Liceo de Cagayan University

LICEO DE CAGAYAN UNIVERSITY
PASEO DEL RIO CAMPUS

COLLEGE OF NURSING
RODELSA CIRCLE, CAGAYAN DE ORO CITY
IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS IN NCM 107
RELATED LEARNING EXPERIENCE (RLE)
OB CASE STUDY
SUBMITTED BY:
Acierto, John Bill V.
Ananggo, Cherine I.
Balaba, Michael Christian
Balase, Xyra Ann Dell L.
Belaya, Martin Louie F.
Blanila, Allyah Marie E.
Bongcales, Jesha G.
Cabantac, Rochel Nicca C.
Cabunoc, Zyla Mae Andrea P.
Casanos, Chiela Mae B.
SUBMITTED TO:
Mrs. Irene. Mina
DECEMBER 2022
Table of Contents
I. Introduction -------------------------------------------------------------------------------------------- 1
II. Patient’s Profile ------------------------------------------------------------------------------------- 2
III. Physiology of Labor/ Pregnancy --------------------------------------------------------------- 3
Definition of Labor
Theories of Labor
Signs of Labor
Components of Labor
IV. Ideal Nursing Intervention ---------------------------------------------------------------------- 11
Antepartum
Intrapartum
Postpartum
Newborn Care
V. Nursing Assessment with Observation and Actual Implementation with NCP ----- 18
VI. Referral and Summary ------------------------------------------------------------------------- 47
VII. Bibliography ------------------------------------------------------------------------------------- 48

INTRODUCTION
Obstetrics and gynecology as a branch of medicine in caring women during

pregnancy and childbirth is the main topic of this case study. Caring for the unique client
from the time she is pregnant is critical to getting a better outcome during the birthing phase.
This case study discusses the events of pregnancy from the perspective of the chosen client
of the study's proponents. This case study is about gaining a better understanding of
pregnancy and childbirth to form better opinions regarding acceptable care for expectant
women. The primary purpose of this study is to fill gaps in knowledge and offer a bridge to a
better understanding of pregnancy and delivery care
Taking on OB case studies, or any case studies, has been shown to benefit nursing
students' development. For that matter, an OB case study is one factor that will assist nursing
students, such as the study's proponents, in achieving a greater magnitude of understanding
about pregnancy and childbirth, health related to that, and the identification of appropriate
nursing care and intervention to advocate and promote well-being to clients. The primary
purpose of this research is to improve nursing care and gain a better understanding of
pregnancy and delivery concepts.
In line with this, the main subject of this case study is M.P.V, and she is currently a
gravida 4, para 4 patient who gave birth to her current child last December 4, 2022. The
proponents of this study have assessed this patient for the past four months, and the
developments from the second trimester to the postpartum stage have been noted and
documented in a critical fashion to serve as the foundation of the main goal of this study,
which is to build a better foundation of knowledge and to develop one's ability to provide
nursing care. This research is carried out through assessments, the identification of nursing
difficulties, diagnosis, and the development of nursing care plans that are prioritized to
minimize or eliminate recognized mother and child nursing problems.
The nursing assessments, diagnosis, and planning are all included in this case study.
This case study aims to assist and provide therapeutic interventions to the selected client. The
mother nursing concerns are recognized with the help of this case study, and the goals will be
fulfilled utilizing nursing assessments, interventions, planning, diagnosis, and evaluation.
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PATIENT’S PROFILE
Name Meldred P. Villamero
Sex Female
Birth Date December 31, 1998
Age 23 years old
Civil Status Single
Nationality Filipino
Address Takisay, Tunhai Phase 2, Indahag
Cagayan de Oro City
Religion Roman Catholic
Educational Attainment Grade 7
Occupation None
Income None
Weight 59 kg
Height 144 cm
Allergies No known allergy
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PHYSIOLOGY OF LABOR/ PREGNANCY
➢ Definition of Labor
Term labor is a physiologic process involving a sequential, integrated set of changes
within the myometrium, decidua, and cervix that occur gradually over a period of
days to weeks, culminating in rapid changes over hours that end with expulsion of the
products of conception (fetus and placenta).
➢ Theories of Labor
Theories have been proposed to explain how and why labor occurs.
o Uterine Stretch theory

The idea is based on the concept that any hollow body organ when stretched
to its capacity will inevitably contract to expel its contents. The uterus, which
is a hollow muscular organ, becomes stretched due to the growing fetal
structures. In return, the pressure increases causing physiologic changes
(uterine contractions) that initiate labor.
o Oxytocin theory
Pressure on the cervix stimulates the hypophysis to release oxytocin from the
maternal posterior pituitary gland. As pregnancy advances, the uterus
becomes more sensitive to oxytocin. Presence of this hormone causes the
initiation of contraction of the smooth muscles of the body (uterus is
composed of smooth muscles).
o Progesterone deprivation theory

Progesterone is the hormone designed to promote pregnancy. It is believed
that presence of this hormone inhibits uterine motility. As pregnancy
advances, changes in the relative effects estrogen and progesterone encourage
the onset of labor. A marked increase in estrogen level is noted in relation to
progesterone, making the latter hormone less effective in controlling rhythmic
uterine contractions. Also, in later pregnancy, rising fetal cortisol levels
inhibit progesterone production from the placenta. Reduce progesterone
formation initiates labor.
o Prostaglandin theory
In the latter part of pregnancy, fetal membranes and uterine decidua increase
prostaglandin levels. This hormone is secreted from the lower area of the fetal
membrane (forebag). A decrease in progesterone amount also elevates the
prostaglandin level. Synthesis of prostaglandin, in return, causes uterine
contraction thus, labor is initiated.
o Theory of Aging Placenta
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Advance placental age decreases blood supply to the uterus. This event
triggers uterine contractions, thereby, starting the labor.
➢ Stages of Labor
First stage. During the onset of labor, your cervix will complete dilation. Early in
this stage, you may not recognize that you are in labor if your contractions are mild
and irregular. Early labor is divided into two phases:
a. The latent phase is marked by strong contractions that usually occur at

five- to 20-minute intervals. During this phase, your cervix will dilate approximately
3 to 4 centimeters and efface. This is usually the longest and least intense phase of
labor. You may be admitted to the hospital during this phase. Your doctor will
perform pelvic exams to determine the dilation of the cervix.
b. The active phase is signaled by the dilation of the cervix from 4 to 10

centimeters. Your contractions will likely increase in length, severity and frequency,
occurring at three- to four-minute intervals. In most cases, the active phase is shorter
than the latent phase.
Second stage. Often referred to as the pushing stage of labor, this stage starts when
your cervix is completely opened and ends with the delivery of your baby. During the
second stage, you become actively involved by pushing the baby through the birth
canal. Crowning occurs when your baby’s head is visible at the opening of the vagina.
The second stage is usually shorter than the first stage and may take between 30
minutes and three hours for your first pregnancy.
Third stage. After your baby is delivered, you will enter the third and final stage of
labor. This stage involves the passage of the placenta (the organ that nourished your
baby inside of the uterus) out of the uterus and through the vagina. The delivery of
the placenta may take up to 30 minutes.
➢ Signs of Labor
You know you’re in true labor when:
You have strong and regular contractions. A contraction is when the muscles of
your uterus tighten up like a fist and then relax. Contractions help push your baby out.
When you’re in true labor, your contractions last about 30 to 70 seconds and come
about 5 to 10 minutes apart. They’re so strong that you can’t walk or talk during
them. They get stronger and closer together over time.
You feel pain in your belly and lower back. This pain doesn't go away when you
move or change positions.
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You have an increase in vaginal discharge that can be clear, pink or slightly
bloody (brownish or reddish). This is called bloody show. It can happen a few days
before labor or at the beginning of labor. If you have bright red bleeding or if the
bleeding is heavy, tell your provider right away.
Your water breaks. Your baby has been growing in amniotic fluid (the bag of
waters) in your uterus. When the bag of waters breaks, you may feel a big rush of
water. Or you may feel just a trickle.
➢ Components of Labor
1. Passageway - refers to the route a fetus must travel from the uterus through
the cervix and vagina to the external perineum.
• Soft passages - cervix, vagina and perineum
• Bony passage – pelvis
Division of the pelvis
• True pelvis - lower, curved, smaller portion, the canal through which the
fetus pass
• False pelvis - upper, larger but shallow division, supports the uterus
Bones of the pelvis
- It consists of 4 bones- nominate bones (2), Sacrum (1) and Coccyx (1)
Planes of the pelvis
a. Diagonal Conjugate - measure between sacral promontory and inferior margin

of the symphysis pubis.
Measurement:
11.5 cm - 12.5 cm basis in getting true conjugate,
(DC-11.5 cm= true conjugate)
b. True conjugate /conjugate vera - measure between the anterior surface of the
sacral promontory and superior margin of the symphysis pubis.
Measurement: 11.0 cm
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c. Obstetrical conjugate - smallest AP diameter.
Pelvis measuring at 10 cm or more.
2. Passenger - refers to the fetus and it's ability to move through the passageway
a. Size of the fetal head and the capacity of the head to mold into passageway.
➢ Fetal head - seven bones
• 2 frontal
• 2 parietals
• 2 temporals
• 1 occipital
➢ Suture - thin spaces in between bones
• Sagittal suture - longitudinal, between two parietal bones.
• Frontal suture - Anterior, between two frontal bones.
• Coronal suture - Anterior located between the frontal and parietal bones
• Lambdoidal suture - Posterior, between parietal and occipital bone
➢ Fontanels - Point of intersection of cranial bones; membranous spaces

between cranial bones during fetal life and infancy.
• Anterior Fontanel
o Bregma
o Formed by 2 frontal bones and 2 parietal bones
o Measures 2.5 cmx2.5 cm
o Closes in 12 to 18 months
• Posterior Fontanel
o Lambda
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o Formed by the union of 2 parietal and 2 occipital bones
o Triangular in shape
o Closes 6-8 weeks or 2 to 3 months
Fetal Head Diameter
• Anteroposterior (AP) diameter
1. Occipito mental
-12.5cm -13.5cm
-widest AP diameter
2. Occipitofrontal
-12cm
3. Suboccipitobregmatic
-9.5 cm
-narrowest
3. Power -Refers to the frequency, duration, and strength of the uterine

contraction to cause complete cervical effacement and the dilation
o Primary power: UTERINE CONTRACTIONS
Characteristics:
- Involuntarily
- Intermittent
- Regular activity of uterine musculature
Purposes
- Propel presenting part downward/forward
- Effacement of the cervix
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- Dilation of the cervix
Effects
1. Increase maternal BP due to peripheral arteriole pressure- therefore check

maternal BP between contractions for accurate result
2. Decreased blood flow to the uterus; prolonged uterine contraction can cause
fetal hypoxia
3. Cervical dilation during the first stage
4. Contraction with pushing/bearing down, expel the fetus and the placenta
during the second and third stages of labor. Respectively.
Phases
1. Increment (CRESCENDO)
- The phase of increasing intensity of contraction; the first phase; the onset
2. Acme (APEX)
- The height of uterine contraction
3. Decrement (DECRESCENDO)
- The phase of decreasing contraction; the last phase; the end
DURATION
o The period from increment to decrement of the same contraction
o Maximum duration under normal circumstances; 90 seconds, found during the

transition phase and second stage of labor.
FREQUENCY
o Period from the increment of the first contraction to the increment of the
second contraction.
INTERVAL
o Period from the decrement of the first to the increment of the second
contraction
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o Time for checking maternal BP, FHT, Delivering the fetal head in
participating labor to prevent laceration
o Time for maternal sleep and relaxation during labor.
INTENSITY
o May be mild, moderate, and strong
o -With uterine contraction. These uterine changes occur.
o Upper uterine segment becomes thicker and shorter; lower uterine segment
become thinner and longer
o Secondary power: Involuntarily bearing down, abdominal muscle

contraction, contraction of levator ani muscle.
o Ferguson Reflex- maternal involuntary urge to push stimulated by stretch

receptor in the pelvic area.
o Psyche/Person – (mother) psychological stress exist when the mother is

fighting the labor experience (effective pushing)
a. Cultural Interpretation
b. Preparation
c. Experience
I. Person - Pregnant women’s general behavior and influences upon her and
influence labor progress.
o Cultural influence and perceptions about labor and delivery
o Responses to uterine contraction
o Childbirth preparation process (classes)
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o Support system
o Previous experiences
o Ability to communicate feelings to significant others
Causes of pain in labor
➢ Traction on the peritoneum - Uterine contraction
➢ Emotional tension
➢ Hypoxia
➢ Pressure
➢ Relaxation, awareness, and participation in labor result to less intense and

shorter labor
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IDEAL NURSING INTERVENTION
Antepartum Period
Assessment
During the home visitation to our client, we are going to assess the patient by taking
her.
o Name o Insurance
o Age o Information
o Occupation o Vital signs
o Marital status
a. Determine if the woman smokes or drinks, its frequency, and amount because these
vices could cause fetal alcohol syndrome or preterm birth.
b. Assess any early signs of pregnancy such as nausea and vomiting, fatigue, and breast
tenderness
c. Assess possible symptoms such as headaches, altered vision, abdominal pain, nausea
or vomiting, vaginal bleeding, leakage of fluid, or dysuria. During early second
trimester gestations, patients may begin to endorse the perception of fetal movement.
1. Proper gestational age and dating
2. Determine the first day of the last menstrual period of the woman.
3. A complete history should be taken including.
O Detailed history of past medical problems that may be of concern

during pregnancy
O Previous surgeries
4. Assess the woman’s pregnancy history using GTPALM.
a. G is the gravid classification or the number of times the woman
became pregnant.
b. T is the number of full-term infants born.
c. P is the number of preterm infants born.
d. A is the number of miscarriages or therapeutic abortions.
e. L is the number of living children.
f. M refers to multiple pregnancies
5. Current issues and complaints should also be addressed.
6. Determine the presentation of the fetus by doing the Leopold’s maneuver
7. Perform health teachings to the client.
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Medication
o Take a prenatal vitamin as ordered by the doctor
Exercise
o Encourage to have antepartum exercises- these exercises will help reduce the
circulation of the blood, relieve discomfort, alleviate pain and preparation for labor
and delivery
o Pelvic rocking o Ribcage lifting
o Knee-chest twist o Shoulder circling
o Leg raising o Knee-bending
o Tailor sitting o Calf stretching
Treatment
o To encourage the client to visit a health center or hospital for laboratory tests , fetal
heart rate of the patient and to know what kind of medication or vitamins that she
will be taking.
o Encourage the client to get enough sleep
Diet
o Encourage the client to eat healthy foods
o Encourage the client to eat high-fiber foods.
o Choose foods and drinks with less added sugars, saturated fats, and sodium (salt).
o Take a prenatal vitamin
o Record the updated histories with each visit, reviewing current pregnancy-related
issues and reviewing newly occurring issues
o Review of new symptoms such as headaches, altered vision, abdominal pain, nausea
or vomiting, vaginal bleeding, leakage of fluid, or dysuria.
Dependent
o Administered medication if there’s any complications as order by the doctor
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Intrapartum Period
1. Assessment level
• Location
• Duration
• intensity of pain
• factors that intensify or relieve pain.
• Check regularity
• Interval
• Frequency
• and duration of contraction by palpation with finger trips.
• Check show (bloody) of true labor.
2. Promoting comfort
• touching and reassurance as a basic nursing intervention.
• damp washcloths on the women’s face.
• Give Ice chips, frozen juice bars, or hard candy on a stick to reduce the
discomfort of dry mouth.
3. Provide emotional support and encourage verbalization of feelings to reduce anxiety.
4. Promote changes position
• Facilitate and encourage women for frequent position changes while women
in bed.
• Ensure upright position to promote effective pushing and take advantage of
gravity.
• Place woman’s legs in stirrups
5. Show respect to the woman and allow her family member if she wants.
6. Perform vaginal examination;
• determine cervical effacement
• fetal presentation position
• station.
7. Check fetal heart rate by auscultation and apply an external fetal monitor.
8. Assess Fetal Heart Rate more frequently if abnormalities are identified.
9. Carefully monitor intake output and each time of void
10. Encourage the woman to void 2-3 hourly to avoid bladder distension.
11. Arrange all instruments for final preparation of the birth.
• Baby’s cloth, bonnet, gloves and socks
• Dry towel
• Cord clamp
• Surgical scissor
• Kelly curved
• Kelly Straight
• Sterile gloves
• 3cc syringe
• Gauze
• Thumb forceps with teeth and without
12. Keep the perianal area clean during baby out.
13. Encourage women to put all their efforts into pushing the newborn to the outside
world.
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14. Assess the newborn and provide initial nursing care
15. Clean the perineum area after delivery to find any laceration.
16. Check uterine contraction, fundus of the uterus after delivery.
17. Transfer the mother to the recovery room and ensure a warm environment.
18. Check vital signs every 15 minutes of the mother after delivery.
• Blood pressure
• Temperature
• Respiratory rate
• Pulse rate
• Oxygen level
Dependent
• Administer oxytocin as order and indicated after placental expulsion.
Postpartum Period
Providing nursing care to a postpartum woman during the first 24 hours entails the
following:
o Assess the woman’s family profile to determine the impact that the newborn would
give to the family and to the woman.
o Assess the woman’s pregnancy history, especially if the pregnancy was planned or
unplanned as it will determine the ability of the woman to bond with the newborn.
o Assess the labor and birth history such as the length of labor and if any analgesia or
anesthesia was used to determine any necessary procedures to be done.
o Determine the infant’s data and profile to help with planning the care of the newborn
and promote bonding between the parents.
o The woman would also need a postpartum course such as her activity level after birth,
any difficulties or pain felt, and if she is successful with infant feeding to determine
any need for anticipatory guidance in home care.
o Assess any laboratory data of the woman to be certain that she is recovering well and
if any procedures or additional diagnostic tests need to be performed.
o Assess the woman’s general appearance because it is a reflection of how well the
woman is moving into the taking hold phase of recovery.
o Assure the woman that losing a quantity of her hair is not a sign of illness but because
she is returning to her nonpregnant state, as hair grows rapidly during pregnancy
because of increased metabolism.
o Assess for facial edema, especially for a woman with pregnancy-induced
hypertension.
o Advise the woman to purchase a nursing bra that is one to two sizes larger than her
pregnancy size to allow for increase.
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o Assess the woman’s breast for any cracks or fissures, and avoid squeezing the nipple.
Also, assess for signs of mastitis such as inflammation of a certain part of the breast.
o Assess the location, consistency, and height of the fundus through palpation.
o If the uterus is not firm upon palpation, massage it gently. Placing the infant on the
mother’s breast also aids in stimulating contractions.
o Lochia is expected in a postpartum woman for 2 to 6 weeks, so assessment of its
characteristics is necessary to determine if it is the normal lochia or not.
o Observe the perineum for ecchymosis, hematoma. Edema or any drainage and
bleeding from the stitches.
Newborn Care
Assessment for Well-Being
Assessment of the newborn immediately starts the moment he or she is delivered, and there
are a lot of standard assessments used to evaluate them rapidly.
Apgar Scoring
The Apgar Scoring is done during the first 1 minute and 5 minutes of life. The heart rate,
respiratory rate, Muscle tone, reflex irritability, and color are evaluated in an infant. Apgar
score is the baseline for all future observations.
Indicator 0 1 2
A Activity Absent Flexed arms and legs Active
P Pulse Absent Below 100 bpm Over 100 bpm
Minimal response to Prompt response to

G Grimace Floppy
stimulation stimulation
Blue; Pink body, blue

A Appearance Pink
pale extremities
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R Respiration Absent Slow & irregular Vigorous cry
• Each parameter can have the highest score of two and the lowest is 0.
• The scores of the five parameters are added to determine the status of the
infant.
Apgar scoring
• 0-3 points: the baby is serious danger and need immediate resuscitation.
• 4-6 points: the baby’s condition is guarded and may need more extensive
clearing of the airway and supplementary oxygen.
• 7-10 points: are considered good and in the best possible health.
•
Care for the newborn after a vaginal delivery.
1. Apply appropriate cord clamp.
2. Providing warmth for the newborn.
• Encouraging Skin-skin care of the mother
• Dress the infant
• using heated mattresses and blanket wraps
Physical exam for the newborn in the delivery room.

Some of these techniques consist of:
• Measurement of the temperature, heart rate, and respiratory rate
• Measurement of weight, length, and head circumference.
• Cord care
• Bath.
• Eye care
• Initiate breastfeeding.
Assessing heart rate

• Lay your baby down on the back with one arm bent so the hand is up by the ear.
• Feel for the pulse on the inner arm between the shoulder and the elbow: Gently press
two fingers (don't use your thumb) on the spot until you feel a beat.
• When you feel the pulse, count the beats for 15 seconds.
• If the baby isn't crying at 1 minute of life, measure the heart rate by auscultation or
palpation.
• Often, the umbilicus is used to palpate the heart rate. Use your index finger and
thumb to “tap” out the heart rate, holding up your index finger so all can see the taps.
Dependent Ideal Nursing Newborn Care Interventions
Administer prophylactic eye ointment or drops
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Administer prophylactic eye ointment or drops after baby makes eye contact with
parents.Initiate breastfeeding.Wean from radiant warmer.
Administer hepatitis B immunization with parent consent

Administer hepatitis B immunization with parent consent. Administer vitamin K
(phytonadione [AquaMEPHYTON]) intramuscularly.
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ACTUAL NURSING INTERVENTION
Antepartum Period
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ACTUAL INTERVENTIONS
During antepartum period, our patient was able to apply some nursing interventions and we
discussed to her that she could do the following interventions at home.
● The group provided a nursing intervention for the client, who is 36 weeks of gestation
along in her pregnancy, to introduce soothing activities like having a warm bath,
listening to peaceful music, reading a book, and relaxing exercises before bed, as well
as milk consumption.
● The group was concerned about the client's rapid weight gain at 36 weeks of
gestation, so they gave her a nursing intervention about a balanced diet and eating
schedule
● The client was given nursing intervention on antepartal activities since the group was
concerned about the client’s contraction around her abdomen and weight increase at
36 weeks of gestation
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● The group also provided a nursing intervention on how to breastfeed the baby
appropriately.
HEALTH TEACHING
Name of patient: M.P.V
Medicatio Vitamin B12 and vitamin D are important since they support the
n development of the baby's nervous system (B12) and skeleton (D). Also,
the ferrous sulfate, it will prevent iron deficiency
Exercise The patient is recommended to do exercises like pelvic tilting and pelvic
rocking, since it relieves backache during pregnancy at it can strengthens
back. She can also do tailor sitting or ribcage lifting since it helps the
muscles of the back
Treatmen She can try heat or cold massage. Application of a heating pad or ice pack
t to the back can help to ease pain and for good circulation
Out- Since the patient is at 8 months on her pregnancy. It is much better, and
patient light recommended to have prenatal checkup regularly. And prepare the
(Check- woman for upcoming labor, lactation, and child rearing
up)
Diet The patient should eat light, nutritious, and easily digestible
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Intrapartum Period
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• Promoted comfort by touching and reassurance as a basic nursing intervention.

• Promoted comfort by cool, damp washcloths on the women’s face.
• Established a therapeutic relationship with the pregnant woman and with her
relatives.
• The most important nursing interventions were providing emotional support and
encourage verbalization of feelings to reduce anxiety.
• Facilitated and encouraged women for frequent position changes while women in
bed.
• Checked maternal vital signs to identify the sign of hypertension or hypotension.
• Checked regularity, interval, frequency, and duration of contraction by palpation with
finger trips.
• Assessed level, location, duration, intensity of pain, and factors that intensify or
relieve pain.
• Assessed the severity of pain whether additional pain control measures are needed.
• Checked show (bloody) of true labor.
• Checked fetal heart rate by auscultation and apply an external fetal monitor.
• Checked Fetal Heart Rate hourly during the latent phase, every 3o minutes during the
active phase, and every 15 minutes during the second stage.
• Assessed Fetal Heart Rate more frequently if abnormalities are identified.
• Ensured upright position to promote effective pushing and take advantage of gravity.
• Placed woman’s legs in stirrups.
• Encouraged client to put all their efforts into pushing the newborn to the outside
world.
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HEALTH TEACHINGS
Name of Patient: M.P.V
Instruct client to take medication as directed, those antibiotics such as

cephalexin and amoxicillin. At the same time each day, even if
MEDICATION feeling well, do not skip or double up on missed doses.
Avoid any activity that could cause trauma to your abdomen. Don’t
EXERCISE perform exercises that involve bouncy jerky motions.
TREATMENT
- Take medications as prescribed by the physician.
- Monitor Vital Signs before and after labor.
OUT-PATIENT Advice to see a physician four to six weeks after delivery for
(Check-up) further check-up.
DIET Eat a well-balanced and healty foods diet.
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Postpartum Period
BIBL
]\
Page 33
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During postpartum or after the delivery, our patient was able to apply some nursing
interventions we discussed that that she could do at home.
• One of these is bathing and sitz baths, she applied this for herself to prevent from
any infection after delivery. Also, according to her, it makes her body relaxed after
taking a bath.
• She also monitored herself for any vaginal bleeding or other vaginal discharge.
• Even though it is not new to her to give birth and do breastfeeding, she applied our
health teachings about how to do breast care before breast feeding the newborn. To
make sure that her breast was clean.
• Postpartum exercises.
• Every time she felt any discomfort or minimal pain on her uterus, we instructed the
family to massage uterus or and apply ice compact.
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• We demonstrated the principles of perineal care for fast recovery and healing.
• We advised her to keep on visiting the health center to keep her and her baby
monitored. She was also advised about the different family planning that she could
use while she is still recovering from the delivery and when is the best time for her
and her partner to be engaged again in sexual intercourse.
• She took medications prescribed by the doctor.
HEALTH TEACHINGS
Name of Patient: M.P.V

MEDICATION The patient is taking Cefalexin as her
antibiotic, Mefenamic Acid to reduce pain,
and Tranexamic for bleeding. 500 mg good
for three times a day.
EXERCISE Postpartum Exercise (During our semi-final
visit, we advise and taught our patient about
some postpartum exercises she can apply
after giving birth as long as the assigned
physician allow her to do so. She did listen on
what we have said because she takes notes on
what exercises she could do with the doctor’s
approval as long as she will not strain herself
too hard.)
TREATMENT The client was experiencing perineal
discomfort and pain. We advise the patient
change sanitary pads if she is advised to have
it, at least every four hours—this can help
reduce the risk of infection. Also, to lie down
for approximately 20–40 minutes in each hour
for the first 24 hours, if you can, as this
reduces any swelling and assists healing.
Get plenty of rest, get as much sleep as

possible to cope with restlessness and fatigue.
OUT- PATIENT It is recommended to have a check up for at
least 3 weeks after giving birth, to monitor the
patient’s health. During the check-up, the
patient should undergo physical exam,
exercise needed, immunization and
medication. Family planning will also be
discussed.
DIET - Stay hydrated all day
- Keep an eye to her calories
- Continue prenatal vitamins
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Newborn Care
Actual Nursing Interventions for Newborn care:

- Monitor/Check the infant’s vital signs.
- Provide health teaching for mother of child on how to take care of a newborn.
- Ensure that the infant is living in a clean environment.
- Encourage breastfeeding.
Weight: 3.8 kls

Temperature: 36.7 °c
Head circumference: 35cm
Abdominal circumference: 32.5cm
Mid-Arm circumference: 7.5 cm
Length: 57cm
HEALTH TEACHING
• Taught the parents on how to properly and securely handle a newborn baby.
o Told them to wash their hands (or use a hand sanitizer) before handling their
baby.
o Support the baby's head and neck when carrying the baby.
o Never shake the newborn, whether in play or in frustration.
o Make sure the baby is securely fastened into the carrier, stroller, or car seat.
• Instructed the parents to have bond and soothing with their babies.
o For infants, the attachment contributes to their emotional growth, which also
affects their development in other areas, such as physical growth.
• Instructed the parents to give their baby a sponge bath at least two or three times a
week in the first year of the baby. Because more frequent bathing may be drying to
the skin.
• Taught the mother on how to feed her newborn baby.
Page 43
• Instructed them that a newborn baby needs to be fed every 2 to 3 hours. If
you’re breastfeeding, give your baby the chance to nurse about 10–15 minutes
at each breast. If you’re formula-feeding, your baby will most likely take
about 2–3 ounces (60–90 milliliters) at each feeding.
• Sleeping guidance for the baby.

o It’s important to always place babies on their backs to sleep to reduce the risk
of SIDS (sudden infant death syndrome).
o Don’t use blankets, quilts, sheepskins, stuffed animals, and pillows in the crib
or bassinet because these can suffocate a baby.
o Told the parents to be sure to alternate the position of the baby’s head from
night to night (first right, then left, and so on) to prevent the development of a
flat spot on one side of the head.
Page 44
REFERRAL AND SUMMARY
Ob case studies are extremely important in understanding the progression of

pregnancy, from conception to postpartum and childcare. Through examinations like these,
we truly may infer something specifically on understanding the progress throughout time.
Assessments also assisted the study's proponents in becoming aware of the issues and
moving forward by implementing appropriate treatments and protocols.
Based on the data acquired, the mother does not need to seek urgent treatment from a
healthcare provider because the pregnancy progressed regularly, and the baby's condition is
normal. Furthermore, even though the delivery was successful, there is still a larger emphasis
on immunization of the newborn owing to a lack of vitamin K vaccine injection, and they are
sent to the health center for that subject.
To summarize the patient's pregnancy results, supporters can conclude that the
development of M.P.V pregnancy was normal, despite the fact that the patient is
multigravida. There were no reports of prolonged labor or delivery. The duration of labor and
delivery was within the typical range for a multigravida patient. Additionally, the time of
dilations of the mother since the moment she was admitted was on the normal standard for
multigravida patient. Her delivery at the health center went well, as noticed and confirmed by
the patient.
As previously said, case studies like this can be quite beneficial in shaping the student
nurses' base of knowledge and skills. Studies like these can significantly contribute to the
body of information regarding pregnancy and delivery. Based on assessments during the last
four months, crucial knowledge on the early stages of pregnancy was gathered, bridging the
understanding gap. Overall, the purpose of this case study was met in the end, which was to
understand the problem and solve it with appropriate and precise nursing interventions based
on the pillars of evidence-based practice. This study also accomplished another purpose,
which was to thoroughly analyze patients' conditions as well as the interventions provided.
The study's proponents were able to apply what they had learnt in school to the study's main
subject, the patient. As a result of the group's delivery of appropriate health education and
nursing interventions, the patient was able to completely understand and appreciate the need
of living a healthy lifestyle and following to health precepts.
Page 47
BIBLIOGRAPHY
Chapter 21: Physiology of Labor. AccessMedicine. (n.d.). Retrieved December 20, 2022,
from
https://accessmedicine.mhmedical.com/content.aspx?bookid=1057§ionid=59789161
Components of the birth process: Nursing | osmosis. (n.d.). Retrieved December 19, 2022,
from https://www.osmosis.org/learn/Components_of_the_birth_process:_Nursing
Mayo Foundation for Medical Education and Research. (2022, January 13). Stages of labor
and birth: Baby, it's time! Mayo Clinic. Retrieved December 20, 2022, from
https://www.mayoclinic.org/healthy-lifestyle/labor-and-delivery/in-depth/stages-of-
labor/art-20046545
Mcleod, S. (n.d.). Freud's 5 stages of psychosexual development. Freud's 5 Stages of

Psychosexual Development | Simply Psychology. Retrieved December 19, 2022, from
https://www.simplypsychology.org/psychosexual.html
UpToDate. (n.d.). Retrieved December 20, 2022, from

https://www.uptodate.com/contents/physiology-of-parturition-at-
term#:~:text=Term%20labor%20is%20a%20physiologic,conception%20(fetus%20and
%20placenta)
NHS. (n.d.). NHS choices. Retrieved December 20, 2022, from

https://www.nhs.uk/pregnancy/labour-and-birth/signs-of-labour/signs-that-labour-has-
begun/
Page 48

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LICEO DE CAGAYAN UNIVERSITY

PASEO DEL RIO CAMPUS

II. Patient’s Profile ------------------------------------------------------------------------------------- 2

III. Physiology of Labor/ Pregnancy --------------------------------------------------------------- 3

IV. Ideal Nursing Intervention ---------------------------------------------------------------------- 11

VI. Referral and Summary ------------------------------------------------------------------------- 47

VII. Bibliography ------------------------------------------------------------------------------------- 48

Obstetrics and gynecology as a branch of medicine in caring women during

Name Meldred P. Villamero

Birth Date December 31, 1998

Age 23 years old

Civil Status Single

Address Takisay, Tunhai Phase 2, Indahag

Cagayan de Oro City

Religion Roman Catholic

Educational Attainment Grade 7

Allergies No known allergy

o Uterine Stretch theory

o Progesterone deprivation theory

o Theory of Aging Placenta

a. The latent phase is marked by strong contractions that usually occur at

b. The active phase is signaled by the dilation of the cervix from 4 to 10

• Soft passages - cervix, vagina and perineum

• Bony passage – pelvis

Division of the pelvis

Bones of the pelvis

Planes of the pelvis

a. Diagonal Conjugate - measure between sacral promontory and inferior margin

11.5 cm - 12.5 cm basis in getting true conjugate,

(DC-11.5 cm= true conjugate)

Pelvis measuring at 10 cm or more.

➢ Fetal head - seven bones

➢ Suture - thin spaces in between bones

• Sagittal suture - longitudinal, between two parietal bones.

• Frontal suture - Anterior, between two frontal bones.

• Lambdoidal suture - Posterior, between parietal and occipital bone

➢ Fontanels - Point of intersection of cranial bones; membranous spaces

o Formed by 2 frontal bones and 2 parietal bones

o Measures 2.5 cmx2.5 cm

o Closes 6-8 weeks or 2 to 3 months

Fetal Head Diameter

• Anteroposterior (AP) diameter

3. Power -Refers to the frequency, duration, and strength of the uterine

o Primary power: UTERINE CONTRACTIONS

- Regular activity of uterine musculature

- Propel presenting part downward/forward

- Effacement of the cervix

1. Increase maternal BP due to peripheral arteriole pressure- therefore check

3. Cervical dilation during the first stage

- The height of uterine contraction

- The phase of decreasing contraction; the last phase; the end

o The period from increment to decrement of the same contraction

o Maximum duration under normal circumstances; 90 seconds, found during the

o Time for maternal sleep and relaxation during labor.

o May be mild, moderate, and strong

o -With uterine contraction. These uterine changes occur.

o Secondary power: Involuntarily bearing down, abdominal muscle

o Ferguson Reflex- maternal involuntary urge to push stimulated by stretch

o Psyche/Person – (mother) psychological stress exist when the mother is

o Cultural influence and perceptions about labor and delivery

o Responses to uterine contraction

o Childbirth preparation process (classes)

o Ability to communicate feelings to significant others