off her body. Always wash your
own hands first and put on surgical gloves before you touch the mother’s genitals,
just as you did before the birth. This will protect her from any bacteria that may be
on your hands. Clean the mother’s genitals very gently, using soap and very clean
water and a clean cloth. Do not use alcohol or any other disinfectant that might
irritate her delicate tissues. Wash downward, away from the vagina. Be careful not
to bring anything up from the anus toward the vagina. Even a piece of stool that is
too small to see can cause infection.
Check for heavy bleeding (haemorrhage).
After the birth, it is normal for a woman to bleed the same amount as a heavy
monthly period. The blood should also look like monthly blood — old and dark, or
pinkish. At first, the blood comes out in little spurts or gushes when the uterus
contracts, or when the mother coughs, moves, or stands up, but the flow should
reduce over the next two to three days and become the more watery reddish
discharge known as lochia.
Check the mother’s genitals for tears and other problems. Use a gloved hand to
gently examine the mother’s genitals for tears, blood clots, or a haematoma
(bleeding under the skin). If the woman has a tear that needs to be sewn, apply
pressure on it for 10 minutes with a clean cloth or pad and refer her to the health
centre. If the tear is small, it can probably heal without being sewn, as long as it is
kept very clean to prevent wound infection.
Help the mother to urinate. A full bladder can cause bleeding and other problems.
A mother’s bladder will probably be full after the birth, but she may not feel the
need to urinate. Ask her to urinate within the first two to three hours. If she is too
tired to get up and walk, she can squat over a bowl on the bed or on the floor. She
can also urinate into a towel or thick cloth while lying down. If she cannot urinate,
it may help to pour clean, warm water over her genitals while she tries.
12.Identify two nursing problems. Formulate nursing care plan.
In Belle’s situation in delivering, these problems may occur:
1.Excessive bleeding
2.Infection or sepsis
COLLEGE OF NURSING
NCM 107 RLE

CASE STUDY 5:
POST PARTUM

BSN 2-G
Group 3

Clinical Instructor
I. Introduction
Post-Partum period is the time after birth, when this period takes place, the mother
will be experiencing a lot of changes after birth both emotional and physical
changes.
As postpartum period begins, a woman will notice a great changes in her role for
now that she is finally a certified mother. The mother will be adjusting with this
and other changes as well that will start gradually and slowly. The mother should
be knowledgeable about what to do with these changes.
During the 24 hours of postpartum is the most curial for the woman, especially that
psychological changes set in and might affect the woman permanently when not
given immediate and appropriate attention and care.
The taking phase usually sets 2 days after delivery and during this time is the time
of reflection for the woman, she becomes independent to her healthcare provider
and other support person to make decisions and daily task. This dependence is
mainly due to the physical discomforts after birth and this stage provides woman
time to regain her physical strength and organize her thoughts about becoming a
mother.
Taking hold phase starts 2-5 days after delivery and this is the time where the
woman starts to initiate actions and make her own decisions without the help of
others. She will finally start focusing on her newborn and participates in newborn
care.
Letting go stage, during this stage the woman finally accepts her role and gives up
her old role like being childness woman. During this stage is also where
postpartum depression may set in.
After birth readjustments and support system is needed by the mother in order to
cope up with the changes she may encounter during postpartum period.
II. Objectives
General Objectives:
educated about the physiological and psychological changes that a woman may
encounter after birth and during postpartum period. Also be able to manage and
give proper care and assessment for the mother who is in transition to motherhood.
Understand the roles of healthcare providers in giving complete care and apply
corresponding nursing care interventions and management. Acquire proper
knowledge, skills and attitude in providing care to the mother during postpartum
period.
Specific objectives:
Knowledge
1. Recognize and identify major changes that may happen during postpartum
period.
2. Describe how to manage postpartum issues and complications.
3. Discuss health teachings about postpartum care.
Skills
1. Make accurate and attainable nursing care plan for the mother.
2. Implement proper nursing interventions to postpartum care.
3. Provide appropriate patient education and anticipatory guidance to the
patient in postpartum period.
4. Provide support and encouragement for woman to breast feed during
postpartum period.
5. Evaluate process of the patient in learning through patient’s self-report and
demonstrations.
Attitude
1. Provide culturally competent care to the patient.
2. Utilize support systems, consultation and follow-up care for the patient.
3. Establish rapport with the patient and family.
4. Recognize the needs of the patient by using a holistic approach.
5. Show an outmost respect and confidence when managing patient’s bed side
care.

A. Biographic Data
Address:
Age: 21 years old
Sex: Female
Occupation: None
Religion:
Date of Admission:
Time of Admission:
Chief Complaint:
B. Chief Complaint

Breast symmetrical in size, no masses or dimpling and areola is dark in color
with no cracks and erect. Fundus at midline with one finger breath below
umbilicus. Abdomen not distended.
V. Anatomy and Physiology

Reproductive System
 Involution occurs during postpartum wherein the reproductive organs return
to their nonpregnant state. The area where the placenta was implanted is
sealed off to avoid bleeding.
 The uterus returns to its prepregnant size.
 Involution occurs more quickly in women who are well nourished and
ambulate early after birth.
 Contraction plays a very important role in the postpartum period for it
allows the uterus to return to its former size quickly and also prevents
hemorrhage.
 Lochia starts to appear as a bloody discharge for the first 3 days after birth
and is termed as lochia rubra.
 Lochia serosa or the brownish to pinkish discharge starts on the fourth day,
and the amount of blood and tissue decreases.
 Lochia alba appears on the tenth day and the discharge decreases and almost
looks colorless or whitish. It may last until the third week after birth.
 The cervix is soft and malleable immediately after birth, but once
contraction of the cervix takes place it also returns to its prepregnant state.
 postpartum period but remains slightly distended than before.
 Kegel’s exercise helps return the strength and muscle tone of the vagina.
 The labia minora and majora are still atrophic and soft after birth and would
never return to its prepregnant state.
 The perineum is edematous and tender immediately after birth.
 Hormonal System
Urinary System
 Immediately after birth, dieresis sets in to rid the body the excess fluid that
has accumulated during pregnancy.
 On the second to fifth day after birth, the urinary output of the woman
increases to as much as 3000 mL per day.
 The woman’s abdomen must be assessed frequently during the postpartum
period to prevent damage to the bladder due to overdistention.
 Urine may contain more nitrogen postpartum because of the increased
activity of the woman during labor.
 Lactose levels may be slightly elevated to prepare the body for
breastfeeding.
Circulatory System
 Blood volume returns to its prepregnancy level by the first or second week
of birth.
 A 4-point decrease in hematocrit and a 1-g decrease in hemoglobin occur
with each 250 mL blood loss.
 Hematocrit levels reach its normal prepregnancy level 6 weeks after birth.
 An increase in leukocytes and plasma fibrinogen occurs in the first
postpartum weeks as a defense mechanism against infection and
hemorrhage.
Gastrointestinal System
 The woman will feel hungry and thirsty almost immediately after giving
birth,
 Digestion and absorption are active again after birth except for women who
underwent a caesarean section.
 Passage of stool may still be slow because of the relaxing that is still present
in the bowels.
 Bowel evacuation may still be difficult because of the pain of episiotomy.

Hematology
CBC
Results Normal Values
Hemoglobin 11.8 12.3-15.3 g/dl
Hematocrit 0.34 0.37-0.7
RBC 4.41 4.5-6.1 x 10 12/L
WBC 10 4.4-11.0x10^9/L Urinalysis
Neutrophils 0.55Results
0.54 – 0.58
Eosinophils
Color 0.03Pale amber
0.01-0.04
Basophil 0.01 0.00-0.01
Transparency Hazy
Lymphocyte 0.28 0.25-0.33
pH Acidic 6.4
Monocyte 0.05 0.03-0.07
Specific Gravity 1.015
MCV 86.5 76.0-96
RBC +1
MCH 29.5 27.0-32
Pus Cells 0
Platelet Count 375 150-450x10^9/L
Epithelial cells 0
Cast 0
Glucose (-)
Protein (-)
VII. Drug Study

DRUG CLASSIFICATI MECHANISMS OF INDICATIONS CONTRATINDICATIONS ADVERSE NURSING
NAME ON ACTION REACTION RESPONSIBILITY
Generic Therapeutic  An antibiotic that  It is used to treat  Hypersensitivity to  Skin rash or  Assess bowel
Name: Class: combines infections caused Co-amoxiclav or any itching. pattern before and
Co-amoxiclav Antibiotic amoxicillin and by certain ingredient in the  White patches during treatment as
clavulanic acid. It bacteria. product. in your mouth pseudomembranous
Pharmacologic destroys bacteria Amoxicillin  Alllopurinol, or throat. colitis may occur.
class: by disrupting their works by killing Probenecid: increased  Vaginal yeast  Report hematuria or
Route: Oral Aminopenicillin,
Dosage: 625 ability to form cell the bacteria that is incidence of skin infection oliguria as high
Beta-lactam walls. Clavulanic causing infection. rashes, particularly in (itching or doses can be
mg. (Beta-Lactam acid blocks the  Clavulanic acid patients with gout. discharge) nephrotoxic.
Frequency: and Beta- chemical defense, helps make the  Oral contraceptives: Side effects:  Assess respiratory
1 tab bid 7 Lactamase known as beta amoxicillin more decreased efficacy of status.
 Nausea
days Inhibitor lactamase that effective. This contraceptives,  Vomiting  Observe
Combination) some bacteria have medication is increased incidence  Headache anaphylaxis.
against penicillin’s most commonly of bleeding.  Diarrhea  Ensure that the
 Co-amoxiclav is used to treat  Stomach pain patient has adequate
active against infections of the fluid intake during
bacterial infections sinus, ear, lung, any diarrhea attack.
that have become skin and bladder.
resistant to
amoxicillin.
DRUG NAME CLASSIFICATION MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE REACTION NURSING RESPONSIBILITY
ACTION
Generic Name: Pharmacologic: Anti- Relief for Hypersensitivity to CNS: Headache, dizziness, Check doctor’s order.
Mefenamic Acid NSAID inflammatory, moderate pain mefenamic acid, aspirin insomnia Assess pain score.
analgesic and when therapy will allergy and as treatment of Assess for history of
Trade Name/s: Therapeutic: antipyretic not exceed 1 preoperative pain with Dermatologic: rash, pruritus, allergies to NSAIDs
Ponstel Analgesic activities related to week. Treatment coronary artery bypass sweating Educate patient
Antipyretic inhibition of of primary grafting. regarding desired and
Route: Oral prostaglandin dysmenorrhea. GI: nausea, diarrhea, adverse effect.
Pregnancy category synthesis; exact constipation Educate patient that
Dosage: risks: mechanisms of prolonged used of drug
500 mg/capsule C actions are not Hematologic: may damage the liver.
known. Bleeding, platelet inhibition Give drug with food, milk
Frequency: with higher doses, neutropenia or antacids.
1-tab q6h prn for Onset: varies Do not increase or
pain Respiratory: Dyspnea, double the dose, follow
Peak: 2-4hrs hemoptysis, pharyngitis as prescribed.
Administer with a full
Duration: 6hrs Other: perineal edema, glass of water.
anaphylactoid reactions to Do not break, chew or
Metabolism: anaphylactic shock. crush capsule and tablet.
Hepatic, 2-4hrs Do not administer with
anticoagulants and other
Distribution: drugs that causes GI upset.
Crosses placenta Document accordingly.
enters breastmilk Monitor for adverse effects.
Instruct discontinuation
Excretion:
of medication if adverse
Feces urine
effect occurs.
Assess for occurrence of
GI ulcers after taking.
DRUG NAME CLASSIFICATIO MECHANISM INDICATION CONTRAINDICATION ADVERSE REACTION NURSING RESPONSIBILITY
N OF ACTION S S
Generic Name: Prevention of May be taken with other
Obimin Plus vitamin mineral without food. May also be
deficiencies during taken with meals
Classifications: pregnancy and
Vitamins and lactation.
Minerals
(Pre and
postnatal)/
Antianemics
Dosage:
1 tab/ day
Route: Oral
DRUG NAME CLASSIFICATIO MECHANISM OF INDICATION CONTRAINDICATION ADVERSE NURSING
N ACTION S S REACTION RESPONSIBILITY
Generic name: Iron supplement Iron combines with Treat iron Iron metabolism disorder Gastrointestinal Assess nutritional status,
Ferrous sulfate porphyrin deficiency causing (Stomach and dietary history. Question
and globin chains anemia (a increased iron storage. bowel) problems history of
Trade name/s: to form hemoglobin lack of red An overload of iron in the like constipation, hemochromatosis,
Femiron, which is critical blood cells blood. A type of blood nausea, vomiting, hemolytic anemia,
Hemocyte, Iron for oxygen caused by disorder where the red and ulcerative colitis. Question
delivery from having too blood cells burst diarrhea. When use of antacids, calcium
Dosage: the lungs to little iron in called hemolytic taken in empty supplements.
Route: other tissues. the body) anemia. An ulcer from stomach they can Monitor serum iron, total
Per orem Iron defiency too much stomach acid, damage iron-binding capacity,
causes a and a the lining of the reticulocyte count, Hgb,
Frequency:1-tab microcytic type of stomach stomach. ferritin. Monitor daily
q.d. anemia due to irritation called pattern of bowel activity,
the formation gastritis. stool consistency. Assess
Timing: of small for clinical improvement,
erythrocytes record relief of iron
with insufficient deficiency symptoms
hemoglobin. (fatigue, irritability, pallor,
paresthesia of extremities,
headache).
DRUG NAME CLASSIFICATIO MECHANISM INDICATIONS CONTRAINDICATI ADVERSE REACTION NURSING RESPONSIBILITY
N OF ACTION ONS
Generic Name: Pharmacothera Increases tone, Prevention/Treatment of Hypersensitivity to Side effects: • Nurses must do baseline
Methylergonovine peutic: rate, amplitude postpartum, Postabortion methylergonovine. Frequent: Nausea, assessment and determine
Ergot alkaloid Of contraction Hemorrhage Hypertension, uterine cramping, the baseline serum calcium
Trade name/s: of uterine smooth pregnancy, vomiting. kevel, B/P, pulse and assess
Methergine Clinical: muscle. toxemia. Occasional: for any evidence of
Maleate Oxytoxic agent, Therapeutic Abdominal pain, bleeding before
uterine effect: shortens diarrhea, dizziness, administration.
Dosage: stimulant. third stage diaphoresis, tinnitus, bradycardia, • Monitor uterine tone,
of labor, reduces chest bleeding, B/P, pulse q15min
blood loss. pain. until stable (about 1-2hrs).
Route: Rare: • Assess extremities for color,
Po Allergic reaction, warmth, movement, pain.
(rash, pruritus), Report chest pain
Onset: 5-10 min dyspnea, severe or promptly.
sudden hypertension. Severe • Provide support with
Peak: N/A
hypertensive ambulation if dizziness
Duration: 3hrs episodes mat result occurs.
in CVA, serious • Give patient/family
arrhythmias, seizures. teachings such as:
Hypertensive effects are more • Avoid smoking: causes
frequent Increased vasoconstriction.
with pt susceptibility, • Report increased cramping,
rapid IV administration, bleeding, foul-
concurrent use of smelling lochia.
regional anesthesia, Report pale, cold hands/feet
vasoconstrictors. (possibility of diminished
Peripheral ischemia may lead to circulation).
gangrene.

HARACTERISTIC DIAGNOSIS
S
Subjective: Pain related to breast Short term: Independent: Frequent breastfeeding increases At the end of each nursing
“My breast feels engorgement. After 30 mins of nursing Encourage patient to do frequent milk supply and will stimulate the intervention the patient is able
full, I am able to interventions patient will be breastfeeding at regular episode at 2-3 body to produce more milk. to understand breast
feed my baby but able to understand what is hours or as needed. engorgement and develop
both of my breast is breast engorgement and why it interventions to stop the
in moderate pain.” (Reference: causes pain. The baby must be breastfed at least aggravation of pain and
Ladwig-Nursing 2-3hrs to provide proper nutrition to verbalized relief. The patient
Objective: Diagnosis Handbook: Advice mother not to skip breastfeeding the baby and prevent low milk is accommodating, attentive
Breast an Evidence based Long term: sessions. supply. and confident in handling her
engorgement noted Guide to planning Patient will be able to newborn and also very eager
Care 11th edition verbalize relief and perform to take care of her newborn.
Postpartum, Normal proper breastfeeding
Care page 96) technique. Also, help mother Teach mother to pump breast when
to be confident in handling her away from the baby and make sure
baby. Teach mother to be alert to feeding to position the baby properly.
problems.
In order to keep the breast

symmetrical and avoid reduction of
milk supply to the other breast.
Always make to switch breast when
feeding the baby.
Unhealthy and exhausted mother

produces inefficient milk.
Promote healthy diet, rest and sleep.
Drinking alcohol and smoking can

decrease milk production and may
Advice patient to avoid vices such as also be dangerous to the baby.
smoking and alcohol intake.
Supplemental breastfeeding can
interfere with the infant’s desire to
breastfeed and may also increase
Discourage supplemental bottle risk for allergies.
feedings and encourage exclusive,
effective breastfeeding.
To prevent infections to the breast
and provide comfort to the mother.
Instruct mother to use supportive bra
and wash breast only with water. To relieve pain and helps with
swelling.
Advice patient to use icepacks on the
breast when they are full.
Dependent: Prevention of vitamin mineral

Take medications as ordered by the deficiencies during pregnancy and
doctor. lactation
Iron supplement
1.Obimin Plus 1 tablet OD for 1 month
Low thyroid level reduces milk

2. Ferrous Sulfate 1 tablet OD for 1 supply.
month
Collaborative:
Check for mother’s thyroid level.
CHARACTERISTICS DIAGNOSIS
Subjective: Acute pain related to Short term: Independent: Perineal care will help perineum After each nursing interventions
Patient verbalized pain on her episiotomy. After 1 hour of nursing Advice patient to perform proper perineal heal faster and help prevent the patient will be able to
perineum with a scale pain of interventions the patient will be care by keeping the area warm and dry. infections. verbalize relief as pain was
6/10 able to verbalize relief and know reduced and know different
(Reference: nursing interventions to reduce Instruct mother to put on clean pads and nursing interventions to be
Ladwig-Nursing pain. gowns before settling back to bed. To provide comfort and prevent performed when caring for the
Objective: Diagnosis Handbook: the patient from infections. incision. She performs pericare,
Mediolateral episiotomy with an Evidence based Long term: Assess patient and note for lochia vaginal as instructed, puts on clean pads
stiches 2 inches long is slightly Guide to planning The patient will be able to discharge note color and odor. Assessing lochia status will help and gowns and settles
bruised and perineum is slightly Care 11th edition perform proper perineal and indicate signs of infections and back to bed. Very eager to take
swollen. Postpartum, Normal wound care. Also, demonstrate enable healthcare providers to care of her newborn.
Care page 96) comfort and ease. address it as soon as possible.
To obtain baseline data and

Assess the episiotomy wound for facilitate prompt treatment.
abnormal discharge and signs of infection.
Monitor patient’s vital signs. To detect early sighs of

potential-life threatening
Maintain aseptic technique when complications.
changing, dressing and caring for the Regular wound dressing
wound. promotes fast healing, drying of
wounds and clean technique
prevent the introduction of
potentially pathogenic
infections.
To prevent bleeding of the

incision.
Instruct patient to avoid strenuous
activities and exercise.
Dependent:
Advice patient to take medications as
ordered by the doctor.
1. Co- Amoxiclav 625 mg 1 tablet It is used to treat infections

BID for 7days caused by certain bacteria.
Amoxicillin works by killing the
bacteria that is causing infection.
2. Mefenamic Acid 500 mg 1 tablet

every 6 hours prn for pain
3. Methergine 1 tablet TID x 9 doses Relief for moderate pain
Reduce blood loss

Health teachings:
1. Get as much sleep as possible to cope with tiredness and fatigue.
2. Maintain a healthy diet to promote healing.
3. Apply a warm or cold compress to your breasts.
4. Try to breastfeed more often. Pump your breasts if your baby won't
breastfeed. Take care to empty your breasts each time.
5. Soften your breasts before feedings. You can apply a warm compress for a
couple of minutes before you breastfeed.
6. Wear a bra that fits well and provides good support.
7. Take warm baths but wait until 24 hours after you have given birth. Make
sure that the bathtub is cleaned with a disinfectant before every bath.
8. Change pads every 2 to 4 hours.
9. Keep the area around the stitches clean and dry. Pat the area dry with a
clean towel after you bathe.
Call Doctor if:
1. our pain gets worse.
2. You go for 4 or more days without a bowel movement.
3. You pass a blood clot larger than a walnut.
4. You have a discharge with a bad odor.
5. The wound seems to break open.
Discharge plan:
Continue Medications as ordered:
1. Co- Amoxiclav 625 mg 1 tablet BID for 7days
2. Mefenamic Acid 500 mg 1 tablet every 6 hours prn for pain
3. Obimin Plus 1 tablet OD for 1 month
4. Ferrous Sulfate 1 tablet OD for 1 month
5. Methergine 1 tablet TID x 9 doses
QUESTIONS:
1. Why is it important to breastfeed immediately after birth? Does
breastfeeding help with postpartum?
Breastmilk provides the perfect nutrition to match your baby's needs for growth
and development. Colostrum, the breastmilk produced in the first few days after
birth, is very rich in the nutrients and immune components of breastmilk which
help to protect your baby from infection.
2. What is breast engorgement? What causes breasts engorgement after
delivery?
Breast engorgement means your breasts are painfully overfull of milk. This usually
occurs when a mother makes more milk than her baby uses. Your breasts may
become firm and swollen, which can make it hard for your baby to breastfeed.
Engorged breasts can be treated at home. Breast engorgement is the result of
increased blood flow in your breasts in the days after the delivery of a baby.
3. What are your management for breast engorgement?
 using a warm compress, or taking a warm shower to encourage milk let
down
 feeding more regularly, or at least every one to three hours
 nursing for as long as the baby is hungry
 massaging your breasts while nursing
 applying a cold compress or ice pack to relieve pain and swelling
 alternating feeding positions to drain milk from all areas of the breast
 alternating breasts at feedings so your baby empties your supply
 hand expressing or using a pump when you can’t nurse
 taking doctor-approved pain medication
For those who don’t breastfeed, painful engorgement typically lasts about one day.
 taking pain medication approved by your doctor
 wearing a supportive bra that prevents your breasts from moving
significantly
4. What is the level of the fundus after delivery? How do you check fundus
after delivery?
The fundus is usually midway between the umbilicus and symphysis 1 to 2 hours
after delivery, 1 cm above or at the level of the umbilicus 12 hours after delivery,
and about 3 cm below the umbilicus by the third day after delivery. The fundus
(top portion of the uterus) should be felt at the level of your belly button or lower.
You can attempt to feel your fundus by gently pressing on your abdomen. The
uterus shrinks at about the rate of one cm. per day.
5. Determines the amount and characteristic of the lochial discharges. Is it
scanty, moderate or heavy? Explain the 3 stages of postpartum bleeding:
a. Lochia Rubra- dark red discharge, 1- 3 days
b. Lochia Serosa- pink or brownish serosanguinous discharge - 4-7 days/may
last up to 10 days
c. Lochia Alba- creamy or yellowish discharge (white) - 7 – 10 days or up
6. What are the types of episiotomy? What are the reasons/rationale of
performing episiotomy? What are the possible complications of episiotomy?
 Midline (median) incision. A midline incision is done vertically. A midline
incision is easier to repair, but it has a higher risk of extending into the anal
area.
 Mediolateral incision. A mediolateral incision is done at an angle.
Rationale:
 Speed prolonged labor
 Assists vaginal delivery
 Breech presentation
 Delivery of large baby
 Previous pelvic surgery
 Abnormal position of baby’s head.
 Delivery of twins
Possible complications:
 bleeding.
 Tearing into the rectal tissues and anal sphincter muscle which controls the
passing of stool.
 Swelling.
 Infection.
 Collection of blood in the perineal tissues.
 Pain during sex.
7.What are some common postpartum complications? Enumerate and discuss
briefly.
1. Excessive bleeding -While bleeding after giving birth is normal — and most
women bleed for 2 to 6 weeks
2. Incontinence or constipation- Sneezing and peeing your pants in the baby
aisle at Target is no fun for anyone — but it’s also perfectly normal.
3. Infection- This typically occurs as the baby is passing through the vaginal
opening, and it often requires stitches.
4. Breast pain- typically 3 to 5 days after birth — you may notice significant
breast swelling and discomfort.
5. Postpartum depression- Feeling a little up and down, or feeling more weepy
than usual in the weeks after birth is normal. Most women experience some
form of the “baby blues” very quickly.
8. Assess emotional state of the patient after delivery. Discuss & explain
the following:
a. What is postpartum depression and “Baby Blues”? How long does it last?
When It’s the Baby Blues
 Your mood swings quickly from happy to sad. One minute, you’re proud of
the job that you’re doing as a new mom. The next, you’re crying because
you think you’re not up to the task.
 You don’t feel like eating or taking care of yourself because you’re
exhausted.
 You feel irritable, overwhelmed, and anxious.
When It’s Postpartum Depression
 You feel hopeless, sad, worthless, or alone all the time, and you cry often.
 You don’t feel like you’re doing a good job as a new mom.
 You’re not bonding with your baby.
 You can’t eat, sleep, or take care of your baby because of your
overwhelming despair.
 You could have anxiety and panic attacks.
b. What are the causes of postpartum depression and how can it be prevented?
Postpartum depression is a complex mix of physical, emotional, and
behavioral changes that occur after giving birth that are attributed to the chemical,
social, and psychological changes associated with having a baby. More research is
needed to determine the link between the rapid drop in hormones after delivery and
depression. The levels of estrogen and progesterone, the female reproductive
hormones, increased tenfold during pregnancy but drop sharply after delivery. By
three days postpartum, levels of these hormones drop back to pre-pregnant levels.
How to prevent it:
 Exercise when you can
 Maintain a healthy diet
 Create time for yourself
 Make time to rest
 Examine breastfeeding
 Resist isolation
9. What are the physiologic changes during postpartum?
Reproductive System
 The cervix is soft and malleable immediately after birth, but once
contraction of the cervix takes place it also returns to its prepregnant state.
 The vagina returns to its prepregnant state through contractions after the
entire postpartum period but remains slightly distended than before.
 Kegel’s exercise helps return the strength and muscle tone of the vagina.
 The labia minora and majora are still atrophic and soft after birth and would
never return to its prepregnant state.
 The perineum is edematous and tender immediately after birth.
Hormonal System
 As soon as the placenta is no longer present, pregnancy hormones start to
decrease.
 hPL and hCG are insignificant by 24 hours.
 Progestin, estrone, and estradiol return to their prepregnancy levels a week
after birth.
 FSH remains low for 12 days and then starts to increase to signal the start of
a new menstrual cycle.
Urinary System
 Immediately after birth, dieresis sets in to rid the body the excess fluid that
has accumulated during pregnancy.
Circulatory System
 A 4-point decrease in hematocrit and a 1-g decrease in hemoglobin occur
with each 250 mL blood loss.
Gastrointestinal System
 The woman will feel hungry and thirsty almost immediately after giving
birth,
COLLEGE OF NURSING
NCM 107 RLE

Case Study 6:
BELLE’S BABY GIRL

BSN 2-G
Group 3

Clinical Instructor
I. Introduction
The neonatal period is the first 4 weeks of child’s life, newborns or neonates
are closely observed during the first few hours of life. The healthy new born infant
is someone who is born at term, between 38-42 weeks. A pre-term infant is born
before 37 weeks gestation and accounting for 10% of births, a term is a baby who
is born between 37 and 42 weeks of completed gestation and post-term for a baby
that is born more than 42 weeks of gestation accounting for less than 5% of births.
Baby’s birth is one of the most anticipated and life’s most wondrous moment
newborn babies have amazing abilities. Yet, they are still depending to other like
the mother, family members and the healthcare provider for feeding, warmth and
comfort.
At birth there are many staggering physical changes that occurs, when the
baby is delivered the umbilical cord is clamped and cut near the navel and ends the
dependence of baby on the placenta for the oxygen and nutrition.
Providing warmth for the newborn is done because the baby is wet from the
amniotic fluid and baby gets cold easily. Early skin-to-skin contact is also
introduced to reduce crying and improve the interaction of the mother and the
newborn and also helps for a successful breastfeeding.
Immediate health assessments for the newborn like to APGAR Test to
evaluate the condition of the baby and give immediate care if the baby does not
meet the desired normal score of 7-10. Physical exam is also done in the delivery
room to check for any obvious signs that the baby is healthy. These procedures
include: measurement of the temperature, heart rate and respiratory rate,
measurement of weight, length and head circumference. Cord care, bath, eye care
and footprints. Before a baby leaves the delivery area, ID bracelets are placed for
the identification of the baby. Within the first 24 hours of birth the nurse will then
record the baby’s first poos and wees and the mother will be asked for permission
for the baby’s injection and these includes vitamin K and hepatitis B, newborn
screening is also done. The baby’s body system must work together in order to find
out if the baby is doing well or having problems.
II. Objectives
General Objectives:
educated about how to take good care of the newborn and the appropriate
procedures and evaluation to the done in order to assess whether the baby is in
good condition or not also to know the physiological and psychologic changes and
aspects of the baby after birth. Also, the mother will be able to manage and give
proper care of the baby during discharge and acquire proper knowledge, skills and
attitude in providing care for the newborn.
Knowledge
1. Recognize and identify major changes and condition of the newborn after
birth.
2. Describe how to manage complications and issues of newborn.
3. Discuss health teachings to the mother about newborn care.
4. Discuss about immunization and breastfeeding.
Skills
1. Make accurate and attainable nursing care plan for the baby.
2. Understand about care of newborn for example immediate and routine care.
3. Provide appropriate education and guidance to the mother and guide her
about newborn care.
4. Discuss and perform about warmth, care of skin, eyes and care of cord.
5. Counsel the mother how to identify danger signs and demonstrate evidence-
based daily care for the newborn baby.
Attitude
1. Provide competent care to the baby.
2. Recognize the needs of the newborn by using a holistic approach.
3. Show an outmost respect and confidence to the newborn and the mother
when managing care.

A. Biographic Data
Patient’s Name:
Address:
Age:
Sex:
Marital Status:
Occupation:
Religion:
Source of Information:
Date of Admission:
Time of Admission:
Chief Complaint:
B. Chief Complaint
IV. Physical examination

Anthropometric measurements taken as follows:
 Head circumference = 34 cm
 Chest Circumference = 32 cm
 Abdominal Circumference = 30 cm
 Length = 47 cm
 Weight = 3,200 grams
 Temp = 36.5°C
 CR= 140 bpm
 RR= 48 breaths/min
 APGAR score 9/10
Slight caput succedaneum with anterior fontanel not depressed nor bulging.
Skin is bright red with soft downy hair in the body, jaundice and cyanosis not
noted. Eyes are symmetrical without opacity or white spots, tearless when crying.
Ears are well formed and no presence of anomalies, upper borders are in line with
the outer canthus of the eyes. Nares are patent with white papules seen over the
nose.
Mouth is moist and lips in pinkish color, palate intact, no drooling.
Neck moves freely, no torticollis.
Nipples have fluid leak or witch milk.
No signs of respiratory distress; nasal flaring, grunting, retraction not noted. No
gross distention or bulging in the abdomen.
Genitalia shows slight edematous labia and clitoris with vernix caseosa between
folds with occasional blood-tinged vaginal discharge/
Intact, straight and flat spine with no masses nor dimple sac. Dark, flat
pigmentation of the lower back noted and with patent anal opening.
Good muscle tone, arms and legs are equal in length, normal palm and plantar
creases on the entire sole.
FETAL CIRCULATION AIM
 Oxygenated placental blood is preferentially delivered to the brain,
myocardium and upper torso
Fetal cardiac output is therefore measured as a combined ventricular output closure
of the intracardiac (foramen ovale) and extracardiac shunts (ductus venosus and
ductus arteriosus).
FETAL CIRCULATION (PARALLEL CIRCULATION)
 Oxygenated blood via umbilical vein either through the liver or via the
ductus venosus to reach IVC
 blood remains on the posterior wall of the inferior vena cava, allowing it to
be directed across the foramenovale into the left atrium by the Eustachian
valve
 blood passes left ventricle and aorta to supply the head and upper torso.
 deoxygenated blood returning from the SUPERIOR vena cava and
myocardium via the coronary sinus is directed through the right ventricle
and into the pulmonary artery.
 Most of this blood is returned to the descending aorta via the ductus
arteriosus; (8-10%of total cardiac output passes through the high-resistance
pulmonary circulation.)
 Blood in the descending aorta either supplies the umbilical artery to be
reoxygenated at the placenta or continues to supply the lower limbs.
PHYSIOLOGICAL CHANGES AT BIRTH UMBILICAL VESSELS-
IMMEDIATELY AFTER CLAMPING:
 constrict in response to stretching and increased oxygen content at delivery
 large low-resistance placental vascular bed removed from the circulation
 increase SVR
 Reduction of blood flow along ductus venosus (passive closure over the
following 3-7 days), reduced blood flow in IVC
Lung expansion
 drops pulmonary vascular resistance
 increase in blood returning to the LA These two changes reduce right atrial
and increase left atrial pressures, functionally closing the foramen ovale
within the first few breaths of life
TRANSITION AT BIRTH
 Successful transition from fetal to postnatal circulation requires
 clamping of umbilical cord and removal of the placenta
 increased pulmonary blood flow
 Shunt closure
RESPIRATORY CHANGES
What part do each of these factors play in initiation of respirations in the
Mechanical Chemical Sensory/ Thermal Initiation of Breathing neonate?
CHANGES AT BIRTh MECHANICAL
Compression of fluid from the fetal lung during vaginal delivery establishes the
lung volume As the chest passes through the birth canal the lungs are compressed
Subsequent recoil of the chest wall produces passive inspiration of air into the
lungs Negative inspiratory pressures of up to 70-100 cm H2O are initially required
to expand the alveoli (LaPlace’s relationships) which facilitate lung expansion by
overcoming: airways resistance inertia of fluid in the airways surface tension of the
air/fluid interface in the alveolus.
CHEMICAL EVENTS
1. With cutting of the cord, remove oxygen supply
2. Asphyxia occurs
3. CO2 and O2 and pH = ACIDOSIS
4. Acidotic state-- stimulates the respiratory center in the medulla and the
chemoreceptors in carotid artery to initiate breathing
SENSORY / THERMAL EVENTS
 Thermal - the decrease in environmental temperature after delivery is a
major stimulus of breathing
 Tactile - nerve endings in the skin are stimulated
 Visual - change from a dark world to one of light
 Auditory - sound in the extrauterine environment stimulates the infant.
BIOPHYSICAL CHANGE
1)Alveolar distension, cortisol and epinephrine further stimulate typeII
pneumocytes to produce surfactant
2)Expiration
 initially active
 Pressures of 18-115 cm H2O generated
 amniotic fluid forced out from the bronchi.
PHYSIOLOGICAL CHANGES LEAD TO-
 increasing blood flow
 and initiating the cardiovascular changes.
SHUNT CLOSURE
physiological reverse shunt from left to right commonly occurs. FORAMEN
OVALE
 completely closed in 50% of children by 5 years
 remains probe patent in 30% of adults
 can facilitate paradoxical embolus and potential stroke.
DUCTUS ARTERISUS
 drop in pulmonary artery pressure and increase in SVR reverses flow across
the ductus arteriosus from L TO R
 affected by blood oxygen content
 circulating prostaglandins. E2
 Functional closure occurs by 60 hours in 93% of term infants.,4-8 weeks
permanent structural closure occurs via endothelial destruction and
subintimal proliferation.
GI system
Neonate’s stomach capacity increases from 6 ML/kg to 90 ML by end of first
week.
 Low amylase, lipase and bile acids = difficulty in fat digestion.
 No salivation for the first 3 months.
 Cardiac sphincter is immature (leads to regurgitation)
 Small intestines are long
 First meconium stool within hours of life
 Absence of a bowel movement by 72 hours of age may be indicative of an
obstructive bowel problem.

VII. Drug Study
DRUG NAME CLASSIFICATION MECHANISM OF INDICATIONS CONTRAINDICATION ADVERSE NURSING
ACTIONS S REACTION RESPONSIBILITY
Generic name: Tetracyclines/Topical Oxytetracycline Crede’s Hypersensitivity to Anorexia, nausea, Wash hands before
Oxytetracycline Antibiotics /Eye Anti- binds reversibly to Prophylaxis for tetracyclines, children < vomiting, diarrhea, administering
HCI 5 mg Infectives and the 30s and Superficial 8yr renal damage, glossitis, ointment.
polymyxin B Antiseptics possibly 50s ophthalmic pregnancy, lactation dysphagia,
sulfate. ribosomal subunits, infections esophageal
thus inhibiting irritation and
Brand: bacterial protein ulceration,
Terramycin synthesis and nephrotoxicity,
Ophthalmic arresting cell enterocolitis, rash,
ointment growth. It is active blood dyscrasias.
against a wide Headache, visual
range of gram- disturbances:
positive and gram- Intracranial
negative organisms. Hypertension
Bulging fontanelles
(infants)
DRUG NAME CLASSIFICATION MECHANISM INDICATIONS CONTRAINDICATION ADVERSE NURSING
OF ACTION S REACTION RESPONSIBILITIE
S
Functional: Promotes hepatic Prevention treatment of Renal impairment for Newborn especially Monitor PT,
Phytonadione Antihemorrhagic formation of hemorrhagic states in newborns especially premature infants may international
Vitamin K coagulation neonates. Antidote for premature, risk for develop normalized ratio
Chemical: factors II, VII, hemorrhage induced by hemolysis, jaundice and hyperbilirubinemia. (INR) routinely in
Fat soluble vitamin IX, X. Essential oral anticoagulants, hyperbilirubinemia. Severe reaction those taking
for normal hypoprothrombinemia (cramp-like pain, anticoagulants.
Vitamins and clotting of blood. states due to vitamin k dyspnea, chest pain, Assess skin for
minerals Readily absorbed deficiency. facial flushing, ecchymoses,
Pregnancy risk from GI tract Hypoprothrombinemia dizziness, rapid/weak petechiae.
after IM, caused by malabsorption pulse, rash, Assess gums for
subcutaneous or inability to synthesize diaphoresis, gingival bleeding,
administration. vitamin K. hypotension erythema.
Metabolized in progressing to shock, Assess urine for
liver. Excreted in cardiac arrest) hematuria.
urine eliminated Assess Hct, platelet
by biliary count, urine/stool
system. Onset of culture for occult
action increased blood.
coagulation Assess for peripheral
factors pulses.
Check for excessive
bleeding from minor
cuts.
DRUG NAME CLASSIFICATIO MECHANISM OF ACTION INDICATIONS CONTRAINDIC ADVERSE REACTION NURSING
N ATIONS RESPONSIBILITIES
GENERIC: PHARMACOLO Hepatitis B vaccine has been shown Every person may be at some risk for a Severe allergic pain, severe itching, reddening of Communicate or assure
GICCLASS: to elicit anti bodies to hepatitis B hepatitis B infection during their lifetime, reaction after a the skin, weakness, feeling patient that the pain
Hepatitis B previous dose of unwell (malaise),nausea, due to injection is mild
virus as measured by ELISA. so getting the hepatitis B vaccine should be
vaccine(recombin Hepatitis B vaccine any hepatitis B vomiting, abdominal and generally tolerable.
Antibody concentrations considered by all people. There are,
ant) containing pain/cramps, difficult or labored Provide immunization
THERAPEUTIC however, groups that the CDC recommends
≥10mIU/Ml against HBsAg are vaccine or to any breathing, diminished appetite, schedule to client
BRAND: CLASS: should definitely receive the hepatitis B
recognized as conferring protection component pf stuffy nose, influenza, cough, (Vaccination requires
vaccine, which are listed below:
EngerixB ANTI- HEPATITIS against hepatitis B infection. hepatitis B sweating, achiness, sensation of three IM injections at
bVACCINE Infection with hepatitis B virus can All infants, beginning at birth vaccine including warmth, lightheadedness, chills, prescribed intervals.)
Hepaccine, have serious consequences yeast. flushing diarrhea, sore throat, Administer dosage
All children aged <19 years who have not upper respiratory infection, correctly (Vaccine
HBV including acute massive hepatic
been vaccinated previously burning, nodules, headache, must be administered
necrosis and chronic active
Recombivax fever, spinning sensation intramuscularly.)
hepatitis. Chronically infected Susceptible sexual partners of hepatitis B- (vertigo),numbness or tingling, Instruct client to return
persons are at increased risk for positive persons skins welling, hives, muscle pain, at 1 month after the
cirrhosis and heap to cellular back pain, neck pain, shoulder first injection for the
carcinoma. Sexually active persons who are not in a
pain, stiff neck, ear ache inability second dose and at 6
long-term, mutually monogamous
to sleep (insomnia),irritability, months after the first
relationship (e.g.,>1 sex partner during the joint pain, constipation, Lupus- injection for the third
previous6 months) like syndrome (rash, joint pain dose.
Persons seeking evaluation or treatment for and fatigue), Systemic Lupus
Erythematous (autoimmune
a sexually transmitted disease
disease),polyarthritis nodules,
Men who have sex with men enlargement of lymph nodes, fast
heartrate, fainting, inflammation
Injection drug users of the cornea, inflammation of
the optic nerve, ringing in the
Susceptible household contacts of hepatitis ears (tinnitus),
B-positive persons injection for the third dose.
Healthcare and public safety workers at risk
for exposure to blood
Persons with end-stage renal disease,
including pre-dialysis, hemodialysis,
peritoneal dialysis, and home dialysis
patients
Residents and staff of facilities for
developmentally disabled persons
Persons with chronic liver disease other
than hepatitis B
Defining Nursing diagnosis Outcomes Intervention Rationale Evaluation
Characteristics
Objective: Risk for Infections Short term: Independent: After each nursing
The baby was delivered related to newly clamped The mother will be able to Advice patient to watch the umbilical intervention the area
via NSVD, cord was umbilical cord and identify factors that is stump for infection that includes: Early assessment can prevent the around the cord is dry
clamped and cut exposure of eyes to associated with umbilical  Foul-smelling, yellow drainage spread of the infection if treated right and free of erythema.
aseptically after vaginal secretions. and eye infections. from the stump away Eyes are free from
pulsation.  Redness, swelling or tenderness inflammation and
Reference: Long term: or skin around the stump. drainage.
Ladwig-Nursing The mother will be able to Educate patient that fever of 38°C or
Diagnosis Handbook: an perform care procedures higher, poor feeding, lethargy and
Evidence based Guide to and identify and avoid floppy poor muscle tone is a sign of a
planning Care 11th infection. The newborn more serious infection and healthcare
edition will be free of erythema provider should be contacted
Newborn Normal page around the cord and free immediately. When clamp loosens before
86) eyes from inflammation. thrombosis obliterates the umbilical
When handling the newborn inspect the vessels hemorrhage could result.
cord if it is clamped securely.
Breastfeeding allows the passage of

antibodies to the baby which could
help their immune systems develops
Encourage breastfeeding. and strengthens.
Babies who got skin-to-skin contact

were 36% likely to develop umbilical
cord infection than babies who didn’t
Allow mother and the baby to have
have skin exposure.
skin-to-skin contact, to expose the baby
from normal skin bacteria.
Keeping the cord dry can heal and

Educate the mother that the cord falls fall off the cord easily.
off the about 7-10 days of life and
newborn should receive sponge bath
rather than be immersed in a tub of
water. Diapers are folded down below
the level of the umbilical cord.
Remind parents to continue to keep the Tends to slow down the drying of the
cord dry until it falls off after they cord and invite infections.
return home. Creams, lotions and oils
near cord should be discouraged. Other applications and manipulations
could invite infections.
Recommend the use of rubbing alcohol
to the cord site once or twice a day to This could be a sign of infection.
hasten drying.
Remind mother that if the cord doesn’t

fall beyond 3 weeks the healthcare
provider must be called immediately.
To prevent infections that are usually
Dependent: acquired from mother as the infant
Administer eye care ordered by the passes through birth canal.
physician.
 Apply Terramycin ointment
When applying the ointment make sure
to open the newborn’s eyes and squeeze
a line along lower conjunctival sac from
inner canthus outward.
To prevent and reduce infections.
Collaborative:
Healthcare workers, parents or relatives
handling the newborn should wash their
hands and arms to elbows thoroughly The newborn should be excluded and
with antiseptic soap before handling the should not contact sick individuals to
infant. avoid possibility of contagion.
Staff member and relatives with
infections such as sore throats upper
respiratory tract infections, skin lesion
or gastrointestinal upset should be
excluded for the infant and mother.
Going home instructions given and health education includes: cord care, feeding
pattern, observe for signs of breathing problems, dehydration, infection, jaundice
and initial clinic visit schedule was given.
Newborn Handling
1. Wash your hands (or use a hand sanitizer) before handling your baby.
Newborns don't have a strong immune system yet, so they're at risk for
infection. Make sure that everyone who handles your baby has clean hands.
2. Support your baby's head and neck. Cradle the head when carrying your
baby and support the head when carrying the baby upright or when you lay
your baby down.
3. Never shake your newborn, whether in play or in frustration. Shaking can
cause bleeding in the brain and even death. If you need to wake your infant,
don't do it by shaking — instead, tickle your baby's feet or blow gently on a
cheek.
4. Make sure your baby is securely fastened into the carrier, stroller, or car
seat. Limit any activity that could be too rough or bouncy.
5. Remember that your newborn is not ready for rough play, such as being
jiggled on the knee or thrown in the air.
Bathing
1. You should give your baby a sponge bath until: the umbilical cord falls off
and the navel heals completely (1–4 weeks)
2. A bath two or three times a week in the first year is fine. More frequent
bathing may be drying to the skin.
Umbilical cord care
1. swabbing the area with rubbing alcohol until the cord stump dries up and
falls off, usually in 10 days to 3 weeks
2. An infant's navel area shouldn't be submerged in water until the cord stump
falls off and the area is healed.
3. Call your doctor if the navel area looks red or if a foul odor or discharge
develops.
Feeding and burping
1. A newborn baby needs to be fed every 2 to 3 hours.
2. If breastfeeding, give your baby the chance to nurse about 10–15 minutes at
each breast. If you're formula-feeding, your baby will most likely take about
2–3 ounces (60–90 milliliters) at each feeding.
3. Call your baby's doctor if you need to wake your newborn often or if your
baby doesn't seem interested in eating or sucking.
4. Try burping your baby every 2–3 ounces (60–90 milliliters) if you bottle-
feed, and each time you switch breasts if you breastfeed.
Burping tips:
 Hold your baby upright with his or her head on your shoulder. Support your
baby's head and back while gently patting the back with your other hand.
 Sit your baby on your lap. Support your baby's chest and head with one hand
by cradling your baby's chin in the palm of your hand and resting the heel of
your hand on your baby's chest (be careful to grip your baby's chin — not
throat). Use the other hand to gently pat your baby's back.
 Lay your baby face-down on your lap. Support your baby's head, making
sure it's higher than his or her chest, and gently pat or rub his or her back.
5. It's important to always place babies on their backs to sleep to reduce the
risk of SIDS (sudden infant death syndrome). safe sleeping practices
include: not using blankets, quilts, sheepskins, stuffed animals, and pillows
in the crib or bassinet (these can suffocate a baby); and sharing a bedroom
(but not a bed) with the parents for the first 6 months to 1 year.
6. Be sure to alternate the position of your baby's head from night to night (first
right, then left, and so on) to prevent the development of a flat spot on one
side of the head.
7. Keep the lights low, such as by using a nightlight. Reserve talking and
playing with your baby for the daytime. When your baby wakes up during
the day, try to keep him or her awake a little longer by talking and playing.
QUESTIONS
1. What is the rationale of drying the newborn thoroughly?
The indicator measures one of the main thermal care practices that are essential for
preventing children's temperatures to drop rapidly after birth, causing potentially
life-threatening neonatal hypothermia.
2. Should the vernix caseosa be wiped off after the delivery? Why?
The World Health Organization (WHO) recommends waiting at least 6 hours
before bathing the newborn baby and ideally waiting about 24 hours. The WHO
also recommends not wiping off the vernix at birth. Vernix is nature's protection
against these infections. S
3. When is the ideal time to clamp and cut the cord? Why?
The World Health Organization currently recommends clamping the umbilical
cord between one and three minutes after birth, “for improved maternal and infant
health and nutrition outcomes.
4. Discuss the significance of performing APGAR Scoring. Is 9/10 APGAR
Score normal? Why?
Apgar is a quick test performed on a baby at 1 and 5 minutes after birth. The 1-
minute score determines how well the baby tolerated the birthing process. The 5-
minute score tells the health care provider how well the baby is doing outside the
mother's womb. In rare cases, the test will be done 10 minutes after birth. 9/10 is
normal because it indicates that the baby is stable and healthy.
5. What are the 5 signs to be assessed in APGAR Scoring?
 Appearance (skin color)
 Pulse (heart rate)
 Grimace response (reflexes)
 Activity (muscle tone)
 Respiration (breathing rate and effort)
6. What is the importance of Crede’s prophylaxis? How should the medication
be administered?
Credé's prophylaxis represented a tremendous step forward in the prevention of
inflammatory eye disease in newborns in the late 19th century. But his original
prophylaxis is mainly effective against gonococcal ophthalmia whereas chlamydial
ON is now more widespread, and silver nitrate may cause chemical conjunctivitis.
7. What is the importance of Vit. K injection? Give the dosage, route and site
of administration?
Vitamin K helps the blood to clot and prevents serious bleeding. In newborns,
vitamin K injections can prevent a now rare, but potentially fatal, bleeding disorder
called 'vitamin K deficiency bleeding' (VKDB), also known as 'haemorrhagic
disease of the newborn' (HDN). For prevention of bleeding in newborns: The usual
dose is 0.5 to 1 mg, injected into a muscle or under the skin, right after delivery.
8. Why is Hepa vaccine given? Give the dosage, route and site of
administration.
Hepatitis A vaccine can prevent hepatitis A. Hepatitis A is a serious liver disease.
It is usually spread through close, personal contact with an infected person or when
a person unknowingly ingests the virus from objects, food, or drinks that are
contaminated by small amounts of stool (poop) from an infected person. Dosages
of Hepatitis B Vaccine:
 10 mcg/ml (Recombivax HB)
 20 mcg/ml (Engerix B)
 40 mcg/ml (Recombivax HB [dialysis formulation])
 Intramuscular suspension (pediatric/adolescent formulation)
 5 mcg/0.5 ml (Recombivax HB)
 10 mcg/0.5 mg (Engerix B)
9. What is the significance of Newborn Screening? How it is being done?
Newborn screening allows health professionals to identify and treat certain
conditions before they make a baby sick. Most babies with these conditions who
are identified at birth and treated early are able to grow up healthy with normal
development. Newborn screening usually starts with a blood test, followed by a
hearing test and possibly other tests. After warming and careful sterilizing of the
infant's heel, medical staff do a "heel stick," in which they make a small puncture
in the baby's heel and squeeze out a few drops of blood. They put the absorbent
part of the card in contact with the blood drop. They continue until all the printed
circles on the card contain a blood sample.
10. Based on the scenario, are the results of anthropometric measurements
normal? Explain briefly.
Yes,
Gende Means and Ranges Neonatal Weight Neonatal Head Circumference Neonatal Length
r (kg) (cm) (cm)
Male Mean 3.1640 34.7403 48.9187
Range (3rd to 2.4 – 4.1 46.1 – 51.4 32.3 – 36.9

97th centiles)
Female Mean 3.1145 34.1685 48.4984
Range (3rd to 2.1 – 4.2 45.1 – 51.7 32.3 – 36.4

97th centiles)
Total Mean 3.1407 34.4707 48.7205
11. Differentiate between physiologic and pathologic jaundice. Give the

management for each.
Physiological Jaundice vs Pathological Jaundice
In a healthy neonate, jaundice can Pathological jaundice can
appear because of increased occur in any person and is a
hemolysis and the immaturity of the result of an ongoing
liver to rapidly metabolize the bilirubin pathological process that
produced during the process. This is interrupts the normal
known as physiological jaundice. bilirubin metabolism.
Pathology
There is an underlying
There is no underlying pathology.
pathology.
Victims
Pathological jaundice can
Physiological jaundice is seen in
occur in both adults and
neonates.
children.
Treatment
The patient should be treated
No treatment is required. according to the underlying
cause of jaundice.
12. Formulate your Nursing Care Plan and Drug Study.
DRUG NAME CLASSIFICATION MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE NURSING
ACTION REACTION RESPONSIBILITIES
Functional: Promotes hepatic Prevention treatment of Renal impairment for Newborn especially Monitor PT, international
Phytonadione Antihemorrhagic formation of hemorrhagic states in neonates. newborns especially premature infants may normalized ratio (INR)
Vitamin K coagulation factors Antidote for hemorrhage premature, risk for hemolysis, develop routinely in those taking
Chemical: II, VII, IX, X. induced by oral anticoagulants, jaundice and hyperbilirubinemia. anticoagulants.
Fat soluble vitamin Essential for normal hypoprothrombinemia states hyperbilirubinemia. Severe reaction Assess skin for ecchymoses,
clotting of blood. due to vitamin k deficiency. (cramp-like pain, petechiae.
Vitamins and minerals Readily absorbed Hypoprothrombinemia caused dyspnea, chest pain, Assess gums for gingival
from GI tract after by malabsorption or inability to facial flushing, bleeding, erythema.
Pregnancy risk IM, subcutaneous synthesize vitamin K. dizziness, rapid/weak Assess urine for hematuria.
administration. pulse, rash, Assess Hct, platelet count,
Metabolized in diaphoresis, urine/stool culture for occult
liver. Excreted in hypotension blood.
urine eliminated by progressing to shock, Assess for peripheral pulses.
biliary system. cardiac arrest) Check for excessive bleeding
Onset of action from minor cuts.
increased
coagulation factors
COLLEGE OF NURSING
NCM 107 RLE

Case Study 7:
BABY GIRL

BSN 2-G
Group 3

Clinical Instructor
I. Introduction
From helpless newborns to active toddlers, it takes only 12 months for a
baby to experience this incredible change. Babies are growing and changing at an
amazing pace, bringing new and exciting developments every month.
The neonatal reflex, also known as the baby's reflex or the infant's reflex, is
normal and important for the baby's survival. These are the reaction of the baby's
muscles, involuntary movements, or neurological reactions to stimuli or triggers,
including sound, light, sudden movements, stroking and touching.
There are different types of reflexes in newborns. Some reflexes appear only
at certain stages of the baby's development, while other reflexes can last for years
into adulthood. By the time the baby is 4-6 months old, the brain should have
matured and replaced these involuntary movements with spontaneous movements.
These reflexes include: asymmetrical tonic neck reflex, Babinski reflex and
grasp reflex, Moro or startle reflex, rooting reflex, step reflex and truncal
incurvation or Galant reflex.
A baby shows the asymmetrical tonic neck reflex when they are lying down and
the head is turned gently to the side. If the baby’s head is turned to the right, the
baby will assume the opposite position. The Babinski reflex is tested by stroking
the underside of the baby’s foot, from the top of the sole toward the heel. The
grasp reflex is tested by placing a finger in the baby’s open palm. The baby should
grasp the finger and may even maintain a firm grip on the finger. The Moro reflex
is tested by gently positioning a baby in a seated stance with the head supported. If
a baby’s Moro reflex is present, the baby should appear startled and lift its palms
upward, with its thumbs out. When the baby is caught, the baby will bring its arms
back to its body. The rooting reflex is commonly used to achieve a breastfeeding
latch. When a baby’s cheek is stroked, the baby will turn toward the cheek that was
stroked and will make a gentle sucking motion. The step reflex by holding the baby
upright and gently touching the baby’s feet to a surface. The baby will appear to
step or dance. The Galant reflex is tested by holding the baby face-down in one
hand while using the other hand to stroke the baby’s skin along either side of the
spine.
In the first stages of development, the baby's body and brain learn to live in the
outside world. Babies can start within 3 months of birth: smiles, within three
months, they will smile in response to your smile and try to make you smile again.
Raise your head and chest when lying on your stomach. Track the object at eyes
and gradually reduce eye crossings. Open and close both hands and bring both
hands to your mouth. Grab an object with your hand. Strokes or reaches hanging
objects, usually when they are still unreachable. During these months that the baby
actually learns to reach and manipulate the world around him. They have mastered
the use of these amazing tools, by their hands. And they discover their voice. By 4-
6 months of age, your baby will Roll from front to back or back to front. Usually,
front to back is first. Bubble makes a sound that may sound like a real speech.
Laughter. Reach for objects (be careful with your hair) and manipulate toys and
other objects by hand. AT 7 to 9 months the baby begins to crawl. This includes
scooting (floating on the hips) or army crawling (pulling the stomach with the arms
and legs), and normal crawling of the hands and knees. Some babies never crawl,
but they switch directly from running to running. sitting without support.
Responds to well-known words such as names. They can also pause and look at
you and answer "no" by starting to talk "mother" and "dada". Finally at 10-12
months the baby point at objects they want in order to get your attention. Begin
“pretend play” by copying you or using objects correctly, such as pretending to
talk on the phone. Take their first steps. This usually happens right around one
year, but it can vary greatly.
II. Objectives
General Objectives:
educated about the different developmental changes and reflexes a newborn will
enter on specific periods. Also, they will be able to acquire proper nursing
interventions and management, skills, knowledge and attitude to provide to the
baby during this different period of changes.
Knowledge:
1. Recognize and describe different types of developmental changes and

reflexes.
2. Discuss the physiologic factors that affects the baby’s development.
3. Identify normal findings of development and reflex changes.
4. Determine advanced and delayed development stage.
Skills:
1. Perform procedures to determine that the baby’s performed reflexes reflect

her age.
2. Document correctly the patient’s condition and development, nursing
interventions and evaluation.
3. Implement proper and attainable nursing care plan for the baby.
Attitude:
1. Provide competent care to the baby.

2. Recognize the needs of the newborn by using a holistic approach.
3. Show an outmost respect, patience and confidence to the newborn and when
managing care.
A. Biographic Data
Patient’s Name:
Address:
Age:
Sex:
Marital Status:
Occupation:
Religion:
Source of Information:
Date of Admission:
Time of Admission:
Chief Complaint:
B. Chief Complaint
IV. Physical examination
37 3/7 weeks AOG, weighed 3,375 gms with an Apgar Score of 9 and 10 at 1 and
5 minutes respectively. Vital signs revealed normal levels and Baby Belle was very
responsive to stimuli.
a. Airway and Respiratory System
 They have a large head, short neck and a prominent occiput.

 The tongue is relatively large.
 Neonates preferentially breathe through their nose. Their narrow nasal
passages are easily blocked by secretions and may be damaged by a
nasogastric tube or a nasally placed endotracheal tube. 50% of airway
resistance is from the nasal passages.
 The airway is funnel shaped and narrowest at the level of the cricoid
cartilage. Here, the epithelium is loosely bound to the underlying tissue.
Trauma to the airway easily results in oedema. One millimeter of oedema
can narrow a baby’s airway by 60%
 Work of respiration may be 15% of oxygen consumption.
 Muscles of ventilation are easily subject to fatigue due to low percentage of
Type I muscle fibres in the diaphragm. This number increases to the adult
level over the first year of life.
 RR = 24 – age/2
 Spontaneous ventilation TV = 6-8 ml/kg; IPPV TV = 7-10ml/kg
 Physiological dead space = 30% and is increased by anaesthetic equipment.
b. Cardiovascular System
 In neonates the myocardium is less contractile causing the ventricles to be

less compliant and less able to generate tension during contraction. This
limits the size of
 the stroke volume. Cardiac output is therefore rate dependent. The infant
behaves as with a fixed cardiac output state. Vagal parasympathetic tone is
the most dominant, which makes neonates and infants more prone to
bradycardias.
 Bradycardia is associated with reduced cardiac output. Bradycardia
associated with hypoxia should be treated with oxygen and ventilation
initially. External cardiac compression will be required in the neonate with a
heart rate of 60 beats per minute or less, or 60-80 beats per minute with
adequate ventilation.
 Cardiac output is 300-400 ml/kg/min at birth and 200 ml/kg/min within a
few months.
C. RENAL SYSTEM
 Renal blood flow and glomerular filtration are low in the first 2 years of life
due to high renal vascular resistance. Tubular function is immature until
8months, so infants are unable to excrete a large sodium load.
 Dehydration is poorly tolerated. Premature infants have increased insensible
losses as that have a large surface area large surface area relative to weight.
There is a larger proportion of extra cellular fluid in children (40% body
weight as compared to 20% in the adult).
 Urine output 1-2 ml/kg/hr
D. HEPATIC SYSTEM
 Liver function is initially immature with decreased function of hepatic

enzymes. Barbiturates and opioids for example have a longer duration of
action due to the slower metabolism.
E. GLUCOSE METABOLISM
Hypoglycemia is common in the stressed neonate and glucose levels should be

monitored regularly. Glycogen stores are located in the liver and myocardium.
Neurological damage may result from hypoglycemia so an infusion of 10%
glucose may be used to prevent this. Infants and older children maintain blood
glucose better and rarely need glucose infusions. Hyperglycemia is usually
iatrogenic
F. HAEMATOLOGY
 At birth, 70-90% of the hemoglobin molecules are HgB. Within 3 months
the levels of HgB drop to around 5% and HgB predominates. A hemoglobin
level in a newborn will be around 18-20 g/dl which is a hematocrit of about
0.6. The hemoglobin levels drop over 3-6 months to 9-12 g/dl as the increase
in circulating volume increases more rapidly the bone marrow function.
I. PSYCHOLOGY
 Children up to 4 years of age are upset by the separation from their parents
and the unfamiliar people and surroundings. It is difficult to rationalise with
a child of this age. The behavior of this group is more unpredictable.
 School age children are more upset by the surgical procedure, its mutilating
effects and the possibility of pain.
 Adolescents fear narcosis and pain, the loss of control and the possibility of
not being able to cope with the illness. This is worsened by long periods of
hospitalization.
VI. Drug Study

VII. Nursing Care Plan
Defining Nursing Diagnosis Outcomes Intervention Rationale Evaluation
Characteristics
Objective: Ineffective coping r/t Short term: Independent: After each nursing
vulnerability related to interventions there is a
Baby Belle cries developmental age. The baby will manifest a Advice caregivers to: Trust and unconditional acceptance decreased in level of
when mother was decrease the level of are necessary for satisfactory anxiety when the baby
not in sight. anxiety. Establish an atmosphere child/family relationship. was separated to the
of calmness, trust and
mother.
Reference: genuine positive regard
Ladwig-Nursing Long term: Provide care and Accurate communication and

Diagnosis Handbook: attention appropriate for attention promote trust and
an Evidence based There will be evidence of age. understanding/accurate expectations.
Guide to planning Care engaging in age-
11th edition Separation appropriate activities and
anxiety page 107) cooperates with other
people even with the Ensure baby of her safety Strange people, changes in
absence of the parents. and security. surrounding and routine creates
anxiety and can be frightening to the
baby.
Provide child with To stop the baby from crying and

possible choices, needs enhance relationship with the baby.
and wants.
Defining Nursing Diagnosis Outcomes Intervention Rationale Evaluation
Characteristics
Objective: Risk for injury: Short term: Asses environmental factors that may lead to injury To determine the After each nursing
risk factor causes of injury. interventions the
Baby Belle learns developmental The mother will Assess coping abilities and personality of the mother is
to roll from front age be able to know mother that may lead to carelessness. To determine level of knowledgeable about
to back and back what are the risk cooperation. the possible risk and
to front. Reference: factors associated Promote safety by providing materials for injury
knows how to prevent
with prevention such as:
injury
Ladwig-Nursing developmental
Diagnosis  Purchase and correctly install an infant car safety
age.
Handbook: an seat.
Evidence based  Avoid burns by not holding your baby while
Guide to planning cooking or holding hot food or beverages.
To lessen the risk for
Care 11th edition Long term:  Never leave baby unattended on beds, sofas,
injury safe
Safety, childhood chairs, or any place where he or she may fall.
The mother will environment and
page 105)  Install baby gates at the top and bottom of
be able to avoid promoted baby’s
stairways.
the risk for injury.  Never leave baby alone with other young comfort.
children or with pets.

 Before baby begins crawling, childproof your
home.
Health Teachings:
Feeding: Baby can rapidly move from breast milk/formula to trying his/her first
table foods. Plus, babies use their mouths to learn about their world, so many non-
food items also find their way into little mouths. Due to all of the action these
mouths see, choking is an inherent danger. Following are a few tips for keeping
your baby safe:
 Provide safe finger foods such as bananas, well-cooked pasta and

vegetables, o-shaped low-sugar cereals (such as Cheerios).
 Keep items such as coins, buttons, balloons, safety pins, barrettes, and
rocks out of your child's reach.
 Follow age recommendations on toys, especially those with small parts,
and make sure toys are in good repair.
 Be vigilant. Small children put many things in their mouths. A watchful
adult is often the best defense.
SAFETY
1.Be aware of poisons (household cleaners, cosmetics, medicines, and even

some plants) in your home and keep them out of your infant's reach.
2. DO NOT allow older infants to crawl or walk around in the kitchen while
adults or older siblings are cooking.
3. DO NOT drink or carry anything hot while holding the infant to avoid burns.
Infants begin waving their arms and grabbing for objects at 3 to 5 months.
4. DO NOT leave an infant alone with siblings or pets.
5. DO NOT leave an infant alone on a surface from which the child can wiggle
or roll over and fall off.
6. For the first 5 months of life, always place your infant on them back to go to
sleep.
7. Never leave small objects within an infant's reach, infants explore their
environment by putting everything they can get their hands on into their
mouth.
8. Place your infant in a proper car seat for every car ride, no matter how short
the distance.
9. Use gates on stairways, and block off rooms that are not "child proof."
Remember, infants may learn to crawl or scoot as early as 6 months.
CONTACTYOUR HEALTH CARE PROVIDER IF:
1. The infant does not look good, looks different from normal, or cannot be
consoled by holding, rocking, or cuddling.
2. The infant's growth or development does not appear normal.

COLLEGE OF NURSING
NCM 107 RLE
CASE STUDY 8:
Newborn Development and Developmental
Milestones

BSN 2-G
Group 3
Clinical Instructor
I. Introduction
An infant during the 7th month of life and beyond is more active than the past
months which requires more hands-on care of the mother. Babies are more mobile,
eating more solid foods and exploring newfound skills such as crawling.
During developmental stage the baby will also develop primitive reflexes which
are reflexes that are involuntary motor responses that originates in the brainstem
present after birth and early childhood development that also facilitates survival.
These are rooting reflex, sucking reflex, moro or startle reflex and steeping reflex,
placing reflex, palmar grasp reflex, Babinski reflex, tonic reflex and gallant reflex.
Primitive reflexes are those reflexes that will disappear after a few months.
Parachute reflex is a reflex that occurs in slightly older infants where they
anticipate fall and reflexively break it.
There are reflexes that persist throughout life these are blinking reflex, cough
reflex, gag reflex, sneeze and yawn reflex. Blinking reflex is blinking the eyes
when they are touched or when a sudden bright light appears. Cough reflex is
coughing when airways is stimulated. Gag reflex is gagging when the throat or
back of the mouth is stimulated. Sneeze reflex is sneezing when the nasal passages
are irritated and yawn reflex yawning when the body needs more oxygen.
Skills such as taking a first step, smiling for the first time, and waving “bye-bye”
are called developmental milestones. Developmental milestones are things most
children can do by a certain age. Children reach milestones in how they play, learn,
speak, behave, and move. During this stage, babies also are developing bonds of
love and trust with their parents and others as part of social and emotional
development. The way parents cuddle, hold, and play with their baby will set the
basis for how they will interact with them and others.
II. Objectives
General Objectives
At the end of this case prestation, the audience or the participants will be educated
about the post-partum period pregnancy and neonatal care, its nursing intervention
and management. They will be able to acquire proper knowledge, skills and
attitude in providing nursing care.
KNOWLEDGE
1. Nursing care of the family with infant
2. Growth and development of an infant
3. Nutritional needs of an infant
4. Health promotion of infant
5. Recognize the different reflexes that may persist and disappears and the
developmental milestones
SKILLS
1. Assess an infant for growth and development milestones.
2. Formulate nursing diagnosis related to infant growth and development
associated with parental concerns.
3. Implement appropriate nursing interventions.
ATTITUDE
1. Recognize patient needs using a holistic approach
2. Show Confidence in facing the patient.
3. Being alert and careful in assessing the patient.

A. Biographic Data
Patient’s Name: Baby Girl- Belle
Address:
Age:
Sex: Female
Occupation: None
Religion:
Source of Information: The patient’s mother Belle
Date of Admission:
Time of Admission:
Chief Complaint:
B. Chief Complaint

 At 7th month Baby Belle becomes more mobile, eating more solid foods, and
exploring with new found skills like crawling, sitting with support, and then
without support, transferring objects from hand to hand.
 At 8th month Baby Belle baby Belle can sit well without support.
 At 9th month Baby Belle can stand up with support and when about to fall she
tries to protect herself by extending her arms and spreading her fingers to
protect her head.
 At 10th month Baby Belle has some problem behavior.
 At 11th month Baby Belle developed into a toddler.

VI. DRUG STUDY
VII. Nursing Care Plan
Defining Nursing Outcome Intervention Rationale Evaluation
Characteristics Diagnosis
Subjective: Risk for injury: Short term: Independent: After each nursing
Baby Belle could risk factor needs After 1 hour of nursing Perform thorough assessments regarding Failure to accurately interventions the mother
already take few for care taking. interventions the safety issues when planning for client’s assess and intervene can will report to injuries
steps and crawl mother will be able to care. place client at risk. and also sign of relief.
(Reference:
up the stairs. Ladwig-Nursing
identify measures to She is able to know
reduce risk of injury. Ascertain knowledge of safety needs/injury different measures on
Diagnosis Handbook:
prevention and motivation. To prevent injury in
an Evidence based
home, community and how to reduce the risk of
Guide to planning Care Long term: incidents and injury.
11th edition The mother will be Assess coping abilities and personality work setting.
Postpartum, Newborn, style.
Normal page 86) able to report no
injuries and relieved May result in
from anxiety caused carelessness/increase
by baby’s Assess muscle strength and motor risk-taking without
development. coordination. consideration of
consequences.
Advise patient to remove sharp objects
away from the reach of the baby. To identify risk for falls.
Ensure that pathway is unobstructed and

floor is not too slippery.
To reduce the risk of
Monitor environment for potentially unsafe injuries to the client.
conditions and modify as needed.
Develop plan for care with family to meet

individual needs and reduce risk of injuries. To maintain safety of the
client.
To modify environment
into a safe place for the
baby.
To lessen the risk for

injury, safe environment
and promote client’s
comfort
HEALTH TEACHING
NUTRITION
1. Eat a well-balanced diet that is high in protein (meat, fish, legumes), fiber
(fruits, vegetables, whole grains), calcium (milk, yogurt, cheese, green leafy
vegetables) and fluids.
2. Recommend the patient top take adequate fluids, it is necessary for tissue
repair, healing, breastfeeding and general health
3. Refrain from any weight-reducing diets until after your postpartum checkup.
4. continue to take your prenatal vitamins.
BREAST FEEDING
5. Encourage breastfeeding frequently, day and night, and advise the mother to
allow the baby to feed for as long as he/she wants.
6. Reassure the parents that there is no need to give the baby any other drink or
food, not even water – breast milk has all a baby needs
7. Help the mother whenever she needs assistance and especially if she is a first
time or adolescent mother or a mother with other special needs.
8. Explain to the mother she should let the baby finish the first breast and come
off on its own before offering the second breast.
Questions:
1. What is a primitive reflex?
Primitive reflexes are involuntary motor responses originating in the brainstem present after birth in
early child development that facilitate survival. Several reflexes are important in the assessment of
newborns and young infants. These central nervous system motor responses are eventually inhibited by
4 to 6 months of age as the brain matures and replaces them with voluntary motor activities but may
return with the presence of neurological disease.
2. What are the primitive reflexes?
● Rooting reflex
-Mouth or cheek touched and infant turns head to that side
-Present at birth
Disappears around 3-4 months, but can be seen in sleeping infants until 7-8 months
● Sucking reflex
-Sucking begins when nipple placed in infant’s mouth, or examiner’s finger is placed at the
commissure of infant’s mouth
-Present at birth
-Disappears around 3-4 months, but can seen in sleeping infants until 7-8 months
● Moro or Startle reflex
-Infant is surprised/startled and the four limbs abduct and extend then abduct and flex. Infants
will also extend the spine initially and then close the fingers. Startle is elicited by striking surface
on either side of infant (original method by Moro), loud noise, or lifting the infant head and
shoulders above body and allowing the head to drop (of course with support).
-Present at birth, can be seen as early as 25 weeks gestation and is elicited by 30 weeks
-Disappears around 3-4 months but normal up until 6 months
● Stepping reflex
-Infant held upright and slightly forward with feet on surface will raise legs and look like
stepping or walking
-Present at birth
-Disappears around 2-3 months
● Placing reflex
-Infant held upright and dorsum of foot is touched by the edge of table. Infant lifts foot and
places it on the table
-Present at birth
-Disappears by first year
● Palmar grasp reflex
-Examiner’s finger placed in infant palm at base of fingers and press applied. Infants finger’s flex
to grasp the examiner’s finger. There are 2 phases – the catching of the examiner’s finger and
the holding of the examiner’s finger
-Present at birth, can be seen as early as 28 weeks gestation
-Disappears by 6 months
● Plantar grasp reflex
-Examiner’s finger placed in infant sole at base of toes and press applied. Infants toes flex to curl
around the examiner’s finger. There are 2 phases – the catching of the examiner’s finger and the
holding of the examiner’s ffinger.
-Present at birth
-Disappears by 15 months
● Babinski reflex
-Pressure applied to sole of foot along the lateral edge starting with the heel and curving around
to the base of big toe. Normal or negative is to have downward curving of the toes or no
movement. A positive Babinski reflex, that of the toes curving upward, is normal in infants
because of their immature neurological sstatus.
-Present at birth
-Disappears by 1-2 years
● Landau reflex
-Infant is placed face down on a surface or in lateral suspension and the infant lifts its head and
extends its legs
-Present starting at 3 months
-Disappears by 2 years
● Blinking or Glabella reflex
-Glabella is lightly tapped and both eyes blink. Habituation occurs with multiple attempts of the
tapping
-Present at birth
-Disappears by 1 year
● Asymmetric tonic neck reflex
-With infant in supine position, head is gently rotated to one side. Extension of the lateral arm
and flexion of the contralateral arm occur. This position is sometimes called the Fencer’s
pposition.
-Present around birth
-Disappears by about 6 months
● Symmetric tonic neck reflex
-With infant in supine position, head is gently flexed. Extension of the head, arms and legs
occurs
-Present around 2 months
-Disappears about 6-9 months
● Parachute reflex
-Infant prone in air and brought to the surface with the head down. Infant reacts as if trying to
cushion a fall with their arms abducted and extended and fingers sspread.-
-Present around 8-9 months
-Present throughout life
● Gallant reflex
-Infant head prone in air and one side of lower spine lightly stroked. Infant’s spine contracts on
that side causing the hips to move laterally on the side stroked (e.g. spine incurves).
-Present at birth
-Disappears around 2-4 months, up to 6 months
● Perez reflex
-Infant head prone in air and both sides of lower spine lightly stroked. Infant extends hips and
llegs.
-Present at birth
-Disappears around 2-4 months
3. Why do primitive reflexes disappear? Explain briefly.
Primitive reflexes are reflex actions originating in the central nervous system that are exhibited by
normal infants, but not neurologically intact adults, in response to particular stimuli. These reflexes are
suppressed by the development of the frontal lobes as a child transitions normally into child
development.
The reflex disappears in normal infants by approximately 6 weeks of age. When the normal infant is
maintained in ventral suspension by the examiner's hand supporting the infant's abdomen, the head,
spine, and legs extend.
4. What is a parachute reflex?
PARACHUTE REFLEX. This reflex occurs in slightly older infants when the child is held upright and the
baby's body is rotated quickly to face forward (as in falling). The baby will extend his arms forward as if
to break a fall, even though this reflex appears long before the baby walks. - When a baby senses that
they're about to fall, their arms reflexively extend to break the fall — just the way you stick out your
arms when you trip and anticipate a fall.
5. What are the 5 reflexes that persist throughout life?
● Blinking reflex: blinking the eyes when they are touched or when a sudden bright light
appears
● Cough reflex: coughing when the airway is stimulated
● Gag reflex: gagging when the throat or back of the mouth is stimulated
● Sneeze reflex: sneezing when the nasal passages are irritated
● Yawn reflex: yawning when the body needs more oxygen
6. What is a developmental milestone?

Developmental milestones are a set of functional skills or age-specific tasks that most children can do at
a certain age range. Your pediatrician uses milestones to help check how your child is
developing. Although each milestone has an age level, the actual age when a normally developing child
reaches that milestone can vary quite a bit. Every child is unique.
7. Why is it important to know the different developmental milestones?

Developmental milestones offer important clues about a child's developmental health. Reaching
milestones at the typical ages shows a child is developing as expected. Reaching milestones much earlier
means a child may be advanced compared with his or her peers of the same age. - Reaching milestones
at the typical ages shows a child is developing as expected. Reaching milestones much earlier means a
child may be advanced compared with his or her peers of the same age.
Not reaching milestones or reaching them much later than children the same age can be the earliest
indication that a child may have a developmental delay.
8. What is play and why is it important?

Play is essential to development because it contributes to the cognitive, physical, social, and emotional
well-being of children and youth. Play also offers an ideal opportunity for parents to engage fully with
their children. Despite the benefits derived from play for both children and parents, time for free play
has been markedly reduced for some children
Play allows children to use their creativity while developing their imagination, dexterity, and physical,
cognitive, and emotional strength. Play is important to healthy brain development. It is through play
that children at a very early age engage and interact in the world around them.
Play is so important to optimal child development that it has been recognized by the United Nations
High Commission for Human Rights as a right of every child
9. Why is talking and communicating to an infant important?

It may seem strange to talk, sing or read to a baby when they can’t understand what’s being said, but it’s
an important part of a baby’s development. When adults spend time with babies singing, talking or
reading, babies are learning the sounds in the language being used. They also learn the rhythm and flow
of language. Eventually, babies will start to babble and practice sounds. They can also learn that certain
sounds or words can be associated with objects. Besides learning language, spending time with babies
can make them feel secure and loved
By talking, singing and reading to your baby, you will be helping them learn the ins and outs of language
and begin laying a strong foundation for later tasks like talking, reading and writing.
10. Is baby Belle’s developmental milestone within normal? What does it indicate if it is not within
normal?
Baby Belle's developmental milestone is normal. She can crawl, sit with support and without support at
7th month. She is more playful and puts everything on her mouth. She can also stand up with support.
She also waver "bye bye" to her mother. She can speak simple worlds like " mama" and "dada" at time.
Not within normal

1. Delayed rolling over, sitting or walking
2. Poor head and neck control
3. Speech delay
4. Muscle stiffness
5. Clumsiness
6. Body Posture that is limp

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ILOILO DOCTORS’ COLLEGE

NCM 107 RLE

Mae Arra G. Lecobu-an

Mrs. Dolly Mia S. Argel

III. NURSING HEALTH HISTORY

C. HISTORY OF PRESENT ILLNESS

F. LIFESTYLE AND HEALTH PRACTICES

IV. PHYSICAL EXAMINATION

V. ANATOMY AND PHYSIOLOGY

VI. Diagnostic and Laboratory

ILOILO DOCTORS’ COLLEGE

NCM 107 RLE

Mrs. Dolly Mia S. Argel

III. NURSING HEALTH HISTORY

Nervous System Respiratory System

Immune System Cardiovascular System

Mammary System Hematological System

Digestive Tract Renal System

 Increase size and cellularity, expansion of splenic red pulp

 Increase size (pelvic and calyceal systems dilation)

 Increase pancreas vascularization and size

 Expandability of adipose tissue: adipocyte diameter and volume

Changes in Mammary Tissue

Changes in the Dermatological System

 Engorgement and venous prominence.

 Becomes softer and swollen in pregnancy (doesn’t change in size only

-The vaginal mucosa becomes thickness, the vaginal muscle hypertrophins.

VI. DIAGNOSTIC AND LABORATORY

VII. DRUG STUDY

ASSESSMENT NURSING OUTCOME INTERVENTION RATIONALE EVALUATION

NCM 107 RLE

Mae Arra G. Lecobu-an

Mrs. Dolly Mia S. Argel

III. Nursing Health History

IV. Physical Examination

V. ANATOMY AND PHYSIOLOGY

VI. DIAGNOSTIC AND LABORATORY

Defining Characteristics Diagnosis Outcome Intervention Rationale Evaluation

7. State and discuss psychological behavior presented in the scenario as

15. Base on this finding formulate 2 nursing diagnosis

NCM 107 RLE

Mae Arra G. Lecobu-an

Mrs. Dolly Mia S. Argel

III. Nursing Health History

IV. ANATOMY AND PHYSIOLOGY

VIII. Nursing Care Plan

The compressions help prevent bleeding and if the muscles of

Provide comfort measures such as

Relief of pain and muscle spasms, increases blood stimulation

Perform perilite exposure to the

IVF od D5LRS 1L to run at 30

Cleaning the site of the wound after using the bathroom

NCM 107 RLE

Mae Arra G. Lecobu-an

Mrs. Dolly Mia S. Argel

III. Nursing Health History

IV. Physical Examination

V. Anatomy and Physiology

VI. Diagnostic and Laboratory

VII. Drug Study

VIII. Nursing Care Plan

In order to keep the breast

Unhealthy and exhausted mother