TAGUM DOCTORS COLLEGE INC.

Mahogany St., Rabe Subd., Visayan Village Tagum City Davao Del Norte
Bachelor of Science in Nursing

In Fulfilment of the Requirements in

RLE 107:
Case Study: Normal Spontaneous Vaginal Delivery with
Gestational Diabetes Mellitus, Meconium Staining and Cord Coil
Complications
Submitted to:

Parcon, Nida, RN

Submitted by:

Pascua, Krizhel Mae M.

Pascual, Decere D.
Pelicano, Barry Ephraim
Peteros, Alyn Kaye D.
Pizon, Marc June D.
Ponsica, Christine Joy R.
Protacio, Alleya Fybes H.
Puno, Gwyneth V.
Quintela, Jana Therezsa B.
Rufo, Hannah D.
Sacatan, Sitti Fatima L.
Silutan, Rexie Louella T.
Villanueva, Bea T.

February 2024
TABLE OF CONTENTS
I. Acknowledgement 2
II. Introduction 3
III. Objectives 5
IV. Patient’s Data 9
V. Developmental Data 11
VI. Definition of Complete Diagnosis 13
VII. Physical Assessment 25
VIII. Anatomy and Physiology 28
IX. Etiology and Symptomatology 47
X. Doctor’s Order 72
XI. Diagnostic Exam 88
XII. Drug Study 90
XIII. Nursing Theories 98
XIV. Nursing Care Plan 100
XV. Discharge Plan (M.E.T.H.O.D) 117
XVI. Recommendation 98
XVII. Bibliography 101

Page | 2
I. ACKNOWLEDGEMENT

We, Group 9 student nurses of BSN- 2C at Tagum Doctors College Inc.,would

like to express our sincere gratitude to everyone who helped us finish this case

presentation successfully. This project would not have been successful without their

steadfast assistance and direction.

First and foremost, we would like to thank the Lord God Almighty his unending

love, provision, and wisdom bestowed upon us. With all of our hearts, we thank Him

for providing us with strength and encouragement as we completed our case study.

This study could not have been completed without His love and kindness.

We would like to express our heartfelt appreciation to our Clinical Instructor,

Ma'am Nida B. Parcon, RN, for her patience, extensive knowledge, and skills, as well

as the encouragement, motivation, and guidance she provided at all times during our

hospital exposure, which meant so much to us and will be treasured and

remembered.

We are deeply grateful to our parents for their unwavering support, sacrifices,

love, and prayers. Their emotional, moral, physical, and financial support inspired us

to strive for achievement and to do our best. Also, to the members of our group for

their unwavering commitment to completing interviews and gathering data in spite of

schedule issues. The success of the project was largely due to the individual

members' collaborative effort and teamwork, highlighting the value of cooperation.

Page | 3
 We extend our profound and heartfelt gratitude to the dedicated staff of

Tagum Doctors Hospital Inc, particularly the nurses of TDH-5A-Ward. Your

unwavering cooperation and invaluable support have been indispensable pillars that

have significantly contributed to the triumphant realization of this noteworthy

endeavor.

Lastly, we want to express our heartfelt appreciation to the client and her

family for their essential contributions to our case presentation. Their willingness to

openly discuss personal experiences and provide thorough medical backgrounds

was critical in influencing the depth and breadth of our analysis.

Page | 4
II. INTRODUCTION

Gestational diabetes mellitus (GDM), which is defined as a state of

hyperglycemia that is first recognized during pregnancy, is currently the most

common medical complication in pregnancy. GDM affects approximately 15% of

pregnancies worldwide, accounting for approximately 18 million births annually. In

addition, GDM increases the risk of complications, including cardiovascular disease,

obesity and impaired carbohydrate metabolism, leading to the development of type 2

diabetes (T2DM) in both the mother and infant. One of the most important risk

factors for abnormal vascular coiling of the umbilical cord is gestational diabetes

mellitus (GDM) (Ezimokhai et al., 2020) which has an injurious effect on the

connective tissue components of the Wharton’s jelly and the umbilical vessels (Singh

et al., 2020). Vascular wall or connective tissue is the most important etiology in the

perinatal mortality and morbidity increment in the GDM. The increase in the

incidence of GDM also leads to a significant economic burden and deserves greater

attention and awareness. Despite numerous studies, the pathogenesis of GDM

remains unclear, and the results obtained so far indicate a complex mechanism of

interaction of many genetic, metabolic and environmental factors. (Plows et al.,

2018). Vagal stimulation from umbilical cord compression causing fetal hypoxic

stress, resulting in increased peristalsis and relaxation of anal sphincter leading to

intrauterine passage of meconium. Placental insufficiency, maternal hypertension,

pre-eclampsia, oligohydramnios or maternal drug abuse (tobacco, cocaine) are

Page | 5
predisposing factors of in utero passage of meconium. Meconium stained neonates

are more prone to develop respiratory distress than neonates born with clear fluid.

Gestational diabetes mellitus (GDM) is a common pregnancy complication

strongly associated with poor maternal-fetal outcomes. Its incidence and prevalence

have been increasing in recent years. Women with GDM typically give birth through

either vaginal delivery or cesarean section, and the maternal-fetal outcomes are

related to several factors such as cervical level, fetal lung maturity, the level of

glycemic control still present, and the mode of treatment for the condition. We

categorized women with GDM based on the latter two factors. GDM that is managed

without medication when it is responsive to nutrition- and exercise-based therapy is

considered diet- and exercise-controlled GDM, or class A1 GDM, and GDM

managed with medication to achieve adequate glycemic control is considered class

A2 GDM. The remaining cases in which neither medical nor nutritional treatment can

control glucose levels or patients who do not control their blood sugar are

categorized as class A3 GDM. (Li et al., 2023). In developing countries, such as

Brazil, oral hypoglycemic agents are also used, mainly metformin and glibenclamide

(Oliveira, 2023). The prevention and appropriate treatment of GDM are needed to

reduce the morbidity, complications and economic effects of GDM that affect society,

households and individuals. Though it is well established that the diagnosis of even

mild GDM and treatment with lifestyle recommendations and insulin improves

pregnancy outcomes, it is controversial as to which type and regimen of insulin are

optimal, and whether oral agents can be used safely and effectively to control

glucose levels. Neonatal outcome and mode of delivery in relation to the grades of

meconium, Low APGAR score, Non-reassuring CTG, MAS, and emergency

Cesarean section were significantly associated with thick meconium stained liquor.

Page | 6
There were 114 (76.5%) cases of thin meconium; out of them 83.3% babies

remained asymptomatic, which was not statistically significant. PIH and GDM were

important risk factors associated with MAS (P-value <0.001), whereas no significant

association was found with parity. MAS was found more in babies born to unbooked

mothers (p-value <0.001) signifying the importance of antenatal care. In present

study, maternal risk factors significantly associated with MAS were anemia in

pregnancy, gestational diabetes, PIH and premature rupture of membranes while

none of the mothers had pre-eclampsia. In our study gestational diabetes was one of

the risk factors associated with MAS (p-value<0.001), while Aviram A et al could not

find any significant association between gestational diabetes and MAS. Thick

meconium stained amniotic fluid has a major impact on both mode of delivery and

neonatal outcome as compared to the other counterpart. GDM and PIH were risk

factors associated with meconium aspiration syndrome. Therefore, presence of thick

meconium needs close monitoring, early and timely obstetrical intervention and

appropriate post-natal care, in order to minimize meconium related complications

and improve fetal outcome.

In the Philippines, Gestational diabetes mellitus (GDM) is known to be

associated with perinatal and maternal morbidity, including excessive fetal size,

which leads to operative delivery and birth trauma. In a study done at the Philippine

General Hospital in 2013, women diagnosed with GDM had an increased risk for

primary caesarean section and infant admission to the neonatal intensive care unit.

Screening for GDM is usually performed between 24 to 28 weeks of gestation

because insulin resistance increases during the second trimester, and glucose levels

increase in women who do not have the ability to produce enough insulin to counter

this resistance. (Berga et al. 2022). Presently, routine screening for GDM in the

Page | 7
Philippines is done at 24 to 28 weeks of gestation. These risk factors include age

≥25 years old, overweight or obese before pregnancy, history of abnormal glucose

metabolism, history of poor obstetric outcome (prior GDM, macrosomia, congenital

malformations, recurrent abortions, unexplained intrauterine death), family history of

diabetes among first degree relatives, intake of drugs affecting carbohydrate

metabolism and glucosuria. (Jimeno, 2018). Having any of these risk factors confers

a high risk for GDM, and a 75 g OGTT should be done as soon as possible.

However, this is not universally followed and screening for GDM before 24 weeks

remains at the discretion of the primary healthcare provider.

Locally in Davao region, approximately 4–6% of pregnancies are complicated

by diabetes mellitus (DM), making it one of the most common serious medical

complications of pregnancy in the region. The majority of cases (>80%) are

diagnosed for the first time during, the remaining cases are pre-gestational diabetes

mellitus (type 1or type 2). Furthermore, the prevalence of diabetes in pregnancy is

increasing in the Davao Region, concurrent with the most rising prevalence of type 2

diabetes in the general population; this increase is not explained by changes in the

prevalence of other known maternal risk factors, such as advanced maternal age.

(Lupase, 2016)

In this Case Study, we provide the clinical profile of a patient who had a

Normal Spontaneous Vaginal Delivery (NSVD) with Gestational Diabetes Mellitus

(GDM). The patient, Ms. L.A.S, is a 38-year-old Multigravida, with an OB score of G4

P4 (4004), all of her children are full term with 38 weeks and 9 days in her (1 st) first

baby, 37 weeks and 6 days in her (2 nd) second baby, 38 weeks and 1 day with her

(3rd) third baby and 38 weeks and 3 days for her (4th) fourth baby. As client

verbalized, that she has experienced Gestational Diabetes mellitus (GDM) with her

Page | 8
3rd and 4th baby. Also verbalized that she controlled her diet and maintained a

healthy lifestyle through House Chores. In her 4th pregnancy, during the delivery,

there was a delivery complication by meconium staining and cord coil. With that said,

the baby was successfully delivered in cephalic presentation, left Occiput-anterior

position, and underwent the 7 cardinal movements before full expulsion of the head

from the mother’s vagina.

III. GENERAL OBJECTIVES

This group case study aimed to broaden our knowledge as student nurses for

Normal Spontaneous Vaginal Delivery by gathering enough information to serve as a

guide for us to improve our skills and attitudes in the application of nursing

processes and post-partum care for Normal Spontaneous Delivery patients.

SPECIFIC OBJECTIVES

The student nurses would be able to:

COGNITIVE

 Remembering: To determine the client's state, gather as much information as

possible and remember it all.

 Understanding: Understand the theoretical basis of pregnancy in relation to

Normal Spontaneous Vaginal Delivery.

 Applying: Conduct the nursing assessments required for an NSVD and record

the results.

 Analyzing: Compare and contrast all of the informations and data, rate the data

by significance, and identify the client's absolute requirements.

 Evaluating: Assess the outcomes of the actions implemented.

Page | 9
 Creating: Analyze and make recommendations mostly for postpartum

management, including how to reach and maintain optimal well-being.

AFFECTIVE

 Advising: Identify the client's concerns and propose solutions throughout the

assessment.

 Responding: Observe the customer and respond to any inquiries they may have,

taking note of the questions asked and the responses provided.

 Valuing: Provide high-quality care possible and contact the client to create

rapport.

 Characterization: As you listen to the client, use the following information to

capture their data.

PSYCHOMOTOR

 Perception: Gradually improve the skill set of student nurses in both independent

and dependent nursing interventions.

 Establish performance standards for student nurses to track skill development

progress.

 Articulation: Perform physical evaluations with timing, coordination, and

assurance.

Page | 10
IV. PATIENT’S DATA

A. Biographical Data

 Patient’s Code Name: LAS

 Age: 38 Years Old Sex: Female

 Nationality: Filipino Civil Status: Married

 Religion: Catholic

 Educational Attainment: College Graduate

 Ward or unit room: 506

 Date and Time of Admission: January 24, 2024 @ 1:03 PM

 Vital Signs upon admission:

BP- 130/90 mmHg

T- 36.6 C

RR- 23 cpm

PR- 87 bpm

Sp02- 98 %

B. Chief Complaints:

Labor pain.

Page | 11
 Initial Diagnosis:

G4P3 (3003) PU 38w3d AOG, Cephalic, In Labor, Gestational Diabetes

Mellitus

 Final Diagnosis:

PU delivered term, cephalic, AGA, female, spontaneous vaginal delivery

G4P4 (4004), labor and delivery complicated by meconium staining & cord

coil

 Surgical procedure performed if any (date and time performed):

SVD w/ repair of perineal laceration (January 24, 2024)

 Attending physician:

Chiara Mae O. Lascuña, MD, FPOGS, FPSUOG, FPSMFM

 Source of Information/ Informant’s: Patient’s Chart

Page | 12
V. DEVELOPMENTAL DATA

In this segment, established theories will be employed to recognize the

anticipated phases of physical, cognitive, and psychosocial development. This

provides the mother with a comprehensive understanding of her personal growth.

Robert Havighurst “Developmental Task Model”

Robert Havighurst’s “Developmental Task Model” is a framework that

identifies key tasks individuals need to accomplish at different stages of life for

successful development. These tasks range from basic skills acquisition in infancy to

career and family-related goals in adulthood. Havighurst emphasizes the importance

of adapting to societal expectations and cultural norms while achieving personal

satisfaction in each life stage.

STAGE ACTUAL FINDINGS JUSTIFICATION

INFANCY AND EARLY ACHIEVED Patient’s parents

CHILHOOD informed her that

Page | 13
 (From birth to age 5 Patient was able to learn by the age of 12

years old) how to walk, talk and able months, she had

Humans learn basic to form a basic already learned

survival skills at this stage. understanding of the world to walk, talk, and

Babies and young children form a basic

gain control of their bodies, understanding of

form friendships, and learn her surroundings.

basic language concepts.

MIDDLE CHILDHOOD ACHIEVED As the patient

enter school age,

(6–12 years old) The patient develops to
she engaged in
establish connections with
tasks related to
her friends and enhance
This is the stage at which education,
her social abilities.
humans learn about socialization, and

themselves, their morals, self-discipline.

their values, and their Learning to read,

personal independence. write, and interact

Children learn rules, with peers.

various societal functions,

The patient
academic skills, and
demonstrates a
attitudes toward various
moral awareness,
groups of people.
distinguishing

between right and

wrong. She is

Page | 14
 able to get along

well with others

as evidenced by

her close

relationship with

her family.

ADOLESCENCE ACHIEVED When she at this

stage, her
(13–17 years old)
dreams were
Humans learn maturity, The patient gained her
high, and said
emotional independence, maturity, she was able to
she wanted to be
and future planning during plan her dreams and
a successful
this stage. Teenagers discover her wants and
woman one day.
discover careers, form needs.

personal ideologies, and

develop social The patient has

responsibility. her own set of

personal ideals

and ideologies.

EARLY ADULTHOOD ACHIEVED

(18 –35 years old) The patient

demonstrated her
The patient was capable of
capacity for
selecting a spouse, and
independent

Page | 15
 starting her own family, as decision-making.
Humans learn to be useful
well as making At 19, she works
members of society. Adults
independent decisions and towards
are able to find a mate,
adapting to changes in her achieving
raise a family, manage a
family and work life. financial
home, and advance in their
independence. At
careers.
21, she selects a

suitable partner

to accompany her

during

pregnancy.

Achieving the

task of starting a

family and having

children

demonstrates

progress,

highlighting

stability and

personal

development over

the years.

Erik Erickson “Theory of Psychosocial Development”

Page | 16
Erikson's "Theory of Psychosocial Development" posited that personality goes

through different stages of development, elucidating the influence of social

experiences on individuals throughout their entire life. Erikson specifically

emphasized the crucial role of social connections and interactions in the maturation

and overall development of individuals.

STAGE ACTUAL FINDINGS JUSTIFICATION

TRUST VS. MISTRUST ACHIEVED She remembers how her

parents took care of what

( infant -18 months)
she needed in a safe and
Her need was met so she
caring place. This helped
developed a sense of
The fundamental challenge her build close relationships
basic trust.
is developing confidence in and set the foundation for

her future social and

caretakers. Infants learn to
emotional development.
rely on their caregivers for

comfort, and if their basic

needs are provided on a

continuous basis, they

acquire a basic trust in the

world.

AUTONOMY VS. ACHIEVED At this point in

SHAME/DOUBT development, Patient LAS

Page | 17
 (2 - 3 years old) are just starting to gain a

little independence. She

Focused on developing a
said according to her
sense of personal control
When children are
parents she is starting to
over physical skills and
encouraged to make
perform basic actions on
cultivating a sense of
choices and take charge of
her own and making simple
independence.
their environment, they start
little decisions about what
to establish their
she prefers.
independence; when they

are restrained or given

harsh reprimands, they may Patient has autonomy and

feel ashamed and that she do many things

mistrusted. independently such as

moving around, taking care

of herself, and helping with

simple tasks around the

house.

INITIATIVE VS. GUILT ACHIEVED The patient engaged in play

with both school friends and

(3 - 5 years old)
neighbors. She develop a
The patient is expressing
sense of initiative if
herself more often by
Children investigate their encouraged but she feel
leading in play and
surroundings and gain guilt if she was criticize.
interacting with others.

She is testing her social

Page | 18
self-confidence. They abilities by starting Patient LAS exhibits

various activities. . initiative by being able to

begin to assume
verbalize her needs and
responsibility and make
make requests

goals. They develop a appropriately.

sense of purpose if they

are encouraged and

supported; otherwise, they

may experience guilt.

INDUSTRY VS. ACHIEVED The patient consistently

INFERIORITY helps her parents with

household tasks and

(6- 11 years old)
actively participates in

The patient learns to feel school and various

Through social interactions, strong and capable in her extracurricular activities.

children begin to develop a development, which is

sense of pride in their called competence. It

accomplishments and means she believes in

abilities. herself to handle tasks She now feels capable and

well. accomplished in many

Children need to cope with
different fields.
new social and academic

demands. Success leads to

a sense of competence,

Page | 19
while failure results
feelings of inferiority.
IDENTITY VS.
CONFUSION (12 - 18
years old)
Adolescents investigate
their identities and form a
sense of self. They may
experiment with various
roles and jobs.
Successfully navigating
this period results in a
distinct sense of identity,
but uncertainty about one's
place in life may result in
an identity crisis.
INTIMACY VS. ISOLATION
(19 - 40 years old)
in
ACHIEVED She is secure in her
personal identity and
understanding of herself as
Patient develop a sense
can be seen in her
of self and personal
conviction to her beliefs and
identity. Her success
values. Particularly, she
leads to an ability to stay
feels strongly connected to
true to herself, while her
her religion.
failure leads to role
confusion and a weak
sense of self.
ACHIEVED The patient has
successfully embraced the
virtue of love,
The patient successfully
Page | 20
 developed close and demonstrating her ability to

affectionate connections establish and commit to

Young adults build close,
with others, resulting in intimate relationships, as
long-lasting bonds with
the establishment of evident in her marriage.

others. The task is to form strong relationships. Patient LAS has conveyed

personal, caring a sense of security and

deep devotion to her

relationships; failing to do
husband.
so, may lead to feelings of

loneliness.

Jean Piaget's "Theory of Cognitive Development"

Jean Piaget's "Theory of Cognitive Development" is a comprehensive

framework that explains how individuals, particularly children, acquire, construct, and

use knowledge. Piaget proposed that cognitive development occurs in distinct

stages, marked by shifts in thinking and understanding.

STAGE ACTUAL FINDINGS JUSTIFICATION

SENSORIMOTOR STAGE ACHIEVED The patient

remembered her
(Birth to nearly 2 years
strong
old)
Patient learn about her
connections with
surroundings through
parents and
sensory perceptions and
friends. She

Page | 21
Coordinates senses with motor activity. shared feeling

uneasy around
motor responses to explore
unfamiliar
their sensory curiosity
individuals.
about the world.

Knowledge of the world is

based on physical

interactions and

experiences. Intelligence is

demonstrated through

motor activity. Object

permanence is developed.

PRE- OPERATIONAL ACHIEVED She mentioned

STAGE that during her

preschool years,
(About 2 to 7 years old)
The patient met her
she was adept at
creativity at this stage by
talking and
engaging in different
Children become interacting with
activities with experiences.
increasingly adept at other children.

symbolic thinking by Playing with

developing mental friends was one of

representations of objects her favorite

based on experiences and activities.

perceptions. Furthermore,

memory and use of

Page | 22
language is further

developed.

CONCRETE ACHIEVED At his age, the

OPERATIONAL STAGE patient has

The patient has acquired
acquired a sense
(6 to 11 years old) the skill of effective
of responsibility
communication and
by assisting with
responsible behavior.
Characterized by the household chores
Additionally, she recognizes
development of concrete for his parents.
that even though things
logical thought, i.e. literal
may appear different,
thinking focused on the
certain qualities remain
physical world, immediate
unchanged.
experiences, and exact

interpretations.

Understanding of inductive

reasoning, reversibility,

and conservation are

especially indicative of this

stage.

FORMAL OPERATIONAL During her

ACHIEVED
STAGE adolescence, the

The patient knows what is patient

(Adolescence to
best for her health and successfully
Adulthood)
understands what is navigated

Page | 23
 challenges,
necessary to preserve her
demonstrating the
At this stage, thinking ability to care for her
ability to think
becomes increasingly children.
clearly and
abstract and they gain an
conceptually. This
understanding of abstract
is evident in her
concepts such as
decisions, such as
metaphors, emotions, and
choosing a
beliefs. Problem-solving
college and
now also uses
engaging in
hypothetical-deductive
employment.
reasoning to ponder “what-

if” scenarios. She also

understands

abstract concepts

as evidenced by

her verbalization

of how GDM,

meconium

staining, and cord

coil affects her

emotionally.

Page | 24
VI. DEFINITION OF COMPLETE DIAGNOSIS

PU delivered term, cephalic, AGA, female, spontaneous vaginal delivery G4P4

(4004), labor and delivery complicated by meconium staining & cord coil

Normal Spontaneous Vaginal Delivery

Spontaneous vaginal deliveries are the most common form of giving birth. It

involves giving birth after the natural onset of labor, without any need for tools to

remove the baby. Vaginal delivery is safest for the fetus and the mother when the

newborn is full-term at the gestational age of 37 to 42 weeks. 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. Labor usually

begins with the passing of a woman’s mucous plug. This is a clot of mucous that

protects the uterus from bacteria during pregnancy. Soon after, a woman’s water

may break. This is also called a rupture of membranes. The water might not break

Page | 25
until well after labor is established, even right before delivery. As labor progresses,

strong contractions help push the baby into the birth canal. The length of the labor

process varies from woman to woman. Women giving birth for the first time tend to

go through labor for 12 to 24 hours, while women who have previously delivered a

child may only go through labor for 6 to 8 hours. The labor leading to the delivery is

divided into 3 stages, and each stage requires specific management. (1) contractions

soften and dilate the cervix until it’s flexible and wide enough for the baby to exit the

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

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

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

nutrition and oxygen.

Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) is a condition in which a hormone made

by the placenta prevents the body from using insulin effectively. Gestational

diabetes is a disease developed during the second and third trimester of pregnancy,

characterized by a marked insulin resistance secondary to placental hormonal

release. Glucose builds up in the blood instead of being absorbed by the cells.

Unlike type 1 diabetes, gestational diabetes is not caused by a lack of insulin, but by

other hormones produced during pregnancy that can make insulin less effective, a

condition referred to as insulin resistance. Gestational diabetic symptoms disappear

following delivery.

Meconium Staining

Page | 26
 Meconium is a thick, greenish-black substance. It forms before a baby is born.

In the womb, a baby swallows and digests the amniotic fluid. Then the intestines

make meconium. When the baby is born, meconium is the first stool the baby

passes. But sometimes meconium comes out before the baby is born. It goes into

the amniotic fluid. This is called meconium staining .During delivery, if meconium-

stained amniotic fluid is noted, a neonatal resuscitation team should be promptly

involved. The baby may breathe the meconium into his or her lungs. This can

happen while the baby is being born or just after the birth. This substance can make

it hard for the baby to breathe. It may also lead to infection.

Cord Coil complications

The umbilical cord is responsible for transporting blood, nutrients, and oxygen

from the placenta to the fetus, as well as for eliminating waste. However, umbilical

problems may occur during pregnancy. One of the most common umbilical cord

injuries is cord coil. A cord coil or nuchal cord occurs when the umbilical cord wraps

around an unborn child’s neck. This is a fairly common complication that can happen

in 15 percent to 35 percent of all pregnancies. Normally, nuchal cords do not cause

any complications to the baby or mother. Cord coil complications arise when there

are multiple or tight coils, though this is a rare scenario. Even with a cord coil, most

babies can still be delivered vaginally. A cesarean section (C-section) is only needed

if the nuchal cord poses a risk to the unborn baby.

Page | 27
VII. PHYSICAL ASSESSMENT

Physical assessment is a systematic and thorough examination of a patient's

body to gather information about their overall health status in an efficient manner

starting at the head and proceeding downward (head- to-toe assessment). The

assessment involves inspecting, palpating, percussing, and auscultating different

parts of the body.

A. Obstetric Sheet

The following are the obstetric data obtained from the patient's chart:

Blood RH: Not OBSTETRIC HISTORY: G 3 P 3

Desired Family
Type: Noted
Not Size: Not noted
Noted

Hbs AG: Antibiotic: Educational Socio- Contraceptive

Not Not Noted Profile: College Economic History: Pills

Page | 28
 Noted Graduate Profile:
Dependent/une
mployed

Pregnancy Pregnancy Year Gestational Birth Present Complica

order: outcome: Completed Weight Status tions
(Weeks)
G1 NSVD 2009 Term 2.5 kg Live No
complicat
ion
G2 NSVD 2013 Term 2.5 kg Live No
complicat
ion
G3 NSVD 2018 Term 2 kg Live No
complicat
ion
G4 NSVD 2024 Term LMP: April 30,Live
2.1kg 2023 No
(current)
PRESENT PREGNANCY: complicat
EDC: NFebruary 03, 2024
ion
PMP: Not Noted
AOG: 38 weeks

PHYSICAL EXAMINATION: T- 36.6 C

DATE: 01/24/24
RR- 23 cpm
TIME: 1 pm
PR- 87 bpm

General Status: Conscious

HEENT: _________
CHEST
Heart: __________
Lungs: Clear Breath Sounds
LEVEL OF SENTORIUM: Breast: Not Palpable Mass
ABDOMEN
Fundic Height: 34 cm
Presentation: Cephalic
FHT: 137 / LLQ

PELVIC EXAMINATION: Dilation: 5 cm Page | 29

Effacement: 80%
B. Vital Signs Monitoring Sheet

DATE/ TIME BP TEMP PR/CR RR SPO2 OUTPUT

SHIFT

11/24/24 1:03 pm 130/90 36.6 87 23 98%

2:30 pm 110/80 36.6 80 21 98%

2:45 pm 100/70 36.6 83 20 99%

3: 00 pm 105/78 36.6 85 20 98%

3:15 pm 100/68 36.6 88 20 98%

3:30 pm 102/58 36.6 86 20 98%

3:45 pm 103/52 36.6 78 20 98%

4:00 pm 112/57 36.7 75 20 99%

4:30 pm 107/55 36.6 85 19 99%

65
5:00 am 100/70 36.2 21 99%

11/24/24 8:00 am 120/80 36.6 73 20 98%

12:00 nn 120/80 36 68 20 96%

4:00 pm 120/70 36.4 80 20 %

11/24/24 8:00 pm 120/80 36 71 20 98%

Page | 30
 12:00 mn 120/70 36 69 20 96%

4:00 am 120/80 36.3 75 20 97%

1/25/24 8:00 am 120/70 36.6 73 19 99%

C. COMPREHENSIVE PHYSICAL EXAMINATION

The assessment was done on January 24, 2024 @ 8:00 AM.

System Normal Findings Actual Findings Implications

GENERAL Able to respond to Upon assessing No deviations

APPEARANCE AND stimuli at the same this system, we assessed

MENTAL STATUS lower level of utilized an

strength as most inspection tool
people who are through the
functioning without sense of sight.
neurologic Patient
abnormality. KJB was seen

lying supine on

bed, well-groomed,

with IVF D5LRS 1L

attached at left arm

and a urinary

catheter attached

to urine bag.

Page | 31
 Patient was

awake, coherent,

and conscious,

was able to

communicate and

speak fluently. She

was oriented when

asked about

herself, the current

date and time, and

the place and did

not show any

symptoms of

neurologic

defects.

GLASCOW SCALE

BEHAVIOR RESPONSE SCORE PATIENT’S

SCORE
Eye opening response - Spontaneou 4 4

sly 3

- To speech 2

- To pain 1

- No

Page | 32
 response

Best verbal response - Oriented to 5 5

time, place, and

person 4

- Confused 3

- Inappropriate 2

words

- Inco 1

mprehensib

le sounds

- No response

Best motor response - Obeys 6 6

commands

- Moves to 5

localized pain

- Flexio 4

n withdrawal

from pain 3

- Abno
rmal flexion
2
(decorticate)

- Abnormal

extension 1
(decerebrate)

Page | 33
 - No

response

Total score - Best 15 15

response

- Comatose 8 or less

client

- Totally unresponsive 3

Head Rounded, smooth, Head is round, No deviations

normocephalic, and normocephalic, assessed

symmetrical. Absence with no

of nodules or masses. abnormalities or

tenderness

detected.

INTEGUMENTARY When skin is pinched it Patient’s skin No deviations

Skin goes back to its color is uniform assessed

previous state from light pink

immediately (2 to light brown,

seconds). No rashes, and is soft and

pallor, jaundice, and smooth. With

cyanosis. With fair good skin turgor

(2 seconds) and

Page | 34
 complexion and no lesions.

soft skin.

· Hair Evenly distributed hair Hair color is No deviations

(long, black, and shiny). black and has a assessed

fine

texture.

Nails Epidermis is intact and Patient’s nails No deviations

smooth. Fingernails and without assessed

toenails are short, cyanosis and

clean, convex and with clubbing.

good capillary refill time Epidermis is

of 1-3 seconds. No intact and

cyanosis, clubbing, and fingernails and

beau’s lines. toenails were

short, clean,

and convex,

with good

capillary refill

time of 2

seconds.

Page | 35
 Face Symmetrical facial Normal head No deviations

movement, palpebral motion and no assessed

fissures equal in size, Involuntary

and symmetric Movements

nasolabial folds.

EYE STRUCTURE

AND VISUAL

ACUITY

Visual Fields Eyelids are intact. Patient’s eyelids No deviations

Visual Acuity Absence of discharges were intact with assessed

and no discharge;

discoloration; eyelids eyelids closed

close symmetrically; symmetrically;

sclera appears white; white sclera; no

absence of edema or edema and

tenderness over tenderness

lacrimal gland; pupils noted. Using a

constrict when looking penlight to

at near objects and assess the

dilate when looking at patient’s pupils,

Page | 36
 far objects. it was found that

her pupils are 4

mm constricting

to 2 mm,

equally round,

and reactive to

light and

accommodation

. The patient is

able to read a

book and can

clearly watch an

illustration.

EARS AND Absence of Examining the No deviations

HEARING deformities, patient's ear assessed. No

discoloration, canal with a conductive

tenderness, or penlight hearing loss

discharge. Hearing is revealed the and

intact bilaterally absence of sensorineural

through whisper test, discharge, loss. The

watch tick test, Weber, redness, patient

and masses, or has a Weber

Rinne test. foreign bodies. negative result

Page | 37
However, a wherein the

small quantity patient

of cerumen was perceives the

observed. With sound as

the whisper being equally

test, the patient distributed

was able to between both

repeat the ears. She also

words has a Rinne

whispered 2 positive test

feet behind her which implies

both ears. that air

Using a watch conduction is

and a tuning more effective

fork, we than bone

assessed the conduction,

patient's since she

hearing with a heard the

watch tick test, tuning fork

Weber test and near the ear

Rinne test. canal more

Patient KJB than near the

verbalized that mastoid bone.

she was able to

Page | 38
 hear the

watch’s ticking

and the sound

of the tuning

fork on both

ears.

NOSE AND External nose is Patient nose is No

SINUSES symmetrical with no symmetrical deviations

discoloration, swelling with no assessed

or malformations. Nasal discoloration,

mucosa is pinkish red swelling or

with no lesions. No

discharge/bleeding nasal drainage

, swelling, and congestion.

malformations or Nasal mucosa

foreign bodies. pink, septum

midline, no

sinus

tenderness

Symmetrical

and no

discharge is

seen.

Page | 39
MOUTH AND Lips are normal in color Patient did not No deviations

THROAT and have no lesions. complain of sore assessed

Teeth present with one throat; had good

loose tooth, good dentition, no

dental hygiene; cracking of lips,

gums and mucous and moist oral

membranes are pink, mucous

no bleeding, lesions, or membrane.

inflammation. No present

inflammation

Absence of

bleeding and

lesions.

OROPHARYNX AND Moist oral cavity. Pink Patient’s uvula No deviations

TONSILS
mucosa with is midline, assessed

no discoloration, pharynx without

lesions, nodules, or exudate,

swelling. Tonsils are swelling, or

visible but not enlarged. ulceration, and

no tonsillar

enlargement.

NECK Positioned at the Is in midline No

Page | 40
midline without position, no deviations

tenderness and flexes tenderness, can assessed

easily. No masses flex neck easily.

palpated. No masses.

Page | 41
THORAX AND Lungs resonant to Lungs expand No deviations
LUNGS
percussion and equally on both assessed
- Anterior
vesicular breath sides. No
Thorax
sounds throughout wheezes; has a
- Posterior
peripheral lung normal vocal and
Thorax
fields. No tactile fremitus.

wheezes, or Thorax - Has a

bronchi; normal good air entry and

vocal and tactile no adventitious

fremitus. sounds across the

Upon palpation of anterior thorax’s

posterior chest lobes. No thorax

wall, client reports deformities or

no pain, masses, spinous

temperature warm process in a

to touch, equal straight line

bilaterally, no

moisture, masses,

swelling, or

deformities, equal

tactile fremitus

Page | 42
HEART AND The jugular vein No swelling No deviations

CENTRAL VESSELS should not be or assessed

distended, bulging, or enlargement

protruding at 45 degrees of the jugular

or greater and carotid

The external chest is veins. The

normal in appearance precordium is

without lifts, heaves, or symmetrical.

thrills. Heart rate and

rhythm are normal.

BREAST AND Breasts are round; Breasts are Patient’s

AXILLA slightly unequal in size; round, slightly breasts are

absence of tenderness, unequal in slightly tender

masses, or nodules. size; absence and sore due to

Axilla has no lesions, of mass and rising hormone

and no large lymph nodules. levels.

nodes Areolas and

nipples are

dark in color

and round.

Axilla is

smooth and

has no

lesions with

no enlarged

Page | 43
 lymph nodes.

ABDOMEN Unblemished skin, Patient’s Presence of

uniform in color, abdomen has striae

symmetric contour, not evident linea gravidarum

distended. nigra, striae (from belly

Normoactive bowel gravidarum, button to pubic

sounds are heard in all and loose area) and linea

four skin around nigra was

quadrants. High-pitched, the navel present due to

gurgling sounds. area. increased

Using hormonal levels.

auscultation, Loose skin is

normoactive present

bowel sounds because as the

were heard abdomen

in all four expands, the

quadrants. skin also

stretches,

leading to loose

skin around the

stomach after

delivery.

GENITO-URINARY Genitals without lesions; Patient has Patient has

inflammation, swelling, mild mild

discharge, enlargement, inflammation, inflammation

Page | 44
 or tenderness. No swelling and and swelling on

urethral discharge or foul a lochia rubra the genito-

smell. discharge. urinary is cause

by the perineal

laceration and

surgical repair.

Lochia Rubra

discharge is

visible from the

1st day up to the

4th day after

delivery.

NEUROLOGIC The patient is alert and Patient is No deviations

Cranial Nerves oriented to person, conscious assessed

Reflex place, and time with and coherent

Motor Function normal speech. No to person,

Pain Sensation motor place, and

deficits are noted, with time with

muscle strength 5/5 normal

bilaterally. speech.

Sensation is intact Oriented and

bilaterally. has a sense

of reality.

Able to speak

and

Page | 45
 understand

clearly.

Symmetrical

reflexes.

Sensation is

intact

bilaterally.

VIII. ANATOMY AND PHYSIOLOGY

The Female Reproductive System

Page | 46
 Figure 1. The Female Reproductive System

The female reproductive system is a complex of network of organs that

function together to facilitate reproduction. The primary parts include ovaries,

fallopian tubes, uterus, vagina, external genitalia, and the mammary glands. The

reproductive system in females is responsible for producing gametes (called eggs or

ova), certain sex hormones, and maintaining fertilized eggs as they develop into

mature fetuses and become ready for delivery (Rosner J, Samardzic T, Sarao MS.,

2023). It consists of internal and external organs. The function of external female

reproductive structures (the genital) is twofold: To enable sperm to enter and to

protect the internal genital organs from infectious organisms.

PARTS OF THE FEMALE REPRODUCTIVE SYSTEM

External Parts:

Page | 47
 Figure 2. External Parts of the Female Reproductive System

Clitoris: a bulb-shaped sexual organ in the female reproductive system, is a

sensitive protrusion similar to the male penis, crucial for sexual pleasure and an

erogenous organ.

Urethral Opening: Urethral opening: the urethral opening is where the urine leaves

the body

Vaginal Opening: The vaginal opening is the area where your baby exits your body

after delivery, and it is responsible for the flow of blood during your menstrual period.

Labia Majora: Labia majora are large lips, fleshy tissue folds protecting external

genital organs, covered with pigmented skin, sebaceous glands, and coarse hair

after puberty, serving as outer skin folds of the vulva.

Labia Minora: The labia minora, small lips, protect the urethra and vagina openings,

but are sensitive and prone to irritation and swelling. They are located under the

labia majora, which extends downward from the mons pubis

Hymen: Hymen is a thin, unique tissue found at the vaginal opening, formed by fetal

tissue fragments. Its size, shape, and thickness are a result of individual

development and can change over time.

Page | 48
Internal Parts:

Figure 3. Internal Parts of the Female Reproductive System

Vagina: The vagina is a muscular canal connecting the cervix to the external body,

providing lubrication and sensation. Its soft, flexible lining ensures smooth

movement. Vagina receives the penis and semen during intercourse and facilitates

menstrual blood flow.

Uterus: The uterus is a pear-shaped organ that holds a fetus during pregnancy. It is

divided into two parts: the cervix, which opens into the vagina, and the corpus, which

can expand to hold the baby. A canal through the cervix allows sperm to enter and

menstrual blood to exit.

Ovaries: Ovaries are oval-shaped glands on either side of the uterus, responsible

for producing, storing, and releasing eggs into fallopian tubes. During ovulation, one

ovaries releases an egg, which, if fertilized by a sperm, can lead to pregnancy.

Fallopian tubes: Fallopian tubes are muscular ducts between the ovaries and

uterus, serving as channels for fertilized eggs to develop into fetuses. They are

Page | 49
narrow tunnels that allow the egg to reach the uterus, facilitating the process of

fertilization.

Cervix: The cervix, a muscular, tunnel-like organ in the lower part of the uterus,

connects the uterus and vagina. It facilitates fluid flow between the two and allows a

baby to exit the uterus for childbirth through the vagina. It is also known as the "neck

of the uterus."

Male Reproductive System

Figure 4: Male Reproductive

The male reproductive system is a complex network of organs intricately

intertwined with both the reproductive and urinary systems in men. Comprising

internal and external components, these crucial organs play a pivotal role in various

physiological functions. Internally housed within the body are organs such as the

testes, epididymis, vas deferens, seminal vesicles, prostate gland, and bulbourethral

glands. Externally, the penis serves as the visible organ, facilitating both urination

Page | 50
and sexual intercourse. This intricate system collaboratively enables men to engage

in essential bodily functions, including urination, sexual activity, and the biological

process of procreation. Together, these interconnected elements harmoniously

contribute to the overall functionality of the male reproductive system.

Anatomy of The Male Reproductive System

 Testes:

The testes (singular: testis) are the primary reproductive organs in males. They are

located in the scrotum, a sac of skin and muscle outside the body, which helps

regulate the temperature of the testes for optimal sperm production.

 Scrotum:

The scrotum is a pouch of skin and muscle that houses the testes. It contracts or

relaxes in response to temperature changes, ensuring that the testes are kept at an

ideal temperature for sperm production.

 Epididymis:

The epididymis is a coiled tube attached to the back of each testis. It serves as a

storage and maturation site for sperm. Sperm produced in the testes move through

the epididymis, gaining the ability to swim and fertilize an egg.

 Vas Deferens:

The vas deferens is a muscular tube that connects the epididymis to the urethra. It

transports mature sperm from the epididymis to the urethra during ejaculation.

Page | 51
  Seminal Vesicles:

The seminal vesicles are two small glands located near the base of the bladder.

They produce a significant portion of the seminal fluid, which nourishes and provides

energy for sperm. This fluid also helps in the transportation of sperm.

 Prostate Gland:

The prostate is a gland located just below the bladder and surrounds the urethra. It

produces a milky fluid that mixes with seminal vesicle fluid and sperm to form

semen. The prostate's fluid also contains enzymes that help activate sperm.

 Bulbourethral Glands (Cowper's Glands):

These small glands are located beneath the prostate. They produce a clear, slippery

fluid that is released just before ejaculation. This fluid lubricates the urethra and

neutralizes any acidic urine residue, creating a better environment for sperm.

 Urethra:

The urethra is a tube that runs through the penis. It serves as a passageway for both

urine and semen. During ejaculation, the urethra carries semen from the

reproductive system to the outside of the body.

 Penis:

Page | 52
The penis is the male external organ involved in sexual intercourse and the passage

of urine. It contains erectile tissue that becomes engorged with blood during sexual

arousal, resulting in an erection.

 Accessory Glands:

Besides the seminal vesicles, prostate, and bulbourethral glands, there are also

accessory glands that contribute to the composition of semen.

The male reproductive system is regulated by hormones such as

testosterone, which is produced by the testes and influences the development of

secondary sexual characteristics and the maintenance of reproductive function. The

coordination of these organs and their functions is essential for successful

reproduction.

ANATOMY OF BREAST

Figure 5. Anatomy of Breast

Page | 53
The breast is located on the anterior thoracic wall. The breast is composed of

mammary glands surrounded by a connective tissue stroma. The mammary glands

are modified sweat glands. They consist of a series of ducts and secretory lobules

(15-20). Each lobule consists of many alveoli drained by a single lactiferous duct.

These ducts converge at the nipple like spokes of a wheel. During pregnancy, high

levels of estrogen and progesterone produced by the placenta inhibit milk secretion.

Estrogen and progesterone levels abruptly alter following placenta ejection. When

the baby sucks, this permits the anterior pituitary gland to release the hormone

called prolactin. Prolactin encourages a baby to suckle and also triggers the 47

posterior pituitary gland to release the hormone oxytocin, which enables the milk to

be expelled from the alveoli and enter the ductal system. At the center of the breast

is the nipple, composed mostly of smooth muscle fibers. Surrounding the nipple is a

pigmented area of skin termed the areolae. There are numerous sebaceous

glands within the areolae – these enlarge during pregnancy, secreting an oily

substance that acts as a protective lubricant for the nipple. Breast development

throughout pregnancy may result in enlargement, tenderness, increased prominence

of veins and striae, areolar enlargement, erectile nipples, and/or nipple sensitivity.

Page | 54
FERTILIZATION

Figure 6: Fertilization

Coitus, or Sexual Intercourse, is the initial stage in reproduction where male genitalia

enter the female reproductive system, potentially leading to fertilization. It begins

when the brain stimulates the corpus cavernosum, allowing blood to flow and the

penis to erect. Females use vaginal glands to protect the vagina. The excitement

phase prepares the body, followed by a plateau phase with increased breathing

patterns and muscular tension. The Orgasmic phase releases sperm and semen,

and the reproductive organs return to their unaroused state.

The process of fertilization involves several steps, including ovulation, ejaculation,

journey through the cervical canal, biochemical changes, branching off, and

fertilization. Ovulation occurs when a mature egg emerges from one of the ovarian

follicles, with a 24-hour window for fertilization. During this time, vaginal discharge

becomes wet and slippery, indicating peak fertility. Semen provides nourishment and

protection for sperm, leaving behind a wall across the vagina to prevent downward

movement.

Page | 55
The cervical canal is a warm and conducive environment that allows sperm to thrive

and move through. It is lined with cervical mucus, which is particularly effective

during the fertile window. The days before ovulation also witness molecular changes,

such as microscopic threads of molecules lining up along the canal.

Sperm entering the canal must change their structural form to survive, triggering

biochemical changes that allow them to travel at breakneck speeds through the

uterus and fallopian tubes. Once in the uterus, they have a critical decision to make:

go right or left, depending on the fallopian tube on either side. Sperm tend to branch

off at this point, some gravitating to the left and others to the right.

Fertilization occurs when only the most resilient sperm reach the egg, which

undergoes chemical changes that block other sperm from entering. The

chromosomes in the egg and sperm combine, giving rise to a zygote.

The egg is alive for about 12-24 hours after its release from the ovary. If it is not

fertilized by this time, it disintegrates and is shed off by the uterine lining. If it is not

fertilized by this time, it disintegrates and is shed off by the uterine lining. The sperm

stays alive for about 72 hours within uterine activity. If the woman is fertile during the

sexual intercourse, fertilization may occur. The sperm will meet the egg cell

produced from the ovary in the fallopian tube. Within 24 hours of fertilization, the

Zygote begins mitotic cell division as it makes its journey into to the uterus, where

fetal development occurs.

In conclusion, the different phases of fertilization include Penetration, where the

sperm releases acrosomal enzymes to penetrate inside the egg; Activation, where

the egg membrane depolarizes; and Fusion of nuclei and formation of zygote. The

human fertilization process ends with the creation of the zygote, which is the

Page | 56
organism's first cell formed when the egg and sperm unite. Karyogamy is the term for

the chromosomal fusion that occurs in male and female gametes. Now fertilized, the

ovum is referred to as a zygote.

IMPLANTATION

Once fertilization happens, the cell starts to divide and multiply within 24 hours in the

fallopian tube. This detached multi-celled structure is called a zygote. Later, after 3-4

days it travels to the uterus and now we call it as an embryo. The embryo undergoes

various stages and attaches to the endometrial layer of the uterus through

implantation. After 72 hours since fertilization, the Zygote then becomes a 16-50 cell

organism called morula which migrates from the fallopian tube right down to the

uterus through a peristaltic movement. The morula becomes hallow and is filled with

a blastocyst, which separates it into two parts: the trophoblast, which allows space

for the placenta and membranes, and the embryoblast, responsible for embryo

formation. The blastocyst usually attaches to the endometrium during the 6th day,

shedding the remaining corona and zona pellucida and sticking to the uterine lining.

To sum up, implantation starts with an initial stage called adaptation, in the first

phase of adaptation, the blastocyst loosely adheres to the endothelium, and in the

second phase, this blastocyst rolls to the site of implantation, and is firmly attached

to the endometrial layer of the uterus, wherein the third phase there is adhesion and

interaction of the blastocyst with uterus takes place.

The implantation should always occur in the body of the uterus, sometimes it does

not happen, it may implant in some loss wrong places like fallopian tubes occur,

Page | 57
which is the abnormal implantation, and sometimes even if implantation is proper but

placenta may not develop properly.

EMBRYO DEVELOPMENT

Figure 7: Embryo Development

The embryonic development then begins and it continues till it reaches the 8th

week. Fertilization forms the zygote, which divides mitotically into 2, 4, 8, or 16-celled

stages called, Blastomeres. An embryo with 8 to 16 blastomeres, is called Morula.

The morula continues to divide mitotically and transforms into a blastocyst. The

blastocyst's outer layer is known as the trophoblast, and it attaches to the uterine

wall known as the endometrium. The implantation process begins in the first week

and is completed by the second week. The blastocyst's inner cell mass develops into

the embryo. Blastocysts differentiate into embryonic and extraembryonic tissues.

The placenta is formed by the interdigitated chronic villi of trophoblast and

uterine cells and serves as the link between the mother and the growing fetus. It

provides nourishment and oxygen to the embryo and helps in removing carbon

Page | 58
dioxide and waste produced by the embryo. It also functions as an endocrine gland,

secreting hormones such as hCG (Human Chorionic Gonadotropin), estrogen,

progestogens, and others to keep the pregnancy going.

Gastrulation begins in the third week, and the embryo differentiates into three

germinal layers: ectoderm, endoderm, and mesoderm. These cells differentiate into

various tissues and organs, including the nervous system, brain, spinal cord,

epidermis, hair, nails, and internal organs.

Weeks after Embryonic Development

Fertilization

Week Three Gastrulation and formation of three germinal layers. Neurulation

follows gastrulation. Notochord is formed

Week Four The heart is the first organ to start functioning. The heart starts

beating. Arm buds and optic pits become visible

Week Five Size ~ 4 mm. Starts becoming C-shape, inner ear starts

developing, pharyngeal arches develop, liver, pancreas, spleen and

gall bladder start developing

Week Six Size ~ 8 mm. Development of eyes and nose, leg buds and hand

as flat paddles appear, stomach and kidney precursors start

developing

Week Size ~ 13 mm. Lungs and lymphatic system and primary sex

Seven organs start developing, arms and legs lengthen and digits start

appearing

Page | 59
 Week Eight Size ~ 20 mm. External ear starts appearing, nipples and hair

follicles start developing, most of the organs start developing by this

time

Week Three Gastrulation and formation of three germinal layers. Neurulation

follows gastrulation. Notochord is formed

Week Four The heart is the first organ to start functioning. The heart starts

beating. Arm buds and optic pits become visible

To sum up, the heart is the first organ to start working, and it develops after

the first month of pregnancy. In the second month, limbs and digits develop, and by

the end of the first trimester, all major organ systems are visible. The embryo moves

during the fifth month, and hairs start appearing on the head. By the end of the

second trimester, eyelashes form, eyelids separate, and the body is covered with

fine hair. By the end of the ninth month, the fetus is fully developed and ready for

birth,

Page | 60
Stages of Fetal Development

Figure 8:

Stages of Fetal Development

Germinal Stage

The germinal stage is the shortest stage of fetal development. This stage of

pregnancy starts at the time of conception, when the sperm and the egg

combine to form a zygote. During the germinal stage, the zygote begins to

divide in order to implant into the uterine wall. The zygote divides multiple

times, creating two structures: embryo and placenta. Rapid cell division turns zygote

into blastocyst, which implants into uterine lining, producing hormones for

pregnancy.

Embryonic Stage

Page | 61
 Once implantation is complete, the embryonic stage begins. The mass of cells

is now known as an “embryo The neural tube, which gives rise to the brain and

spinal cord, as well as the head, eyes, mouth, and limbs, are among the structures

and organs that form. During the sixth week of development, the heart starts to beat

and develop, and buds grow into limbs and legs. The majority of the embryo's

systems and organs begin to take shape by the end of the eighth week. By the end

of the eighth week, most of the embryo's systems and organs take shape, except for

sex organs. The embryo looks like a little tadpole, growing to 1 to 1.5 inches and

weighing 1 gram. By the end of this period, the embryo has all basic organs and

parts.

Fetal Stage

The fetus undergoes a series of stages during its prenatal development. The

fetal stage, lasting from week nine until birth, is crucial for a fetus's brain and spinal

cord development, and sex organ differentiation. Gender can be determined around

18-20 weeks through ultrasound or genetic testing. The second trimester, starting at

week 12, marks the fetus's growth up to 6 inches, with hair, eyelid opening, eyebrow

and eyelash development, fingerprinting, and brain development. The third trimester,

starting at week 27, lasts until birth, with the baby reaching 15 inches and maturing

the lungs and digestive system. The baby is considered full-term at 37 weeks.

SIGNS AND SYMPTOMS OF LABOR

Labor is a physiologic process that includes abdominal pressure and uterine

contractions that expel a fetus and placenta from the uterus. Regular contractions

Page | 62
stimulates progressive dilation of the cervix and generate enough muscular uterine

strength to allow a baby to be pushed out into the extra-uterine world.

A sudden burst of energy (nesting), braxton hicks contraction (false labor), a

feeling that the baby has dropped (lightening), contraction that ranges from mild to

strong, thinning of the cervix (effacement), widening the opening of the cervix

(dilation), water breaking, leg cramping, back pain, and nausea are some of the

common signs of labor. This intricate process can be segmented into distinct stages,

each strategically designed to fulfill a particular function in preparing for and ensuring

the secure delivery of the infant.

Stages of Labor

First Stage of Labor: Cervical Dilation

The first phase of the first

stage of labor is called the latent

phase, when contractions are

becoming more frequent (usually 5 to

20 minutes apart) and somewhat

stronger. However, discomfort is

minimal. The cervix dilates (opens

approximately three or four

centimeters) and effaces (thins out).

Figure 9: Stage 1 of Labor

This stage is divided into three (3) segments which includes Latent, Active and

Transition Phase.

Page | 63
The latent phase is usually the longest and least intense phase of labor. The

mother-to-be is usually admitted to the hospital during this phase. Pelvic exams are

performed to determine the dilation of the cervix.

The second phase of the first stage (active phase) is signaled by the dilation of the

cervix from 4 to 7 centimeters.

Contractions become longer, more severe, and more frequent (usually 3 to 4

minutes apart).

The third phase is called transition and is the last phase. During transition, the

cervix dilates from 8 to 10 centimeters. Contractions are usually very strong, lasting

60 to 90 seconds and occurring every few minutes. Most women feel the urge to

push during this phase.

Second Stage of Labor: Expulsion of the Fetus

The second stage of labor is the period of time from 10 cm full cervical

dilatation and 100% cervical effacement to the delivery of the baby. The

second stage of labor begins when the cervix 10 cm full dilated with 100%

cervical effacement and ends with the delivery of the baby. The second

Figure 10: Stage 2 of Labor

stage is often referred to as the "pushing" stage. During the second stage,

the woman becomes actively involved by pushing the baby through the birth

canal to the outside world. When the baby's head is visible at the opening of

the vagina, it is called "crowning." The second stage is shorter than the first

Page | 64
 stage, and may take between 30 minutes to two hours for a woman's first

pregnancy

Third Stage of Labor: Placental Delivery

The third stage of labor is the period of time from the delivery of the fetus to

the delivery of the placenta. There are several signs associated with the placental

separation from the wall of the uterus. Including, lengthening of the umbilical cord,

fundus become globular in shape and there is a sudden gush of blood. The signs of

separation of the placenta usually

Figure 11: Stage 3 of Labor

become evident within 5 to 10 minutes after birth. This stage includes 2 separate

phases: Placental Separation and Placental Expulsion. There are signs indicating

placental separation including lengthening of the cord, the fundus become globular in

shape and there is sudden gushing of blood. This is followed by delivery of the

placenta. Accordingly, placenta is presented in 2 ways. If the placenta appears shiny

and glistening from fetal membranes, this is called Schultze. On the other hand, if

the placenta looks raw, red, and irregular, with the ridges or cotyledons that

separates blood collection spaces evident, it is called Duncan.

Fourth Stage of Labor: Recovery

The fourth stage of labor or the recovery stage mostly starts after the placenta

have been delivered to the first two hours after birth. During this time, the healthcare

provider may have to repair an incision (episiotomy) or tears (lacerations) made

during the delivery. This repair is made by giving stitches with thread that absorbs on

its own. The baby will be sent to the newborn nursery within two hours of delivery,

and the mother will be moved to a postpartum (after childbirth) room where the
Page | 65
patient will spend the remainder of her hospital stay. Once the examination of your

child in the nursery completes and he or she maintains a stable temperature, the

baby is given back to the mother and continue skin-to-skin contact. During this time,

the uterus contracts here and there, pushing out what’s left inside and reestablishing

muscle tone. These contractions are hastened by breastfeeding, which stimulates

the production of the hormone oxytocin.

GESTATIONAL DIABETES MELLITUS

Figure 12: Gestational Diabetes

Anatomy of Gestational Diabetes Mellitus

Any degree of glucose intolerance with onset or first recognition during pregnancy.
Gestational diabetes occurs when the body is unable to produce enough insulin to
meet the needs of the pregnancy. In pregnancy, there is progressive insulin
resistance. This means that a higher volume of insulin is needed in response to a
normal level of blood glucose. On average, insulin requirements rise by 30% during
pregnancy.

Page | 66
1. Placenta:
A temporary organ that develops during pregnancy, plays a central role in GDM.
It produces hormones like human placental lactogen and others that contribute to
insulin resistance. GDM may lead to placental dysfunction, affecting its ability to
support the growing fetus optimally.

2. Insulin and Pancreas:

The pancreas, an organ with endocrine and exocrine functions, produces insulin.
The fetus pancreas senses this high level of blood sugar and makes more insulin.
GDM involves increased insulin resistance, where the body's cells do not respond
adequately to insulin.

3. Blood Sugar Regulation:

Glucose builds up in the blood instead of being absorbed by the cells. Insulin
normally facilitates the uptake of glucose into cells, regulating blood sugar levels.
In GDM, insulin resistance hinders this process, leading to elevated blood sugar
levels (hyperglycemia).

4. Fetal Impact:

GDM can influence the fetus's development due to exposure to elevated blood sugar
levels.
The baby may experience macrosomia (excessive growth) and an increased risk of
complications during delivery. The baby is at higher risk of being very large (9
pounds or more), which can make delivery more difficult.

Page | 67
MECONIUM STAINING

Figure 13: Meconium Staining

Anatomy of Meconium Staining

Meconium is the dark, thick and sticky first poop of a newborn baby. It is made of
water, cells, hair, mucus, and other materials. Meconium staining occurs when the
baby passes its first stool (meconium) into the amniotic fluid; inside the mother, this
may prompt increased monitoring and potential adjustments in the delivery plan to
ensure the well-being of both the mother and the baby.

 Amniotic Fluid:

Meconium staining indicates the presence of meconium (fetal stool) in the amniotic
fluid. The amniotic fluid surrounds and protects the fetus during pregnancy. The
presence of meconium in the amniotic fluid may prompt a closer examination to
assess fetal well-being during pregnancy.
 Uterus:

The uterus, where the baby develops during pregnancy. May contract differently in
response to meconium staining, especially if it indicates fetal distress. Stress that
your baby experiences before or during birth may cause your baby to pass
meconium stool while still in the uterus.

Page | 68
  Maternal Circulation:

Meconium staining itself doesn’t have a direct impact on the mother’s circulatory
system. But its presence may prompt healthcare providers to closely monitor the
mother for signs and complications or infection. It can also increased risk of
operative delivery.

 Respiratory System:

Meconium aspiration can lead to respiratory distress and may require medical
intervention. Meconium staining can affect the baby’s respiratory system if
meconium is inhaled during labor or delivery. The meconium can also block the
infant’s airways right after birth.

 Lungs:

Meconium aspiration may lead to meconium particles entering the lungs, causing
inflammation and potentially compromising respiratory function. Meconium can
irritate airways and injure lung tissue.

 Infection risk:

Meconium-stained amniotic fluid may indicate a risk of infection for the newborn.
Infections can affect various systems, including the respiratory and circulatory
systems. It is also an establish risk factor for neonatal sepsis and for intrapartum and
postpartum maternal infection.

CORD COIL

Page | 69
Anatomy of Cord Coil

The umbilical cord is considered both the physical and emotional attachment
between mother and fetus. A cord coil or nuchal cord occurs when the umbilical cord
wraps around an unborn child’s neck. Even with cord coil, most babies can still be
delivered vaginally. A cesarean section (C-section) is only needed if the nuchal cord
possess a risk to the unborn baby. Factors contributing to a cord coil include the
baby’s activity, multiple pregnancies, excess amniotic fluid, or a long umbilical cord.

There are 2 types of cord coil:

Type A nuchal cord or unblocked nuchal cord:
This type of nuchal cord is free sliding, meaning that it can spontaneously untangle
with fetal movement.

Type B nuchal cord or locked nuchal cord:

This is a more complicated type of cord coil where fetal movements cannot undo the
coil. Normally, a type B nuchal cord requires a C-section.

1. Umbilical Cord:
It consists of two arteries (carrying deoxygenated blood and waste products away
from the fetus) and one vein (transporting oxygenated blood and nutrients to the
fetus). The umbilical cord connects the developing fetus to the placenta. A cord
coil or nuchal cord occurs when the umbilical cord wraps around the baby’s neck,
forming one or more loops.
2. Amniotic Fluid:
It can decreased the amounts of amniotic fluid. The amniotic fluid surrounds the
baby in the womb and is the medium where the nuchal cord can occur. Amniotic fluid
allows for fetal movement and cushioning.
3. Blood Flow:
Blood flow through the entangle cord may be decreased during contractions. This
can cause the baby’s heart rate to fall during contractions. Prior to delivery, if blood
flow is completely cut off, a stillbirth can occur.
4. Oxygen and Nutrient Supply:
The umbilical cord carries nutrients and oxygen to the fetus in the mother’s womb. A
nuchal cord might interrupt the flow or oxygen and nutrients to the fetus and cause
complications. Fetal well-being depends on the degree of tightness and the ability of
the baby to adapt.

Page | 70
5. Delivery Considerations:
The presence of a nuchal cord may influence the mode and timing of delivery. If the
nuchal cord is tight healthcare providers may consider interventions. If there is
concern about the cord’s enlargement, a baby may be delivered by cesarean.

Page | 71
IX. ETIOLOGY AND SYMPTOMATOLOGY

A. Etiology

Etiology, as defined by Merriam-Webster, pertains to a subdivision of medical

science focused on understanding the causes and origins of diseases. This area of

study delves into exploring the origins, sets of causes, or the way diseases or

conditions are caused.

PREDISPOSING ACTUAL FINDINGS

IMPLICATIONS
FACTORS

Age over 25 years old Present: 38 years old Gestational diabetes is

more common in pregnant

women over 25 than in

younger women (Li et al.,

2020).

Family History of Present: Type II Diabetes Confirming a diabetes

Diabetes Mellitus in both lineages (maternal diagnosis was more often

and paternal side). in people with a moderate

to high familial risk than in

people with a low risk

(Center for Disease

Control and Prevention,

2023).

Insulin-resistant Present: Patient was Pancreatic beta-cell

Page | 72
 conditions diagnosed with Gestational dysfunction in women with

Diabetes Mellitus during preexisting insulin

(Gestational Diabetes
the 34th week of gestation resistance is thought to be
Mellitus (GDM), Polycystic
in her third pregnancy and the cause of GDM, which
Ovary Syndrome (PCOS),
subsequently diagnosed manifested in this patient
Acanthosis Nigricans,
during the 31st week of (Plows et al., 2018).
Chronic Stress)
gestation in her fourth However, Polycystic Ovary

pregnancy. Syndrome (PCOS),

Acanthosis Nigricans, and

Absent: Polycystic Ovary
Chronic Stress was not
Syndrome (PCOS),
seen in this patient.
Acanthosis Nigricans,
Women with PCOS are
Chronic Stress
more likely to develop

gestational diabetes

mellitus, compared to

women without PCOS

(Qiu, Zhang, & Ni, 2022).

Also, Acanthosis nigricans

serves as an indicator of

insulin resistance, though it

can be mistaken for

changes in skin

pigmentation, such as

those occurring during

pregnancy. The correlation

Page | 73
 with gestational diabetes

mellitus (GDM) implies a

link to insulin resistance in

the progression of GDM,

aligning with findings in

other research studies

(Muallem & Rubeiz, 2006;

Lopez-Alvarenga et al.,

2006). Lastly, an increase

in stress hormones and

disruptions in stress

adaptation may be linked

to the development of

gestational diabetes

mellitus (GDM) in pregnant

individuals (Feng et al.,

2020).

Hypertension during the Absent: The patient's blood Gestational diabetes raises

present gestation. pressure falls within the the likelihood of developing

normal range, as specified elevated blood pressure

in the vital signs section and preeclampsia, a

within the patient's data. serious pregnancy

complication characterized
(See page ___).
by high blood pressure and

Page | 74
 other symptoms that pose

significant risks

(Weissgerber & Mudd,

2015).
Ethnic Background Present: Asian-Filipina The current global

statistics indicate that out

of 1,332 women diagnosed

with gestational diabetes

(GDM), 911 met the

inclusion criteria for the

study. The eligible

participants were from

diverse ethnic

backgrounds, with 41.4%

being white Caucasian,

17.1% South Asian, 18.4%

East Asian, 5.8% black,

8.8% Filipina, 5.2% Middle

Eastern, and 3.3%

Hispanic (Read et al.,

2019). Specifically focusing

on the Philippines, a

survey of 1,203

pregnancies revealed a

GDM prevalence of 14%.

Page | 75
 Additionally, data from the

ASGODIP study

highlighted that when

screening for GDM was

conducted beyond the 26th

week of pregnancy,

approximately 40.4% of

high-risk women tested

positive for gestational

diabetes (National Nutrition

Council, 2021).

History of Macrosomia Absent: According to the Women who experienced

(4.5 kg or more) patient’s obstetric records, the delivery of a

spanning from the initial macrosomic infant (>4500

pregnancy to the most grams or 4.5 kg) in their

recent one, the neonate of previous childbirth faced

the patient consistently an elevated likelihood of

exhibited a birth weight developing gestational

within the range of 2 kg to diabetes (McGuire et al.,

2.5 kg. 1996).

PRECIPITATING
ACTUAL FINDINGS IMPLICATIONS
FACTORS

Obesity Absent: Patient is In the context of

Page | 76
 pregnancy, a BMI of 29.9

falls into the "overweight"

category. However, obesity

is not manifested in our

patient. Pregnant women

overweight, with a BMI of with obesity face an

29.63 (height = 1.47 elevated risk of

meters, weight= 64 kg). experiencing various

pregnancy complications,

among which gestational

diabetes mellitus (GDM) is

included (Marchi et al.,

2015).

Diet Present: High in Sugar Excessive consumption of

Diet. The patient's history simple sugars during

indicates a daily pregnancy can contribute

consumption of a minimum to an increase in

of 5 chocolate bars, gestational weight gain

specifically Snickers, each (GWG) and elevate the risk

containing 47 grams of of experiencing other

sugar per bar. It's pregnancy complications,

noteworthy that the including gestational

recommended average diabetes (GDM),

daily sugar intake for preeclampsia, and preterm

Page | 77
 pregnant women is birth (Casas, Castro

generally advised to be Barquero, & Estruch,

less than 30 grams. 2020).

Sedentary Lifestyle Present: The patient A higher likelihood of

reported minimal developing gestational

engagement in physical diabetes mellitus (GDM)

exercise, attributing this to was observed in

her role as a house wife, individuals with lower

responsible for caring for levels of moderate physical

four children. activity during pregnancy.

Extended periods of sitting

were also identified as a

significant risk factor.

Moreover, engaging in

regular exercise serves as

a means to lower blood

glucose levels, as our

muscles absorb more

glucose during physical

activity (Mishra & Kishore,

2018).

A. SYMPTOMATOLOGY OF GESTATIONAL DIABETES MELLITUS

Page | 78
SYMPTOMS PRESENT/ABSENT IMPLICATIONS

Polyphagia Present Excessive accumulation of sugar, or

glucose, in the bloodstream can lead

to its excretion in the urine. This

process, often associated with

conditions like diabetes, results in an

inefficient utilization of glucose for

energy. As a consequence, the

individual may experience heightened

feelings of hunger, prompting

increased food consumption as a

compensatory mechanism to replenish

the lost sugar-derived energy

(Venkatesan, 2021).

Glycosuria Absent Diabetes induces glycosuria due to

insufficient insulin levels or the

ineffective utilization of available

insulin. In the absence of adequate

insulin, blood glucose levels elevate,

exceeding the renal threshold.

Consequently, the kidneys are unable

to efficiently filter and reabsorb the

excess glucose, leading to its

elimination through the urine.

Glycosuria, characterized by the

Page | 79
 presence of glucose in the urine, is a

result of the dysregulation of glucose

metabolism in diabetes, further

highlighting the crucial role of insulin in

maintaining proper blood glucose

levels (Liman & Jialal, 2023).

Polyuria Absent Elevated blood glucose levels,

characteristic of conditions such as

diabetes, can surpass the renal

threshold, exceeding the kidneys'

capacity for filtration. In response, the

kidneys excrete the surplus glucose

into the urine. Since glucose is a

solute, it induces an osmotic effect,

attracting water into the urine. This

osmotic diuresis leads to increased

urine production, a phenomenon

commonly observed in situations

where high blood glucose levels

overwhelm the renal reabsorption

capacity, resulting in the expulsion of

glucose-laden urine accompanied by

an increased volume of urine due to

the osmotic effect (Quigley et al.,

2018).

Page | 80
Polydipsia Absent Polydipsia, or heightened thirst, is a

consequence of elevated blood

glucose levels that contribute to an

increase in blood osmolarity, rendering

it more concentrated. This

phenomenon occurs when an

enzyme, produced by the placenta

during pregnancy, acts to degrade

antidiuretic hormone (ADH) in the

pregnant individual. The reduction in

ADH levels disrupts the normal water

balance regulation, leading to

increased blood osmolarity, and

subsequently triggering polydipsia as

the body attempts to address the

concentrated blood by promoting

increased fluid intake (Mandal, 2023).

Fatigue Present Insufficient insulin production by the

pancreas or ineffective utilization of

insulin by the body results in elevated

blood glucose levels. This excess

glucose in the bloodstream can lead to

fatigue and weakness as cells are

deprived of an adequate supply of

glucose for energy. The impaired

Page | 81
 cellular glucose uptake contributes to

reduced energy production,

manifesting as fatigue and weakness

in pregnant women with diabetes

(Singh, 2016).

Vaginal, bladder Absent Pregnant women with diabetes are at

and skin infection an increased risk of Candida infection

due to the heightened blood sugar

levels, creating a conducive

environment for yeast growth.

Elevated sugar levels serve as a

nutritional source for yeast, fostering

conditions favorable for the

proliferation of Candida, thus raising

the susceptibility of pregnant women

with diabetes to infections caused by

this fungus (Sopian et al., 2016).

Eye Vision Present Elevated glucose levels can induce

Problems alterations in fluid levels, resulting in

swelling of the ocular tissues

responsible for focusing - this swelling

can contribute to blurred vision.

Additionally, damaged blood vessels

may experience fluid leakage, leading

to further swelling. The presence of

Page | 82
 weakened new blood vessels may

initiate growth, potentially causing

bleeding in the central region of the

eye, fostering scarring, and

precipitating elevated pressure inside

the eye, posing potential risks to

ocular health

(National Institute of Diabetes and

Digestive and Kidney Diseases,

2017).

COMPLICATIONS PRESENT/ABSENT IMPLICATIONS

Meconium Staining Present Various risk factors have

been identified as

potential stressors on the

fetus, leading to the

occurrence of Meconium-

Stained Amniotic Fluid

(MSAF). These include

advanced gestational age

at delivery, prolonged

duration of rupture of

membranes (ROM),

Page | 83
extended second stage of

labor, intra-amniotic

infection, placental

insufficiency, maternal

hypertension,

preeclampsia,

oligohydramnios,

Intrauterine Growth

Restriction (IUGR),

Gestational Diabetes

Mellitus (GDM), overt

diabetes mellitus, and

maternal substance

abuse, such as tobacco

or cocaine. The

association of these

factors with the presence

of meconium staining in

the amniotic fluid

underscores the

importance of recognizing

and managing these

conditions to mitigate

potential adverse

outcomes for the fetus

Page | 84
 (Shaikh, Mehmood, &

Shaikh, 2010; Hanoudi,

Murad, & Ali, 2014;

Mahapatro & Ghose,

2014).

Cord Coiling Present An elevation in placental

umbilical cord insertion

(pUCI) has been

associated with an

augmented risk of

spontaneous preterm

delivery in both

uncomplicated

pregnancies and those

complicated by

Gestational Diabetes

Mellitus (GDM).

Additionally, this elevation

in pUCI has

demonstrated an

increased incidence of

Large for Gestational Age

(LGA) neonates and the

presence of meconium-

stained amniotic fluid

Page | 85
 specifically in cases of

GDM-affected

pregnancies. These

findings underscore the

potential impact of pUCI

on adverse perinatal

outcomes, emphasizing

the need for vigilant

monitoring and

management strategies

in pregnancies

characterized by elevated

pUCI (Najafi et al., 2019).

Macrosomia Absent In Gestational Diabetes

Mellitus (GDM), elevated

maternal blood glucose

levels lead to an

increased transfer of

glucose across the

placenta into the fetal

circulation. Consequently,

the excess glucose within

the fetal environment is

converted and stored as

adipose tissue, resulting

Page | 86
in macrosomia, a

condition characterized

by excessive fetal growth

and commonly referred to

as 'large for gestational

age' (LGA). This

phenomenon

underscores the

importance of glycemic

control in GDM

management to mitigate

the risk of macrosomia

and associated

complications for both the

fetus and the mother (Kc,

Shakya, & Zhang, 2015).

Page | 87
X. PATHOPHYSIOLOGY

Page | 88
Page | 89
XI. DOCTOR’S ORDER

Date/Time Doctor’s Order Rationale Remarks

11/24/24  Admit to LR -Done

1:21 pm

 NPO once in acive labor - To minimize the -Done

risk of aspiration

and complications

associated with

anesthesia.

 IVF PLR 1L @40gtts/min - Administered for -Done

aiding in fluid and

electrolyte balance.

-To monitor health

 CBC, UA,VST, HBsAg parameters and -Done

enable timely

interventions if

necessary during

childbirth.

 Refer to Dr. Besas - To provide -Done

 Refer to Dr. Nisperos nutritional support, -Done

maintaining
Page | 90
  Start D5LR 1L @120cc/hr hydration, -Done

electrolyte balance,

and stabilizing blood

glucose levels.

 AP informed -Done

11/24/24  To recovery room now until -Done

2:25 pm stable then to room thereafter

 DAT - For individualized -Done

nutritional intake

based on patient

preferences and

digestive

capabilities.

- Administered to

 Incorporate 20 unit oxytocin stimulate uterine -Done

to present IVF to run contractions,

@30gtts/min then consume prevent postpartum

then discontinue hemorrhage, and

facilitate

Page | 91
 breastfeeding,

Medicine: - Prescribed to treat

1. Co-amoxiclav 625 mg BID postpartum

infections, such as -Done

endometritis or

urinary tract

infections.

- For postpartum

pain relief, uterine

2. Mefenamic Acid 500 mg TID contractions and

perineal discomfort. -Done

- To support

postpartum

recovery, replenish

3. Mosvit Elite 1 tab OD nutrient levels, and -Done

prevent deficiencies

during the healing

process.

- To prevent or

manage postpartum

Page | 92
 hemorrhage by

promoting uterine

contractions and

4. Methylergometrine maleate 1 reducing the risk of -Done

tab TID uterine atony.

- A contracted

uterus post-

childbirth prevents

excessive bleeding,

promotes healing,

and expels residual

blood and debris,

 Keep uterus contracted contributing to the -Done

mother's recovery.

- Essential for

promptly identifying

and addressing

potential health

issues during the

postpartum period.

- To promote

Page | 93
  VS q15 mins x 3 takes then q hygiene, prevent -Done

hourly x 6 hrs then q8 hrs infection, and

facilitate the healing

process of perineal

tissues after

childbirth.

 Perineal care daily with -Done

Betadine feminine wash

 Refer accordingly -Done

01/24/24  Diabetology -Done

8:38 am

 Thank you so much for your -Done

refer

 CBG monitoring BID AC - To regulate blood

Page | 94
 meals sugar levels, -Done

especially in those

with gestational

diabetes reducing

the risk of

hyperglycemia or

hypoglycemia.

01/25/24  Diabetology -Done

7:00 am

 D/C CBG monitoring -Done

 Repeat FBS q2 75g OGTT - Helps detect and -Done

after 1 month manage gestational

diabetes preventing

potential

complications for

both mother and

newborn.

- To monitor

recovery, address

Page | 95
  Follow up check up once ĉ possible concerns. -Done

result

 Off-service. Thanks for the -Done

referral.

01/25/24  MGH -Done

 Home meds -Done

1. Co-amoxiclav 625 mg BID x - Prescribed to treat

2 days postpartum

infections, such as

endometritis or

urinary tract

infections.

- For postpartum

pain relief, uterine

2. Mefenamic Acid 500 mg TID contractions and -Done

x 2 days perineal discomfort.

- To support

postpartum

recovery, replenish

Page | 96
3. Mosvit Elite 1 tab OD nutrient levels, and -Done

prevent deficiencies

during the healing

process.

- To prevent or

manage postpartum

hemorrhage by

promoting uterine

4. Methylergometrine maleate 1 contractions and -Done

tab TID x 2 days reducing the risk of

uterine atony.

- To monitor

recovery, address

possible concerns.

 Ff check-up with me on -Done

2/1/24

 Advised -Done

Page | 97
XII. DIAGNOSTIC EXAM DATE

ORDERED: 01/10/2024.

HEMATOLOGY

EXAMINATION RESULT UNIT NORMAL

VALUES
HEMOGLOBIN 138 g/L 120-140

RED BLOOD 4.33 10^1 4.00-5.00

CELL 2/L
WHITE BLOOD 7.48 10^9/ 4.0-10.0
CELL L
LYMPHOCYTES 0.195 % 0.200-0.400
HEMATOCRIT 0.36 % M: 0.40-0.60
F: 0.38-0.48
PLATELET 419 10^9/L 150-450f

Remarks: RESULT ARE FROM DYMIND

ANALYZER

URINALYSIS

COLOR YELLOW KETONE NEGATIVE

APPEARANCE HAZY NITRITE NEGATIVE
SUGAR NEAGTIVE LEUCOCYTES NEGATIVE
BLOOD NEGATIVE REACTION ACIDIC
BILIRUBIN NEGATIVE SPECIFIC 1.025
GRAVITY
UROBILINOGEN NORMAL

BLOOD TYPING

SPECIMEN WHOLE BLOOD

EXAMINATION BLOOD TYPING

RESULTS

CELL TYPING B

RH TYPING POSITIVE

WEAK “D” TESTING

Page | 98
ORAL GLUCOSE TOLERANCE TEST (OGTT)

RESULT REFERENCE RANGE

Fasting Blood Sugar 5.19 4.1-5.9 mmol/L
After One Hour 10.67
After Two Hours 9.70
After Three Hours 6.67

Page | 99
 Name of Drawing Classification Dosage/ Indication Mechanism of Side Effects Nursing Responsibilities
Drug Time/ Action
Route
Generic Therapeutic Dosage: To prevent Methylergomet CNS: Observe the 10 Rights of Giving
Name: class: and treat rine constricts headache, Medication:
125 mg/ 1
Methylergom Oxytocics postpartum the blood dizziness,
Tab 1. Right Drug
etrine/ hemorrhage vessels and
GI: abdominal
methylergon Pharmacologi cause by promotes 2. Right Patient 3. Right Dose
pain, diarrhea,
ovine c class: uterine uterine muscle
Time: TID GI 4. Right Route 5. Right Time
atony or contractions,
Ergot alkaloids reflux:nausea,
subinvolutio which helps to 6. Right to Refuse
flatulence.
Brand n control
Musculoskelet 7. Right to Educate
name: postpartum
Route: al: leg
Methergine bleeding. 8. Right Documentation 9. Right
PO cramps,chest
pain. Assessment
10. Right Evaluation
-The 10 Rights of Medication
Administration are crucial
guidelines to ensure the safe and
effective delivery of medications.

1. Obtain history to determine

medical conditions and allergies
to this medication.
-A thorough

Page | 100
medical history
helps identify any pre-existing
conditions or
allergies that
may increase the risk of adverse
effects to the medication.

2. Check the doctor’s order and

medication ticket at least three
times .
-Repeatedly verifiying the order
doctor's and medication ticket
minimizes the risk of
administration this errors,
meticulous checking process
ensures that the correct dosage
and medication are
administered,promoting patient
safety.

3. Identify the patient .

-Confirming the patient’s identity
is critical to prevent medication
errors that might result in

Page | 101
unintended side effects. This step
ensures that right the
medication is
administered to the correct
individual,
contributing to
overall patient
safety.

4. Monitor patient’s vital signs

:BP, heart rate.
-Regular
monitoring is
essential
for detecting any adverse
reactions promptly. It aids
early in identification of potential
complications
and ensures the patient's
overallwell-being during and
after medication administration.

Page | 102
5. Administer the medication
according to the doctor’s order.
- Adhering to the doctor's order
ensures that the patient receives
prescribed the dose at the correct
time, promoting the
medication's efficacy and
preventing
potential complications.

6. Inform the patient about the

adverse effects.
-Providing
information about
potential adverse
effects promotes
patient awareness and
cooperation.
It allows the patient
to report any

Page | 103
unusual
symptoms facilitating early
intervention
if needed.

7. Instruct both patient and

watcher to report any adverse
effect .
-Encouraging open
communication with both the
patient and their watcher
increases the likelihood of early
detection and management of
adverse effects, contributing to
overall patient safety.

8. Provide further comfort

measures to reduce pain and to
reduce inflammation (warmth,
positioning, and rest).
-Integrating these measures into
a holistic approach can enhance

Page | 104
overall pain management and
provide individuals with a
comprehensive tool kit for
alleviating discomfort and
promoting a quicker recovery.

9.monitor uterine bleeding and

notify the physician of any
changes.
-Monitoring uterine bleeding and
promptly notifying the physician of
any changes is crucial for
ensuring timely and effective
medical intervention.

Page | 105
 Name of Drawing Classification Dosage/ Indication Mechanism of Side Effects Nursing Responsibilities
Drug Time/ Route Action

Generic Therapeutic Dosage: Mosvit Elite Mosvit Elite CNS:Headac Observe the 10
Name: class: Capsule Capsule is he
1 Tab Rights of Giving
Multivitamins Multivitamins works by used for
GI: Upset
+ minerals. with minerals. providing Pregnancy Medication:
stomach,Gast
nutritional related mineral
(Supplement) rointestinal 1. Right Drug
requirements deficiency,
intolerance
Brand name: Time: OD of the body to Digestive 2. Right Patient
maintain disorders, Other:
Mosvit Elite physiological Minerals 3. Right Dose
Unusual or
balance; related poor unpleasant 4. Right Route
Route: maintaining nutrition, taste in
fluid balance Physiological mouth, 5. Right Time
PO
within body stress, 6. Right to Refuse
cells and Nutritional Allergic
acidity levels. deficiency, manifestation 7. Right to Educate
Mineral ,Idiosyncratic 8. Right
deficiencies reactions
and other Documentation
conditions.
9. Right Assessment
10. Right Evaluation
-The 10 Rights of Medication
Administration are crucial
guidelines to ensure the safe
and effective delivery of
medications.

Page | 106
Assessing the client for signs
and symptoms of vitamin
deficiency prior to initiating
vitamin therapy is essential
-To avoid potential toxicity in
cases where the client does
not actually have a
deficiency.

Instruct the client not to

exceed the recommended
dosage of a multivitamin and
to refrain from using any
other multivitamin product
within a 2-hour window
before or after taking the
medication
-To prevent the risk of
overdose.

Client Teaching: Teach the

client to prevent constipation
with a high-fiber diet and
increased fluid intake

Page | 107
-By emphasizing the
importance of fiber in
promoting healthy bowel
movements. Explain that
fiber adds bulk to the stool,
making it easier to pass
through the digestive system.
Encourage the client to
incorporate fiber-rich foods
such as fruits, vegetables,
whole grains, and legumes
into their daily meals.

Page | 108
 Name of Drawing Classification Dosage/ Indication Mechanism of Side Effects Nursing Responsibilities
Drug Time/ Route Action

Generic Therapeutic Dosage: For the Mefenamic Observe the 10 Rights of

Name: class: NSAID treatment of acid binds Giving Medication:
500 mg CNS:
Mefenamic rheumatoid the
headache, 1. Right Drug 2. Right
Acid arthritis, prostaglandin
Patient 3. Right Dose
osteoarthriti synthetase dizziness,
Pharmacologi Time: TID s, receptors insomnia 4. Right Route 5. Right
c class:
Brand name: dysmenorrhe COX-1 and Time
Anthranilic SKIN: rash,
a, and mild COX-2,
Dolfenal acid 6. Right to Refuse
to moderate inhibiting the peripheral
derivative Route: pain, action of edema 7. Right to Educate
PO inflammation prostaglandin
, and fever synthetase. Gl: nausea, 8. Right Documentation 9.
As these Right Assessment
ulceration,
receptors severe 10. Right Evaluation
have a role as
a major diarrhea, -The 10 Rights of
mediator of Medication Administration
flatulence,
inflammation are crucial guidelines to
and/or a role constipation ensure the safe and
for effective delivery of
GU: dysuria, medications.
prostanoid renal
signaling in
activity impairment
dependent 1. Obtain history to
HEMATOLO determine medical
plasticity, the
GIC: conditions and allergies to
symptoms of
pain are bleeding, this medication.

Page | 109
 temporarily platelet -A thorough
reduced
inhibition medical history
Anthranilic
with
acid helps identify any
derivative. higher
Like pre-existing
doses,
ibuprofen conditions
inhibits neutropenia
prostaglandin or
RESPIRATO
synthesis and RY: dyspnea allergies
affects
platelet that
function. No may increase the
evidence that
it is superior risk of adverse
to aspirin. effects to the
medication.

2. Check the doctor’s

order and medication ticket
at least three times .
-Repeatedly verifying the
order doctor's and
medication ticket
minimizes the risk of
administration this errors,
meticulous checking

Page | 110
 process ensures that the
correct dosage and
medication are
administered, promoting
patient
safety.

3. Identify the patient.

-Confirming the patient’s
identity is critical to
prevent medication errors
that might result in
unintended side effects.
This step ensures that right
the
medication is
administered to the correct
individual,
contributing to
overall patient
safety.

4. Monitor patient’s vital

Page | 111
 signs.
-Regular
monitoring is
essential
for detecting any adverse
reactions promptly. It aids
early in identification of
potential complications
and ensures the patient's
overall well-being during
and
after medication
administration.

5. Administer the
medication according to
the doctor’s order.
- Adhering to the doctor's
order ensures that the
patient receives prescribed
the dose at the correct
time, promoting the

Page | 112
medication's efficacy and
preventing
potential complications.

6. Inform the patient about

the adverse effects.
-Providing
information about
potential adverse
effects promotes
patient awareness and
cooperation.
It allows the patient
to report any
unusual
symptoms facilitating early
intervention
if needed.

Page | 113
7. Instruct both patient and
watcher to report any
adverse effect
-Encouraging open
communication with both
the
patient and their watcher
increases the likelihood of
early
detection and management
of
adverse effects,
contributing to
overall patient safety.

8. Caution patients who are

ambulatory to be careful
when rising and walking.
-Cautioning ambulatory
patients help prevent falls
and injuries, ensuring their
safety during and after
medication administration.

Page | 114
 9. Instruct the patient to
stand slowly to prevent
dizziness.
- Providing clear
instructions for
position slow changes
minimizes the risk of
orthostatic
hypotension and dizziness,
promoting patient safety
and
preventing falls.

10. Provide
kidney basin if the patient
is experiencing nausea and
vomiting.
-Offering a kidney basin
helps maintain cleanliness
and
comfort for the
patient,contributing to

Page | 115
their overall well-being
during treatment.

Page | 116
 XIV. NURSING THEORIES

The fundamental goal of nursing theories in this part is to improve healthcare

quality by favorably improving patients' health and well-being. These theories are

intended to clarify and explain the components of nursing care, to provide guidance

for nursing practice, and framework for clinical decision making. The following are

the theories that will have a big impact on this case.

A. Florence Nightingale's Environmental Theory

Florence Nightingale, often considered the founder of modern nursing,

emphasized the importance of the environment in the healing process. She believed

that a clean, well-ventilated, quiet, and warm environment significantly contributes to

patient recovery.

Nightingale identified five environmental factors: fresh air, pure water, efficient

drainage, cleanliness or sanitation, and light or direct sunlight. She believed that

lacking in any of these areas could hinder the patient's recovery.

In the context of postpartum care for a mother with GDM, here's how Nightingale's

theory can be applied:

1. Fresh Air: Nightingale emphasized the importance of good ventilation. For a

postpartum mother, fresh air can help improve mood, promote better sleep, and

reduce the risk of airborne infections.

2. Pure Water: Hydration is crucial in the postpartum period. It helps the body

recover and is especially important for breastfeeding mothers.

Page | 117
3. Efficient Drainage and Cleanliness: Maintaining cleanliness reduces the risk of

infection, a critical aspect of postpartum care. It includes personal hygiene and

cleanliness of the surroundings.

4. Light: Nightingale believed in the healing power of natural light. Exposure to

natural light can help regulate sleep-wake cycles, improve mood, and aid in vitamin

D synthesis.

This theory is patient-centered and calls for the nurse to manage the

environment to promote health. In the case of a postpartum mother with GDM, this

could mean educating the mother about the importance of a healthy environment,

helping her establish a routine for rest and activity, ensuring she stays hydrated, and

providing guidance on maintaining personal and environmental cleanliness.

In conclusion, Florence Nightingale’s Environmental Theory holds significant

relevance in the context of postpartum care for a mother with gestational diabetes

mellitus (GDM). The theory’s emphasis on the environment as a key factor in patient

recovery aligns well with the needs of a postpartum mother. Ensuring a clean, well-

ventilated, and comfortable environment can contribute to the physical recovery and

emotional well-being of the mother. Moreover, the theory’s focus on patient

education and empowerment can guide nursing interventions to help the mother

manage her health and that of her newborn effectively.

B. Jean Watson's Theory of Human Caring

Jean Watson's Theory of Human Caring emphasizes the humanistic aspects

of nursing in combination with scientific knowledge. It focuses on the holistic

Page | 118
approach to patient care, considering patients not just as individuals with medical

conditions, but as whole beings with emotional, psychological, and spiritual needs.

In the context of postpartum care for a mother with GDM, here's how Watson's

theory can be applied:

1. Caring: Watson's theory emphasizes the importance of caring in the healing

process. For a postpartum mother, this could mean providing emotional support,

understanding, and empathy during her recovery period.

2. Transpersonal Caring Relationship: This concept involves the nurse and patient

influencing one another at the spiritual level. In the case of a postpartum mother with

GDM, the nurse could help the mother understand her condition and its implications,

fostering a sense of hope and positivity.

3. Caring Occasion/Caring Moment: According to Watson, every interaction

between a nurse and patient offers an opportunity for a caring occasion or moment.

For a postpartum mother with GDM, each interaction with the nurse could be used to

provide education about self-care, newborn care, and managing GDM.

4. Carative Factors: Watson proposed 10 carative factors, such as forming a

human-altruistic value system, instilling faith and hope, and cultivating a sensitivity to

self and others. These factors could guide the nursing care provided to a postpartum

mother with GDM, helping her cope with her condition and promoting her overall

well-being.

In conclusion, Jean Watson’s Theory of Human Caring can be significantly

relevant in the context of postpartum care for a mother with gestational diabetes

mellitus (GDM). The theory’s emphasis on caring, the transpersonal caring

Page | 119
relationship, and the importance of each caring moment can guide nursing

interventions to provide holistic care that addresses the mother’s physical, emotional,

and spiritual needs.

C. Dorothea E. Orem's Self-Care Deficit Theory

Orem's theory is based on the premise that individuals are capable of self-care

and they can recover more quickly and holistically when they are allowed to perform

their self-care to the best of their ability. The Dorothea E. Orem's Self-Care Deficit

Theory is comprised of three related parts: the theory of self-care; the theory of self-

care deficit; and the theory of the nursing system.

In the context of postpartum care for a mother with GDM, here's how Orem's theory

can be Dorothea E. Orem's Self-Care Deficit Theory

1. Theory of Self-Care: This involves activities that individuals initiate and perform

on their behalf to maintain life, health, and well-being. For a postpartum mother with

GDM, this could mean managing her diet, monitoring her blood sugar levels, and

taking care of her hygiene.

2. Theory of Self-Care Deficit: This occurs when individuals are not able to perform

self-care. In the case of a postpartum mother with GDM, she might experience a

self-care deficit due to physical discomfort or lack of knowledge about managing

GDM. The nurse's role would be to assess these deficits and provide the necessary

care and education.

3. Theory of Nursing System: For a postpartum mother with GDM, the nursing

system might involve the nurse providing education about GDM management,

Page | 120
assisting with newborn care, and coordinating with other healthcare providers for

comprehensive postpartum care.

In conclusion, Dorothea E. Orem’s Self-Care Deficit Theory can be

significantly relevant in the context of postpartum care for a mother with gestational

diabetes mellitus (GDM). The theory’s emphasis on self-care and the identification of

self-care deficits can guide nursing interventions to empower the mother in

managing her health and that of her newborn. The application of Orem’s nursing

system can further enhance the quality of care, promoting the mother’s well-being

and helping her navigate her new role and health status.

Each of these theories provides a unique perspective on nursing care and can

guide nursing interventions in the postpartum care of a mother with GDM. However,

the specific needs of each patient may require a combination of these theories or the

application of other nursing theories and models.

Page | 121
 XV. Nursing Care Plan

Date/Shift Assessment Need Nursing Diagnosis Plan of Care Nursing Intervention and Evaluation
Rationale

01-25-24 Subjective cues: P Impaired Physical After 8 hours of 1. Built rapport After 8 hours of
7/3 “Makalihok-lihok H Mobility related to nursing R: For a good nurse- nursing
naman ko ma’am Y Perineal Laceration intervention, the client relationship. intervention,
TDH 5A pero dili kayo grabe S and Postoperative patient will be the patient was
WARD jud kay naa man koy I Pain. able to: able to:
2. Assessed mobility by
tahi’, as verbalized O
evaluating range of
by the patient. L Scientific basis: 1. Show 1. Show
motion and pain levels.
O improve improved
Objective cues: G Impaired physical mobility by
R: This helps mobility by
- 6 hours I mobility usually increasing their understand the patient's increasing their
postoperativ C includes impairments range of motion physical capabilities and range of motion
e primary in daily life activities and ability to identify any restrictions and ability to
SVD with N such as walking short perform ADLs. or limitations in perform ADLs.
second- E distances, climbing movement and pain
degree E stairs, and showering 2. Verbalize intensity. 2.Verbalized
perineal D (Asp et al., 2017). understanding understanding
laceration of situation and of situation and
3. Assisted patient with
- Slow and Post-surgery pain risk factors, risk factors,
non-pharmacological
cautious and abdominal cuts therapeutic therapeutic
pain management

Page | 122
 movements can lead to muscle regimen and techniques like regimen and
during guarding, safety positioning, deep safety
position decreased joint measures. breathing exercises, measures.
changes
mobility, and back rub and distraction
- Pain scale of 3. Practice 3. Practiced
inflammation. methods.
6/10 proper body proper body
Individual variations R: Adequate pain control
mechanics and mechanics and
and psychosocial enhances the patient's
techniques for techniques for
factors contribute to willingness and ability to
safe movement. safe
the complex
participate in mobility movement.
relationship between
exercises.
pain and impaired
mobility. Balancing
4. Utilized support aids - GOAL MET -
effective pain control
with strategies to like pillows and bed

promote early features to make it

ambulation is easier for the patient to
essential for move into different
optimizing positions and maintain
postoperative them comfortably.
recovery. R: This prevents
musculoskeletal strain
and reduces the risk of
pressure ulcers by

Page | 123
distributing pressure
evenly, thus promoting
overall comfort.

5. Monitored the patient

for signs of dizziness,
weakness, or fatigue
during movement.
R: To ensure patient
safety and prevent falls.

6. Instructed patient
about the importance of
early ambulation, the
expected progression of
postoperative pain, and
the role of pain
medications in improving
mobility.
R: This encourages
patient engagement,
ensures comprehension,

Page | 124
facilitates adherence to
the treatment plan, and
promotes active
involvement in their care.

7. Incorporated range of
motion exercises and
gradually progressed to
more complex
movements as the
patient became more
comfortable.
R: This enhances
circulation, reduces
discomfort, and supports
the patient's overall well-
being during recovery.

8.Provided patient
energy-conserving
techniques for ADL’s (eg.
Wearing clothes that are

Page | 125
easy to put on or take
off, avoid bending or
reaching and laying out
clothes/toiletries before
dressing).
R: To limit fatigue and
maximize participation.

Dependent:
1. Due meds given
(Mefenamic 500 mg,
TID, PO).
R: To treat mild to
moderate pain,
inflammation, and fever.

Page | 126
Date/Shift Assessment Need Nursing Plan of Care Nursing Intervention and Evaluation
Diagnosis Rationale

01-25-24 Subjective cues: Risk for After 8 hours of 1. Identified the patient by After 8 hours of
7/3 S surgical site nursing intervention, asking the name and birthdate. nursing
“katol siya medyo infection the patient will be R: Misidentification can result intervention,
A
TDH 5A sir, pero dili related to able to: in managing a wrong patient, the patient was
F
WARD naman grabe second- which puts patient safety at be able to:
sakit ang karon” E degree A. Verbalize serious risk. A. Verbalize
as verbalized by perineal understanding of understanding
T
the patient. laceration individual causative 2. Established rapport. of individual
Y
repair after or risk factors. R: To have a good nurse-client causative or
Objective cues: birth. relationship. risk factors.
Sustained a B. Identify B. Identified
A
second-degree preventive 3. Monitored vital signs, preventive
N
perineal Scientific measures against especially temperature. measures
laceration D infection, like Assessed skin color and pain against
Basis:
handwashing and level. infection, like
T – 36.3 °C wound care R: Local and systemic signs handwashing
S
P – 73 bpm A surgical techniques, and of infection may be present and wound
R – 19 cpm E site infection maintaining proper and includes fever, chills, care
BP – 120/90 (SSI) is an hygiene. increased respiratory rate, techniques,
C
mmHG infection that C. Demonstrate tachycardia, fatigue and and

Page | 127
O2 Sat – 99% U develops in proper metabolic disorder. Also, it maintaining
the area of a handwashing, provides information about proper hygiene.
R
surgical perineal care and systemic tissue perfusion that C.
I
procedure. It wound care impacts tissue healing. Demonstrated
T can range technique. proper
from a D. Achieve time 4. Emphasize proper hand handwashing,
Y
superficial wound healing; ease hygiene for both patient and perineal care
skin infection discomfort; be caregiver. and wound
to a more afebrile R: It serves as the first line care technique.
serious E. Be free from any defense against infection. D. Achieved
infection signs and symptoms time wound
involving of infection 5. Provided health teaching to healing; ease
tissues, the patient/significant other in discomfort; be
organs, or Long term goals: incision care (eg. Apply ice afebrile.
implanted packs to decrease swelling or E. Free from
materials. A. Complete itchiness and warm sitz baths any signs and
The CDC antibiotic therapy as to relieve discomfort in perineal symptoms of
provides prescribed. area) infection
guidelines R: To aid healing the perineum.
and tools to Long term
help prevent 6. Instructed the client to goals:
SSIs. provide regular perineal care
Community (Using betadine feminine wash A. Completed
involvement antibiotic

Page | 128
and public as prescribed). therapy as
education R: To reduce the risk of prescribed.
about these ascending urinary tract
infections and infection. - GOAL MET -
protective
measures are 7. Encouraged the patient to
crucial. change peripad with each void
Resources or defecation or at least four
should be times a day.
accessible to R: To prevent vaginal
help the contamination or infection.
public
understand 8. Instructed client to get
SSIs and adequate rest and to increase
take activities gradually but steadily
necessary as tolerated.
precautions. R. To reduce the risks
associated with immobility and
stasis of body fluids.

9. Educated the patient on

signs and symptoms of
infection (post-discharge) such
as fever, persistent pain,

Page | 129
changes in lochia.
R: Prompt recognition and
treatment of these symptoms
can help prevent further
complications.

10. Emphasized to the patient

the importance of taking and
completing the antibiotics
prescribed.
R: Inappropriate use can lead
to development of drug-
resistant strains or secondary
infection.

Page | 130
XVI. DISCHARGE PLAN (METHOD)

A discharge plan is a precise blueprint crafted by healthcare providers to

ensure a patient’s smooth transition from a hospital or healthcare facility to their

home or another care setting.

Medication

 Encourage the client to adhere to all instructions, particularly regarding

medication, as prescribed by the doctor.

Home meds:

1. Co-amoxiclav 625 mg BID x 2 days

2. Mefenamic Acid 500 mg TID x 2 days

3. Mosvit Elite 1 tab OD

4. Methylergometrine maleate 1 tab TID x 2 days

Environment/Exercise

 Encourage the client to begin with gentle exercises such as walking and

gentle stretching. Drink plenty of water before, during, and after exercise to

stay hydrated, especially if you’re breastfeeding.

 Pay attention to how your body feels during and after exercise. If you

experience any pain, discomfort, or unusual symptoms, stop exercising and

consult your healthcare provider.

 Encourage the patient in getting enough sleep and rest.

 To encourage relaxation, advise the patient to keep a calm, serene, and

comfortable environment. Make sure your surroundings are tidy and comfy for

your health.

Page | 131
Treatment

 Patient should focus on balanced meals to manage gestational diabetes

mellitus.

 Encourage client to follow all the instructions including especially the

medications as by the doctor’s order.

 To prevent infection and speed up healing, advise the patient to keep her body

clean, especially the area where she was lacerated.

Health Education/Teaching

 Monitoring Blood Glucose Levels

- Instructing the mother on how to monitor her blood glucose levels regularly

using a glucometer and interpreting the results.

 Lochia

- Instruct client to report any abnormal progression of lochia, excessive bleeding,

foul-smelling lochia or large blood clots to their physician immediately.

- Lochia should never exceed a moderate amount, such as 4 to 8 saturated

perineal pads daily with an average of 6.

 Breast

- Wash breast daily at bath or shower time.

- Wash the breast daily during bathing time. Instruct the client not to wash the

breast with soap because it may eliminate sebaceous secretion in the breast.

- Wash or clean hands when feeding the infant.

- Advise the client to put clean cloth in the bra to absorb the moisture or breast

discharge.

 Sexual Activity

Page | 132
 - Abstain from intercourse until laceration is healed .

Outpatient Schedule

 Repeat FBS q2 75g OGTT after 1 month and Follow up check up once ĉ result.

 Recognize the medications. What they look like, how frequently the medication

should be taken, and why you should take them. Inform the patient to never

take any medication that was not recommended by a doctor.

 Advised the patient’s family to follow up check-up as physician’s order to

prevent further complications and to update the medical team concerning the

progress of the patient’s condition and to promote continuity of care.

Diet

 The client should have a balanced intake of carbohydrates, proteins, and fats,

while also focusing on portion control and frequent, small meals throughout

the day. It often includes whole grains, lean proteins, fruits, vegetables, and

healthy fats.

 Encourage the client to avoid sugary beverages and processed foods is

usually recommended.

 The client may include regular physical activity and close monitoring of blood

sugar levels to maintain stable glucose levels throughout the day.

Spiritual

 Emotional support and spiritual solace through practices like prayer and

meditation for the patient.

Page | 133
  Encourage the client to communicate with the family entails creating an open

and supportive atmosphere where she can openly express her needs,

concerns, and emotions.

XVII. RECOMMENDATIONS

Rest and Recovery: Adequate rest and recovery are crucial during the postpartum

period. Encourage the new mother to rest whenever possible, especially during the

first few weeks after childbirth.

Monitor for Warning Signs: Educate her about the warning signs of postpartum

complications, such as excessive bleeding, high fever, severe abdominal pain, or

signs of infection. Instruct her to seek immediate medical attention if any of these

symptoms occur.

Perineal Care: If there were any perineal tears or stitches during the delivery, advise

her to keep the perineal area clean and dry. Sitz baths or warm water rinses after

using the toilet can provide comfort and promote healing.

Pain Management: Over-the-counter pain relievers, as recommended by her

healthcare provider, can help manage any postpartum discomfort or pain. Ensure

she follows the prescribed dosage instructions.

Pelvic Floor Exercises: Encourage her to perform pelvic floor exercises (Kegel

exercises) as recommended by her healthcare provider to aid in pelvic floor muscle

recovery.

Nutrition and Hydration: A balanced diet with plenty of fluids is essential for recovery

and breastfeeding, if applicable. Ensure she is staying well-hydrated and consuming

nutritious foods.

Page | 134
Emotional Well-Being: Be attentive to her emotional well-being. Postpartum mood

swings, including baby blues or postpartum depression, can occur.

Support Network: Surround her with a support network of family and friends who can

aid with daily tasks and childcare, allowing her time to rest and recover.

Follow-Up Care: Attend all postpartum follow-up appointments with her healthcare

provider. These appointments are essential for monitoring her physical and

emotional well-being and addressing any concerns.

Breastfeeding Support: If she chooses to breastfeed, offer guidance and support.

Ensure she has access to resources such as lactation consultants or breastfeeding

support groups.

Self-Care: Encourage self-care practices, such as taking short walks, practicing

relaxation techniques, and setting aside time for activities she enjoys.

Breastfeeding or formula feeding: Ensure that your baby is feeding well, with a

proper latch if breastfeeding. Feed on demand, as newborns have small stomachs

and need to eat frequently.

Burping: Burp your baby after every feeding to reduce gas and discomfort.

Diapering: Change diapers frequently to keep your baby clean and dry. This is

essential to prevent diaper rash. Apply diaper rash cream or ointment if necessary.

Sleeping: Place your baby on their back to sleep, in a crib or bassinet that meets

safety guidelines. Avoid soft bedding, pillows, and stuffed animals in the crib to

reduce the risk of sudden infant death syndrome (SIDS).

Bathing: Sponge baths are recommended until the baby's umbilical cord stump falls

off. Use mild, fragrance-free baby soap and shampoo.

Page | 135
Temperature: Dress your baby appropriately for the room temperature to prevent

Medical Clearance: Typically, healthcare providers recommend waiting for about 4-6

weeks after a vaginal delivery before engaging in sexual activity. This period allows

the body to heal, and any potential complications to resolve. For those who've had a

cesarean section, the healing process might take a bit longer, often around 6-8

weeks.

Postpartum Recovery: It's crucial for the mother to prioritize her physical and

emotional recovery. Childbirth can be physically demanding, and the body needs

time to heal. The specific timing for resuming sexual activity varies from person to

person. It's recommended to wait until you feel physically comfortable and

emotionally ready.

Page | 136
 XVIII. BIBLIOGRAPHY

References
Casas, R., Castro Barquero, S., & Estruch, R. (2020). Impact of sugary food

consumption on pregnancy: a review. Nutrients, 12(11), 3574.

Feng, Y., Feng, Q., Qu, H., Song, X., Hu, J., Xu, X., ... & Yin, S. (2020). Stress

adaptation is associated with insulin resistance in women with gestational

diabetes mellitus. Nutrition & diabetes, 10(1), 4.

Hanoudi, Murad, & Ali (2014). Meconium staining of amniotic fluid: A clinical study.

Journal of Advances in Medicine and Medical Research. 914-21.

Kc, K., Shakya, S., & Zhang, H. (2015). Gestational diabetes mellitus and

macrosomia: a literature review. Annals of Nutrition and Metabolism,

66(Suppl. 2), 14-20.

Liman, M. N. P., & Jialal, I. (2023). Physiology, glycosuria.

Lopez-Alvarenga, J. C., García-Hidalgo, L., Landa-Anell, M. V., Santos-Gómez, R.,

González-Barranco, J., & Comuzzie, A. (2006). Influence of skin color on the

diagnostic utility of clinical acanthosis nigricans to predict insulin resistance in

obese patients. Archives of medical research, 37(6), 744-748.

Mahapatro, A. K., & Ghose, S. (2014). Obstetrics outcome at term in meconium

stained amniotic fluid-retrospective study. Int J pharm Bio Sci, 71.

Page | 137
Mandal, Ananya. (2023, July 04). Diabetes Pathophysiology. News-Medical.

Retrieved on February 02, 2024 from

https://www.news-medical.net/health/Diabetes-Pathophysiology.aspx.

Marchi, J., Berg, M., Dencker, A., Olander, E. K., & Begley, C. J. O. R. (2015). Risks

associated with obesity in pregnancy, for the mother and baby: a systematic

review of reviews. Obesity Reviews, 16(8), 621-638.

McGuire, V., Rauh, M. J., Mueller, B. A., & Hickock, D. (1996). The risk of diabetes in

a subsequent pregnancy associated with prior history of gestational diabetes

or macrosomic infant. Paediatric and perinatal epidemiology, 10(1), 64-72.

Mishra, S., & Kishore, S. (2018). Effect of physical activity during pregnancy on

gestational diabetes mellitus. Indian journal of endocrinology and

metabolism, 22(5), 661.

Muallem, M. M., & Rubeiz, N. G. (2006). Physiological and biological skin changes in

pregnancy. Clinics in dermatology, 24(2), 80-83.

Najafi, L., Abedini, A., Kadivar, M., Khajavi, A., Bordbar, A., Noohi, A. H., ... & Malek,

M. (2019). Gestational diabetes mellitus: the correlation between umbilical

coiling index, and intrapartum as well as neonatal outcomes. Journal of

Diabetes & Metabolic Disorders, 18, 51-57.

National Institute of Diabetes and Digestive and Kidney Diseases. (2017). Diabetic

eye disease - NIDDK.

https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-

problems/diabetic-eye-disease#:~:text=High%20glucose%20can%20change

%20fluid,level%20gets%20closer%20to%20normal.

Page | 138
National Nutrition Council. (2021). Diabetes and pregnancy.

https://nnc.gov.ph/regional-offices/mindanao/region-ix-zamboanga-

peninsula/5187-diabetes-and-pregnancy

Plows, J. F., Stanley, J. L., Baker, P. N., Reynolds, C. M., & Vickers, M. H. (2018).

The pathophysiology of gestational diabetes mellitus. International journal of

molecular sciences, 19(11), 3342.

Qiu, Y., Zhang, X., & Ni, Y. (2022). Association between polycystic ovarian

syndrome and risk of gestational diabetes mellitus: a meta-

analysis. Gynecologic and Obstetric Investigation, 87(2), 150-158.

Quigley, J., Shelton, C., Issa, B., & Sripada, S. (2018). Diabetes insipidus in

pregnancy. The Obstetrician & Gynaecologist, 20(1), 41-48.

Read, S. H., Wu, W., Ray, J. G., Lowe, J., Feig, D. S., & Lipscombe, L. L. (2019).

Characteristics of Women with Gestational Diabetes From Non-Caucasian

Compared With Caucasian Ethnic Groups. Canadian Journal of

Diabetes, 43(8), 600-605.

Shaikh, E. M., Mehmood, S., & Shaikh, M. A. (2010). Neonatal outcome in

meconium stained amniotic fluid-one year experience. JPMA, 60(9), 711-4.

Singh, R., Teel, C., Sabus, C., McGinnis, P., & Kluding, P. (2016). Fatigue in type 2

diabetes: impact on quality of life and predictors. PloS one, 11(11), e0165652.

Sopian, I. L., Ahmed, M. A., Lung, L. T. T., & Sandai, D. (2016). Yeast infection and

diabetes mellitus among pregnant mother in Malaysia. The Malaysian journal

of medical sciences: MJMS, 23(1), 27.

Page | 139
Venkatesan, S. K. (2021). Classification of Diabetes Mellitus: A Review. International

Journal of Diabetes Management, 1(1), 20-22.

Weissgerber, T. L., & Mudd, L. M. (2015). Preeclampsia and diabetes. Current

diabetes reports, 15, 1-10.

Mohammad N, Jamal T, Sohaila A, Ali SR. Meconium stained liquor and its

neonatal outcome. Pak J Med Sci. 2018 Nov-Dec;34(6):1392-1396. doi:

10.12669/pjms.346.15349. PMID: 30559791; PMCID: PMC6290233.

Plows J.F., Stanley J.L., Baker P.N., Reynolds C.M., Vickers M.H. The

Pathophysiology of Gestational Diabetes Mellitus. Int. J. Mol. Sci. 2018;19:3342.

doi: 10.3390/ijms19113342.

Li X, Li TT, Tian RX, Fei JJ, Wang XX, Yu HH, Yin ZZ. Gestational diabetes

mellitus: The optimal time of delivery. World J Diabetes. 2023 Mar 15;14(3):179-187.

doi: 10.4239/wjd.v14.i3.179. PMID: 37035228; PMCID: PMC10075038.

Oliveira M.M., Andrade K.F.O., Lima G.H.S., Rocha T.C. Metformin versus

glyburide in treatment and control of gestational diabetes mellitus: A systematic

review with meta-analysis. Einstein. 2022;20:eRW6155.

doi: 10.31744/einstein_journal/2022RW6155. [PMC free article] [PubMed]

[CrossRef] [Google Scholar]

Berga SL, Nitsche JF, Braunstein GD. Endocrine changes in pregnancy. In:

Melmed S, Polonsky KS, Larsen PR, Kronenberg HM. Williams Textbook of

Endocrinology E-Book. Elsevier Health Sciences; 2015. [Google Scholar]

Jimeno CA, on behalf of the Technical Review Committee of the UNITE for

DM Clinical Practice Guidelines on the Diagnosis and Mangement of Diabetes . A

Page | 140
summary of the Philippines UNITE for Diabetes Clinical Practice Guidelines for the

diagnosis and management of diabetes (Part I: Screening and diagnosis of DM). J

ASEAN Fed Endocr Soc. 2011;26(1):26-30. 10.15605/jafes.026.01.05.

[CrossRef] [Google Scholar]

Masuda C, Ferolin SK, Masuda K, Smith C, Matsui M. Evidence-based

intrapartum practice and its associated factors at a tertiary teaching hospital in the

Philippines, a descriptive mixed-methods study. BMC Pregnancy Childbirth. 2020

Feb 5;20(1):78. doi: 10.1186/s12884-020-2778-5. PMID: 32024504; PMCID:

PMC7003416.

Ezimokhai M, Rizk DE, Thomas L. Maternal risk factors for abnormal vascular

coiling of the umbilical cord. Am J Perinatol. 2000;17(08):441–446. doi: 10.1055/s-

2000-13452. [PubMed] [CrossRef] [Google Scholar]

Singh SD. Gestational diabetes and its effect on the umbilical cord. Early

Hum Dev. 1986;14(2):89–98. doi: 10.1016/0378-3782(86)90114-3. [PubMed]

[CrossRef] [Google Scholar]

Bhasin S, Jameson J. Disorders of the Testes and Male Reproductive

System. In: Loscalzo J, Fauci A, Kasper D, et al., eds. Harrison’s Principles of

Internal Medicine. 21st ed. McGraw Hill; 2022.

Gurung P, Yetiskul E, Jialal I. Physiology, Male Reproductive

System (https://www.ncbi.nlm.nih.gov/books/NBK538429/). 22 May 8.

In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2023 Jan-.

Accessed 5/8/2023.

Page | 141
 Male Reproductive System. In: Molina PE. eds._ _Endocrine Physiology. 6th

ed. McGraw Hill; 2023.

Merck Manual, Consumer Version. Structure of the Male Reproductive

System (https://www.merckmanuals.com/home/men-s-health-issues/biology-of-the-

male-reproductive-system/structure-of-the-male-reproductive-system). Accessed

5/8/2023. Planned Parenthood. What Are the Parts of the Male Reproductive

Anatomy? (https://www.plannedparenthood.org/blog/what-are-the-parts-of-the-male-

reproductive-anatomy) Accessed 5/8/2023.

Liao JB, Buhimschi CS, Norwitz ER. Normal labor: mechanism and

duration. Obstet Gynecol Clin North Am. 2005 Jun;32(2):145-64, vii. [PubMed]

van der Ham DP, van Melick MJ, Smits L, Nijhuis JG, Weiner CP, van Beek JH,

Mol BW, Willekes C. Methods for the diagnosis of rupture of the fetal membranes in

equivocal cases: a systematic review. Eur J Obstet Gynecol Reprod Biol. 2011

Aug;157(2):123-7. [PubMed]

ACOG Committee Opinion No. 766 Summary: Approaches to Limit Intervention

During Labor and Birth. Obstet Gynecol. 2019 Feb;133(2):406-408. [PubMed]

American College of Obstetricians and Gynecologists' Committee on Practice

Bulletins—Obstetrics. ACOG Practice Bulletin No. 209: Obstetric Analgesia and

Anesthesia. Obstet Gynecol. 2019 Mar;133(3):e208-e225. [PubMed]

ACOG Practice Bulletin No. 107: Induction of labor. Obstet Gynecol. 2009

Aug;114(2 Pt 1):386-397. [PubMed]

Page | 142
 Zhang J, Troendle J, Mikolajczyk R, Sundaram R, Beaver J, Fraser W. The

natural history of the normal first stage of labor. Obstet Gynecol. 2010

Apr;115(4):705-710. [PubMed]

Zhang J, Landy HJ, Ware Branch D, Burkman R, Haberman S, Gregory KD,

Hatjis CG, Ramirez MM, Bailit JL, Gonzalez-Quintero VH, Hibbard JU, Hoffman MK,

Kominiarek M, Learman LA, Van Veldhuisen P, Troendle J, Reddy UM., Consortium

on Safe Labor. Contemporary patterns of spontaneous labor with normal neonatal

outcomes. Obstet Gynecol. 2010 Dec;116(6):1281-1287. [PMC free article]

[PubMed]

Cheng YW, Caughey AB. Defining and Managing Normal and Abnormal Second

Stage of Labor. Obstet Gynecol Clin North Am. 2017 Dec;44(4):547-566. [PubMed]

Pitkin RM. Friedman EA. Primigravid labor: a graphicostatistical analysis. Obstet

Gynecol 1955;6:567-89. Obstet Gynecol. 2003 Feb;101(2):216. [PubMed]

Kilpatrick SJ, Laros RK. Characteristics of normal labor. Obstet Gynecol. 1989

Jul;74(1):85-7. [PubMed]

Güngördük K, Olgaç Y, Gülseren V, Kocaer M. Active management of the third

stage of labor: A brief overview of key issues. Turk J Obstet Gynecol. 2018

Sep;15(3):188-192. [PMC free article] [PubMed]

Harris SJ, Janssen PA, Saxell L, Carty EA, MacRae GS, Petersen KL. Effect of a

collaborative interdisciplinary maternity care program on perinatal

outcomes. CMAJ. 2012 Nov 20;184(17):1885-92. [PMC free article] [PubMed]

Berghella, Vincezo. "Caesarian Delivery: Technique". UptoDate. Woltez

Kluwer. Retrieved 17 December 2016. Wessam, Abuelghar (2013). "Caesarean

Page | 143
deliveries by Pfannenstiel versus Joel-Cohen incision: A randomised controlled

trial". Journal of the Turkish German Gynecological Association. 14 (4): 194–

200. doi:10.5152/jtgga.2013.75725. PMC 3935539. PMID 24592105.

Habib, Jaime. "Which Transverse Incisions Are Best for Cesarean

Deliveries?". Physician Practise. UBM Medica. Retrieved 17 December 2016.

Front Surg. 2023 Sep 26;10:1227338. doi: 10.3389/fsurg.2023.1227338. eCollection

2023.PMID: 37829600

Clapp MA, Barth WH. The Future of Cesarean Delivery Rates in the United

States. Clin Obstet Gynecol. 2017 Dec;60(4):829-839. [PubMed]

Palmer SK, Zamudio S, Coffin C, Parker S, Stamm E, Moore LG. Quantitative

estimation of human uterine artery blood flow and pelvic blood flow redistribution in

pregnancy. Obstet Gynecol. 1992 Dec;80(6):1000-6. [PubMed]

Barber EL, Lundsberg LS, Belanger K, Pettker CM, Funai EF, Illuzzi JL.

Indications contributing to the increasing cesarean delivery rate. Obstet

Gynecol. 2011 Jul;118(1):29-38. [PMC free article] [PubMed]

Boyle A, Reddy UM, Landy HJ, Huang CC, Driggers RW, Laughon SK. Primary

cesarean delivery in the United States. Obstet Gynecol. 2013 Jul;122(1):33-

40. [PMC free article] [PubMed]

American College of Obstetricians and Gynecologists (College). Society for

Maternal-Fetal Medicine. Caughey AB, Cahill AG, Guise JM, Rouse DJ. Safe

prevention of the primary cesarean delivery. Am J Obstet Gynecol. 2014

Mar;210(3):179-93. [PubMed]

Page | 144
 Gestational diabetes mellitus (GDM). (2019b, November 19). Johns Hopkins

Medicine.

https://www.hopkinsmedicine.org/health/conditions-and-diseases/diabetes/

gestational-diabetes#:~:text=Gestational%20diabetes%20mellitus%20(GDM)

%20is,being%20absorbed%20by%20the%20cells.

Professional, C. C. M. (n.d.-b). Meconium. Cleveland Clinic.

https://my.clevelandclinic.org/health/body/24102-meconium

Maamoun, W., Fort, A. E., & Cummings, J. J. (2011b). Neonatal respiratory

disease. In Elsevier eBooks (pp. 590–608). https://doi.org/10.1016/b978-0-323-

07307-3.10046-1

Cabigao, M. (2023b, November 23). Cord coil complications. Hello Doctor.

https://hellodoctor.com.ph/pregnancy/giving-birth/complications/cord-coil-

complications/

Plows, J. F., Stanley, J. C., Baker, P. N., Reynolds, C. M., & Vickers, M. H.

(2018). The Pathophysiology of Gestational diabetes mellitus. International Journal

of Molecular Sciences, 19(11), 3342. https://doi.org/10.3390/ijms19113342

The Healthline Editorial Team. (2023, July 13). Female reproductive. Healthline.

https://www.healthline.com/human-body-maps/female-reproductive-system#1

Desai, N. M. (2023, July 24). Vaginal delivery. StatPearls - NCBI

Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK559197/

Professional, C. C. M. (n.d.). Vaginal delivery. Cleveland

Clinic. https://my.clevelandclinic.org/health/articles/23097-vaginal-delivery

Page | 145
 Gestational diabetes mellitus (GDM). (2021, November 19). Johns Hopkins

Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/

diabetes/gestational-diabetes#:~:text=Gestational%20diabetes%20mellitus

%20(GDM)%20is,being%20absorbed%20by%20the%20cells.

Cabigao, M. (2023, November 23). Cord coil complications. Hello

Doctor. https://hellodoctor.com.ph/pregnancy/giving-birth/complications/cord-coil-

complications/

Nightingale’s environmental theory. (2023, January 16). Wikipedia.

https://en.wikipedia.org/wiki/Nightingale%27s_environmental_theory

Jean Watson Theory of Human Science and Human Caring - PSYCH-MENTAL

HEALTH HUB. (2022, January 3). PSYCH-MENTAL HEALTH HUB.

https://pmhealthnp.com/jean-watson-theory-of-human-science-and-human-

caring/.

Lombardo, C. (2017, January 17). Dorothea Orem Self Care Deficit Nursing Theory

Explained - HRF. HRF. https://healthresearchfunding.org/dorothea-orem-self-

care-deficit-nursing-theory-explained/.

Page | 146