Group3 MCN Gcs Final Paper

Saint Mary’s University
School of Health and Natural Sciences

BAYOMBONG, NUEVA VIZCAYA 3700
Nursing Department
A Clinical Case Study Presented to the faculty of the

Department of Nursing
In Partial Fulfilment
of the requirement of the subject
NCM 107 RLE (OB-Ward)
NORMAL SPONTANEOUS DELIVERY
Submitted by:
Guillen, Marc Rainer C.
Omli, Jay Jordan P.
Pascua, Marc Anthony M.
Uybaan, Mark A.
De Leon, Allysa Audrey M.
Guillermo, Angela S.
Guinid, Jamie Angela E.
Macario, Remelyn B.
Magday, Nadhine L.
Mangibin, Jenlexy A.
Manuel, Erica Joy B.
Mayam-o, Edzyl Joeani Kate
Merto, Kristine Joy S.
Millano, Mmyra Zsakira C.
Samayo, Tania Rose B.
Sison, Kaye Ashley B.
Submitted to:
Mrs. Marie Curie O. de Pona, RN, RM, RSW, LPT
May, 2021
NCM 107_Group Case Study Section C-Group 3 1

TABLE OF CONTENTS
i. Acknowledgement 3
I. 3P’s 4
Personal Data 4
Past Health History 4
Present Health History 5
II. Brief Description of the Patient’s Illness 6
Pregnancy 7
Labor and Delivery 16
Menstruation 23
III. Anatomy & Physiology 32
IV. Physiology (diagram) 34
V. Laboratory Results and Diagnostic Studies 38
VI. Physical Assessment and Its Pathophysiological Basis 47
Psychosocial 47
Elimination 50
Rest and Activity 51
Safe Environment 54
Oxygenation 55
Nutrition 56
Post-partum Assessment 57
VII. Drug Analysis 57
VIII. Course in the Ward 69
IX. Nursing Care Plan 72
X. References 79
XI. Group Assignments 80

ACKNOWLEDGEMENT
The completion of this undertaking could not have been possible without the participation and
assistance of so many people whose names may not all been enumerated. Their contributions
are sincerely appreciated and gratefully acknowledged. However, the group
would like to express their deep appreciation and indebtedness particularly to our Clinical
Instructor Mrs. Marie Curie O. de Pona for her endless support, kind and understanding
spirit in the conduct of this case presentation. To all relatives, friends and others who in one way
or another shared their support, either morally, financially and physically, thank you. Above all,
to the Great Almighty, the author of knowledge and wisdom, for his countless love. We thank
you.
BSN 2-C Group 3

Part 1: 3 Ps
PERSONAL PROFILE
Name of Patient Loraine Esteban Valdez
Age 28 years old
Marital Status Married
Educational Background College Graduate (BS Elementary Education)
Religion Roman Catholic
Address #88 Ballesteros St., Brgy. Osmenia, Solano, Nueva Vizcaya
Contact Number 09156764956
Occupation Elementary Teacher
Employer St. Jude Montessori
Place of Work Brgy. Quirino, Solano, Nueva Vizcaya
Medical Insurance Philhealth
Name of Spouse Comrad S. Valdez
Occupation Elementary Teacher
Educational Attainment BS Elementary Education
Employer St. Jude Montessori
Place of Work Brgy. Quirino, Solano, Nueva Vizcaya
Admitting Diagnosis G1P0 (0-0-0-0)

Expected Date of November 28, 2020
Confinement
Date of Admission November 30, 2020
Name of Physician Dr. Jose Miranda
Name of Hospital Salubris Medical Center
HISTORY OF CONDITION
PRE-PREGNANCY
Patient had her menarche at 12 years of age. Patient has been very healthy
since she was in her 20s. Her only noted illness was flu which she managed on her own
with herbs. There were no previous hospitalizations. She has always relied on natural
means of being healthy and medicating common ailments.
PREGNANCY
Lorraine Valdez, 28 years of age, married, came to the clinic on March 23, 2020 for
her first prenatal check-up. Her last menstrual period was February 21, 2020. She tested
positive recently on the pregnancy test kit she purchased from a local drugstore. At this
time, she would really like to know if she is indeed pregnant as her friend said that
sometimes women get “false positive” results.
Lorraine was attended by Dr. Jose Miranda, assisted by Nurse Remy Mendez. A
transvaginal UTZ was ordered to determine if she is really pregnant. The results showed
that she is indeed, and is at her 4 th week gestation. This is her first pregnancy and no

other previous ones. She was also ordered to undergo CBC and urinalysis.
Nurse Remy made an assessment interview with Lorraine. Patient said that she
was bothered by nausea and vomiting which she has been experiencing for a week now.
She vomits every morning around half a cup of clear fluid and some streaks of digested
food. She also feels nauseated when she smells strong odors like her husband’s cologne
and some food. Likewise, when she misses a meal, she experiences the same. She
easily gets tired. She also has, been craving for sour foods even at night and she fears
that she might have excessive acids already which she thinks may cause ulcer, because
she prefers sour foods already, instead of her regular meal. Lorraine expressed that she
feels nervous about the pregnancy because it is her first and she does not have any idea
what to expect. She is worried about her work as an elementary teacher that the
pregnancy will stop her from working, which is her source of income. She also thinks she
has been very emotional, sometimes easily irritated with everyone around especially her
husband. She thinks that her husband is not totally caring for her at this time and seeks
more attention.
Lorraine is also a vegan which means she does not eat any form of protein from
animal sources. She is very strict with her diet which keeps her on tip-top shape and
keeps her weight within her BMI. She is now worried about gaining weight due to the
pregnancy. Lorraine also noticed that her bowel is harder than usual which she never
had since she is a vegan. She is wondering why she also gets tired easily when she was
always on the go before the pregnancy. Patient’s everyday living or physical activity was
working at school and doing household chores.
After assessment, Dr. Miranda attended to her with the data given by Nurse Remy.
She was given a prescription of Anti-emetic and Metoclopramide, which she can take
when she becomes very nauseated and frequently vomits. She was also prescribed 400
mcg iron with folic acid, and organic multivitamins. She was advised stop being a vegan
while on pregnancy and can resume after she gave birth. She may also continue being a
teacher but make sure not to exhaust herself too much and frequent rest is a must.
Upon leaving the doctor’s room, Lorraine went to Nurse Remy to ask all her
questions about pregnancy. She asked what are the things she should do and not do.
Nurse Remy then proceeds to educate her on all matters to manage her pregnancy such
as management of discomforts, when to report danger signs, diet and nutrition and lastly,
other changes that she should expect in pregnancy. She was scheduled to come back
for her monthly prenatal check-up on April 23, 2020.
Throughout the pregnancy, patient went for her regular monthly prenatal check-up.
In her second trimester she was ordered to undergo glucose testing, urine test, and
ultrasound to make sure her pregnancy is safe and healthy as well as to know the gender
of her child. In her third trimester, she was ordered to undergo again for urine test. 2
weeks prior to LMP, Leopold’s maneuver was done by the doctor. Fundus is palpable
below the xyphoid process, fetus is in LOA and cephalic presentation. No abnormalities
were noted throughout the pregnancy. Her usual iron and folic acid supplements were
given. No other multivitamins were recommended.
LABOR AND DELIVERY
Patient Lorraine Valdez was admitted on November 30, 2020, at 2 pm in labor. She
began having labor contractions at 4am. Upon assessment, she was fully effaced at 6 cm

cervical dilatation, with strong contractions occurring every 4 minutes. Her BP was
110/80. Upon palpation of her abdomen, her contractions originated from the fundus,
bladder was not distended. The child is in LOA, descent is +2, moulding- 0, and FHT 150
bpm. She looked very uneasy, tired and almost cried due to pain at every contraction
with difficulty relaxing and almost panting. She cannot maintain a single position in bed
and almost fell in one occasion. Although regularly had her monthly prenatal check-up,
she failed to attend any birthing classes and this was her first delivery. She has also not
eaten since the start of her labor around 4 am. She had only drink sips of water. The
nurse on duty at the ER called her physician, Dr. Jose Miranda, and was ordered to carry
out the following: IVF- #1 D5LR 1 liter started @ 20 gtts/min, therapeutics such as
Midazolam 1-2 mg IV every 2 hours PRN moderate pain, Promethazine 10 mg IV or IM
every 4 hours PRN nausea and vomiting, Hydroxyzine (Vistaril) 50 mg Intramuscular
ONLY x 1 dose PRN for Anxiety, Lidocaine HCI 5cc, Cefuroxime 500mg I tablet TID
(post). Patient was also ordered to undergo CBC, blood typing, urinalysis and Hepatitis B
Surface Antigen (HBsAG). Labor watch TPR q 4⁰ and NPO should be monitored.
PART 2: DESCRIPTION OF PATIENT’S CONDITION
Part 2 presents the following:

1. Pregnancy 4. Labor and Delivery
2. Fetal Development 5. Menstruation
3. Fetal Circulation
PREGNANCY
Pregnancy is the term used to describe the period in which a fetus develops
inside a woman's womb or uterus. Pregnancy usually lasts about 40 weeks, or just over
9 months, as measured from the last menstrual period to delivery. Health care providers
refer to three segments of pregnancy, called trimester.
Pregnancy commences when a sperm fertilizes a mature egg after its release
from the ovary during ovulation. The fertilized egg then travels down into the uterus,
where implantation occurs. A successful implantation results in pregnancy.
SIGNS OF PREGNANCY
Signs of pregnancy are categorized into three: 1) Presumptive signs which are
subjective signs which the mother reports indicating possibility of pregnancy, 2)
Probable signs which are objective observations of the examiner indicating most
likelihood of pregnancy, and 3) Positive signs which confirms pregnancy.
Trimester Presumptive Probable Positive

First  Amenorrhea  Positive pregnancy test Visualization of fetal
 morning sickness (presence of Hcg in structures thru vaginal
 nausea & vomiting urine) UTZ
 breast tenderness  Chadwick’s Sign Fetal heart sound:
 urinary frequency  Hegar’s Sign  6 wks-vaginal UTZ
 fatigue  Goodel’s Sign  9-10 wks- Doppler

Second Quickening  Braxton Hicks  Fetal movement by
Primi- 20-22 weeks Contractions examiner- Leopold’s
Multi-16 weeks  Skin discolorations Maneuver
(Melasma, Chloasma,  Fetal Health Sounds-
Linea Nigra) Stethoscope (20 wks)
 Ballotement
Third Quickening  Braxton Hicks  Fetal movement by
Urinary Frequency Contractions examiner- Leopold’s
Breast tenderness  Ballotement Maneuver
Fatigue  Fetal Health Sounds-
Stethoscope
The patient reported the following signs of pregnancy:

Presumptive Signs she reported in the first month of pregnancy: Amenorrhea,
nausea, fatigue, constipation, food cravings, mood swings, breast tenderness.
Probable Signs:
first trimester includes: positive result in pregnancy test kit.
2nd to 3rd trimester- Changes in skin pigmentation: Linea nigra, Chloasma,
Quickening
3rd trimester: Braxton Hicks Contractions
Positive: first trimester: visualization of fetus (ultrasound), quickening (18-20
weeks)
THE STAGES OF PREGNANCY
First Trimester of the mother (week 1- week 12)
During the first trimester of the mother, the body undergoes many changes.
Hormonal changes affect almost every organ system the body. These changes can
trigger symptoms even in the very first weeks of pregnancy. The period stopping is a
clear sign that the mother is pregnant. Other changes may include:
 Extreme tiredness
 Tender, swollen breasts. Your nipples might also stick out.
 Upset stomach with or without throwing up (morning sickness)
 Cravings or distaste for certain foods
 Mood swings
 Constipation (trouble having bowel movements)
 Need to pass urine more often
 Headache
 Heartburn
 Weight gain or loss
As the body changes, the mother might need to make changes in her daily routine, such as
going to bed earlier or eating frequent, small meals. Fortunately, most of these discomforts will

go away as the pregnancy progresses. And some women might not feel any discomfort at all! If
they have been pregnant before, the mother might feel differently this time around.
Second Trimester of the mother (week 13- week 28)
Most women find the second trimester of pregnancy easier than the first. But it is
just as important to stay informed about the pregnancy during these months.
A mother might notice that symptoms like nausea and fatigue are going away.
But other new, more noticeable changes to the body are now happening. The abdomen
will expand as the baby continues to grow. And before this trimester is over, she will feel
the baby is beginning to move!
As the body changes to make room for the growing baby, they may have:
 Body aches, such as back, abdomen, groin, or thigh pain

 Stretch marks on your abdomen, breasts, thighs, or buttocks
 Darkening of the skin around your nipples
 A line on the skin running from belly button to pubic hairline
 Patches of darker skin, usually over the cheeks, forehead, nose, or upper lip. Patches
often match on both sides of the face. This is sometimes called the mask of pregnancy.
 Numb or tingling hands, called carpal tunnel syndrome
 Itching on the abdomen, palms, and soles of the feet. (Call your doctor if you have
nausea, loss of appetite, vomiting, jaundice or fatigue combined with itching. These can
be signs of a serious liver problem.)
 Swelling of the ankles, fingers, and face. (If you notice any sudden or extreme swelling
or if you gain a lot of weight really quickly, call your doctor right away. This could be a
sign of preeclampsia.)
Third trimester of the Mother (week20- week 40)
The mother is in the home stretch! Some of the same discomforts they had in the
second trimester will continue. Plus, many women find breathing difficult and notice they have to
go to the bathroom even more often. This is because the baby is getting bigger and it is putting
more pressure on your organs. Don't worry, the baby is fine and these problems will lessen
once they give birth.
Some new body changes they might notice in the third trimester include:
 Shortness of breath
 Heartburn
 Swelling of the ankles, fingers, and face. (If you notice any sudden or extreme swelling
or if you gain a lot of weight really quickly, call your doctor right away. This could be a
sign of preeclampsia.)
 Hemorrhoids
 Tender breasts, which may leak a watery pre-milk called colostrum
 Your belly button may stick out
 Trouble sleeping

 The baby "dropping", or moving lower in your abdomen
 Contractions, which can be a sign of real or false labor
As the due date, the cervix becomes thinner and softer (called effacing). This is a
normal, natural process that helps the birth canal (vagina) to open during the birthing process.
The doctor will check the progress with a vaginal exam as near as the due date. the final
countdown has begun.
DIAGNOSTIC PROCEDURE FOR CONFIRMATION OF PREGNANCY
Urine Test
- A human chorionic gonadotropin (HCG) urine test is a pregnancy test. A pregnant
woman’s placenta produces HCG, also called the pregnancy hormone. If you’re
pregnant, the test can usually detect this hormone in your urine about a day after your
first missed period. During the first 8 to 10 weeks of pregnancy, HCG levels normally
increase very rapidly. These levels reach their peak at about the 10th week of
pregnancy, and then they gradually decline until delivery.
Ultrasound
- Ultrasound is used during pregnancy to check the baby's development, the presence of
a multiple pregnancy and to help pick up any abnormalities. The advantages of the test
are that it's non-invasive, painless and safe for both mother and unborn baby.
Blood test
- Blood tests are done in a doctor's office. They can pick up HCG earlier in a pregnancy
than urine tests can. Blood tests can tell if you are pregnant about six to eight days after
you ovulate. Doctors use two types of blood tests to check for pregnancy:
Leopold’s Maneuver
- are used to palpate the gravid uterus systematically. This method of abdominal palpation
is of low cost, easy to perform, and non-invasive. It is used to determine the position,
presentation, and engagement of the fetus in utero. This activity describes the four
Leopold maneuvers and explains the method of systematic abdominal palpation used to
assess fetal presentation and position in the third trimester of pregnancy.
METHODS OF DELIVERY
Normal Spontaneous Delivery
- A spontaneous vaginal delivery is a vaginal delivery that happens on its own, without
requiring doctors to use tools to help pull the baby out. This occurs after a pregnant
woman goes through labor. Labor opens, or dilates, her cervix to at least 10 centimeters.
Vaginal delivery is the method of childbirth most health experts recommend for women
whose babies have reached full term.
With the following conditions avoid spontaneous vaginal deliveries:

 complete placenta previa, or when a baby’s placenta fully covers its mother’s
cervix
 herpes virus with active lesions
 untreated HIV infection
 more than one or two previous cesarean deliveries or uterine surgeries
Other methods of delivery are the following:
Cesarean Section
- A cesarean section, also called a c-section, is a surgical procedure performed if a
vaginal delivery is not possible. During this procedure, the baby is delivered through
surgical incisions made in the abdomen and the uterus.
- A cesarean delivery might be planned advance if a medical reason calls for it, or it might
be unplanned and take place during your labor if certain problems arise.
You might need to have a planned cesarean delivery if any of the following conditions
exist:
1. Cephalopelvic disproportion (CPD)---is a term that means that the baby’s head or
body is too large to pass safely through the mother’s pelvis, or the mother’s
pelvis is too small to deliver a normal-sized baby.
2. Previous cesarean birth---Although it is possible to have a vaginal birth after a
previous cesarean, it is not an option for all women. Factors that can affect
whether a cesarean is needed include the type of uterine incision used in the
previous cesarean and the risk of rupturing the uterus with a vaginal birth.
3. Multiple pregnancy---Although twins can often be delivered vaginally, two or
more babies might require a cesarean delivery.
4. Placenta previa---In this condition, the placenta is attached too low in the uterine
wall and blocks the baby’s exit through the cervix.
5. Transverse lie---The baby is in a horizontal, or sideways, position in the uterus. If
your doctor determines that the baby cannot be turned through abdominal
manipulation, you will need to have a cesarean delivery.
6. Breech presentation---In a breech presentation, or breech birth, the baby is
positioned to deliver feet or bottom first. If your doctor determines that the baby
cannot be turned through abdominal manipulation, you will need to have a
cesarean delivery.
An unplanned cesarean delivery might be needed if any of the following conditions arise
during your labor:
 Failure of labor to progress---In this condition, the cervix begins to dilate and
stops before the woman is fully dilated, or the baby stops moving down the birth
canal.
 Cord compression---The umbilical cord is looped around the baby’s neck or
body, or caught between the baby’s head and the mother’s pelvis, compressing
the cord.

 Prolapsed cord---The umbilical cord comes out of the cervix before the baby
does.
 Abruptio placentae---In rare occurrence the placenta separates from the wall of
the uterus before the baby is born.
Forceps Delivery
Forceps look like two large spoons that the doctor inserts into the vagina and around the
baby’s head during a forceps delivery. The forceps are put into place and, the doctor
uses them to gently deliver the baby’s head through the vagina. The rest of the baby is
delivered normally.
Vacuums Extraction
A vacuum extractor looks like a small suction cup that is placed on the baby’s head to
help deliver the baby. A vacuum is created using a pump, and the baby is pulled down
the birth canal with the instrument and with the help of the mother’s contractions. The
pump can often leave a bruise on the baby’s head, which typically resolves over the first
48 hours.

SAFE MOTHERHOOD SUPERVISORY FLOWCHART
PRENATAL ACTIVITIES
(World Health Organization Protocol)
First Trimester
Second Trimester Third Trimester
4-16 weeks
17-28 weeks 29-36weeks 37-40weeks
 Compute AOG, EDC  Validate AOG and EDC,  Validate AOG and EDC, update  Validate AOG and
Prepare Home based update HBMR HBMR EDC, update
maternal record (HBMR) HBMR
 Physical Examination and  Physical examination, fundi  Physical examination, fundi

Vital Signs height, quickening, vital height, quickening, vital signs,
signs fetal heart tone
 Screening for medical  Screen danger signs:  Screen danger signs:

problems and dangers signs  Pallor  Pallor
 Bleeding  Bleeding
 Abdominal pain  Abdominal pain
 Screen for:  Screen for:
 Preeclampsia  Painless vaginal bleeding
 GDM  Preterm labor
 Urinalysis and random blood  Headaches
sugar  Puffiness
 Provide 1st aid measure  Edema
 Provide routine care:  Provide routine care:  Low dose of Vit. A supplement  Low dose of Vit. A
 Iron supplements  Iron supplements  Tetanus toxoid immunization supplement
 Low dose Vit. A  Low dose Vit. A  Repeat hemoglobin, protein in  Tetanus toxoid
 Tetanus toxoid  Tetanus toxoid urine and random blood sugar immunization
 Malaria Prophylaxis in  Repeat CBC/hgb,
endemic areas CNC,

urinalysis blood typing
First Trimester
Second Trimester Third Trimester
4-16 weeks
17-28 weeks 29-36weeks 37-40weeks
 Provide counseling:  Provide counseling:  Provide counseling:  Provide counseling:
 Nutrition and hygiene  Nutrition and hygiene  Nutrition and hygiene  Nutrition and
 Discomfort in pregnancy  Discomfort in pregnancy  Discomforts in pregnancy hygiene
 Do’s and don’ts in pregnancy  Do’s and don’ts in pregnancy  Do’s and don’ts in pregnancy  Discomfort in
 Fertility awareness and FP  Fertility awareness and FP  Warning signs of pregnancy pregnancy
 Breastfeeding, child care and  Breastfeeding, child care and  Fertility awareness and FP  Do’s and don’ts in
family care family care  Breastfeeding, child care and pregnancy
 Delivery emergency  Delivery and emergency family care  Warning signs of
preparations preparations  Delivery and emergency pregnancy
 Schedule 2nd prenatal visit preparations  Fertility awareness
and update HMBR  Schedule 3rd prenatal visit  Personal hygiene after delivery and FP
and update HBMR  Schedule 4th prenatal visit  Breastfeeding, child
preferably 1-2 weeks before care and family
delivery care
 Delivery and
emergency
preparations
 Personal hygiene
after

LABOR AND DELIVERY
Labor (Childbirth)
 An involuntary process whereby contents of the uterus are expelled.

True Labor False Labor
 Contractions are regular  Irregular contractions
 Increased intensity  No increase in intensity
 Pain- Begins at the lower back  Pain- Confined to abdomen
radiate to abdomen  Pain- Relieved by walking
 Pain- Intensified by walking  No cervical changes
 Cervical effacement and dilation
*Major sign of true labor
Four Ps of Labor:
1. Passage- pelvis
2. Passenger- fetus
a. Attitude- relationship of fetal body towards each other. Norma: full flexed, abnormal:
extended
b. Fetal presentation
a. Cephalic- occiput, mentum, brow
b. Breech- fetal sacrum if presented. Risk for cord prolapse, meconium staining
and fractures.
c. Shoulder- high risk for fractures.
c. Station- extent of fetal engagement. Negative- above the ischial spine (floating),
Zero- at the level of the ischial spine (engaged), Positive- engaged below the ischial
spine.

d. Fetal lie- relationship of the long axis of the fetus to long axis of the mother
e. Position- relationship of presenting part to the four quadrants of the mother’s

abdomen.
f.

3. Powers- uterine contractions, must originate from the fundus.
4. Psych- preparedness of the mother
THE STAGES OF LABOR

THE STAGES OF LABOR
1. First stage of labor

(from first true sign of labor-true contractions & cervical dilation until full dilation)
During the first stage of labor, contractions help your cervix to thin and begin to
open. This is called effacement and dilation. As your cervix dilates, your health care
provider will measure the opening in centimeters. One centimeter is a little less than half
an inch. During this stage, your cervix will widen to about 10 centimeters. This first stage
of labor usually lasts about 12 to 13 hours for a first baby, and 7 to 8 hours for a second
child.
Phases in The First Stage of Labor

TYPE OF DURATION FREQUENCY NURSING CARE
CONTRACTION
LATENT Contractions mild 20- 40 seconds 6 hours in Nullipara  Chest breathing
(0-3 cm) and short 4-5 hour in Multipara  Ambulation should be
6 hrs for primi encouraged
4.5 hrs-multi  Support person
 Encourage to avoid
every 2-3 hours, full bladder
inhibits contractions
ACTIVE Stronger 40- 60 3 hours in Nullipara  Medications should be
(4-7 cm) contractions seconds 2 hours in Multipara readied
3 hrs- primi every, 3-5  Assess vital signs
2 hrs-multi minutes
 Abdominal Chest
Breathing
 Oral care
TRANSITION Very strong 60- 90  Tired, loss of sense of

(8-10 cm) contractions seconds control
 Inform the progress of
labor
 Restless, support her
with breathing technique

2. Second stage of labor
(From full cervical dilatation to birth of the fetus)
The baby moves through the birth canal

The second stage of labor begins when the cervix is completely dilated (open), and ends
with the birth of your baby. Contractions push the baby down the birth canal, and you
may feel intense pressure, similar to an urge to have a bowel movement.
Your health care provider may ask you to push with each contraction. The contractions
continue to be strong, but they may spread out a bit and give you time to rest. The length
of the second stage depends on whether or not you've given birth before and how many
times, and the position and size of the baby.
The intensity at the end of the first stage of labor will continue in this pushing phase. You
may be irritable during a contraction and alternate between wanting to be touched and
talked to, and wanting to be left alone. It isn't unusual for a woman to grunt or moan
when the contractions reach their peak.
Mechanisms of Labor:
1. Engagement & Descent- descent of the fetus into the pelvic cavity onto the pelvic floor.
2. Flexion- the chin of the child touches the chest to present the occiput, the smallest
diameter of fetal head.
3. Internal Rotation- turning of the fetus into the curved pelvic cavity to deliver the fetal
head.
4. Extension- fetal head exits the pelvic floor to vagina.
5. External rotation- fetus rotates to deliver the shoulders.
6. Expulsion- complete delivery of the child.

Nursing Intervention:
 Prepare the patient for delivery
 Assist the physician in episiotomy and episiorrhaphy
 Perineal preparation using 7 and
the inverted 7 technique
 Assist the patient in breathing techniques
 Bring a multiparous patient to the
Delivery Room at 7-8 Cm
3. Third stage of labor

(Birth of the infant to placental expulsion)
- After the birth of the baby, the uterus continues to contract to push out the placenta
(afterbirth). The placenta usually delivers about 5 to 15 minutes after the baby arrives.
Placental Separation
 Signs of placental separation
 Appearance of the placenta at the vaginal opening
 Sudden gush of blood
 Uterus becomes firm and globular- Calkin’s Sign
 Uterus rises in the abdomen
 Lengthening of the cord
Types of Placental Separation:

A. Schultz B. Duncan C. Placental Expulsion
 Separation of the  Peripheral separation to  Delivery of placenta by bearing down

placenta from the the central effort
central to the  Dirty  DELIVERY OF PLACENTA BY
periphery  Bloody BRANT ANDREW’S MANUEVER:
 Silent/ shiny downward, sideways gentle traction
 Minimal blood of the cord
 DELIVERY BY CREDE’S
MANEUVER: gentle pressure on the
uterine fundus
Nursing Interventions:
 Observe lochia for color and amount
 Offer fluids as indicated
 Palpate fundus immediately after delivery of placenta; massage gently if not firm
 Palpate fundus at least every 15 minutes for first 1-2 hours
 Inspect Perineum
Assist with maternal hygiene as needed:
 Clean gown
 Warm blanket
 Clean perineal pads
 Promote beginning relationship with baby and parents through touch and privacy
 Administer medications as ordered/ needed methergine (Pitocin added to IV if
present)
4. Fourth stage of labor (IMMEDIATE POST-PARTUM)

Recovery
- Your baby is born, the placenta has delivered, and you and your partner will probably
feel joy, relief, and fatigue. Most babies are ready to nurse within a short period after
birth. Others wait a little longer. If you are planning to breastfeed, we strongly encourage
you to try to nurse as soon as possible after your baby is born. Nursing right after birth
will help your uterus to contract and will decrease the amount of bleeding.
CHARACTERISTICS OF DISCHARGE AFTER

DELIVERY
TYPE COLOR DAY POSITION
Rubra Red 1-3 days Blood, WBCs Decidua and some
microorganism
Serosa Pink 3-10 days Blood, mucus tissues and WBCs
Alba White 10-14 Mucus
days
*NOTE: ADVICE client to take note of any changes in the lochia and report to her care
provider

Nursing Interventions:
 Check mother’s blood pressure, pulse, respiration every 15 minutes for the
first 1-2 hours until stable
 Inspect perineum every 15 minutes for first 1-2 hours
 Palpate fundus every 15 minutes for first 1-2 hours; massage gently if not firm
 Check lochia for color and amount every 15 minutes for the first 1-2 hours
 Encourage mother to void, particularly if fundus not firm or displaced
 Apply ice to perineum if swollen or if episiotomy
MENSTRUATION
- is the female reproductive cycle that is characterized by the bleeding of the uterus as a
response to the system of hormonal changes. During the menstrual cycle, the ovum
reaches its maturity, and a new uterine bed is made ready for the implantation of the
fertilized ova.
- typically occurs in 28day cycles so most women get their period every 28 days.
However, some women have longer cycle and may only get their period every 40 days,
while other have shorter menstrual cycles and may get their periods as often as every 21
days. It isn't possible to have a period while you're pregnant.
- The purpose is to bring ovum to maturity and renew the uttering tissue bed
CHARACTERISTIC AVERAGE RANGE

Beginning (Menarche) Onset age 12.4 years 9-17 y/o
Interval b/w cycles 28 days 23-35 days
Duration Flow ,3-7 days 1-9 days
Average Amount 50 ml 30-80 ml
Color Dark red
Odor Marigolds
Initial Signs of Menstruation:
1. Abdominal cramps 6. Bowel issues

2. Breakouts 7. Headache
3. Tender breasts 8. Mood swings
4. Fatigue 9. Lowe back pain
5. Bloating 10. Trouble sleeping

The Phases of the Menstrual Cycle
The uterus is the main chamber where the main event occurs. Let us take a peek at how the
series of events takes place and becomes the ultimate show of reproduction.
Proliferative Phase
 After 4 to 5 days of the menstrual cycle, the lining of the uterus is only one cell layer
deep, which is very thin.
 The ovary produces estrogen as the endometrium proliferates to approximately an
eightfold of the usual layer.
 From day 5 to 14 of the cycle, the endometrium continues to increase in thickness.
Secretory Phase
 Through the LH, progesterone is formed in the corpus luteum, leading to the
endometrium becoming twisted in appearance.
 There is an increase in the amount of the capillaries, and the lining becomes rich and
spongy.
th th
 After ovulation (15 - 26 )
Ischemic Phase
 When there is no fertilization, regression of the corpus luteum starts until its tenth
day.
GROUP CASE STUDY_NCM 107_GROUP 3 22

 Progesterone and estrogen decrease which causes sloughing off of the uterine lining
and the capillaries rupture.
 This is the end of the menstrual cycle which contains blood, mucus, endometrial
tissues and the unfertilized ovum.
 The menses is the only external marker of the cycle, and it also marks the first day of
the next cycle

UPDATES ON PREGNANCY & DELIVERY
NEW PROTOCOL FOR PREGNANCY, LABOR AND DELIVERY DURING COVID (2020)
Coronavirus Disease 2019 in pregnancy: A clinical management protocol and

consideration for practice:
Summarized management of COVID-19 during pregnancy. COVID-19, coronavirus disease
2019; CPAP, continuous positive airway pressure; CTG, cardiotocography; LMWH, low-
molecular-weight heparin; SO2, oxygen saturation.

Mild Infection at Home Isolation
 Hydration.
 Temperature control (twice a day and opportunistically if new-onset symptoms occur, such
as sweating, shivering, or headache), and if needed paracetamol up to 500–1,000 g/6–8 h
(up to a maximum of 4 g/day).
 Although available, use of home pulse oximetry by smartphone or smartwatch apps is not
recommended as there is concern regarding reliability
 During influenza season, if no confirmation of COVID-19 infection and no exclusion of
influenza: oseltamivir 75 mg every 12 h for 5 days.
 Home isolation with measures of droplet and contact isolation (online suppl. Annex 2).
 Give clear indications on reasons for emergency consultation (among others, respiratory
distress, fever resistant to antipyretics).
 Prolonged bed rest should be discouraged given the risk of thrombosis associated both with
pregnancy and COVID-19 infection.
 Schedule a telehealth visits in 24–48 h to assess the clinical evolution and plan further
follow-up according to clinical evolution.
 Routine pregnancy visits, tests, and screening ultrasounds will be postponed until the end of
the isolation period (4 weeks after the appearance of symptoms) or following negative PCR
test after 2 weeks from the presence of symptoms, depending on public health authority’s
strategy. Follow-up of ambulatory cases with any maternal or fetal risk that need in-person
evaluation (such as fetal growth restriction) will require individualized consideration by
maternal-fetal specialists.
Delivery Care and Other Obstetric Procedures

In pregnant women with COVID-19 infection without severity criteria with spontaneous-onset
delivery or with an indication of induction due to obstetric indications, the mode of delivery will
depend on obstetric conditions and fetal status. In case of severe maternal disease, read below.
Testing is critical for risk mitigation. Policies for PCR testing on admission largely depend on
disease prevalence, test availability, and laboratory response time. Priority testing of
symptomatic cases and elective surgeries seems a reasonable first-step strategy.

Labor should be attended in a dedicated delivery room, preferably with negative pressure.
Ideally, this delivery room should be convertible to allow a caesarean section, thus avoiding
unnecessary transfers. The patient should use a surgical mask throughout labour. Read the
Personal Protective Equipment for Obstetric Procedures section for instructions on protection
for healthcare professionals.
Fetal Procedure
 Although the risk of spontaneous vertical transmission is low [26], it seems prudent to avoid
transplacental access during invasive procedures. A balance between the fetal benefit of
evidence-based therapies against the potential risks for the fetus, mother, and healthcare
providers should be made on an individual basis.
Vaginal Delivery
 Continuous CTG monitoring is advised due to possible increased risk of fetal distress, as
reported in some early reports. Although there is no evidence on the presence of SARS-
CoV-2 in vaginal secretions, it seems reasonable to avoid fetal scalp pH testing or internal
fetal heart rate monitoring. If fetal well-being loss is suspected, immediate delivery of
pregnancy by the most appropriate mode of delivery according to obstetric conditions will be
decided.
 Monitor temperature, respiratory rate, and SO2 hourly.
 Under normal labor progression, vaginal examinations should be minimized (i.e., every 2–4
h). Ideally, a minimal number of professionals should be involved in labour management to
minimize the risk of professional exposure.
 Neuraxial analgesia is not contraindicated, and by providing good analgesia, it may reduce
cardiopulmonary stress from pain and anxiety. Preferably, it should be administered early to
minimize the risk of requiring general anaesthesia for an emergency caesarean section, as
airway manipulation, intubation, and extubation are high-risk procedures for professional
infection. Some societies recommend against the use of nitrous oxide because of the risk of
aerosol generation.
 Consider shortening the second stage of labour (forceps or vacuum) according to obstetric
criteria as active pushing while wearing a surgical mask may be difficult for the woman.
 Unless indicated for suspected fetal or neonatal distress, routine umbilical cord gas analysis
is avoidable.
 Allowing people support on labour and delivery is a controversial issue, mainly because in
most of the situations, they are close contacts. In any case, the support person should be

screened for symptoms (online suppl. Annex 3) before admission to the delivery room,
wearing appropriate protective equipment (at least a surgical mask) and keeping droplet and
contact isolation measures.
 Any generated material during labour should be treated as contaminated. This includes
biological samples (such as the placenta) and other potential fomites such as neonatal
finger- or footprints or CTG strips. As a general rule, their reduction is desirable. During the
COVID-19 pandemic, the placenta should not be handed over to the patient.
 Newborn care should be carried out in the same operating/labour room unless resuscitation
measures are required that cannot be provided in-room.
 Although evidence of mother-to-child transmission is lacking, early cord clamping may be
discussed with the patient and recommended to minimize the risk of transmission after 34
weeks of gestational age. Before 34 weeks, a risk-benefit decision should be made regarding
delayed clamping.
 The patient could informedly decide skin-to-skin contact with the newborn. This can only be
offered if a good mother-child placement can be ensured, and in asymptomatic newborns
>34 weeks, ensuring precautions for respiratory droplets with the use of a mask as well as
hand and skin hygiene.
Caesarean Delivery
 Caesarean section should follow usual obstetric indications. The potential risk of vertical
transmission is not an indication for caesarean section.
 Maternal indication: in women with respiratory compromise, labour may stress the pulmonary
situation, and maternal hypoxia also has fetal risks. Under this rationale, a caesarean section
could be considered after 32–34 weeks in women with severe illness, when the risks of
prematurity could be assumed. Before 32 weeks, multidisciplinary team decisions should be
made, balancing maternal and neonatal risks, especially in intubated patients or those with
need for maternal prone position due to acute respiratory distress syndrome. Continuing
maternal support with fetal monitoring in women that remain stable may be an option for
severe preterm cases.

PART 3: ANATOMY & PHYSIOLOGY
ORGAN ANATOMY USE DURING CHANGES PURPOSE OF

PREGNANCY CHANGES
Uterus The uterus is nourish and The lining of the To provide
described as a house a fertilized uterus thickens nourishment for the
hollow, muscular, egg until the and the blood fetus and to make
pear-shaped fetus, or offspring, vessels enlarged. room for the baby
organ. It is located is ready to be
at the lower pelvis, delivered. Softening of the
which is posterior lower segment
to the bladder and (Hegar’s sign)
anterior to the
rectum. The
uterus has an
estimated length
of 5 to 7 cm and
width of 5 cm. it is
2.5 cm deep in its
widest part.
Cervix lowest region of the cervix The cervix will To prepare the
the uterus; it produces a good gradually soften. mother to give birth
attaches the deal of clear As body gets
uterus to the mucus which ready for labor,
vagina and helps to promote the cervix
provides a pregnancy. decreases in
passage between During length, becomes
the vaginal cavity pregnancy, the thinner and finally
and the uterine mucus produced opens when the
cavity. The cervix, by the cervix mother is
only about 4 thickens to create prepared to give
centimeters (1.6 a cervical "plug." birth. If the cervix
inches) long, This shields the begins to open
projects about 2 growing embryo before 37 weeks,
centimeters into from infection. you could give
the upper vaginal The cervical plug birth prematurely.
cavity. thins and is
expelled when
birth is imminent.
Vagina The vagina is a an elastic, increased For child birth canal.
muscular tube that muscular canal production of
extends from the with a soft, cervical mucus
cervix to the flexible lining that and vaginal
vaginal orifice in provides discharge.
the perineum lubrication and
(pelvic floor). It is sensation that
posterior to the receives penis
urethra and during sexual
anterior to the intercourse and a
rectum. The child birth canal.
vaginal opening is

usually partially
covered by a thin
membrane called
the hymen.
Breast The mammary Breast changes the veins become To accommodate
gland is an organ are a normal part more noticeable storage of milk for
of ectodermal of pregnancy and under the skin. milk for the baby.
origin whose occur as a result The nipples and To produce milk for
structure reflects of hormonal the area around nutrition of the
its function: the fluctuations. the nipples infant.
production of milk (areola) become
for lactation. The darker and larger.
inner structure of Small bumps may
the mammary appear on the
gland is made of areola.
an epithelial
component that
consists of
lobules, where
milk is made,
which connect to
ducts that lead out
to the nipple.
These lobules and
ducts are located
spread throughout
the background
fibrous tissue and
adipose tissue that
form the main
mass of the
breast.
Pituitary The pituitary gland During enlarges gradually Thyroid-stimulating
Gland is small and oval- pregnancy, the during pregnancy hormone (TSH) is
shaped. It’s maternal pituitary because of produced in the
located behind gland undergoes estrogen- pituitary gland in
your nose, near remarkable stimulated the brain and it
the underside of hemodynamic hyperplasia and helps regulate other
your brain. It’s changes. First is hypertrophy of important thyroid
attached to the the increase in prolactin cells. hormones. In
hypothalamus by the levels of pregnancy, those
a stalklike binding proteins thyroid hormones
structure. and second need to increase in
production of order to support the
many hormones baby’s
both from pituitary neurodevelopment
and placenta. and bone
development.

OTHER ORGANS OF THE REPRODUCTIVE SYSTEM
Female External Structures

Perineum
The perineum is separated from the pelvic cavity superiorly by the pelvic floor. This region
contains structures that support the urogenital and gastrointestinal systems – and it therefore
plays an important role in functions as such micturition, defecation, sexual intercourse and
childbirth.
Mons pubis/ mons veneris
The mons pubis is located over the symphysis pubis, the two pubic bones of the pelvis and is
shaped like an inverted triangle. This structure is composed of adipose tissue lying beneath the
skin and, from puberty on, is covered with varying amounts of pubic hair. The purpose is to
protect the junction of the pubic bone from trauma.
Labia Minora
The labia minora is a spread of two hairless folds of connective tissue that are pinkish in color.
The internal surface is composed of mucous membrane and the external surface is skin. It
contains sebaceous glands all over the area.
Labia majora
Labia majora are two folds of fat tissue covered by loose connective tissue and epithelium. Its
function is to protect the external genitalia and the distal urethra and vagina from trauma. It is
covered in pubic hair that serves as additional protection against harmful bacteria that may
enter the structure.
Hymen
This covers the opening of the vagina. It is tough, elastic, semicircle tissue torn during the first
sexual intercourse.
Clitoris
The clitoris is a small, circular organ of erectile tissue at the front of the labia minora. The
prepuce, a fold of skin, serves as its covering. This is the center for sexual arousal and pleasure
for females because it is highly sensitive to touch and temperature.
Fourchette
This is a ridge of tissue which is formed by the posterior joining of the labia minora and majora
This is the structure that sometimes tears or is cut during childbirth to enlarge the vaginal
opening.
Vestibule
It is a smooth, flattened surface inside the labia wherein the openings to the urethra and the
vagina arise.

Female Internal structures
Ovaries
The ovaries are the ultimate life-maker for the females. For its physical structure, it has an
estimated length of 3 cm and width of 2 cm and is 1.5 cm thick. It appears to be shaped like an
almond. It looks pitted, like a raisin, but is grayish white in color. It is located proximal to both
sides of the uterus at the lower abdomen. For its function, the ovaries produce, mature, and
discharge the egg cells or ova.
Fallopian Tubes
The fallopian tubes serve as the pathway of the egg cells towards the uterus. Their function is to
convey the ovum from the ovaries to the uterus and to provide a place for fertilization of the
ovum by sperm. Each fallopian tube is about 10 cm in length with finger-like structures at the
end called "fimbria" that are involved in capture of the oocyte ("egg") after ovulation.
It is a smooth, hollow tunnel that is divided into four parts:
 the interstitial, which is 1 cm in length
 the isthmus, which is 2 cm in length
 the ampulla, which is 5 cm in length
 the infundibular, which is 2 cm long and shaped like
a funnel.
The fallopian tube is lined with mucous membrane, and

underneath is the connective tissue and the muscle layer.
The muscle layer is responsible for the peristaltic
movements that propel the ovum forward. The distal ends
of the fallopian tubes are open, making a pathway for
conception to occur

FETAL DEVELOPMENT
Source: Tprovax.weebly.com

FETAL CIRCULATION
Placenta (oxygenated blood)
Umbilical Vein
Liver
(for nourishment)
Ductus Venosus
(bypasses liver)
Inferior Vena Cava
Right Atrium Foramen Ovale Placenta

(bypasses lungs) (oxygenated
blood)
Right Ventricle
Placenta
(oxygenated
blood)
Lungs for
Pulmonary Artery
nourishment
Ductus Venosus Aorta

(bypasses lungs)
Fetal circulation has three bypasses to drive oxygenated blood away from minor Circulation
organs to major organs. Oxygenated blood from placenta goes to the umbilical throughout fetal
vein, a small amount of blood goes to the lover for nourishment but much of it body
passes thru the ductus venosus directing blood to the Inferior vena cava. From
there The blood circulates into two directions: 1) blood goes to the right ventricle
to pulmonary artery nourishing lungs then goes to the ductus arterosus bypassing
the lungs to bring much blood to the aorta; 2) blood goes to the foramen ovale,
also bypassing the lungs, onto to the left atrium to left ventricle then to the same
aorta to bring blood to the circulation to the entire body.

PART 4: PHYSIOLOGY OF PREGNANCY & LABOR
ENDOCRINE CHANGES
(pituitary glands, placenta, thyroid & parathyroid glands
Progesterone, Hcg, estrogen, relaxin, prolactin)
Reproductive System Psychological Changes

1. Enlarged uterus
 1st: trim-self-centered due
a. pressure on diaphragm
to adjustments to
: difficulty of breathing
changes, ambivalent
- positioning
b. pressure on bladder  2nd: - excited due to
: frequent urination movements, choosing
c. striae gravidarum names
- avoid scratching  3rd: - nesting-preparations
-moisturize for childbirth
d. pressure on lower
extremities
-avoid standing
-raise legs Cardiovascular Changes
-elevate feet 1. Blood volume increased
e. abdominal discomfort
: effleurage a. cardiac workload
2. Cervix  risk for heart
: Goodell’s sign enlargement
: mucus plug  fatigue palpitation
-Prevent the entry of o rest
infection b. haemodilution
3. Vagina  risk of anaemia
a. increased blood o intake iron
circulation & folic acid supplement
: Chadwick’s sign
: hypersensitivity
b. leukorrhea
: acidity
: prone to yeast infection
-avoid frequent touching GUT
-increase intake of fruit 1. Fluids in the body
juices a. frequent urination
b. relaxed bladder
 retention of fluids
 risk for UTI
Skeletal system o frequent
1. Change center gravity emptying
-Lordosis GIT of bladder
 prone to slippage 1. Increased peristalsis - juices
o use low heeled  heartburn c. decreased acidity
shoes  constipation  risk for UTI
o promote safety o Nutrient
 back discomfort absorption
-back rub warm packs 2. Decreased Gastric acidity
2. Relaxation of pelvic  increased retention
ligaments of food in stomach
for increased
absorption

ENDOCRINE CHANGES IN PREGNANCY
Anterior Pituitary Posterior Pituitary

 Stimulates production of  At the end of the term, it will begin
breast milk to secrete oxytocin that was
produced in the hypothalamus
 Initiate labor
Thyroid Gland
 Increases in size-
increases metabolism
Parathyroid Gland
 in size slightly
Placenta
 Acts as a temporary  It meets the
endocrine gland during requirements for
pregnancy calcium needed for the
fatal growth
Progesterone
 laxity or loosening of
Estrogen
ligaments or joints
 estrogen
: risk for strains and sprains
- : improve vascularization of uterus and
placenta
: transfer nutrients
 size of ureters : support the developing baby
 responsible for the elasticity of
 Rapid estrogen (1st trimester)
the uterus
: nausea
: changes in sense of balance -
-  2 trimester
nd
: milk duct development

: enlarged breasts

PHYSIOLOGICAL CHANGES DURING
LABOR AND DELIVERY
Fight or Flight Mode
 Cardiac workload
 RR Relaxation and
 Unrelaxed muscles Breathing
 Fainting
Techniques
 n/v
 Oxytocin let down
 Panic
 Prolactin
Breastmilk
Theories of Contraction and

Widening of pelvic ligaments
Expulsion
Back pain
1) Oxytocin
2) Progesterone
 Message back
3) Prostaglandin
4) Uterine size to maximum  Warm compress
Cervix
1) Estrogen
a. Removal of mucus plug Risk of infection
- avoid douching
- no sex
- avoid several IE's
b. Softening
c. Chadwick’s sign
d. Fluids
2) Contraction of Uterus Dilatation of Cervix

PART 5: LABORATORY RESULTS & DIAGNOSTIC STUDIES
A. LABORATORY RESULTS
COMPLETE BLOOD COUNT

Nursing Considerations
 Explain test procedure. Explain that slight discomfort may be felt when the skin is punctured
 Encourage to avoid stress if possible because altered physiologic status influences and changes normal hematologic values.
 Monitor the puncture site for oozing or hematoma formation.
COMPLETE BLOOD COUNT REPORT

EXAM Result Ref. Value Significance Implications
1st 2nd
3rd
March 23, April 23, November

2020 2020 30, 2020
Hemoglobin 123 g/dl 126 g/dl 132 g/dl 120-160 g/L It provides direct indication Normal
(Hgb) of the oxygen-carrying
capacity of the blood. Interpretation:
Low-patient is suffering Have enough Hgb in the
from blood loss. RBC to transport oxygen
High- may indicate
polycythemia.
Hematocrit 37.3 vol% 39.2 vol% 43.2 vol% 37-47 vol % It determines the volume Normal
(Hct) percentage of RBC
compared to the total blood Interpretation: Have
volume thus the oxygen- proportion RBCs in the
carrying capacity of the blood.
blood.
Low-indicate presence of
bleeding.
High- may indicate
dehydration
RBC count 4.03 x 4.48 x 5.03 x 3.50-5.50 x A test used to measure the Normal
10^12/L 10^12/L 10^12/L 10^12/L RBC in blood.
Interpretation: Have enough
Low-may indicate loss of RBC in the blood to

blood. transport oxygen to the body
High- may indicate bone cells and carbon dioxide in
marrow over production the lungs.
WBC count 8. 03 x 8.96 x 9.95 x 5-10 x A test that measures the Normal
10^9/L 10^9/L 10^9L 10^9/L number of white blood cells
in the body. Interpretation: There is
Low- high risk of getting an enough WBC to fight
infection infections and defend the
High- indicate that the body against other foreign
immune system is working materials.
to destroy an infection.
DIFFERENTIAL COUNT
Neutrophils 0.55 0.60 0.65 0.40-0.70 They constitute to the Normal
body’s first line of defense
to heal damage tissues, Interpretation: Have enough
remove debris, and resolve neutrophils to heal damage
infections. An increase tissues and resolve
neutrophil is the response infections
of leukocytes to fight
physical stress and acute
infection. An increase or
decrease neutrophils
(neutropenia) may indicate
infection.
Lymphocytes 0.28 0.30 0.32 0.20-0.40 Lymphocytes are white Normal
cells responsible for body’s
immune defense and Interpretation: Have enough
response. Low- indicate lymphocytes for body’s
infection. immune defense and
High- harmless due to response.
body’s’ normal response to
an infection.
Monocytes 0.58 0.62 0.73 0.12-1.20 Monocytes may play a Normal
central role in this
inflammatory response.

High-indicates chronic Interpretation: high ability of
inflammatory disorders. the body to destroy
Low- result of medical invaders, and to facilitate the
conditions that lower the healing and repair into the
overall WBC count or body
treatments that suppress
the immune system
Eosinophils 0.02 0.03 0.05 0.00-0.07 The eosinophils combat Normal
parasitic infections and are
involved in asthma or Interpretation: Have enough
allergic responses. eosinophils to fight allergic
Low- indicate eosinopenia infection
High- indicates allergic
reaction.
Basophils 0.00 0.00 0.00 0.00-0.01 In addition to fighting Normal
parasitic infection,
basophils are play a role in Interpretation: Have enough
allergy responses. basophils to fight infection
Low- indicate infection
High - indicate acute
allergic reaction.
Platelet count 362 x 378 x 396 x 150-450 x It helps the in-blood clotting Normal
10^9/L 10^9/L 10^9/L 10^12/L and prevent excessive
bleeding. Interpretation: No
High- indicates thrombocytosis and
thrombocytosis thrombocytopenia
Low-indicates
thrombocytopenia
RBC INDICES
Mean 88.3 fl 91.2 fl 92.3 fl 82.0-95.0 fl An MCV blood test Normal
Corpuscular measures the average
Volume volume of the red blood Interpretation: No implication

(MCV) cell, also known as the of iron-deficiency anemia
erythrocytes.
Low- indicates bleeding or
microcytosis. High- is called
macrocytosis.
Mean 27.3 pg 29.4 pg 30.1 pg 27.0-31.0 pg MCH levels refers to the Normal
corpuscular average amount of high
hemoglobin found in the red blood cell Interpretation: No implication
(MCH) in the body. of iron-deficiency anemia
Low- indicates blood loss
and microcytic anemia
High- indicate macrocytic
anemia
Mean 321 g/L 335 g/L 358 g/L 320-360 g/L The test describes the Normal
Corpuscular average concentration of
Hemoglobin high in a given volume of Interpretation: Have enough
Concentratio RBC. oxygen in the hemoglobin
n (MCHC) Low- indicates low hgb.
High- indicates more
concentrated hgb.
RDW-CV 11.8 % 12.6 % 13.2 % 11.6-14.6 % It measures the amount of Normal
red blood cell variation in
volume and size. This is the Interpretation: Normal size
test used to help diagnose of red blood cell
type of anemia. Low-
indicates that the RBC are
all the same size
High- indicates that you
have bot very small and
very large RBC.
Blood Typing
March 10, 2021

EXAMINATION RESULT
Blood Type “A”
Rh Type Positive
INTERPRETATION:
This blood type A has A marker but not B marker.
A positive blood type has A marker and it has Rh factor.
SEROLOGY-IMMUNOLOGY
March 23, 2020
Test Method Result Significance Implications

Hepatitis B Immunochromatography Non-Reactive It determines if someone is Negative of Hepatitis B
Surface infected with hepatitis b virus
Antigen
(HBsAG)
HIV1 Particle Agglutination Non-Reactive A test to detect HIV antibodies Negative HIV antibodies detected
in your blood
Rubella IgG Immunosorbent assay Reactive Indicates consistent immune to Positive Rubella IgG detected
Rubella virus
Rubella IgM Immunosorbent assay Non-reactive Indicates current or very recent Negative Rubella infection
infection
VDRL Particle Agglutination Non-reactive This test is used to screen for Negative for Syphylis
(Syphylis) syphilis.
Nursing Considerations
 Instruct the patient to void directly into a clean, dry container. Women should always have a clean-catch specimen if a
microscopic examination is ordered.
 Cover all specimens tightly, label properly and send immediately to the laboratory.
URINALYSIS REPORT
EXAM Result Ref. Value Significance IMPLICATIONS
Upon 2nd 3rd
Admission
March 23, April 23, November
2020 2020 30, 2020

Color yellow yellow yellow Yellow to It provides a clue to certain Normal
Amber diseases or conditions.
Red urine indicates The body is hydrated and
hematuria, brown/black kidneys are in good
indicated metastatic condition. Negative in
melanoma, yellow-brown hematuria, metastatic
indicates hepatitis. melanoma, and hepatitis.
Transparency clear clear clear Clear Turbid or cloudy urine may Normal
indicate increased number
of WBC or epithelial cells. Clear urine is unlikely to be
infected
Pus Cell 0-2 /hpf 0-4/ hpf 0-4 /hpf 5-10/hpf Sent by the body’s Normal
immune system to combat
infection. Presence of pus cells
means the body naturally
responds to infection
RBC 0-2/ hpf 0-2 /hpf 0-2 /hpf 0-4/hpf Presence of abdominal Normal
number of RBC in urine is
called hematuria which Free from hematuria
indicates urinary system
disease.
Bacteria moderate moderate moderate Fail Bacteria is only present if Normal
there is an UTI.
Free from UTI
Mucus Threads negative negative negative Negative A small amount of mucus Normal
in your urine is normal. An
excess amount may The urethra and bladder
indicate a urinary tract create mucus naturally.
infection (UTI) or other Mucus travels along your
medical condition urinary tract to help wash
out invading germs and
prevent possible issues,
including urinary tract
infection and kidney
infection.
Protein negative negative negative Negative It is an important indicator Normal

of renal disease. Increased
amount of protein is called No infection or kidney
proteinuria. problem
Glucose negative trace trace Negative/ Presence of detectable Normal
Trace glucose in urine is called
glycosuria. A sugar or Free from diabetes
glucose in urine can be
sign of diabetes mellitus.
pH 6.0 6.0 7.0 5.0-8.0 It measures the degree of Normal
acidity or alkalinity of the
urine. A pH below 5.0 pH level is neutral
indicates acid urine and a
pH above 8.0 indicates
alkaline urine
Specific Gravity 1.020 1.023 1.025 1.010-1.025 It estimates the Normal
concentration of solutes in
the urine. Higher specific Well hydrated
gravity is usually darker in
color and more
concentrated and indicates
dehydration. Low specific
gravity indicates a person
is healthy because the
kidneys have not matured
sufficiently to concentrate
urine.
Epithelial Cell rare few rare 0-few It is constantly shed from Normal
the lining of the tract and
washed in the urine. Large Free from acute renal
number of epithelial cells diseases.
indicate acute renal
disease
B. Diagnostic Studies

DIAGNOSTIC DATE IMPRESSION INTERPRETATION PURPOSE Nursing Considerations
STUDIES AND
TIME
Transvaginal March Gestational Confirmed Transvaginal BEFORE THE PROCEDURE:

Ultrasound 23, sac with MSD pregnancy; ultrasound uses  Instruct the mother to empty her
(Confirmatory 2020 3 mm in gestational sac an ultrasound bladder prior the procedure.
Test) 10:00 diameter suggestive of IUP probe or
AM located in corresponding to 4 transducer RATIONALE:
endometrium, weeks and 2 days inserted into the  A full bladder would not only distort the
double pregnancy. vagina. It is image of the uterus but it will also be
decidual sign Expected to deliver usually done to uncomfortable for the client.
present. EDD on November 28, view female
Nov. 28, 2020 2020 reproductive
organs such as DURING THE PROCEDURE:
the uterus,  Client’s dignity and privacy must be
cervix, and protected during the examination.
ovaries. Doctors
often recommend RATIONALE:
transvaginal  The procedure requires assessing the
ultrasound to private part of the client.
confirm early
pregnancy as it is
AFTER THE PROCEDURE:
able to provide
 The client should be informed on the
much more
detailed pictures results of the procedure.
of the organs in RATIONALE:
the pelvis,  The client has the right to know the
particularly the
results of the procedure done.
uterus.

STUDIES AND
TIME

Abdominal June Single live The client is 20 This is done to BEFORE THE PROCEDURE:
Ultrasound 18, female, weeks pregnant to assess the  Instruct the mother to have a partially
(fetal well- 2020 intrauterine a baby girl. development of full bladder prior the procedure.
being UTZ) pregnancy; Fetal wellbeing is the fetus in the
with fetal normal as abdomen. RATIONALE:
growth evidenced by  Partial full bladder provides a clearer
corresponding adequate amniotic image detection and promotes comfort
to 20 weeks fluid and regular for the mother during the procedure.
AOG; cardiac activity.
adequate DURING THE PROCEDURE:
amniotic fluid;  Provide client’s privacy.
placenta is
posterior, RATIONALE:
Grade 2;  During the procedure client’s abdomen
normal and will be exposed thus it requires proper
regular draping to protect the client’s dignity
cardiac and privacy.
activity
present. AFTER THE PROCEDURE:
 Evaluate the result and document any
abnormal findings.
RATIONALE:
 This help to determine abnormalities of
the child which is necessary to
determine appropriate interventions.

STUDIES AND
TIME
Leopold’s Fundus is The presenting part Leopold’s BEFORE THE PROCEDURE:

Maneuver 0ctober palpable is the head, the maneuver is a  Instruct the mother to void or empty her
31, below the fetus is in left systematic bladder prior the procedure.
2020 xyphoid occiput anterior abdominal

11:30 process, fetus position, and the palpation to RATIONALE:
am is LOA and in baby has started to determine the  The contour of the fetus will not be
cephalic descend preparing position and obscured, thus results to more accurate
presentation. for delivery about presentation of findings. The client will also become
2-3 weeks from the the fetus. comfortable during the procedure.
day the procedure
was done. DURING THE PROCEDURE:
 Make sure to warm hands before
placing them on the mother’s abdomen.
Rub hands together.
RATIONALE:
 To avoid uterine contraction.
AFTER THE PROCEDURE:
 Evaluate and document findings.
RATIONALE:
 Evaluate result to determine any
abnormal findings, and to be able to
provide necessary interventions.
PART 6: PHYSICAL ASSESSMENT & PHYSIOLOGICAL BASES
CRITERIA 1ST ASSESSMENT 2nd ASSESSMENT PHYSIOLOGICAL BASIS

(Upon admission in active phase) (Within 2 hours after delivery)
PSYCHOSOCIAL:
1. Type of family Nuclear family Nuclear family
2. Significant Others Husband Husband
3. Coping Mechanism Problem-focused: Fight Problem-focused: Flight Fight and flight modes are
normal responses to stress

The patient complies with anything Patient is too tired to respond in order to cope with
that the nurse says regarding with the questions that was being stressful situations.
measures that will help her in her asked to her during the
current condition. assessment and asks her
husband to answer the questions
instead.
Patient: “Ano pong dapat kong Patient: “Asawa ko po muna ang

gawin?” tanungin niyo, nanghihina pa kasi
ako.”
4. General Appearance Patient appears to be physically fit Patient appears to be exhausted, Primiparous woman, due to
and dressed very neatly on her lying in bed wearing a clean lack of preparation, may feel
pajamas. She tries to be calm in bed hospital gown. She slept during being out of control. During
in between contractions but appears most of the assessment time and the early labor, patient may
to be agitated during contractions. asked her husband to answer normally feel ambivalent
She lets her husband answer most most of the questions instead. and becoming more agitated
of the questions being asked. as the labor progresses to
the transitional stage.
5. Affect Restricted affect Blunted affect Patient during active phase
thinks about herself and the
Patient appears to be restricted in Patient shows a little or no baby as well as on how to
responding to any questions. When response to questions due to cope with contractions. Also,
asked, she only display one type of visible exhaustion. patient after delivery will
expression which is serious because enter the “taking in” phase
she is focused on the pain on her where she is centered on
abdomen due to contractions. her own needs.
6. Orientation Patient is well oriented to time, place Patient is well oriented to time,
and who is with her. place and who is with her.
Nurse: “Anong oras po kayo naadmit Nurse: “Ano pong pinangalan

dito sa hospital?” niyo kay baby?”
Patient: “Kaninang mga alas dos.” Patient: “Elizabeth po.”

Nurse: “Anong pangalan po ng Nurse: “Anong pangalan po ng
hospital na ito ma’am?” hospital na ito ma’am?”
Patient: “Regional 2 Trauma Medical Patient: “Regional 2 Trauma

Center.” Medical Center.”
Nurse: “Sino po kasama niyong Nurse: “Sino pong nagbabantay

pumunta ditto/” sa inyo ngayon?”
Patient: “Yung husband ko.” Patient: “Yung asawa ko.’
7. Memory According to some findings,

a) Immediate Patient was asked to repeat “2-4-6- Patient was asked to repeat “1-3- primiparous women are not
9” and was not able to repeat the 4-7” and was able to repeat the able to recall events
series of 4-digit numbers due to series of 4-digit numbers. because of anxiety.
labor pain.
Nurse: “Anong oras po kayo na-
b) Recent Nurse: “Paano po kayo nakapunta admit ma’am.”
dito sa ospital ma’am?”
Patient: “Hindi ko na alam.” Patient: “Mga 2pm.”

Remote
Nurse: “Kailan po kayo grumaduate Nurse: “Kailan po kayo ikinasal ni
ng highschool ma’am?” mister?”
Patient: “Hindi ko na matandaan.”

Patient: “Noong April 14, 2018”
8. Speech Patient speaks in a serious tone and Patient speaks in low volume but
staggering manner as she speaks it was audible due to exhaustion.
between contractions.
9. Non-Verbal Behavior Patient shows non-verbal behavior Patient shows non-verbal

that is appropriate with her emotion. behavior that is inappropriate with

When asked about how does she her emotions. She was asked
feel, she stated that she was in pain about how she feels, patient
with a grimace on her face. She also verbalized “Okay lang.” but her
nods when agrees. face is gloomy and tired. She
cannot maintain eye contact with
the student nurse.
ELIMINATION
1. Stool
a) Consistency Patient did not defacate during the Patient did not defecate yet. Primiparous women will
labor. Last bowel movement was a have a bowel movement
b) Pattern day before labor. within two to three days
after giving birth.
c) Color
2. Urine
a) Quantity Per Voiding Patient says that she urinated Patient did not urinate yet. During early postpartum
approximately 1 cup. period, there can be some
temporary neve issues
which decreases the
b) Pattern Patient urinated once from mother’s sensation or
admission feeling of need to urinate.
c) Color Light Yellow
d) Odor Aromatic

3. Abdomen
a) Bowel sounds Consist of clicks and gurgles (5-30 Consist of clicks and gurgles (5-
per minute) 30 per minute)
Symmetrical around the midline Symmetrical around the midline

b) Contour
No visible masses
With visible masses
c) Palpation Absence of lesions
Absence of lesions
d) Lesions Without ascites
Without ascites
e) With ascites
4. Toileting Ability The patient is dependent or needs The patient cannot go to the toilet After delivery, women are
assistance from her husband when at this moment. reserved due to episiotomy.
going to the toilet.
REST AND ACTIVITY

1. Current Activity Level Patient mostly lies on the bed and Patient is lying on the bed and During taking-in phase, the
have difficulty relaxing and almost she tries breastfeeding her baby. mother is dependent on her
panting. She cannot maintain a She said that she is still too tired healthcare provider or
single position in bed and almost fell to care for her newborn and she support person with some
from one occasion. needs assistance from her tasks and decision-making.
husband.
2. ADL’s
a) Hygiene Patient can’t groom herself Patient can’t groom herself
independently such as combing her independently such as tying her
hair hair
b) Feeding Patient was not able to eat since her Patient was not able to eat at this
labor began. moment.

c) Dressing Patient can’t groom herself Patient was not able to dress
independently such as wearing herself.
hospital lab gown
d) Toileting Patient is slightly dependent to Patient was not able to go to the

significant other. toilet.
e) Ambulating Patient was not able to ambulate Patient was not able to ambulate
at this moment.
f) Communication Patient was able to communicate but Patient can slightly communicate
still needs her husband’s assistance and needs her husband’s
to answer with the questions assistance to answer with the
questions
3. Sleep Sleeping history: Sleeping history:

Before admission, patient slept at Patient has no continuous sleep
8:30 pm and wakes up at 4 am due due to discomfort and she also
to abdominal pain. She barely had needs to breastfeed her newborn.
sleeps since then.
Duration:
Patient said that it was only
approximately 30 minutes every 2
hours interval.
4. Body Frame Patient is physically fit and has a Patient is physically fit and has a
medium frame (Mesomorph) medium frame (Mesomorph)
5. Posture Upon admission, posture is not Posture of the patient cannot be

upright because her back is slightly determined because patient is in
bent forward due to abdominal pain. bed rest.
6. Balance Patient cannot maintain balance and Patient cannot maintain balance.
almost fell from one occasion. She needs assistance when
sitting down and when
breastfeeding her newborn.

7. Muscle Patient is physically fit and has Patient is physically fit and has
normal size on both sides of the normal size. She also regains
body muscle mass
She experiences contractures but it Patient is more relaxed and is

is normal taking rest.
Patient has tremors due to anxiety Patient has slight tremors and is
related to labor hesitant to hold her newborn due
to anxiety
Muscle weakness due to

She has muscle weakness due to episiotomy and slight swelling on
fatigue the vagina.
Arms
Arms • Can extend and bend arms
• Can extend and bend arms
Elbows
Elbows •There is no resistance
•There is no resistance
Wrists
Wrists • The client is able to bend both
• The client is able to bend both wrists down and back
wrists down and back
Hands and fingers
Hands and fingers • The client was able to move
• The client was able to move both both hand and fingers
hand and fingers
Knee
Knee • The client was not able to
• The client was able to extend and extend and flex both knees
flex both knees
Feet

Feet • The client was not able to
• The client was able to extend, flex, extend, flex, and rotate both feet.
and rotate both feet.
Tone:
Tone: • Firm
• Firm
8. Motor Function
a) Gross: Patient cannot flex on the bed due to Patient can flex and extend lower
labor pain. extremities. Cannot bend waist
and head is at one side only.
b) Fine: Patient can only hold light materials Patient can hold light objects and
and her ability to hold is poor due has a slight grip due to
labor pain and fatigue. exhaustion.
9. Range of Motion
Patient has limited movement and Patient has limited movement
feels pain upon lifting her both legs. due to exhaustion and
She can also adduct and abduct episiotomy. Arms cannot be
extremities within normal range but adducted and abduct, flex and
needs support to perform in extend because of exhaustion.
moderation.
10. Pain
a) Scale Patient rated her pain 8/10 Patient rated her pain 5/10
b) Relief measure Patient performed a patterned Patient relies on medication such

breathing relaxation and changes as pain killer.
position and movement
11. Mobility and Assistive Crutches: None Need assistance of significant Patient use wheelchair for
Devices Walkers: None other with an alternative of minimal assistance
Wheelchair: need the assistance assistive device
Cane: None

SAFE ENVIRONMENT
1. Allergies/ Reaction
a) Medication None None
b) Food None None
c) Environment None None
2. Eye Vision
a) Glasses Patient is not wearing eyeglasses. Patient is not wearing
eyeglasses.
b) Pupils PERRLA (Pupils, equal, round and
reactive to light and accommodation) PERRLA (Pupils, equal, round
and reactive to light and
Normal accommodation)
c) Visual acuity
Normal
3. Hearing
a) Hearing Aid None None
b) Hearing Acuity Able to repeat whispered words. Able to repeat whispered words.
4. Skin Integrity Perineal laceration is the

a) Lesions/ Scars No presence of lesion/scar 2nd degree of perineal laceration most common type during
childbirth that extend
b) Hematoma/ Bruises No presence of hematoma/bruises No presence of through the skin and
hematoma/bruises muscular tissue of the
c) Surgical perineum and vagina.
Incision/Wounds No surgical wounds present Most common type of
2nd degree of episiotomy episiotomy that extends
through the vaginal lining as
well as the vaginal tissue.
5. Mucous membranes

a) Nasal Moist Moist
b) Oral Moist Moist
c) Temperature 36.5 oC 36.7 oC
d) Route Right Axilla Right Axilla
OXYGENATION
1. Airway Clearance
a) Nose No secretion noted No secretion noted
b) Mouth No obstruction noted No obstruction noted
2. Lung sound No adventitious sound No adventitious sound
3. Capillary Refill Goes back within 1-2 seconds Goes back within 1-2 seconds
4. Tissue Perfusion
a) Skin Skin is brown, smooth Skin is brown, smooth
b) Nails Pinkish with good capillary refill Pinkish with good capillary refill
c) Lips Moist Moist
5. Peripheral Pulse
a) Rate 82 bpm 75 bpm
b) Rhythm Regular Regular
c) Blood Pressure 120/80 mmHg 120/80 mmHg
d) Edema No presence of edema No presence of edema
e) Homan’s Sign No pain in the calf No pain in the calf
NUTRITION:
a) Diet Patient has not eaten yet DAT

b) Fluid Intake Patient only drank sip of water 2-3 L per day
c) Height 5’6 feet (167.64 cm) 5’6 feet (167.64 cm)
d) Weight 58 kg 54 kg
e) BMI 20.64 19.21
f) Tissue Turgor Goes back within 1-2 seconds Goes back within 1-2 seconds
Ability to:
a) Chew Patient able to chew Patient able to chew
b) Swallow Patient able to swallow Patient able to swallow
c) Tolerate Food Patient able to tolerate food Patient able to tolerate food
d) Feed self Patient able to feed self Patient was not able to feed self
BUBLEEH: 2nd ASSESSMENT

(Within 2 hours after delivery)
a) Breast Enlarge, soft with no pain
b) Uterus Contracting below the navel
c) Bladder Not distended
d) Bowel Patient did not yet defecate
e) Lochia Rubra
f) Episiotomy 2nd degree of episiotomy
g) Emotions Taking-in-phase
h) Homan’s Sign No pain in the calf

PART 7: DRUG ANALYSIS
General Responsibilities for Safe Medication Administration
The right patient
The right medication (drug)
The right dose
The right route
The right time
The right reason
The right documentation
NAME OF MODE OF INDICATION CONTRA- SIDE EFFECTS ADVERSE NURSING
DRUG ACTION INDICATIONS EFFECTS CONSIDERATIONS

Generic Name: Iron is essential Prevention and Hypersensitivity Constipation Gastrointestinal Assess nutritional status
Ferrous Sulfate for hemoglobin, treatment of Hemochromato Black tarry stool irritation or bowel function
myoglobin and Iron deficiency sis, hemolytic Stomach cramps, Nausea Monitor hemoglobin,
Trade Name: enzymes, it is anemias. anemia or upset stomach Epigastric pain hematocrit and iron
Feosol, Fer Iron, transported to Altered bowel levels
Fer-Gen-Sol, organs where it habits Educate patient to take
Fer-in-Sol, becomes part of drug as prescribed
Feratab, iron stores Report constipation or
FeroSul,
diarrhea to physician
Classification:
Iron preparation,
blood formers,
coagulators,
anticoagulants
Dosage:
400 mcg
Form:
Oral
Date:
March 23, 2020

Generic Name: Folic acid is used Treatment of Folic acid, USP Flushing Adverse reaction Monitor client’s dietary
Folic Acid to treat folic acid Folic acid is Loss of appetite of Folic Acid intake of food containing
deficiency and deficiency contraindicated Insomnia Sleep folic acid.
Trade Name: certain types of anemia. in patients who Irritability disturbance Encourage patient to
Folvite anemia (lack of Prophylaxis have shown Depression High dose take drug as prescribed.
red blood cells) for deficiency previous Confusion causes irritation Instruct patient to eat
Classification: caused by folic during intolerance to Impaired judgment deteriorates zinc foods high in folic acid
-Nutrition and acid deficiency. pregnancy. the drug. absorption and consult healthcare
blood It is a water- Prevention of Hypersensitivity Intravenous provider concerning
-Vitamin B soluble compound neural tube to folic acid or Nutritional amount of folic acid that
complex group that plays defects. its formulation Product should be in the diet.
important role in is a potential drowsiness
Dosage: DNA biosynthesis. contraindication
500mg to its
administration.
Form:
Oral
Rout:
Per Orem
Date:
March 23, 2020

NAME OF MODE OF INDICATION: CONTRA- SIDE EFFECTS ADVERSE NURSING
Generic Name: Actif contains For prenatal Hypersensitivit Abdominal cramps irritability Take supplement as
Actif Organic folate, the organic megaloblastic y to folic acid or Diarrhea confusion prescribed
Prenatal Vitamin and most effective anemias its formulation Rash stomach upset Remind patient to read
form of folic acid, is a potential Sleep disorder behavior the labels carefully,
Trade Name: which is clinically contraindicatio nausea changes check expiration dates
N/A proven to reduce n to its seizures before purchasing
the risk of neural administration. Difficulty in Alert patient to the
Classification: tube defects. Avoid breathing signs and symptoms
Folic Acid,
megadose in of hypervitaminosis
Organic Vitamin
the first
Dosage:
400 mcg trimester
because it
Date: might cause
March 23, 2020 birth defects
NAME OF MODE OF INDICATION: CONTRA- SIDE EFFECTS ADVERSE NURSING

Generic Name: Hypertonic D5LR, USP is Solutions Coughing Febrile response Solution containing
D5LR (Dextrose solutions are indicated as a containing Sneezing Venous dextrose should be
5% in Lactated those that have source of dextrose may be Rash and itching thrombosis or used with caution in
Ringer’s an effective water, contraindicated Headache phlebitis patients with known
solution) osmolality electrolytes in patients with Chest pain Extravasation subclinical or overt
greater than the and calories known allergy Troubled hypervolemia diabetes mellitus.
Trade Name: body fluids. or as an to corn or corn Breathing Discard unused
D5LR (Dextrose This pulls the fluid alkalinizing products. Decreased Blood portion.
5% in Lactated into the vascular agent. Pressure Label the IV fluid
Ringer’s by osmosis Persons properly
Solution) resulting in an needing extra Observe aseptic
increase calories who technique when
Classification: vascular volume. cannot changing IV fluid.
Intravenous It raises tolerate fluid Caution must be
Nutritional intravascular overload practiced in the
Product, osmotic pressure Treatment of administration of
Hypertonic and provides shock parental fluid
Nonpyrogenic fluid, electrolytes Do not administer
parenteral fluid, and calories for unless solution is clean
electrolyte and energy. and container is
nutrient undamaged.
replenisher Assess patient
carefully for signs of
Dosage: hypervolemia such as
#1 D5LR 1L bounding pulse and
started @ shortening of breath.
20gtts/min
Form:
Solution
Rout:
Intravenous fluid

Date Given:
November 30,
2020

Generic Name: Midazolam is a Pre-operative Hypersensitivity Agitation Apnea Assess level of sedation
Midazolam drug used as a sedation May increase the Drowsiness Laryngospasm and level of
sedative for risk for Excess sedation Respiratory consciousness
Brand Name: operation and congenital Headache, depression throughout the
Midazolam helps also for malformation blurred vision Cardiac arrest administration
treating seizures. When given or Bronchospasm Monitor vital signs
Classification: It is given before used in the last Coughing continuously during
Sedative/ the administration weeks of Arrhythmia administration.
hypnotic of the anesthesia. pregnancy, it Hiccups Maintain patent airway
Antianxiety agent may cause CNS Nausea and assist ventilation if
Onset: 15 minutes depression in the Vomiting needed
neonate Rashes
Date Given: Duration: 2-6 Use cautiously: Pain in the
November 30, hours to patient with injection site
2020 pulmonary
Excretion: disease, CHF,
through urine renal
impairment,
severe hepatic
impairment,
obese pediatric
patients
NAME OF MODE OF INDICATION: CONTRAINDIC SIDE EFFECTS ADVERSE NURSING

DRUG ACTION ATIONS EFFECTS CONSIDERATIONS

Generic Name: Promethazine is Sedation Hypersensitivity Sedation CNS depression Assess for history of
Promethazine an antihistamine Antihistamine Newborn/ Confusion paradoxical hypersensitivity to
and works by Nausea and premature Disorientation excitation, antihistamine or
Brand Name: blocking a certain vomiting infants less than Blurred vision dryness of phenothiazine
Phenergan, natural substance Motion 2 years old (risk Hallucinations mouth, Do not administer
Phenadoz (histamine) that sickness of potentially Muscle spasms blurring of subcutaneously; tissue
your body makes fatal respiratory Catatonic states vision, necrosis may occur
Classification: during an allergic depression) Euphoria retention of Do not administer
Antihistamines, reaction. SC or intra- Excitation urine, intra-arterially;
1st Generation: arterial Extrapyramidal constipation, arteriospasm and
Antiemetic Its other effects administration symptoms glaucoma, gangrene of the limb
Agents may work by Coma Fast or Tachycardia may result.
affecting other Treatment of slow heart rate headache, Monitor for signs and
Dosage: natural lower respiratory Photosensitivity hypotension, symptoms of potential
25mg substances and by tract symptoms, Obstructive jaun tinnitus tissue injury including
acting directly on including asthma dice burning or pain at site
Date: certain parts of Dry mouth of injection, phlebitis,
March 10, 2021 the brain. Skin swelling swelling, and blistering
Involuntary mov Educate patient to take
Prevent and treat ements drug exactly s
nausea and Hives prescribed. Avoid
vomiting. Antineurotic using alcohol and
edema driving or engaging in
Use to treat Impotence other dangerous
allergy symptoms Urinary retentio activities.
like rash, runny n Educate patient to
nose and itching. avoid prolonged
exposure to sun, or
use a sunscreen or
covering garments.
Educate patient to
maintain fluid intake,
and use precautions
against heat stroke in
hot weather

NAME OF DRUG MODE OF INDICATION: CONTRA- SIDE ADVERSE NURSING
ACTION INDICATIONS EFFECTS EFFECTS CONSIDERATIONS
Generic Name: Hydroxyzine is an Treatment for Hypersensitivity Dizziness Restlessness Assess patients for
Hydroxyzine antihistamine that anxiety Potential for Blurred vision Confusion profound sedation and
blocks certain Preoperative congenital defects Constipation Hallucinations provide safety
Brand Name: natural substance sedative (oral clefts, Dry mouth Tremors precautions as indicated
Vistaril such as histamine Antiemetic hypoplasia or cerebral Difficulty urinating Assess mental status
that our body Antipruritic hemisphere) Seizure such as the orientation,
Classification: produce during May be Lactation Fast/irregular mood and behavior
Anxiety agents allergic reactions. It combined with Use cautiously with heartbeat Lab test
Antihistamines also helps treat opioid patients with severe Severe dizziness considerations: may
Sedatives/ anxiety and helps a analgesics hepatic dysfunction, Fainting cause false-negative skin
Hypnotics patient relax and woman in labor, may Serious allergic test results using
feel sleepy before cause potentially fatal reactions allergen extracts.
Doctor’s Order: and after surgery. gasping srome to Trouble breathing Discontinue hydroxyzine
Hydroxyzine neonates when at least 72 hours before
(Vistaril) 50 mg Onset: 15-30 injected test
Intramuscular minutes
ONLY x 1 dose Duration: 4-6
PRN for anxiety hours
Excretion:
Date Given: eliminated by stool
November 30,
2020
NAME OF DRUG MODE OF ACTION INDICATION CONTRA- SIDE EFFECTS ADVERSE NURSING
INDICATIONS EFFECTS CONSIDERATIONS
GENERIC NAME: Lidocaine acts as an Ventricular Hypersensitivity Hypotension Cardiac arrest Monitor ECG
Lidocaine anesthesia by nerve arrhythmia to lidocaine Swelling (edema) Abnormal continuously and
blocking at the Local Severe Redness at the heartbeat blood pressure and
BRAND NAME: various sites of the anesthetic hypotension injected site Methemoglobine respiratory status
Lidocaine CV body. It stabilizes Anesthetic Hypovolemia Small red or purple mia frequently during
Lidopen the neural lubricant Paracervical spots on the skin Seizures administration

membrane by when used block Skin irritation Severe allergic Assess degree of
CLASSIFICATIO impeding the ionic as topical Use with caution Constipations reaction numbness of affected
N: response that is agent in patient with Nausea Malignant part
Antidysrhythmic required in the liver disease, Confusion hyperthermia Monitor pain intensity
Local anesthetic initiation and epilepsy, Dizziness in affected area
conduction of impaired Headache periodically during
DOCTOR’S impulses. After cardiovascular Numbness and therapy.
ORDER: absorption, it may function and tingling Lab test consideration:
Lidocaine HCl cause stimulation on respiratory Drowsiness serum electrolyte level
5cc the CNS and in the ailment Tremor should be monitored
cardiovascular periodically
Date given: system that results IM administration
November 30, in a decrease in causes increase CPK
2020 electrical excitability, level
conduction rate and Serum lidocaine level
force of contraction. ranges from 1.5 to
5mcg/ml
Onset:
IV: immediate
IM: 5-15 minutes
Local: rapid
Duration:
IV: 10-20 minutes
IM: 60-90 minutes
Local: 1-3 hours
Excretion: through
urine
NAME OF DRUG MODE OF INDICATION: CONTRA- SIDE EFFECTS ADVERSE NURSING

ACTION INDICATIONS EFFECTS CONSIDERATIONS
GENERIC NAME: Ibuprofen inhibits Treatment of Hypersensitivity Upset stomach Easy bruising/ Patients with asthma,
Ibuprofen prostaglandin mild to Active GI bleeding or Nausea bleeding allergic to aspirin and has
synthesis and moderate pain ulcer disease Vomiting Ringing in the nasal polyps at highly at
BRAND NAME: decreases pain and fever Contraindicated in Headache ears risk to develop

Caldolor and inflammation. Moderate to patients with pre- Diarrhea Mood changes hypersensitivity reactions
It also helps severe pain operative pain from Constipation Unexplained Assess for any signs and
CLASSIFICATION: reduce fever. with opioid a heart surgery Dizziness/ stiff neck symptoms of GI bleeding,
Antipyretics analgesics Avoid after 30 wks. drowsiness Fluid retention renal dysfunction and
Antirheumatics Onset: Gestation (may Hypertension hepatic impairment
Nonopioids cause premature Worsening of Assess for any signs of
analgesics Duration: closure of fetal asthma allergic reaction
Nonsteroidal anti- ductus arteriosus) Bleeding in Assess the pain such as
inflammatory Excretion: Use cautiously in the stomach the type, location and
agents patients with: Severe intensity prior to and 1-2
cardiovascular allergic hours during
DATE GIVEN: disease, renal and reaction administration
November 30, hepatic disease, Liver disease Lab test considerations:
2020 dehydration, patients Abdominal evaluate periodically the
on nephrotoxic pain BUN, serum creatinine,
drugs, aspirin triad CBC and liver function
patients. test. Increased serum
Can cause fatal potassium, BUN, serum
anaphylactic creatinine, alkaline
reactions phosphatase, LDH, AST,
Use cautiously when and ALT levels. Decrease
mother is lactating in blood glucose,
Extrema caution to hemoglobin and
patients with history hematocrit concentrations,
of GI bleeding and leukocytes and platelet
ulcer disease. counts and CCr
MODE OF INDICATION CONTAINDICATI SIDE ADVERSE NURSING

ACTION ON EFFECTS EFFECTS CONSIDERATION
GENERIC NAME: Cefuroxime is a Treats Hypersensitivity Diarrhea Seizure Assess for presence of
Cefuroxime drug used to treat respiratory to cephalosporin Nausea Pseudomembran infection
certain infections tract infections, Vomiting ous colitis Obtain history to
BRAND NAME: caused by bacteria. skin and skin Serious Jarisch/ Anaphylaxis determine previous use
Ceftin It works by structure hypersensitivity to Herxheimer Serum sickness and reaction to penicillin
Zinacef interfering with the infections, penicillin reaction or cephalosporins

forming of the bone and joint Observe patent for any
CLASSIFICATIO bacteria’s cell wall infections, Use cautiously in signs and syptoms of
N: causing it to urinary tract patients with anaphylaxis
Cephalosporine- rupture resulting in infection, renal impairment Monitor bowel function
Second the death of the meningitis,
Generation bacteria gynecological
infection, Lyme
DOCTOR’S Onset: Rapid disease, otitis
ORDER: media,
Cefuroxime Duration: 6-12 septicemia,
500mg TID hours and
perioperative
DATE GIVEN: Excretion: through prophylaxis
November 30, urine
2020 Breast milk

Generic name: Oxytocin is used to Induction of Hypersensitivity Redness or CNS: coma, Assess character,
Oxytocin help the uterus labor Anticipated irritation on the seizure, frequency and duration
contract during Facilitation of nonvaginal injection site intracranial of uterine contractions,
Brand name: childbirth and also threatened delivery Loss of appetite hemorrhage uterine resting tone and
Pitocin for lactation or abortion Use cautiously in Nausea fetal heart rate
Syntocinon production of milk. Postpartum the first and Vomiting CV: hypotension continuously
Also, it is used to control of second stage of Cramping Monitor maternal blood
help speed up the bleeding after labor Stomach pain F & E: pressure and pulse
Classification: expulsion of the expulsion of Slow infusion More intense and hypochloremia, frequently throughout the
Oxytocic placenta and placenta over 24 hours frequent hyponatremia administration
hormones reduce the risk of may cause water contractions Monitor patient for any
hemorrhage. intoxication with Runny nose MISC: increase undesirable signs and
seizure and coma Sinus pain and uterine motility, symptoms and report it
Onset: occurs or maternal death irritation painful to the physician
Doctor’s order:
immediately due to oxytocin’s Memory problem contractions, Monitor maternal
Oxytocin 10 u IM
antidiuretic effect abruption electrolytes
Date Given: Duration: 1 hour placentae,
decrease uterine

November 30, bold flow,
2020 hypersensitivity

Generic Name: Methergine is used Control of Hypersensitivity Nausea Fast or slow Monitor blood pressure,
Methylergonovine to help stop the uterine Decrease the Vomiting breathing heart rate and uterine
bleeding from the hemorrhage amount of breast Stomach pain Shortness of response frequently
Brand Name: uterus by milk Diarrhea breath during medication
Methergine increasing the rate Medical history: Leg cramps Cold hands and administration
Classification: and strength of the kidney disease Increase feet Notify health care
contractions and high blood sweating Pain, redness professionals if uterine
Ergot Alkaloids the stiffness of the pressure Skin rash and swelling of relaxation become
uterus muscles. heart disease Headache arms or legs prolonged or if character
Doctor’s Order: diabetes Dizziness Chest pain of vaginal bleeding
Methergine I Amp high cholesterol Ringing in the Vision changes changes
VVTT smoking ears Confusion Assess for signs of
Raynaud’s Stuffy nose Seizure ergotism (cold, numb
Date Given: disease Unpleasant taste Serious allergic fingers and toes, chest
November 30, Complications on in the mouth reaction (rash, pain, nausea, vomiting,
2020 pregnancy itching or swelling headache, muscle pain,
of face, tongue weakness)
and throat, Lab test
severe dizziness, considerations:
trouble breathing) If no response to
medication, assess
calcium level.
Effectiveness of
medication decreases
with hypocalcemia
May cause decrease on
the serum prolactin level
PART 8: COURSE IN THE WARD (LABOR & DELIVERY)

DATE/ TIME DOCTOR'S ORDER NURSE NOTE
November 30,
2020 Admit patient to OB LR/DR Focus: Acute pain r/t labor pains
2 PM Data:
Secure consent for admission and management Subjective:
IVF- #1 D5LR 1 liter started @ 20 gtts/min,  Pain Scale: 8/10
 Guarding of abdomen and back
Diagnostic:  “Parang di ko.na kaya.”
• CBC, blood typing, urinalysis, HBsAG and  Unable to maintain one position in bed.
labor watch. Objective:
 Contractions are strong, q 4-6 mins,
Therapeutic: duration: 50 secs
 Midazolam PRN moderate pain  Fully effaced at 6 cm cervical dilatation
 Promethazine 25 mg PRN nausea and  Vital Sign: BP- 110/80
vomiting  LOA, Descent +2, moulding- 0, FHT 150
 Hydroxyzine (Vistaril) 50 mg Intramuscular bpm
ONLY x 1 dose PRN for Anxiety, Action:
 Lidocaine HCI 5cc,  Given meds for pain.
 Cefuroxime 500mg I tablet TID (post)  Back and abdominal rubs
 Warm compress over back
 Breathing Exercises
 Music Therapy
TPR q 4⁰, NPO Response:
Refer  Pain reduced: 4/10
Focus: Fluid Volume Deficit

Data:
 Feelings of nausea & vomiting
 Drank only sips of water
Action: Given anti-emetic, gave ice chips
Response: no incident of vomiting
Focus: Anxiety r/t labor experience

Data:
 “ayaw ko na, ang hirap pala”
 Not able to calm down
 Not able to position well in bed.
Action:
 Given meds for anxiety
 Breathing exercises
 Music therapy
November 30, Focus: Preparation for delivery

2020 Internal Examination Data:
6:00 pm - Fully dilated
- Vital signs taken: BP 120/80
- FTH: 150 bpm
- Moulding- 0
- Liquor Clear
Action: positioned client for IE, prepared patient for
transfer
Response: patient ready for transport
6:10 pm Transfer to DR Focus: Safety of transfer
Data: patient needing assistance from bed to
wheelchair
Action: assisted transfer
Response: safely transferred to DR
6:45 PM Delivered female baby via NSD Focus: Safe delivery
Episiotomy done Data: V/S normal, FHT- 150-155, contractions
progressing well
Action: assisted doctor, monitored v/s, FHT,
contractions, breathing techniques, coaching of
patient
7:10 PM Delivered placenta (Shultz) Focus: Safe placental delivery

Data: Fundus contracting regularly, bladder not
Therapeutics: distended, no bleeding noted, Shultz presentation
 Oxytocin 10 U IM Action: given medications ordered, monitoring of

 Methergine 1-amp VVTT uterine involution and bleeding.
 Cefuroxime 500mg I tablet TID (post) Response: placenta safely delivered
 NSAIDS (Ibuprofen) PNR episiotomy wound
Given Immediate post-partal and newborn care.
8:10 PM Transfer to room. Focus: Safe immediate post-partal stage
TPR q 4 hrs Data:
- Uterus is contracting below the navel
- Bladder not distended
- No bleeding, lochia rubra noted
- BP: 120/80
Action: monitored v/s, uterine contractions and

lochia discharge, provided post-partal care,
promoted rest
Response: safe and comfortable immediate post-
partal stage
Focus: Altered Tissue Integrity

Data: episiotomy wound
Action: monitored bleeding from wound &
inflammation, advised on wound care and healing
in vaginal area.
Response: no wound complications
PART 9: NURSING CARE PLAN
Nursing Diagnoses (labor and delivery)

1. Acute pain R/T uterine contractions
2. Fatigue R/T labor and delivery
3. Impaired skin integrity r/t episiotomy wound
4. Risk impaired mother-infant attachment
ASSESSMENT NURSING SCIENTIFIC PLANNING/ NURSING RATIONALE EVALUATION

DIAGNOSIS EXPLANATION GOAL INTERVENTION

Pain during Acute pain Pain during labor STG: Independent: 1.Attitudes and After giving
labor & delivery related to and delivery is - Develop coping 1.Assess the level reaction s to pain independent and
labor and caused by the mechanism to of discomfort are individual and dependent
Subjective: delivery contractions of decrease using verbal and based on past interventions of
Mother the uterus irritability non-verbal cues experience, the nurse, the
verbalized “Doc! muscles and the and take note on understanding of goal was met.
Hindi ko na kaya strain on cervix. -Between cultural practices physiological
sobrang saking Heavy cramping contractions, the on pain response. changes, and -The client
ng tiyan ko” can be felt in the client will appear cultural expectations developed coping
belly, groin, and relaxed/resting. 2.Time and record mechanism to
“I cesarean niyo back. the uterine 2.Monitoring the decreases
nalang ako, LTG: contractile labor progress will irritability.
sobrang sakit -The client will pattern’s provide the patient
na” learn and frequency, information about -The client was
practice strength, and her status. able to use pain
Objective: pain/discomfort length and discomfort
-The patient management 3.The most common management
looks uneasy, strategies. 3. For the first 15. side effect of strategies.
and is almost Min after regional regional block
crying due to -Clients injection, check anesthesia is - Between
pain at every discomfort blood pressure maternal contractions, the
contraction and during labor will and pulse every hypotension, which client appeared
with difficulty be minimized. 1-2 minutes, then may interfere with relaxed/resting.
with relaxing and 10-15 minutes for fetal oxygenation.
almost panting. the rest of the The block is -The client’s
labor. Elevate the prevented from discomfort was
-The patient patients head migrating up and minimized.
cannot maintain about 30 degrees causing respiratory
a single position then switch distress by elevating
in bed. position by turning the head. lateral
side to side and positioning boosts
-With every rolling her hips. placental circulation
contraction the and increases
patient shouts 4. Monitor FHT venous return.
and feels and note for
compelled to reduced variability 4. Decreased FHR

push. or bradycardia. variable is a
common side effect
5. Assist with of many anesthetic
relaxation or analgesic.
measures
(head/leg rubs, 5.Relaxation
sacral pressure, enhances sense of
back rest, wellbeing. Lateral
changing recumbent position
positions) lowers uterine
pressure on the
6. Assist with vena cava,
effleurage and the repositioning on
use of adequate regular basis avoids
breathing and/or tissue ischemia
calming strategies and/or muscle
stiffness and
7. Massage the improves comfort.
patient’s back
6. Via conditioned
responses and
Dependent: cutaneous
-Administering stimulation, it may
analgesics/pain be possible to
killers and anti- suppress pain
anxiety signals to cerebral
medication cortex. It also aids
natural progression
of labor.
7. Massaging the
patient’s back will
help to ease the
labor pain of the
mother.

Dependent:
-The IV route is
favored because it
means that
analgesics is
absorbed more
quickly and evenly,
Medication given IM
can take up to 45
minutes to achieve
sufficient plasma
levels, and maternal
absorption can be
unpredictable
particularly if the
drug is injected into
subcutaneous fat
rather than muscle.
When IV drug is
given during a
uterine contraction,
the amount of
medication that
enters the fetus right
away is reduced.
ASSESMENT NURSING SCIENTIFIC PLANNING/ INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION GOAL
Exhuastion Fatigue The North STG: Independent: Independent: After 1 hour of
related to American Within 1 hour 1. Restrcit 1. Vivid lightning, nursing
Subjective: labor and Nursing of nursing environmental noise, visitors, intervention,
“Namamanhid delivery. Diagnosis intervention, stimuli, especially numerous the goal was
buong katawan Association the mother will during planned distractions and met:

ko, at parang (NANDA) identify basis times for rest and litter in the
hindi ko kayang defined fatigue of fatigue. sleep. sorroundings can -The mother
buhatin ang related to labor limit relaxation, verbalized
baby” as and delivery is Within 1 hour 2. Instruct the disturb rest or feelings about
verbalized by an unpleasant of nursing mother to listen on sleep, and the impact of
the mother. feeling of intervention, relaxing music. contribute to fatigue.
consistent with the mother will fatigue.
Objective: “an manifest 3. Encourage -The mother
-lack of energy overwhelming comfort, ease, verbalization of 2. Relaxation manifested
- She looks sustained and alertness feelings about the techniques helps comfort, eased
very exhausted sense of actively impact of fatigue. the mother cope up and alertness
and almost not exhaustion and participate in pain and improve actively
able to hold her decreased nursing 4. Help the patient the ability to fall participated in
baby when capacity for activities to be set priorities for asleep. nursing
given to her. physical and done. desired activities activities.
mental work. and role 3.Acknowledgement
LTG: responsibilities. that living with After 7 hours
Within 6-8 fatigue is both of nursing
hours of 5. Educate the physical and intervention,
nursing patient and family emotionally the goal met:
intervention, about task challenging helps in -The mother
the mother will organization coping. reported
report improve methods and time improved
sense of organization 4. Setting priorities sense of
energy. methods. is one example of energy.
an energy
Dependent: conservation
-Administer pain technique that
relief as ordered by allows the patient to
the physician. use available
energy to
-Promote sufficient accomplish
nutritional intake. important activities.
5. Organization and
management of

time can assist the
patient save energy
and avoid fatigue.
Dependent:
- To reduce the
effect of pain and to
able to resume
activity, maintain
effect, mood, and
sleep.
-The mother will

need properly
balanced intake of
fats, carbohydrates,
proteins, vitamins,
and minerals to
provide energy
resources.

Episiotomy Impaired skin Episiotomy STG: Independent: Independent: After giving
wound integrity related involves surgical After 3 hrs. of nursing
to episiotomy incision on the intervention, the 1. Monitor status 1.Individualized intervention, the
Subjective: tissue between client was able around wound. care plan is was goal met:
According to the the vagina and to describe Monitor patient’s necessary -The client was
client she stated the anus or off measures to skin care according to able to
that she can feel to the side of the protect and heal understand the
practices, noting patient’s skin
pain around the vagina to the wound. causative risk
incision site. enlarge the the type of soap condition, factors.
outlet. Research LTG: or other needs, and
The client suggests that an After 2 days of cleansing -The patient was

verbalized that episiotomy nursing agents used, preference. able to initiate
"May konting when combined intervention: and temperature behaviors to
hapdi po akong with -The pain felt by of water. 2. Cleaning limit and reduce
nararamdaman instrumentation the client is removes the risk of
sa part po ng makes it more lessen. 2. Demonstrate urinary/fecal complications.
tahi kop ag likely that the contaminants. It
correct perineal
naglalakad po woman will have -The client was also prevents -The client
cleaning after bacterial growth.
ako at umuupo" deep perineal able to clean her achieves timely
tears and incision voiding. healing, with
normal perineal independently 3. Elevations in normal vital
tears. 3. Monitor vital signs
Objective: signs.
temperature, accompany
V/S
T: 36.5 °C pulse, and infection.
R:18 cpm respirations.
P:80 bpm Note presence Dependent:
BP: 120/80 of chills. -Wound
-The episiotomy infections may
wound has a Dependent: be managed
sign of swelling well and more
and redness -Administer efficiently with
around the antibiotics as topical agents,
incision area ordered although
intravenous
antibiotics may
be indicated.

Psychological Risk impaired According to STG: Independent: Independent: The goal was
changes in mother-infant North American After 8 hours of 1.Educate 1.Helps clarify met:
taking-in phase attachment Nursing comprehensive parents realistic -The mother will
Diagnosis interventions the regarding child expectations identify and
Subjective: Association, risk patient will: growth and demonstrate
The mother for impaired Be able to development, 2.Reinforces techniques to

verbalizes: parent-infant interact with addressing continuation of enhance
"hindi pa po ako attachment newborn to the parental desired behavioral
ready na defined as very least way. perceptions behaviors organization of
alagaan yung disruption of the Be able to the neonate
anak ko, interactive identify parental 2.Recognize 3.To know what
natatakot po process between strengths. and provide the parent’s
akong buhatin parent/significant positive feelings about -After discharge
baka mahulog other and infant LTG: feedback for the situation. the parents will
ko po" that fosters the After a week of nurturing and be able to have
development of comprehensive protective Dependent: a mutually
Objective: a protective and interventions, parenting -The mother satisfying
T:37°C nurturing the patient will: behaviors needs support interactions with
PR: 70 bpm reciprocal Be able to to manage their newborn.
RR: 17 cpm relationship. restore her 3. Interview appropriate
BP: 120/80 Possible causes health. parents, noting behaviors
mmHg include Be able to their perception towards the
-Mother cannot inadequacy of spend more of situational infant. Use of
hold the baby the parent or time with and individual support systems
parent substitute newborn, concerns. and social
(such as anxiety discharge/room- service can
or substance in provide
abuse), illness in opportunity to
the child, decrease
Dependent:
physical feelings of
-Initiate referrals
separation, lack inadequacy.
to community
of privacy, and
agencies, parent
others.
education
opportunities,
stress
management
training, and
social support.
References:

1. Pilliteri A., Maternal and Child Health Nursing, 4th ed, Philadelphia: Lippincott
2. Fraser, D & Cooper, M. Myles Textbook for Midwives. 14th ed. Toronto, Churchill: Livingstone.
3. https://www.onhealth.com/content/1/pregnancy_stages_trimesters#:~:text=A%20typical%20pregnancy%20lasts
%2040,undergoes%20many%20changes%20throughout%20maturation.
4. https://www.womenshealth.gov/pregnancy/youre-pregnant-now-what/stages-pregnancy
5. https://helloclue.com/articles/life-stages/most-common-symptoms-early-pregnancy
6. https://wa.kaiserpermanente.org/healthAndWellness/index.jhtml?item=%2Fcommon%2FhealthAndWellness%2Fpregnancy
%2Fbirth%2FlaborStages.html
7. https://www.stanfordchildrens.org/en/topic/default?id=fetal-circulation-90-P01790
8. https://www.healthline.com/health/womens-health/period-signs#breakouts
9. https://www.heart.org/en/health-topics/congenital-heart-defects/symptoms--diagnosis-of-congenital-heart-defects/fetal-
circulation#:~:text=When%20blood%20goes%20through%20the,right%20side%20of%20the%20heart.
10. https://my.clevelandclinic.org/health/articles/9675-pregnancy-types-of-delivery
11. https://www.webmd.com/baby/guide/first-trimester
12. https://kidshealth.org/en/parents/week1.html
13. https://www.news-medical.net/health/Episiotomy-Procedure.aspx#:~:text=An%20episiotomy%20procedure%20is
%20done,the%20baby%20to%20come%20out.
14. https://www.karger.com/Article/FullText/508487
15. https://nurseslabs.com/menstrual-cycle-disorders/#definition
GROUP ASSIGNMENTS:
1. 3 Ps- MAGDAY-NADHINE,
2. Brief Description or Background of Patient’s Pregnancy, labor and delivery, menstruation

 OMLI-JAY, PASCUA-MARC,
3. Anatomy and Physiology-

 UYBAAN-MARK, GUILLERMO-ANGELA

4. Physiology of Pregnancy, labor & delivery –it should be in paradigm format
 MACARIO-REMELYN, MANGIBEN-JENLEXY,
5. Laboratory Results and Diagnostic Studies-
 MANUEL-ERICA, NAYAM-O-EDZYL
6. Physical Assessment and Its Physiological Basis

 MAGDAY-NADHINE, SAMAYO-TANIA ROSE,
7. Drug Analysis
 MERTO, KRISTINE JOY, MILLANO-MMYRA
8. Course in the Ward

 DE LEON-AUDREY
9. Nursing Care Plan

 GUILLIEN-MARC, GUINID-JAMIE, & SISON-KAYE

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Saint Mary’s University

School of Health and Natural Sciences

A Clinical Case Study Presented to the faculty of the

NORMAL SPONTANEOUS DELIVERY

NCM 107_Group Case Study Section C-Group 3 1

NCM 107_Group Case Study Section C-Group 3 2

BSN 2-C Group 3

NCM 107_Group Case Study Section C-Group 3 3

Admitting Diagnosis G1P0 (0-0-0-0)

NCM 107_Group Case Study Section C-Group 3 4

LABOR AND DELIVERY

NCM 107_Group Case Study Section C-Group 3 5

PART 2: DESCRIPTION OF PATIENT’S CONDITION

Part 2 presents the following:

Trimester Presumptive Probable Positive

NCM 107_Group Case Study Section C-Group 3 6

The patient reported the following signs of pregnancy:

THE STAGES OF PREGNANCY

First Trimester of the mother (week 1- week 12)

NCM 107_Group Case Study Section C-Group 3 7

Second Trimester of the mother (week 13- week 28)

 Body aches, such as back, abdomen, groin, or thigh pain

NCM 107_Group Case Study Section C-Group 3 8

DIAGNOSTIC PROCEDURE FOR CONFIRMATION OF PREGNANCY

NCM 107_Group Case Study Section C-Group 3 9

NCM 107_Group Case Study Section C-Group 3 10

NCM 107_Group Case Study Section C-Group 3 11

 Physical Examination and  Physical examination, fundi  Physical examination, fundi

 Screening for medical  Screen danger signs:  Screen danger signs:

NCM 107_Group Case Study Section C-Group 3 12

NCM 107_Group Case Study Section C-Group 3 13

NCM 107_Group Case Study Section C-Group 3 14

e. Position- relationship of presenting part to the four quadrants of the mother’s

NCM 107_Group Case Study Section C-Group 3 15

4. Psych- preparedness of the mother

THE STAGES OF LABOR

NCM 107_Group Case Study Section C-Group 3 16

1. First stage of labor

Phases in The First Stage of Labor

TRANSITION Very strong 60- 90  Tired, loss of sense of

NCM 107_Group Case Study Section C-Group 3 17

The baby moves through the birth canal

NCM 107_Group Case Study Section C-Group 3 18

3. Third stage of labor

Types of Placental Separation:

NCM 107_Group Case Study Section C-Group 3 19

 Separation of the  Peripheral separation to  Delivery of placenta by bearing down

4. Fourth stage of labor (IMMEDIATE POST-PARTUM)

CHARACTERISTICS OF DISCHARGE AFTER

NCM 107_Group Case Study Section C-Group 3 20

CHARACTERISTIC AVERAGE RANGE

Interval b/w cycles 28 days 23-35 days

Duration Flow ,3-7 days 1-9 days

Average Amount 50 ml 30-80 ml

Color Dark red

Initial Signs of Menstruation:

1. Abdominal cramps 6. Bowel issues

NCM 107_Group Case Study Section C-Group 3 21

GROUP CASE STUDY_NCM 107_GROUP 3 22

GROUP CASE STUDY_NCM 107_GROUP 3 23

Coronavirus Disease 2019 in pregnancy: A clinical management protocol and

GROUP CASE STUDY_NCM 107_GROUP 3 24