A Case Presentation on Normal Spontaneous Vaginal Delivery

In partial fulfillment of the requirements in

Care of Mother, Child, Adolescent
Related Learning Experience

Submitted to:
Cathleen Mae Pineda
Jenneth Dela Cerna
Dinna Rose Bayog
Apple Alvarez
Rochelle Lim

Submitted by:
Angel Mikaela Cillado
Lady Lou Dela Seña
Chrislynd Jane Derla
Kynan Andrew Dimaandal
Melody Heart Donguines
Angellie Fate Duran
Yna Marrey Esquivel
September 2021
 INTRODUCTION

Pregnancy is the term used to describe the time where there is a developing fetus inside
the womb of the mother that usually lasts for forty weeks or nine months (NICHD, 2017). During
those months, a mother would start to feel gradual changes physiologically and emotionally,
which is one of the normal symptoms of pregnancy. According to The World Count (2021), the
number of births every year is around 140 million worldwide. While in the Philippines, a total of
1,673,923 live births were registered in 2019 (PSA, 2021). However, according to UNICEF
(2019), there are 211 maternal deaths per 100,000 live births globally and 160 deaths per
100,000 live births in the Philippines caused by direct obstetric causes such as hemorrhage,
infection, hepatitis, or anemia.

Thus, The Maternal, Newborn, Child Health and Nutrition (MNCHN) Strategy was made
in line with the DOH to reduce maternal and fetal deaths rapidly. It focuses on strengthening
maternal and newborn care, emphasizing nutrition policies or programs, and integrates early
childhood development (DOH, 2011). The care for mothers during childbearing and childrearing
is an essential part of the entire nursing process. It is known that the goal of nursing care is the
health of an individual, so nurses should first ensure the health of the mother and their child’s
health so that they will grow as healthy individuals. The childbearing woman must be kept
healthy from the moment of conception until the day of the delivery. Then, the health care
providers can assist in keeping the baby healthy as they grow up until they have reached
adulthood.

To ensure that nurses can provide care to the mother and her baby, case situations
practices are given to apply their knowledge about the nursing process and to deeply
understand the concepts. According to Crowe (2011), It successfully prepares students,
especially in clinical practices, to study real-life situations, problems, and issues. For this case
study, a primigravida mother in her third trimester is expected to have a normal spontaneous
vaginal delivery and discuss how to handle this kind of patient.

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 Table of Contents

I. Introduction 1

II. Table of Contents 2

III. Objectives 3

IV. Patient’s Data 3

V. Patient’s Diagnosis 5

VI. Anatomy and Physiology 6

VII. Review of Systems 11

VIII. Physical Assessment 12

IX. Etiology and Symptomatology 19

X. Physiology of Pregnancy 26

XI. Doctor’s Order 35

XII. Diagnostics/Laboratory 41

XIII. Drug Study 44

XIV. NCP 50

XV. Discharge Plan 63

XVI. References 65

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OBJECTIVES

The aim of this case study is to enhance the reader’s awareness of the importance of a
comprehensive approach to handling the complex issues that the patient introduces. This
attempts to highlight the understanding about Mrs. SCD’s general health and illness condition
with diagnosis, disease mechanism, potential complications, care plan, medical and nursing
interventions.

By the end of this case study, we will be able to:

A. Understand and analyze the process of NSVD

B. Determine the possible causes and effects of the NSVD in relation to nursing processes
C. Apply nursing interventions into the actual nursing practice
D. Acquire physical assessment to determine the patient’s overall health status.
E. Review the patient’s health history to determine the underlying causes that could refer to
the status of the patient.
F. Discuss the anatomy and physiology of reproductive system to the patient
G. Interpret the client’s laboratory and diagnostic test
H. Understand the purpose of the doctor’s order
I. Identify the doses and frequency, mechanism of action, indications, and nursing
interventions of the drug administered by the doctor to the patient
J. Formulate a discharge plan for the continuity of care

PATIENT'S DATA
✓ Patient
Biographical:
Patient’s Name: SCD
Address: Maharlika Village, Ma-a, Davao City
Date of Birth: October 1, 1999
Birthplace: Tagum City
Occupation: N/A
Usual Source of Health Care: Southern Philippines Medical Centre, Davao City
Source of Information: Patient, Patient’s Chart

Profile:
Age: 21 yr old
Gender: Female
Race/Ethnic Background: Filipino

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Civil status: Single
Date of Admission: August 4, 2021 4:21AM
Health Care Institution: Southern Philippines Medical Center (SPMC)
Informant’s name: Joendel (Live in partner)
Admitting Dr.: Dr. Karla Carise J. Vinluan
Admitting clerk: Maria Fe Esaga
Admitting diagnosis: G1P0 Pregnancy Uterine 41 1/7 WKS AOG Cephalic in Latent Phase of
Labor
Principal diagnosis: G1P1 (1001) Pregnancy Uterine delivered term cephalic live birth baby boy
via Normal Spontaneous Delivery
Other diagnosis: Obstetric with secondary right mediolateral episiotomy and repair

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 PATIENT’S DIAGNOSIS

Admitting Diagnosis: G1P0 Pregnancy Uterine 41 1/7 Weeks Age of Gestation Cephalic in
Latent Phase of Labor

Principal Diagnosis: G1P1 (1001) Pregnancy Uterine delivered term Cephalic live birth baby
boy via Normal Spontaneous Vaginal Delivery.

Other Diagnosis: Obstetric with secondary right mediolateral episiotomy and repair.

● GTPAL is an acronym used to assess pregnancy outcomes.

- Gravidity: Number of times a woman has been pregnant (includes current).
- Term Births: Number of full-term babies born beyond 37 weeks.
- Preterm Births: Number of preterm babies born before 37 weeks.
- Abortion or Miscarriges: Number of forced abortions and spontaneous
miscarriages.
- Living Children: Number of living children.

Age of Gestation

During pregnancy, gestational age is a frequent word used to express how far along the
pregnancy is. From the beginning day of the woman's last menstrual cycle to the present date, it
is counted in weeks. A normal pregnancy lasts between 38 and 42 weeks. Premature babies
are those born before 37 weeks of pregnancy.

Cephalic

Birthing Positions for fetuses, the baby should be placed head-down, facing your back, with its
chin tucked to its chest and the rear of its head ready to enter the pelvis during labor. Cephalic
presentation is the term for this. Between the 32nd and 36th weeks of pregnancy, most babies
settle into this position.

Normal Spontaneous Vaginal Delivery

A spontaneous vaginal delivery occurs when the baby is born without the need for doctors to
utilize instruments to help pull the baby out. After a pregnant lady has gone through childbirth,
something happens. Her cervix dilates to at least 10 cm during labor.

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 ANATOMY AND PHYSIOLOGY

The Female Reproductive System

The female reproductive system includes the ovaries, fallopian tubes, uterus, vagina,
external genitalia, and mammary glands. These organs are involved in the production and
transportation of gametes and the production of sex hormones. It also facilitates the fertilization
of ova by sperm and supports the development of offspring during pregnancy and infancy. The
female reproductive system consists of the external and internal structures.

External Structures of the Female Reproductive System

The structures that form the female external genitalia are termed the vulva (from the
Latin word for “covering”). The mons veneris is a pad of adipose tissue located over the
symphysis pubis, the pubic bone joint. Covered by a triangle of coarse, curly hairs, the purpose
of the mons veneris is to protect the junction of the pubic bone from trauma. The Labia Minora,
immediately posterior to the mons veneris, spread two hairless folds of connective tissue.
Normally, the folds of the labia minora are pink in color; the internal surface is covered with
mucous membrane, and the external surface is covered with skin. The area is abundant with

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sebaceous glands. The labia majora are two folds of tissue, fused anteriorly but separated
posteriorly, which are positioned lateral to the labia minora and composed of loose connective
tissue covered by epithelium and pubic hair. The labia majora serve as protection for the
external genitalia; they shield the outlets to the urethra and vagina.

The vestibule is the flattened, smooth surface inside the labia. The openings to the
bladder (the urethra) and the uterus (the vagina) both arise from this space. The clitoris is a
small (approximately 1 to 2 cm), rounded organ of erectile tissue at the forward junction of the
labia minora. It’s covered by a fold of skin, the prepuce; is sensitive to touch and temperature;
and is the center of sexual arousal and orgasm in a woman. It becomes engorged with blood
during sexual stimulation. The fourchette is the ridge of tissue formed by the posterior joining of
the labia minora and the labia majora. This is the structure that sometimes tears (laceration) or
is cut (episiotomy) during childbirth to enlarge the vaginal opening. Posterior to the fourchette is
the perineal muscle (often called the perineal body). Because this is a muscular area, it
stretches during childbirth to allow enlargement of the vagina and passage of the fetal head.
The hymen is a tough but elastic semicircle of tissue that covers the opening to the vagina
during childhood. It is often torn during the time of first sexual intercourse.

Internal Structures of the Female Reproductive System

Female internal reproductive organs include the ovaries, the fallopian tubes, the
uterus, and the vagina. Ovaries are a pair of small glands about the size and shape of
almonds, located on the left and right sides of the pelvic body cavity lateral to the superior

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portion of the uterus. The function of the two ovaries is to produce, mature, and discharge ova.
A woman is born with approximately 400,000 immature eggs called follicles. In the process of
producing ova, the ovaries also produce estrogen and progesterone and initiate and regulate
menstrual cycles. The ovaries are held suspended and in close contact with the ends of the
fallopian tubes by three strong ligaments that attach both to the uterus and the pelvic wall.
Specifically, there’s the broad ligament, the ovarian ligaments, and the suspensory ligaments.
The function of the fallopian tubes is to convey the ovum from the ovaries to the uterus and to
provide a place for fertilization of the ovum by sperm. Fertilized eggs take approximately 6 to 10
days to travel through the fallopian tube to implant in the uterine lining. Although a fallopian tube
is a smooth, hollow tunnel, it is anatomically divided into four separate parts. (1) The most
proximal division, the interstitial portion, is the part of the tube that lies within the uterine wall. (2)
The next distal portion is the isthmus. This is the portion of the tube that is cut or sealed in a
tubal ligation, or tubal sterilization procedure. (3) The ampulla is the third and also the longest
portion of the tube. The portion of the tube where fertilization of an ovum usually occurs. (4) The
infundibular portion is the most distal segment of the tube. Covered by fimbria. It helps to guide
the ovum into the fallopian tube. The uterus is commonly referred to as the womb. A hollow,
muscular, pear-shaped organ about the size of a clenched fist. The function of the uterus is to
receive the ovum from the fallopian tube; provide a place for implantation and nourishment;
furnish protection to a growing fetus; and, at maturity of the fetus, expel it from a woman’s body.
Anatomically, the uterus consists of three divisions: the body or corpus, the isthmus, and the
cervix. (1) Fundus is the portion of the uterus between the points of attachment of the fallopian
tubes. The fundus is the portion that can be palpated abdominally. (2) The isthmus is a short
segment between the body and the cervix. It is the portion where the incision is most commonly
made when a fetus is born by a cesarean birth. (3) The cervix is the lowest portion of the
uterus. Its central cavity is termed the cervical canal. The opening of the canal at the junction of
the cervix and isthmus is the internal cervical os; the distal opening to the vagina is the
external cervical os. The vagina is a hollow, musculomembranous canal located posterior to
the bladder and anterior to the rectum. It extends from the cervix of the uterus to the external
vulva. Its function is to act as the organ of intercourse and to convey sperm to the cervix. With
childbirth, it expands to serve as the birth canal. As a passageway for the menstrual flow and for
uterine secretions to pass down through the introitus. It is lined with stratified squamous
epithelium. Under this, it has a middle connective tissue layer and a strong muscular wall.
Normally, the walls contain many folds or rugae. These folds make the vagina very elastic and

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able to expand so much that at the end of pregnancy, a full-term baby can pass through without
tearing.

Mammary Glands

The mammary glands, or breasts, form early in intrauterine life. They then remain in a
halted stage of development until a rise in estrogen at puberty causes them to increase in size.
This increase occurs mainly because of growth of connective tissue plus deposition of fat.
Breasts are located anterior to the pectoral muscle, and, in many women, breast tissue extends
well into the axilla.

Uterine (menstrual) Cycle

The menstrual cycle refers to the series of cyclical changes that the endometrium goes
through each month as it responds to changing blood levels of ovarian hormones. The cyclic
production of estrogens and progesterone by the ovaries is, in turn, regulated by the anterior
pituitary gonadotropic hormones, follicle stimulating hormones (FSH) and luteinizing hormones
(LH). The menstrual cycle has three phases: (1) Menstruation Phase. This phase usually
happens on days 1-5. During this interval, the superficial functional layer of the thick endometrial

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lining of the uterus detaches from the uterine wall. By day 5, growing ovarian follicles are
beginning to produce more estrogens. (2) Proliferative Phase happens on days 6-14, it is
stimulated by a rising level of estrogens produced by the growing follicles of the ovaries, the
basal layer of the endometrium regenerates the functional layer, glands form in it, and the
endometrial blood supply increases. (3) Secretory Phase happens on days 15-28. A rising level
of progesterone production by the corpus luteum (hormone-producing structure) acts on the
estrogen-primed endometrium and increases its blood supply even more. Progesterone also
causes the endometrial glands to grow and begin secreting nutrients into the uterine cavity.
These nutrients will sustain a developing embryo (if one is present) until it is implanted.

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 REVIEW OF SYSTEMS

Breast
The patient has symmetrical breasts and the nipples are everted. No engorgement,
swellness, and dimpling of the breast and nipple was observed. No lumps and masses were
palpated, and there is a presence of colostrum discharge on the nipples.

Respiratory system
The patient has no difficulty in breathing, no cough, or chest pain. The patient has no
history of bronchitis or rheumatic heart disease.

Cardiovascular system
The patient does not have abnormal heart rhythm, chest pain, or palpitations.

Gastrointestinal system
The patient does not have any problems in swallowing, no nausea, or changes of
appetite. The patient does not experience constipation or diarrhea.

Genitourinary system
Bladder is tender since the patient has voided 6 hours after delivery. The patient said
that she urinated 4 times and each urine output is estimated to be half a cup. The patient has
not yet defecated after 8 hours of delivery. The patient does not have any sexually transmitted
infection, urinary tract infection, and hematuria.

Reproductive system
Upon palpation, the uterus is firm, contracted, and the fundus is 1 cm below the
umbilicus. There is also a bluish discoloration in the vagina, cervix, and labia.

Musculoskeletal system
The patient’s range of motion of both arms and the joints have no limitations and can
move freely without discomfort or pain. The patient is able to walk however, unable to move her
legs freely or without limitations due to the pain brought by the secondary right mediolateral
episiotomy. Varicose veins are not present. There were no edema, pain, scars, lesions, and
stiffness present.

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 PHYSICAL ASSESSMENT

Name of Patient: SCD Age: 21 Sex: Female

Status: Single Date of Admission: 08/04/2021

General Assessment
Patient SCD is a 21-year old NSVD mother who gave birth to her first child at Southern
Philippines Medical Center delivery room. Patient is conscious upon admission and is a little
anxious because it is her first time delivering a baby. Her obstetric score is G1P1 and vital signs
are as follows; blood pressure - 130/80 mmHg, temperature - 36.7 ˚C, pulse rate - 82 BPM, and
respiratory rate - 22.

Skin
Upon inspection, the patient’s skin appears to be uniformly brown in color. There are no
discoloration, rashes, masses, lesions, or wounds. There are visible striae at the abdomen,
breasts, and thighs of the patient. Upon palpation, skin temperature is warm and smooth.
Patient has good skin turgor as evidenced by skin springs back to the normal state when
pinched.

Hair
The patient's hair is black in color, shoulder length, is healthy, and moist. The patient
verbalized that she had lost a slight quantity of hair after birth. However, no alopecia was
observed.

Nails
Upon inspection, the patient’s nails appear to be round, hard, immobile, and smooth.
Free edges are neatly trimmed and clean. Nails are also non-brittle, no splitting, nail thickness is
uniform, and nail bed is firm upon palpation. The tissues surrounding the nails of the patient are
intact. Color of the nail of the client returns to pink in less than 2 seconds after the blanched
test.

Head
The patient’s head is normocephalic, symmetric, hard, and smooth. Upon palpation, no
lesions, nodules, masses, and depressions were present. Absence of tenderness on the
temporomandibular joints upon palpation and with full range of motion.

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Face
The patient has a normal facial symmetry such as the eyebrows and nasolabial folds.
There is no presence of edema, no abnormalities, or swelling. Facial grimace was observed due
to the pain brought by the secondary right mediolateral episiotomy. No chloasma present on the
face.

Eyes
The patient’s eyebrows are symmetrically aligned with equal movement, indicating intact.
Her eyebrows are evenly distributed with intact skin. The sclera of the patient appears white.
Her palpebral conjunctiva is dry and pale in color. The patient’s cornea appears transparent,
shiny and smooth. The details of the iris are observable. No presence of edema or tenderness
can be observed in the lacrimal gland and lacrimal sac.

Ears

The auricles are equal size bilaterally with no swelling or thickening and its color is
consistent with her facial skin color. When palpating for the texture, the auricles are mobile, firm,
and not tender. There was no redness, drainage, deformities or lesions seen. Tympanic
membrane is pearly gray with well-defined landmarks. The patient is able to hear sound equally
in both ears.

Nose, Mouth and Throat

Upon inspection, the nose is symmetrical, in the midline, and in proportion to other facial
features. There are no deformity, asymmetry, inflammation, discharge, or skin lesions can be
observed. Both nostrils are patent. Inferior and middle turbinates dark pink, moist, and free of
lesions. Frontal and maxillary sinuses are nontender upon palpation and percussion. Upon
inspection of the mouth, lips are normally symmetrical, pink, smooth, and moist. No presence of
abnormal growths, lumps or discoloration. The patient’s teeth are white to yellowish and clean
with no decay. Gums are pink with no redness or swelling. The tongue of the patient is
symmetrical, pink, moist, slightly rough from the papillae, with a thin, whitish coating. Ventral
surface of the tongue is smooth and shiny pink with small visible veins present. Upon inspection
of the throat, tonsillar pillars are pink and symmetrical.

Neck
The patient’s neck is equal in size, and symmetrical. The trachea is on central placement
in the midline of the neck, spaces are equal on both sides. The thyroid gland is not visible in
inspection, gland ascends during swallowing, no masses palpated and no lesions.

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Breast
The patient has symmetrical breasts and the nipples are everted. No engorgement, swellness,
and dimpling of the breast and nipple was observed. No lumps and masses were palpated, and
there is a presence of colostrum discharge on the nipples.

Chest
Breathing pattern is quiet, rhythmic, and effortless. Chest is symmetric upon expansion,
has flat sound, the part with heavy muscles and bony prominences. Upon palpation of the inner
chest wall, there are no tenderness, masses, lumps, and skin lesions noted

Heart

Upon palpation, the carotid pulse is equal bilaterally and graded as 2 +. Upon
auscultation of the carotids, no bruits were noted. Pulsations are normal with regular rhythm
upon palpation of the apical pulse. Upon auscultation of the heart, heart rate is 80 BPM with no
irregular rhythm and no arrhythmias. S1 is best heard at the apex, while S2 is best heard at the
base.

Abdomen
Upon inspection of the abdomen of the patient, there were no lesions or lumps
observed. The patient has striae gravidarum and linea nigra present on the abdomen. The
uterus is at 1 cm below the umbilicus and non-tender

Upper extremities
Upon inspection, arms are symmetrical in size and length. No presence of redness,
lesions, abrasions, edema, and swelling. Upon palpation of the radial and brachial pulses,
pulsations are normal with regular rhythm and strength is graded as 2 + bilaterally. Upon testing
the range of motion, both arms and the joints have no limitations and can move freely without
discomfort or pain.

Lower extremities
Upon inspection of the legs, it is symmetrical in size and length. Skin color from legs to
toes are the same as the patient’s skin tone. Hair is evenly distributed and normal hair growth.
Absence of edema, swelling, lesions, atrophy, and ulcer. The skin is warm indicating good blood
flow; patient is also negative for homan’s sign. Capillary refills on the toe nails are less than 2
seconds. Upon palpation of the legs bilaterally, femoral pulse is graded as 3 +, popliteal
pulsation is graded as 2 +, posterior tibial is graded as 3 +, and dorsalis pedis is graded as 2+.

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Upon testing the range of motion, the patient is unable to move her legs freely or without
limitations due to the pain brought by the secondary right mediolateral episiotomy.

Female genitourinary
Upon inspection of the external genitalia, hair distribution is normal, no presence of
lesions, or masses but there is redness upon inspection. There is also a bluish discoloration in
the vagina, cervix, and labia.

Musculoskeletal
Upon inspection, the joints of the upper and lower extremities are all symmetrical in form
and size. The skin and tissues around the joints are free of lesions and have good turgor. No
presence of edema, deformity, or lumps. There is no tenderness, discomfort, swelling, or mass
felt upon palpation of each joint. The range of motion of joints in the lower and upper extremities
had no limitations, soreness, pain, or crepitation.

Neurologic

Cranial Nerve Findings

I - Olfactory The patient was able to identify different

smells.

II - Optic The patient was able to read with each eye

and both eyes. No signs of visual loss.

III - Oculomotor The pupils of the patient are equally round

IV - Trochlear and reactive to light and accommodation, and
VI - Abducens their eyes are able to move freely without
pain or difficulty.

V - Trigeminal The patient was able to maintain a corneal

reflex, was sensitive to pain stimuli, and could
tell the difference between hot and cold.

VII - Facial The patient can make different facial

expressions without any difficulty.

VII - Vestibulocochlear The patient was able to hear in both ears and
was able to stand, walk straight, and maintain
balance.

IX - Glossopharyngeal The patient can stimulate gag reflex and is

X - Vagus able to speak and swallow without difficulty.

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XI - Accessory The patient can move her shoulder and head
without any difficulty.

XII - Hypoglossal The patient was able to move her tongue in

different directions.

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 BUBBLE HE ASSESSMENT

(B) breast

Upon inspection, there were visible stretch marks and striae at the breast. There were no
bruises at the breasts, lacerations, pain, palpable mass, bleeding, and blisters were observed.
Upon palpation, breasts are tender and heavy.

(U) uterus

Upon palpation, the uterus is firm, contracted, and the fundus is 1 cm below the
umbilicus.

(B) bladder

Bladder is tender since the patient has voided 6 hours after delivery. The patient said
that she urinated 4 times and each urine output is estimated to be half a cup. Upon assessment
of urine, it is pale yellow, odorless, with slight blood, glucose, ketones, protein, and a pH of 6.

(B) bowel

Upon auscultation, there are active bowel sounds in all four quadrants. However, the
patient has not yet defecated after 8 hours of delivery.

(L) lochia

The patient verbalized that there is minimal red, bloody discharge or minimal lochia rubra
found in the diaper. She also stated that she changed sanitary pads 4 times in a span of 8
hours. Lochia rubra has no unpleasant odor and small clots are present.

(E) episiotomy

The patient had undergone secondary right mediolateral episiotomy.

REEDA SCALE

Points Redness Edema Ecchymosis Discharge Approximation

0 None None None None None

1 Within .25 cm Perineal less Within .25 cm Serum Skin separation

of incision than 1 cm bilaterally or 3 mm or less
bilaterally from incision .5 cm
unilaterally

2 Within .5 cm Perineal Between .25 Serosanguin Skin and

of incision and/or vulvar to 1 cm ous subcutaneous

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 bilaterally between 1 to bilaterally or fat separation
2 cm from between .5 to
incision 2 cm
unilaterally

3 Beyond .5 cm Perineal Greater than Bloody Skin

onf incision and/or vulvar 1 cm purulent subcutaneous
bilaterally greater than bilaterally or fat and fascial
2 cm from 2 cm layer sep
incision unilaterally

Score 1 0 0 0 0

Total = 1

(H) homan’s sign

Patient is negative for Homan’s Sign as evidenced by no pain in the popliteal region and
the calf was elicited when the foot was in dorsiflexed position.

(E) emotional status & bonding

The patient verbalized that she feels fine. However, she said she’s a little uncomfortable
due to the pain from the episiotomy but it is bearable. Promote skin-to-skin contact as well as
breastfeeding because it may contribute to a closer bond between the mother and baby.

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 ETIOLOGY AND SYMPTOMATOLOGY

Diagnosis: G1P1 (1001) PREGNANCY UTERINE DELIVERED TERM CEPHALIC LIVE

BIRTH BABY BOY VIA NORMAL SPONTANEOUS VAGINAL DELIVERY.

Etiology
The term etiology is the study of causes. In this case we will study the cause of pregnancy
which includes the Predisposing Factors (non-modifiable) and Precipitating Factors (modifiable).
This section also includes the rationale, justification, and if it is present or absent to the patient.

Predisposing Absent/Present Rationale Justification

Factors
(Non-modifia
ble)

Gender Present Anyone with a uterus and ovaries has the The patient is a female
(Female) potential to get pregnant and give birth. with a uterus and
People who are born masculine and live as ovaries; thus, she is
guys are unable to conceive. However, a capable of conceiving.
transgender guy or nonbinary person might
be able to. A person can only be pregnant if
they have a uterus.

Age Present Women under the age of 20 are at a far The patient’s age is 21
(20yrs old - 35 higher risk of serious medical issues during years old.
yrs old) pregnancy than women over the age of 20.
In their 20s, women are most fertile and
have the best chance of becoming
pregnant. Fertility starts to drop at the age
of 32. After the age of 35, the decline
accelerates. After the age of 35, the risk of
miscarriage and genetic disorders
increases. If you have a baby later in life,
you may experience greater issues
throughout your pregnancy or during
delivery.

Genetics Absent When one or more genes are aberrant, it is The patient did not state
called a genetic abnormality. Some genetic any genetic
abnormalities are passed down through the abnormalities and family
generations from parents to their children. history relating to genetic
Without a prior family history, spontaneous abnormalities.
alterations in the DNA of a gene can cause
the developing kid to be affected.

Number of Absent If you've had five or more previous The patient is

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Pregnancies pregnancies, you're more likely to primigravida.
experience abnormally quick labor and
substantial blood loss in subsequent labors.

Pre-existing Absent High blood pressure, diabetes, and The patient stated that
medical cardiovascular disease are more common she does not have any
conditions in older women, which might make underlying or pre-existing
pregnancy more difficult. When these medical conditions.
disorders aren't properly managed, they can
lead to miscarriage, fetal growth problems,
and birth abnormalities.

Precipitating Absent/Present Rationale Justification

Factors
(Modifiable)

Full term Absent The baby is born between 39 Upon admission the patient
pregnancy weeks, 0 days and 40 weeks, 6 is already 41 weeks AOG
days. which is considered a
late-term pregnancy.

Toxin exposure Absent Environmental toxins have been The patient was extra
associated with birth abnormalities, careful during her
premature births, stillbirths, and pregnancy and did not
low-birth-weight newborns, as well claim any exposure to
as issues with nervous system toxins. She is at home
development. New evidence also most of the time.
reveals that some environmental
contaminants in both men and
women's bodies are connected to
decreased fertility.

Weight Absent Obese women are also more likely The patient’s BMI is 22.
(Overweight or to be diagnosed with gestational
Underweight) diabetes or have high blood
pressure during pregnancy. This can
result in a smaller baby than
planned and raise the risk of
preeclampsia. Women who are
under 100 pounds are more likely to
give birth prematurely or to a baby
who is underweight.

Alcohol Use Absent The effects of alcohol on the The patient never tried
growing fetus are most sensitive drinking any alcoholic

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 during the first trimester. During this beverages.
time, women who followed the
guidelines were nonetheless at risk
of having an unfavorable pregnancy
result. According to the findings,
women should be encouraged to
avoid alcohol while trying to
conceive and during pregnancy.

Smoking Absent Preterm birth, low birth weight, and The patient never tried
birth abnormalities of the mouth and smoking.
lip are all increased risks for
growing kids when mothers smoke
during pregnancy. Smoking raises
the risk of sudden infant death
syndrome both during and after
pregnancy (SIDS).

Nutritional Absent During pregnancy, a lack of proper The patient is eating a

Deficiencies quality and quantity diet can cause balanced diet and it is
health issues for both the mother evident to her BMI.
and the fetus. Malnutrition during
pregnancy increases the risk of
gestational anemia, hypertension,
miscarriages, and fetal fatalities, as
well as preterm birth and maternal
mortality.

Cephalic Fetal Present The baby ideally should be placed The uterine delivered term
Presentation head-down, facing the mother's is cephalic live birth baby
back, with its chin tucked to its chest boy by NSVD.
and the rear of its head ready to
enter the pelvis during labor.
Cephalic presentation is the term for
this position. During the 32nd to
36th weeks of pregnancy, most
babies settle into this position.

Oligohydramni Absent A condition in which the amniotic The patient’s amniotic sac
os fluid for a baby's gestational age is doesn’t have any rupture
lower than predicted. During birth, while the pregnancy is in
there is a small chance of progress. Rupture of
intrauterine growth limitation and membrane happened when
umbilical cord constriction. You may the patient was 8cm
also have a higher chance of having dilated.
a C-section.

21
 Symptomatology
A group of symptoms associated with a medical condition or manifested by a patient. This
section contains the list of symptoms with rationale and if it is present or absent to the patient
with justification.

Symptoms Present/Absent Rationale Justification

Presumptive Symptoms

Nausea and Absent According to ACOG (2020), the exact The patient stated that she
Vomiting reason for morning sickness is did not experience any
unknown. Low blood sugar or an morning sickness.
increase in pregnancy hormones like
human chorionic gonadotropin (HCG)
or estrogen may be to cause. Stress,
being overtired, eating specific foods,
or having motion sensitivity can all
make morning sickness worse
(motion sickness).

Amenorrhea Present The absence of menstruation, often The patient stated that she
known as amenorrhea, is described did not have her menstrual
as missing one or more menstrual cycle for months.
periods. In normal circumstances, a
woman's hormones thicken the
uterine lining in preparation for
pregnancy. Human Chorionic
Gonadotropin (HCG) is secreted in
the case of amenorrhea caused by
fertilization.
The remnant of the ruptured follicle
begins to grow and secrete
progesterone as a result of HCG.
During this time, progesterone
maintains the thickness of the uterine
wall, resulting in amenorrhea
(Flagg,2018).

Frequent Present In spite of the fact that side effects The patient reported that
urination might differ from one individual to she is going to the CR more
another, numerous pregnant often than before.
individuals notice they start to have
to pee all the more often during their
first trimester (week 1 to week 12).
Certain individuals may likewise
encounter spillage or stress urinary
incontinence (SUI) while pregnant as

22
 the hatchling develops and pushes
down on the bladder, urethra, and
pelvic floor muscles (Britt, 2021).

Breast changes Present Breast changes are perhaps the An increase in breast size
soonest indication of pregnancy. This was observed. Also areolas
is an aftereffect of the hormone turn darker and the breasts
progest ko erone. Also, the dull are producing colostrum as
spaces of skin around the areolas the patient stated.
(the areolas) start to enlarge. This is
trailed by the quick expansion of the
actual breast. Most pregnant ladies
feel touchiness down the sides of the
breast, and areola shivering or
irritation. This is a direct result of the
development of the milk ducts and
the arrangement of a lot more
lobules. By the fifth or 6th month of
pregnancy, the breasts are
completely fit for producing milk. As
in adolescence, estrogen controls the
development of the ducts, and
progesterone controls the
development of the glandular buds.
Numerous different hormones
additionally assume essential parts in
milk creation. These incorporate
follicle-animating hormone (FSH),
luteinizing hormone (LH), prolactin,
oxytocin, and human placental
lactogen (HPL) (Hopkin, 2021).

Linea Nigra Present Linea nigra is a physiological type of A 10cm linea nigra was
hyperpigmentation normally found in observed when assessing
the primary trimester of pregnancy. It the abdomen.
is a dim vertical line that runs down
the center of the mid-region and it
tends to be perhaps the soonest
pointer of pregnancy. It is otherwise
called the 'pregnancy line'. Linea
nigra happens in over 90% of
pregnant ladies, and is frequently in
relationship with hyperpigmentation
of areolas, areola, and genital
regions (Roh, 2021)

Melasma Absent Evolving hormones, especially the No mask of pregnancy was

abundance of estrogen and observed when assessing
progesterone, is the primary driver of the face of the patient.
melasma during pregnancy. Past

23
 that, the darker patches on the face
can be exacerbated by sun
exposure, the utilization of certain
healthy skin items or medicines, and
even genetics.Chloasma may
likewise be deteriorated by hormonal
irregular characteristics that might
have been available even before
pregnancy (Marcin, 2021)

Striae Present Striae gravidarum (stretch marks) Upon inspecting the

gravidarum happen in around half to 90% of abdomen of the patient light
pregnant ladies as a result of the striae gravidarum was seen.
partition of fundamental connective Around 5-10cm in length.
tissue as the uterus enlarges inside
the stomach pit. Blood vessels dilate
and dermal collagen are damaged,
bringing about the development of
rosy purple early stretch marks.
Collagen renovating frequently
prompts loss of melanocytes, or
pigment creating cells, which
prompts the whitish mature stretch
imprints. Stretch imprints will in
general happen principally on the
mid-region, thighs, and breasts. A
lady's skin type and hereditary history
assume a critical part in the degree
of the striae (Dog, 2005).

Normal Weight Present Weight gain becomes more common The patient was able to gain
Gain as your first trimester progresses. 15kg in her entire
During the first few months, you may pregnancy.
gain between 1 and 4 pounds. Early
in pregnancy, your calorie needs will
be similar to your normal diet, but
they will increase as the pregnancy
progresses. If your BMI was 18.5 to
24.9 before becoming pregnant, you
were in a healthy weight range, and
you should gain between 11.5 and 16
kilograms: 1 to 1.5 kilograms in the
first three months, then 1.5 to 2
kilograms per month until you give
birth. You should gain less if you
were above the healthy weight range.
You should acquire weight if you are
under the healthy weight range.

Probable Symptoms

24
Chadwick’s Absent Chadwick's sign is a pre-pregnancy During assessment no
Sign symptom. Around the fourth week of change in color in the vagina
pregnancy, blood flow to the cervix was observed.
and vagina increases, causing those
tissues to turn purplish-red (Metzger,
2012)

Hegar’s Sign Absent Softening of the lower uterine Upen palpating the uterus
segment is a possible pregnancy instead of softening of the
indication that might appear in the uterus, constricted uterus
second and third months of was palpated.
pregnancy. The lower section of the
uterus is easily crushed on bimanual
examination between the fingers
placed in the vagina and those of the
other hand positioned over the pelvic
area. This is related to the uterus'
overall softening due to increased
vascularity and edema, and the
space is empty and compressible at
this stage because the fetus does not
fill the uterine cavity (Farlex, 2009).

25
 PHYSIOLOGY OF PREGNANCY
Pregnancy is a physiological event involving the sequential and integrated set of changes.
These changes start after conception and affect every organ system in the body.

Oogenesis and Ovulation

The creation of gametes in the ovaries, known as oogenesis, begins in females before they are
even born. The oogonia, or female stem cells, grow fast during a woman's fetus' development,
creating primary oocytes that push into the ovary's connective tissue, establishing a primary
follicle. The oogonia is no longer alive after delivery. The primary oocytes are subsequently
implanted in the ovarian follicle and allowed to undergo meiosis, which produces functional
eggs, usually between the ages of 10 and 14.The anterior pituitary glands begin to secrete
stimulating follicular hormone (FSH) throughout puberty, which stimulates the maturation of the
primary follicles each month. Ovulation, which happens every month between the uterine cycle
and menstruation, is the process through which the ovaries generate a mature ovum.

Hormone Production

When the ovaries begin to become active throughout puberty, estrogen and progesterone are
produced. Estrogen is the hormone that causes young women's secondary sex characteristics
to change. Enlargement of the reproductive system's accessory organs, breast growth,
production of axillary and pubic hair, increased adipose tissue deposits, broadening and
lightening of the pelvis, and the onset of menstruation are all examples of these changes.
Estrogen also aids in the maintenance of bone density by lowering total blood pressure and
calcium ion absorption. Progesterone, on the other hand, interacts with estrogen to regulate the
menstrual cycle, keep the pregnancy going, and prepare the breasts for milk production during
pregnancy.

Fertilization

Fertilization normally takes 18 to 24 hours and takes place in the fallopian tube. The fertilized
oocyte is referred to as a zygote. The zygote starts out as a single cell with 46 chromosomes,
23 from each parent. The genetic code for that individual is produced at this point. The cells
divide and form new cells as the zygote passes through the fallopian tube and into the uterine
cavity. These cells, known as blastomeres, are held together by the zona pellucida and form the
morula, which is a solid ball of 12 to 16 cells. Intracellular fluid swells and a central cavity forms
as the morula enters the uterus, which happens about 4 days after fertilization. The blastocyst, a
rapidly dividing ball of cells, is today known as the zygote. When a blastocyst sheds its zona
pellucida, it is referred to as "hatch."

Uterine Cycle (Menstruation)

The uterine cycle, commonly known as the menstrual cycle, is a sequence of cyclic changes
that the endometrium, or the uterus's innermost layer, undergoes each month as a result of

26
ovarian hormone-induced variations in blood levels. Ovulation normally happens on the 14th
day of the ovarian and uterine cycles, which last about 28 days. The menstrual cycle is divided
into three phases: the first is the menstrual phase, which lasts from day 1 to 5, but can last
longer or shorter. The stratum functionalis of the endometrium detaches from the uterine wall
and escapes through the vagina, resulting in menstruation or "period." The ovary begins to
release more estrogen on day 5 and enters the proliferative phase, also known as the
preovulatory phase. The endometrium's stratum basalis regenerates the stratum functionalis,
which was shed off during the menstrual phase, during this phase, which normally occurs on
days 6-13. Towards the end of this stage, ovulation occurs. The secretory phase, also known as
the postovulatory phase or luteal phase, occurs approximately day 15-28 after ovulation and is
the third and final phase. Progesterone levels are high at this point, and the uterus begins to
secrete nutrients. If fertilization occurs, these nutrients will nourish a developing embryo; if not,
the uterine cycle will begin again.

Pregnancy

The events that begin during conception and terminate after birth are referred to as pregnancy.
After fertilization, the zygote travels down the fallopian tube to the uterus, where it is nurtured,
developed, and eventually becomes a fetus. It will begin to develop the amniotic cavity, umbilical
cord, and placenta by implanting itself to the endometrium, the uterus' innermost lining. The
gestation period refers to the time between the woman's last menstrual period and the delivery
of her child, which is approximately 38-40 weeks. During this time, the woman's progesterone
and estrogen levels rise, allowing her to maintain her pregnancy. When the placenta develops, it
acts as an endocrine gland, secreting estrogen and progesterone to keep the pregnancy going.
Additionally, these hormones raise a woman's blood pressure throughout her pregnancy. The
fetus now becomes a newborn after delivery.

First Trimester

The blastocyst is implanted on the decidua 10 to 12 days after conception or 1 to 2 gestational

weeks (3-4 weeks after the last menstrual period). This is when the implantation process begins.
The embryo will emerge from the inner set of cells. The embryo grows to be 0.2 mm long (about
1/100 inch).

A tube grows throughout the embryo's length about 3 to 4 weeks of gestation (5-6 weeks after
the previous menstrual cycle) as the blastocyst attaches closely to the uterus wall and absorbs
sustenance from the mother's blood, preparing to expand into the brain and spinal cord. The
heart begins as a tube that beats as it expands. Limb buds, which resemble bumps, begin to
grow and will eventually become arms and legs. The embryo grows to about 6 mm (1/4 inch) in
length.

Weeks 5 to 6 of gestational weeks (7-8 weeks after the last menstrual period). The head takes
up around half of the embryo's length due to the brain's rapid expansion. The heart begins to

27
divide into its regular four chambers. The eyes and ears return to their original positions on the
head. The kidneys start to develop. The placenta and the embryo are connected by the
umbilical cord (or afterbirth). Closes the neural tube that leads to the brain and spinal cord. The
embryo is approximately 14 mm (1/2 inch) in length.

Weeks 7 to 8 of gestational weeks (9-10 weeks after the last menstrual period). As the face
develops, the embryo changes shape.It begins to straighten out from its C-shape. Small tail bud
begins to vanish. All of the essential organs, including the basic parts of the brain and the heart
are now formed. Fingers and toes are now developing. Eyelids over the eyes but they cannot
open yet. Muscles begin to form as well as early bones. Arms can bend at the elbow. Intestines
are also growing rapidly. The embryo is about 31 mm (1 1⁄4 inches) long.

9 to 10 weeks of gestational weeks (11-12 weeks after the last menstrual period) In this stage,
all the main body parts are formed and present. The embryo is now called a “fetus”. Fetal length
is measured from the top of the head to the curve of the crown rump length. Crown rump length
is 61 mm (about 2 1⁄3 inches). Nipples and hair follicles form. Fetal movements and heartbeat
can be seen on ultrasound. Various glands begin to work. Kidneys also begin to make urine.
Fetus weighs 14 grams (under one ounce).

The gestational weeks range from 11 to 12 weeks (13-14 weeks after the last menstrual period)
The gender of the fetus can often be seen at this point. The fetus starts to drink fluid from the
amniotic sac (bag of waters). The kidneys produce urine to replenish the fluid. The placenta has
completed its development. In the bone marrow, blood cells have already grown. Between the
head and the body, the neck is clearly visible. The crown rump is 86 mm (3 12 inches). The
fetus is 45 grams in weight (about an ounce and a half).

Second Trimester

13 to 14 weeks of gestational weeks (15-16 weeks after the last menstrual period). The fetal
head is still large as the body straightens out. The arms and legs are also formed, and can
already move and bend. Sex organs are almost fully formed. Toenails and fingernails have also
begun growing. Face is well formed due to the eyes moving forward and the ears reaching
normal position. Crown rump length is 120 mm (about 4 3⁄4 inches). Fetus weighs 110 grams
(about 4 ounces).

15 to 16 weeks of gestational weeks (17-18 weeks after the last menstrual period). At this stage,
some women begin to feel the first fetal movements called “quickening”. Growth begins to
speed up. Legs began to grow longer so the fetal head seems less large. Slow fetal eye
movements can be seen by ultrasound. Bones start to gain calcium at a rapid rate. Ears stand
out from the head. Skin is almost transparent. Crown rump length reaches 140 mm (about 5 1⁄2
inches). Fetus weighs 200 grams (about 7 ounces).

28
17 to 18 weeks of gestational weeks (19-20 weeks after the last menstrual period). The fetal
skin is covered by a naturally occurring biofilm called “vernix caseosa”. This is about the halfway
point of a normal pregnancy.

The gestational weeks range from 19 to 20 weeks (21-22 weeks after the last menstrual period).
The vernix caseosa that was mentioned a few weeks ago could still be developing. The
mid-pregnancy ultrasound is right around the corner in a few days. The baby's size is predicted
to be similar to that of a mango. At this point, the baby's physical parts will be more developed.
The crown rump is 190 mm (7 34 inches). The fetus is 460 grams in weight.

The gestational weeks are between 21 and 22 weeks (23-24 weeks after the last menstrual
period). During this time, fetal weight gain is rapid. There's a good probability the fetus will be
delivered alive. Lung development hits a plateau. the moment at which a few gas exchange
sacs form A stethoscope can be used to listen to the heartbeat. The crown rump measures 210
mm (8 12 inches). The fetus is 630 grams in weight (1 pound, 6 ounces).

The gestational weeks range from 23 to 24 weeks (25-26 weeks after the last menstrual period).
The baby's characteristics have become more developed. The fetus starts to store fat beneath
the epidermis. In response to loud noises near the woman's belly, the fetus can blink and act
scared. The length of the crown rump exceeds 230 mm (about 9 inches). The fetus is 820
grams in weight (a little less than 2 pounds).

Third Trimester

Between 25 and 26 weeks of pregnancy (27-28 weeks after the last menstrual period). The
lungs continue to expand in tandem with the weight growth. As the brain develops, it begins to
do increasingly complicated tasks. The eyes of the fetus will open somewhat. The rump of the
crown reaches a length of 250 mm (about 10 inches). The fetus is 1000 grams in weight (about
2 pounds and 3 ounces).

The gestational weeks range from 27 to 28 weeks (29-30 weeks after the last menstrual period).
The fetal brain can now regulate body temperature and breathing patterns. The fetus has a
shaky handle on things. The eyes have opened wide and the toenails have grown in length. The
length of the crown rump is around 270 mm (nearly 11 inches). The fetus is 1300 grams in
weight (almost 3 pounds).

The gestational weeks are between 29 and 30 weeks (31-32 weeks after the last menstrual
period). The baby is most likely lying down with his or her head down. The baby is floating in 1.5
pints of amniotic fluid, which allows the baby to move around freely. The length of the crown
rump is approximately 280 mm (just over 11 inches). The fetus weighs approximately 1700
grams (3 3/4 pounds).

The gestational weeks are between 31 and 32 weeks (33-34 weeks after the last menstrual
period). Fat is still accumulating beneath the fetus's skin. Lungs continue to develop and

29
produce more surfactant. Muscle tone in the fetus rises. The length of the crown rump is
approximately 300 mm (just under 1 foot). The fetus is about 2100 grams (over 4 1/2 pounds) in
weight.

33 to 34 weeks of gestational weeks (35-36 weeks after the last menstrual period). Lungs and
the nervous system continue to mature in this stage. Also, more fat is building up under the skin.
Fetus begins to look chubby. Hair on the head begins to look normal. For the male fetuses,
testes start to move from the abdomen into the scrotum. For the female fetuses, labia begins to
cover the clitoris. Fetus moves into a head-down position to prepare for delivery. Average crown
rump length is over a foot. Fetus weighs around 2500 grams (over 5 pounds).

35 to 36 weeks of gestational weeks (36-37 weeks after the last menstrual period). Womb is
beginning to feel snug as the fetus grows. The following weeks will be for the maturing of the
baby’s lungs and brain. Baby’s kidneys are fully developed during this stage. Liver can also
process some waste products. Fetus may be born now or may stay in the womb while building
up more fats under the skin.

37 to 40 weeks of gestational weeks (39-42 weeks after the last menstrual period). This is full in
pregnancy. Most babies are born during this stage considering that they have reached full term.
Baby’s facial features will be similar to a newborn. On average, a full term baby weighs 3400
grams (7 1⁄2 pounds).

Lactation

Lactation, or the process by which the mammary glands of the breast synthesis, secrete, and
discharge milk, is the process by which women produce milk after giving birth. When the
mammary gland, which includes the milk-secreting glands known as alveoli, begins to make
milk, lactation begins. Lactiferous sinuses are formed when milk is transported from the alveoli
to a series of secondary tubules and subsequently into the mammary ducts. Finally, before
being drained into a lactiferous duct, the milk is held in the lactiferous sinuses. Oxytocin, which
is released when the infant begins licking the mother's nipple after delivery, stimulates milk
ejection.

30
 PHYSIOLOGIC CHANGES OF PREGNANCY

Introduction

Pregnancy is a time when the body undergoes significant anatomic and physiological changes.
After conception, these alterations begin and affect every organ system in the body. All maternal
physiologic systems, in addition to the reproductive organs, make constant modifications that
the body needs to support the development of the fetus. Understanding these changes in the
mother is critical for proper interpretation of physiological and laboratory data, as well as the
implementation of care strategies to reduce problems.

Cardiovascular

Increased cardiac output, increased blood volume, and lower systemic vascular resistance and
blood pressure are the key hemodynamic alterations associated with pregnancy. These
changes help the fetus grow and develop normally while also protecting the mother from the
risks of childbirth, such as hemorrhage. All of these circulatory changes, on the other hand,
might cause common symptoms like palpitations, decreased exercise tolerance, and dizziness.

The majority of cardiovascular alterations occur during the first trimester of pregnancy.
Increased circulating levels of progesterone, estrogen, and prostaglandins cause vascular
smooth muscle relaxation, which lowers systemic and pulmonary vascular resistance. During
the third trimester, cardiac output gradually increases, finally reaching 40-50 percent. Because
of the dilated impact of progesterone, vascular resistance falls by 20%. The systolic and
diastolic blood pressures drop 10-15 mmHg in the first trimester, then rebound to normal in the
second half of pregnancy. Increases in stroke volume reach their apex between weeks 16 and
24. Although the heart rate rises, it does not exceed 100 beats per minute. All of these changes
are normal and should not be mistaken for a cardiac condition; they can typically be addressed
with just reassurance. Pregnant women, on the other hand, are more likely to experience atrial
tachycardia paroxysms, which may necessitate preventive digitalization or other antiarrhythmic
medicines.

Respiratory

According to study, 70 percent of healthy pregnant women experience dyspnoea, or shortness

of breath, during daily activities beginning in the first trimester of pregnancy. The physiological
shift of hormone rhythms is the primary cause of ventilatory changes in respiratory function. This
would include progesterone increasing respiratory sensitivity to carbon dioxide, creating nasal
congestion, oestrogen acting as a mediator for progesterone receptors, and prostaglandins
increasing airway resistance by constriction of bronchial smooth muscle.

Hematological

31
Several physiologic and hematological changes that occur during pregnancy can signal
problems in the non-pregnant state. Physiologic anemia, neutrophilia, mild thrombocytopenia,
increased procoagulant factors, and decreased fibrinolysis are the key hematologic alterations
that occur during pregnancy.

At 6 to 12 weeks of pregnancy, plasma volume increases by 10 to 15%; nevertheless, it

expands fast until 30 to 34 weeks, implying only a minor increase. At 8 to 10 weeks of
pregnancy, red blood cell mass begins to climb, continuously increasing by 20 to 30 percent
from 250 mL to 450 mL over non-pregnant levels by the end of pregnancy. The abrupt drop in
hemoglobin levels (physiologic or dilutional anemia during pregnancy) observed in healthy
pregnant women is caused by an increase in plasma volume due to the increased hemoglobin
mass and erythrocyte volume. Anemia is defined as hemoglobin levels of less than 11 g/dL in
the first and third trimesters, and less than 10.5 g/dL in the second trimester, according to the
Centers for Disease Control and Prevention. Platelet counts in pregnant women may be
somewhat lower than in healthy pregnant women, according to one study. In the second month
of pregnancy, the neutrophil count begins to rise and peaks in the second or third trimester,
when the total white blood cell count varies from 9000 to 15,000 cells/microL. The absolute
lymphocyte count remains unchanged. The amounts of numerous coagulation factors in the
blood will fluctuate during pregnancy, leading to alterations in thrombosis and anti-fibrinolysis.

Neuromuscular

In the occurrence of pregnancy, elongation of the abdominal muscles and separation of the linea
alba are caused by the enlargement of the uterus. Passive joint disability alters afferent input
from joint mechanoreceptors and affects motor neuron recruitment. Poor recruitment of muscles
impact pelvic girdle stability and may result in decreased tension of these muscles during
walking, perhaps resulting in pelvic girdle pain or PGP.

Pituitary Gland

The anterior pituitary enlarges dramatically during pregnancy, with a 33 percent rise in pituitary
weight, as well as a 33 percent increase in cross-sectional area and gland. When viewed
radiographically, this expansion causes an upward convexity of the gland's superior surface.
During pregnancy, the human pituitary gland undergoes a remarkable metamorphosis in
response to a shifting hormonal environment. The fetoplacental unit's substances have a
significant impact on the structure and function of the maternal hypophysis.

Gastrointestinal

During pregnancy, the gastrointestinal (GI) tract experiences anatomic and physiologic changes,
resulting in nausea, emesis, constipation, hemorrhoids, and gastroesophageal reflux. Some

32
patients have underlying gastrointestinal illnesses including Crohn's disease or ulcerative colitis,
which might affect pregnancy results.

Progesterone causes smooth muscle relaxation which slows down GI motility and decreases
lower esophageal sphincter (LES) tone. The resulting increase in intragastric pressure
combined with lower LES tone leads to the gastroesophageal reflux commonly experienced
during pregnancy. Gastrointestinal complaints, such as heartburn, nausea, and vomiting or
constipation are commonly known as “morning sickness”. It begins between 4 to 8 weeks of
pregnancy and usually subside in 14 to 16 weeks. This correlates with an increase in the levels
of human chorionic gonadotropin and progesterone, as well as a relaxation of the stomach
smooth muscle. Constipation and hemorrhoids are also possible during pregnancy.

Musculoskeletal

During pregnancy, many women feel low back pain, pelvic pain, sacroiliac joint pain, and/or hip
pain. Achy, acute, radiating, or scorching pain can arise in the front or back of the pelvis. The
pubic symphysis joint, which connects the two sides of the pelvis, is frequently the source of
pain in the front of the pelvis. Bending over, walking, extended standing, rolling over in bed, or
getting in and out of a car can all aggravate this type of discomfort.

Reproductive System

Pregnancy lasts approximately 266 days or 38 weeks from ovulation. During this phase, the
reproductive system underwent anatomical and physiological changes to accommodate the
changes and development of the fetus.

Uterus

The uterus provides the fetus with a nourishing and protecting environment in which to grow and
develop. The uterus leaves the pelvis and ascends to the abdominal activity as the pregnancy
progresses.

The abdominal contents are displaced as a result of the uterus's enlarged size, which is five
times larger than normal, and the increased size of the uterus is linked to increased blood
supply and uterine muscle activity. After then, its weight climbs from 50mg to 1000mg, and it no
longer becomes heavier, instead expanding to the size of the fetus, which is related with an
increase in the fundus' thickness and length.

Cervix

33
Cervix is integral to the maintenance of pregnancy in keeping and developing the baby in the
uterus and forming a barrier to the ascending of microorganisms from the vagina.

During the pregnancy before delivery, the softening of the cervix occurs in response to the
increasing uterine contractions.

Vagina

Throughout pregnancy, the vaginal blood supply increases, changing its color from pink to
purple and becoming more elastic in the second trimester.

Renal

The smooth muscle in the renal pelvis and ureter relaxes and dilates during pregnancy. The
length of the kidneys grows in tandem with the lengthening and curving of the ureters, as well as
an increase in residual urine volume. The smooth muscle of the bladder relaxes as well,
increasing capacity and raising the risk of urinary tract infection. The ureters may be put under
pressure as a result of the larger uterus.

Postural

Pregnant women, according to mayoclinic.org, have a certain posture. This shows a

kyphosis-related lumbosacral curvature. The center of gravity and posterior shift in body weight
are also involved, as described in the musculoskeletal portion, and are compensated by
increased lumbar and cervical lordosis.

34
 DOCTOR’S ORDER

Date ordered Doctor’s order Rationale Remarks

August 4, 2021 Please admit - The condition should be -Done 08/4/21

4:30 AM under green managed under a 4:30 AM.
service specialized doctor. Patient was
admitted
under green
service.

Secure consent - Signed informed consent - Done 08/4/21

to care signifies a patient agrees 4:40 AM.
to undergo treatment or Patient
procedure, thus the verbalizes
patient would be aware consent to the
of the associated benefit, nurse
risks, and alternative
treatments.

- Nothing per orem was - Done

NPO once inside ordered because of the 08/04/2021
DR risk of vomiting and 4:50 AM
aspirating later in labor. The patient
and the
watcher were
instructed not
to allow the
patient to
intake
anything per
orem because
of the risk of
vomiting.

35
 - To increase fluid volume - Done
To start D5LR @ and avoid 08/04/2021
120cc/hr oligohydramnios or 5:00 AM
amniotic fluid that is less Patient
than expected for received
gestational age. D5LR @ 120
cc/hr.

Labs: - Helps determine the - Done

CBC count of red blood cells 08/04/2021
to diagnose the presence 5:10 AM
of polycythemia, anemia, A sample was
hematocrit levels and taken to
hemoglobin levels. It also determine ​red
checks the differential blood cells
count of white blood cells (RBCs), white
(detection of infections) blood cells
and platelet count. (WBCs), and
During postpartum, a platelets
CBC estimates blood (PLTs) and
loss during delivery and detect a
to identify if there is a variety of
need for blood diseases and
transfusion. conditions.

- Done
08/04/2021
A fresh catch
UA - A urine test is used to urine was
assess bladder or kidney collected for
the urine test,
infections, diabetes, this is to
dehydration, and assess any
infection.
Preeclampsia by
screening for high levels
of sugars, proteins,
ketones, and bacteria
- Done
08/04/21
A sample was
HBsAg - To prevent perinatal taken to
determine if

36
 hepatitis B virus the patient
has hepatitis
transmission which
that may lead
possess a serious risk to to
complications
her infant at birth.
to the baby.

- Done
08/04/21
Blood typing A blood
- Blood typing is done to
sample was
ensure that a woman taken to
determine the
receives the right kind of
blood type
blood if there is a need and Rh factor
of the patient.
for blood transfusion and
the Rh factor helps to
determine if there is a
need for the mother to
- Done
receive a RhoGAM.
08/04/21
The FHT and
Monitor FHT and UC was
- To help detect changes in
UC monitored and
the normal heart rate there were no
abnormal
pattern during labor and
changes
to determine if UC is detected.
well-controlled to avoid
complications. - Done
08/04/21
Monitor VS q4, I Vital signs
and O q shift - To be able to record and was checked
every 4 hours
keep track with the
and as well
patient’s temperature, bp,
rr, pr, and I&O.
- Done
08/04/21
Administer Oxytocin was
Oxytocin 10 IU, - Promotes rapid uterine injected
IM intramuscularl
contraction and stops
y to promote
bleeding. uterine
contraction

37
 and avoid
bleeding.

- Done
08/04/21
Refer - To facilitate immediate
intervention and avoid
further complications.

August 4, 2021 To OB ward - To provide continuous - Done

7:00 AM care and maternal 08/04/2021
monitoring. 7:00AM the
patient was
brought to the
OB Ward after
delivering the
baby.

Diet: DAT - To provide energy lost - Done

from labor and delivery. 08/04/2021
The patient
was offered
food and fluid
to provide the
lost energy
from giving
birth.

VS Q1 X1, Q30 - An increase in blood - Done

X2, Q hourly X4, 08/04/2021
pressure may indicate
then q4 Taking the
the development of vital signs in
Q1, Q30, Q
hypertension,
hourly, and
temperature greater than Q4 to keep in
track and
37.2 degree celsius may
record every
indicate infection, VS which may
indicate
persistent pulse rate of
complication if
more than 100bpm could abnormalities

38
 be tachycardia from are recorded.
dehydration or
hemorrhage so needs
investigation, and
observe for
hyperventilation (rapid,
deep respirations)
because prolonged
hyperventilation can
cause a “blowing off” of
carbon dioxide and
accompanying symptoms
of dizziness and tingling
of hands and feet

Meds: - To reduce the incidence - Done

08/04/2021
of infections such as
Cefuroxime 7:00AM
500mg PO BID x endometritis, an The patient
5 days was able to
inflammation or irritation
take the
of the lining of the uterus. prescribed
medication to
reduce
occurrence of
infection.

Mefenamic Acid
- To relieve pain following
500mg PO TID - Done
for pain a normal spontaneous 08/04/21
The patient
vaginal delivery and
was able to
episiotomy. drink
Mefenamic
acid to
alleviate pain
from normal
spontaneous
vaginal
delivery and

39
 episiotomy.

- Maternal iron
FeSO4 1 tab OD - Done
requirements are
08/04/2021
increased in 7:00AM
The patient
breastfeeding women.
was able to
Iron is present in breast drink the
prescribed
milk so there must be
medication
adequate iron FeSO4to
avoid the
concentrations for the
occurrence of
fetus. anemia.

- To facilitate immediate
Refer - Done
intervention and avoid
08/04/21
further complications.

DIAGNOSTICS/ LABORATORY RESULTS

40
 Hematology
Blood typing – August 4, 2021

Test Referenc Result Clinical significance Nursing Responsibilities

e range

Blood type: ABO “A” For emergencies in any 1. Explain the test to the
Group instance where a blood patient that it is needed
transfusion would need to determine her blood
to be performed. type.
2. Inform that it is to
RH Group Positive The Rh factor may play a
transfuse the right blood
role in the baby's health.
to her body to prevent
complications

Complete Blood Count August 4, 2021

Test Result Normal Clinical Significance Nursing Responsibilities

Values

Hemoglobin 124.0 115-155 The hemoglobin test 1. Identify and verify the
NORMAL measures the amount of patient’s consent before
hemoglobin in the body and to taking the test.
assess the ability of the blood
to carry oxygen to different 2. Explain the purpose for
parts of the body. This test is the laboratory and
often used to check for diagnostic tests to the
anemia. patient and family
members/caregivers.
Hematocrit 0.37 0.36 – 0.48 A hematocrit test measures
NORMAL how much of your blood is 3. Explain the procedure of
made up of red blood cells. the blood test and the use
Hematocrit levels that are too of a tourniquet.
high or too low can indicate
blood disorder and other 4. Properly and accurately
medical conditions. label all specimens that
are obtained by the nurse
RBC Count 4.39 4.20 – 6.10 RBC count is a test that
measures how many red that includes the patient’s
NORMAL
blood cells you have in your name and the date of
blood. It can help diagnose time of the specimen
blood-related diseases such collection.
as anemia.
5. Collect the blood sample

41
 WBC Count 21.73 5.0 – 10.0 WBC is a test to measure the and deliver it to the
HIGH number of white blood cells in laboratory immediately.
the blood. It is also used to Notify the physician as
detect disease conditions soon as the results are
affecting white blood cells. An returned.
increase of WBC can indicate
conditions such as infections 6. Instruct the patient to not
or inflammations. drink or eat before the
blood test to ensure the
Neutrophils 90 55 – 75 A neutrophil test estimates the level or iron detected in
HIGH ability of the body to fight the blood for accurate
infections such as bacterial results.
infections. A high neutrophil
count could mean that the 7. Monitor the patient’s vital
body has an infection. signs before and after the
laboratory and diagnostic
Lymphocytes 7.0 20 – 35 This test is requested if tests. Report to the
LOW doctors suspect that a disease physician if there are any
or infection is present. Severe abnormal changes.
or chronic low counts can
indicate a possible infection or 8. Observe and assess for
other significant illness excess bleeding and
apply pressure if
Monocytes 3 2 – 10 Monocyte test is used to know appropriate, then report
NORMAL the level of monocytes that to the physician if
helps at fighting infections and persists.
disease such as cancer.
9. Dispose all used supplies
Platelet Count 247 150 – 400 A platelet count test measures and equipment during the
NORMAL the number of platelets in your diagnostic test.
blood. A lower platelet count is
called thrombocytopenia
which means you bleed too
much after a cut or other
injury. While a higher than
normal platelet count is called
thrombocytosis.

Urinalysis

42
 Date performed: August 4, 2021

Test Result Normal Clinical Significance Nursing Responsibilities

Value

Appearance Clear Clear This is to detect disorders. Urine

NORMAL is typically clear, cloudiness or 1. Instruct the patient to
unpleasant odor may indicate void into the clean and
problems such as infection. dry container. Sterile and
disposable containers
Color Light light yellow Used to test the hydration status should be utilized.
yellow to dark of the patient. Darker colors
NORMAL amber may indicate dehydration or 2. Instruct the patient not to
other issues. allow any part of the
color
body to touch the rim of
pH 6.0 4.5 - 7.2 Used to determine the level of the inside of the
acid in the urine and determine container.
NORMAL
renal disease.
3. Instruct the patient to not
Specific 1.020 1.005 to Used to determine how well completely fill the
gravity NORMAL 1.025 your kidneys dilute your urine. container. A small urine
Urine that is too concentrated sample is only required.
could mean that the kidney is
not functioning well or the 4. Securely cover all
patient is dehydrated. specimens, label
properly and accurately,
Epithelial cells 13 0-1 Used to determine if the number and deliver it to the
HIGH of your epithelial cells is in the laboratory
normal range. A low amount of
epithelial cells in your urine is 5. If the specimen cannot
normal. But a large amount may be delivered to the
be a sign of infection, kidney laboratory after an hour
disease, or another serious or if the specimen is
medical condition. collected at home, it
should be kept
Bacteria 3 0- 278 Used to find bacteria in the refrigerated immediately.
NORMAL urine that can cause an
infection. Bacteria can enter
through the urethra and may
cause urinary tract infection
(UTI).

Serology and Immunology

43
 Date performed: August 4, 2021

Test Result Normal Value Clinical Significance Nursing Responsibilities

HBSAG Non-Reactive Negative/Non-reac This test may be used to 1. Inform the patient
Qualitative NORMAL tive screen for, detect, and help about the test to gain
diagnose acute and chronic their trust and
HBV infections. Most cooperation.
people with hepa B don't
show symptoms, so 2. After obtaining the
screening for this disease laboratory results,
enables early detection so inform the patient
that patients can receive about it.
treatment and avoid
unknowingly spreading the
virus to others. Normal
results are negative or
nonreactive, meaning that
no hepatitis B surface
antigen was found.

DRUG STUDY

Drug Data Generic name: cefuroxime

Brand name: Ceftin

Zinacef

Classification Cephalosporin antibiotics

44
Mechanism of Action Interferes with bacterial cell wall synthesis by inhibiting the
final step in the cross-linking of peptidoglycan strands.
Peptidoglycan makes the cell membrane rigid and
protective. Without it, bacterial cells rupture and die.

Indications Treatment of susceptible infections due to group B

streptococci, pneumococci,

staphylococci, H. influenzae, E. coli, Enterobacter,

Klebsiella, including acute/chronic bronchitis, gonorrhea,
impetigo, early Lyme disease, otitis media,
pharyngitis/tonsillitis, sinusitis, skin/skin structure, UTI,
perioperative

Route PO

Contraindication History of hypersensitivity/anaphylactic reaction to

cefuroxime, cephalosporins.

Dosage and Frequency 500mg BID x 5 days

Side effects Frequent: mild abdominal cramping, mild diarrhea,

discomfort with IM administration, vaginal candidiasis,
thrush

Occasional: Nausea, serum sickness-like reaction (joint

pain, fever; usually occurs after second course of therapy
and resolves after drug is discontinued).

Rare: Allergic reaction, thrombophlebitis.

45
Adverse effects Antibiotic-associated colitis, other superinfections may
result from altered bacterial balance in GI tracts such as
abdominal cramps, severe watery diarrhea, and fever.
Nephrotoxicity may occur especially for patients with
preexisting renal disease. Patients with a history of
penicillin allergy are at risk for developing a severe
hypersensitivity reaction like severe pruritus, angioedema,
bronchospasm anaphylaxis.

Nursing Consideration 1. Obtain baseline assessment such as CBC and renal

functions tests.

2. Ask the patient questions for history of allergies

specifically cephalosporin and penicillin.

3. Examine the oral cavity for white patches on the

mucous membranes and tongue (thrush).

4. Keep track of the patient’s bowel movements and

stool consistency on a daily basis. Mild GI side effects may
be manageable, but increasing severity could signal the
start of antibiotic-associated colitis.

5. Inspect I&O and renal function tests for signs of

nephrotoxicity. Fever, vomiting, diarrhea, anal/genital
pruritus, and changes in the oral mucosa are all signs of
superinfection (ulceration, pain, erythema).

6. Inform the patient and the patient’s family that

discomfort may occur with IM injection.

7. Doses should be evenly spaced.

8. Cefuroxime may upset the GI tract, in this case the

patient may take with food and milk.

9. Continue antibiotic therapy for full length treatment.

46
Drug Data Generic name: mefenamic acid
Brand name: Ponstan,
Ponstel

Classification Nonsteroidal anti-inflammatory drug

Mechanism of Action Binds the prostaglandin synthetase receptors COX-1 and

COX-2 inhibiting the action of prostaglandin synthetase.

Indications Short-term relief of mild to moderate pain including primary

dysmenorrhea

Route Oral

Contraindications Hypersensitivity to drug;GI inflammation,or

ulceration.Safety in children <14 y, during pregnancy.

Dosage and Frequency 500mg TID

Side Effects
Nausea, tiredness. Itching, yellowing of the skin, pain the
upper stomach, fever, constipation, diarrhea

Adverse Effects Pyrosis, GI bleeding, ulceration, anorexia, gastritis, renal

failure,

Nursing Considerations 1. Explain what the drug is for to the patient

2. Inform the patient about the possible side effects of
the drug and report it immediately if it prolongs.
3. Notify the physician if persistent GI discomfort, sore
throat, fever, or malaise occur.
4. Instruct to follow the doctor’s dosing instructions
very carefully.
5. Avoid drinking alcohol. It may increase your risk of
stomach bleeding.
6. Stop using mefenamic acid and call your doctor at
once if you have shortness of breath (even with mild

47
 exertion) or swelling or rapid weight gain
7. Do not engage in potentially hazardous activities
until response to drug is known. It may cause
dizziness and drowsiness.
8. Do not breast feed while taking this drug without
consulting a physician.

Drug Data Generic name: ferrous sulfate

Brand name: Fer-In-Sol

Fer-Iron

Slow-Fe

Classification Enzymatic mineral

Mechanism of Action Essential component in formation of Hgb, myoglobin,

enzymes. Promotes effective erythropoiesis and transport,
utilization of oxygen.

Indications Treatment of iron deficiency anemia

Route Oral

Contraindication Hypersensitivity to iron salts. Hemochromatosis, hemolytic

anemias

Dosage and Frequency 1 tab OD

Side effects Occasional: Mild, transient nausea

Rare: Heartburn, anorexia, constipation, diarrhea

48
Adverse effects Severe iron poisoning occurs most often in children,
manifested as vomiting, severe abdominal pain, diarrhea,
dehydration, followed by hyperventilation, pallor, cyanosis,
cardiovascular collapse. Large doses may aggravate
existing GI tract disease (peptic ulcer, regional enteritis,
ulcerative colitis).

Nursing Consideration 1. Assess the nutritional status and dietary history of

the patient.

2. Ask the patient questions about the history of

hemochromatosis, hemolytic anemia, and ulcerative colitis.

3. Ask patient questions if they are using antacids

and/or calcium supplements.

4. Monitor serum iron, total iron-binding capacity,

reticulocyte count, Hgb, and ferritin.

5. Keep track of the patient’s bowel movements and

stool consistency on a daily basis.

6. Assess for clinical improvement, record relief of iron

deficiency symptoms like fatigue, irritability, pallor,
paresthesia of extremities, and headache.

7. Inform the patient to expect darkening of stool color.

8. If GI discomfort occurs, take the drugs after meals

or with food.

9. Do not take antacids or OTC calcium supplements.

49
 NURSING CARE PLAN

NCP #1
Assessment Nursing Diagnosis Need Planning Intervention Evaluation

50
Subjective: Pain related to After 3 hours Independent: After 3 hours of
episiotomy as C of nursing nursing intervention
Patient verbalizes evidenced by O intervention 1. Teach the the patient was able
“Nurse sakit na verbalization of the G the patient patient about to:
kaayo akong tiyan N will be able breathing GOAL MET
patient.
murag dili na jud I to: techniques.
kaya.” T Rationale: A. Express relief and
Rationale: I A. Verbalize Breathing verbalized “Nurse
V relief and techniques can nakatabang kaayo
Objective: An episiotomy is a E comfort by help relax and ang imong gitudlo
cut or incision - performing reduce pain na breathing
Pain scale of 8/10. through the area in P breathing that the mother techniques kay
your vaginal E techniques. is feeling while medyo okay na
Patient has a opening, and your R putting her in a akong gibati ug
grimace face and anus called the C B. Have a mindful state. makaya nalang ang
guarding behavior. perineum. This E relaxed facial sakit.”
method is done to P expression 2. Position the
Medications as make your vaginal T after having patient in her B. Patient has a
prescribed by the opening larger for U adequate desired relaxed facial
Doctor: childbirth. A sleep. comfortable expression
Episiotomy is mainly L position. verbalized
-Mefenamic Acid
associated with C. Pain scale Rationale: “Nurse, medyo
500mg PO TID for perineal damage, P is reduced Mothers tend niarang arang najud
Pain particularly with A from 8/10 to to find their akong pamati
third- and T approximatel own sitting or nakatulog napud ko
Vital Signs:
fourth-degree tears, T y 4/10. lying down ug tarong.”
which will cause E position to
BP - 130/80 mmHg
pain. The amount of R alleviate their C. Patient reported
T- 36.7 ˚C pain and discomfort N pain and her current pain
following an discomforts. scale and verbalized
PR- 82 BPM episiotomy or deep “Nurse 4/10 na lang
tear varies among 3.Assess the akong gi bati na
RR - 22 BPM
individuals. It is patient’s pain. sakit arang arang na
Principal caused by the Determine the dili pareho ganina”
swelling of the location,
Diagnosis:
tissues surrounding characteristics,
G1P1 (1001) the vagina as well onset,
Pregnancy Uterine as by the incision or duration,
deep tear. frequency,
delivered term
quality and
cephalic live birth
Source: severity of
baby boy via ​ pain.
Normal Postpartum Pain
Spontaneous Management.
Delivery (2014). Retrieved
from Mass General
Other Diagnosis: Brigham
Newton-Wellesley
Hospital:
https://www.nwh.org/

51
Obstetric with patient-guides-and-f
secondary right orms/postpartum-gui Rationale:
mediolateral de/postpartum-chapt Assessing the
episiotomy and er-2/postpartum-car patient’s pain
repair. e-pain-management enables to help
in the
diagnostic
process and
determine the
best treatment.

4.Monitor the
patient’s vital
signs.
Rationale:
It is essential
to monitor the
patient's vital
signs since
vital signs are
usually
affected when
pain is present.

5. Encourage
the patient to
have a warm
sitz bath.
Rationale:
The sitz bath's
warm water
increases
blood flow to
the perineal
area,
promoting
faster healing
and relieving
itching.

6. Encourage
the patient to
do exercises
such as kegel
exercise.
Rationale:
Kegel exercise
helps improve
and maintain

52
bladder and
bowel control
by increasing
these
important
muscles'
strength,
endurance,
and correct
function.

7. Observe for
nonverbal
indicators of
pain such as
moaning,
guarding,
crying and
facial grimace.
Rationale:
Observing
these
behaviors can
help with the
proper
evaluation of
pain as some
patients may
deny the
existence of
pain.

8. Provide a
quiet
environment
for the patient.
Rationale:
Additional
stressors can
intensify the
patient’s
perception and
tolerance of
pain.

Dependent:

9.Administer
pain
medications as

53
per doctor's
order.
Rationale:
Administration
of pain
relievers helps
lessen the pain
and would
ease the
feeling of the
patient.

Collaborative:
10. Refer the
client for
individually
appropriate
diagnostic
procedures or
screenings
Rationale:
This helps in
further
assessment of
the patient’s
health as well
as to detect
complications
and other
conditions that
can put the
patient at risk.

54
 NCP #2
Assessment Nursing Diagnosis Need Planning Intervention Evaluation

Subjective: Fatigue related to C After 8 hours Independent: After 8 hours of

delivery of the baby O of nursing 1. Assist the nursing intervention
Patient verbalizes as evidenced by G intervention client in the patient was able
“Nurse kanang na verbalization of N the patient developing a to:
bantayan nakong feeling of having no I will be able schedule for GOAL MET
luya ko human energy. T to: daily activity
nakog panganak” I and rest. A. Verbalized
V A.Verbalize Rationale: reduction of fatigue “
E reduction of Developing a Nurse, medyo okay
Rationale: - fatigue and daily routine na akong paminaw,
The process of labor P reports can reduce dili napud ko luya
Objective: and delivery, E increased stress, tan’awon. Nakatulog
combined with little R energy and increase the nako ug tarong ug
Diagnosis: sleep and the stress C ability to feeling of mahimo na nako
of caring for a E perform security, and akong gusto
- G1P1
newborn can result P desired improve sleep. buhaton.”
(1001) to postpartum T activities.
Pregnancy fatigue U 2. Promote B. Verbalized
Uterine A B. Verbalize sufficient understanding of the
delivered L understandin nutritional disease and
term g of the intake. treatment plan.
Reference: P disease and Rationale: “Nurse, nakasabot
Cephalic
live birth A treatment The patient willnako kung unsa ni
T plan. need properly akong ginabati
baby boy
T balanced karon ug kabalo
via Normal Bellefendos, C.
E intake of fats, nako sa akong mga
Spontaneou (2020, March 15).
R carbohydrates, dapat buhaton
Postpartum Fatigue.
s Vaginal N proteins, pareho anang mag
Retrieved from
Delivery vitamins, and inom ug iron
https://www.whattoe
- Obstetric minerals to supplements og
xpect.com/first-year/
with provide energy mag kaon sa
postpartum-health-a
resources. pagkaon na taas og
secondary nd-care/postpartum-
iron pareha anang
right fatigue/
3. Provide mga seafood para
mediolateral comforts such mapadali akong pag
episiotomy as gentle touch ayo.”
and repair or massage
and cool
showers.
Vital Signs: Rationale:
BP - 130/80 mmHg, These
T- 36.7 ˚C comforts
reduce
PR- 82 BPM nervous
energy, which
RR - 22 bpm
can lead to
relaxation.

55
4. Ensure that
the patient is in
her desired
comfortable
position.
Rationale:
Being in her
desired
comfortable
position
enables the
patient to have
adequate rest.

5. Aid the
patient to
develop habits
to promote
effective
rest/sleep
patterns.
Rationale:
Promoting
relaxation
before sleep
and providing
for several
hours of
uninterrupted
sleep can
contribute to
energy
restoration.

6. Ensure that
the patient is in
a quiet
environment.
Rationale:
A quiet
environment
helps the
patient to be
able to rest
well.

7.Monitor the
cbc count of
the patient.

56
Rationale:
The CBC
result provides
baseline data
for having a
risk of
developing
anemia and
helps diagnose
the cause of
these signs
and symptoms.

8. Encourage
the patient to
have an
increased fluid
intake.
Rationale:
Having an
increased fluid
intake will help
replenish the
water your
body loses
throughout the
day and helps
maintain
energy.

Dependent:
9. Administer
ferrous sulfate
medication as
per doctor’s
order.
Rationale:
Administration
of medications
will help
prevent
anemia in
fatigue
patients.

Collaborative:
10. Refer the
client for
individually
appropriate

57
diagnostic
procedures or
screenings.
Rationale:
This helps in
further
assessment of
the patient’s
health as well
as to detect
complications
and other
conditions that
can put the
patient at risk.

58
 NCP #3
Assessment Nursing Need Planning Intervention Evaluation
Diagnosis

Subjective: Risk for infection C After 8 hours Independent: After 8 hours of

Patient related to O of nursing 1. Monitor nursing intervention
verbalizes presence of G intervention temperature, the patient was able
“Nurse sakit episiotomy N the patient will pulse, and to:
kaayo akong wounds as I be able to: respirations. GOAL MET
kinatawo didto evidenced by 2nd T A.Express Rationale:
sa gi tahi-an degree laceration. I relief and Elevations in vital A.Verbalized “ Nurse
banda.” V comfort signs accompany medyo makaya na
E obtained from infection; ang sakit mga 5/10
Objective: Rationale: - incision by fluctuations, or nalang iyang
A second-degree P reduced pain changes in kasakit.”
Pain scale of laceration is a E scale from symptoms,
8/10. common tear that R 8/10. suggest
can occur while C alterations in B. Verbalized “
Based on the lab having a baby. E B.Verbalize client status. kabalo nako kung
results: These tears go P understanding unsa ka importante
WBC=21.73 through the skin T of self-care to 2.Observe ang mag alaga sa
HIGH and muscles of U speed up the perineum/incision sarili para mapadali
Epithelial cells= the perineum. A healing for other signs of ang akong proseso
13- HIGH Some L process. infection (e.g., sa pag-ayo.”
Neutrophils= 90- second-degree redness, edema,
HIGH tears may even go P ecchymosis,
deep into the A discharge and
Diagnosis: vagina and are T approximation
Obstetric with unlikely to cause T [REEDA scale]).
secondary right long-term E Rationale:
mediolateral problems, but they R Allows early
can be very sore. N identification and
episiotomy and
Episiotomy tripled treatment and
repair
the risk of infection promotes
– contamination of resolution of
Medications as the wound due to infection.
prescribed by microorganisms
the doctor: associated with 3.Apply ice pack
-Cefuroxime 500 episiotomy site to the episiotomy
mg PO BID for 5 infection such as site for the first
days Staphylococcus or several hours
Streptococcus after birth
-Mefenamic Acid species and Rationale:
500mg PO TID gram-negative This is to alleviate
for Pain organisms’ leads the pain and
to infection. swelling as result
Vital Signs: from an
Source: episiotomy, and
BP-130/80mmHg Martin, P. (2019). will also
4 Puerperal encourage fast

59
T- 36.7 ˚C Infection Nursing healing.
Care Plans.
PR- 82 BPM Retrieved from: 4. Demonstrate
https://nurseslabs. correct perineal
RR - 22 BPM com/puerperal-infe cleaning after
ction-nursing-care- voiding and
plans/#risk_for_inf defecation.
ection Rationale:
Proper perineal
cleaning helps
clean the area
and check for
infections or
lesions in the
area.

5. Instruct the
patient about
frequent changing
of peripads at
least 2-4 hours.
Rationale:
Changing pads
removes a moist
medium that
favors bacterial
growth.

6. Encourage the
patient to have a
well balanced
diet.
Rationale:
A well-balanced
diet supplies the
nutrients your
body needs to
work effectively
and helps fight
diseases,
infections,
fatigue, and low
performance.

7. Monitor
oral/parenteral
intake, stressing
the need for at
least 2000 ml
fluid per day. Note

60
urine output,
degree of
hydration, and
presence of
nausea, vomiting,
or diarrhea.
Rationale:
Increased intake
replaces losses
and enhances
circulating
volume,
preventing
dehydration and
aiding in fever
reduction.

Dependent:

8.Administer pain
medications to
the patient to
reduce and ease
the patient’s pain,
as ordered by the
physician.
Rationale:
Administration of
pain relievers
helps lower the
pain and would
ease the feeling
of the patient.

9. Administer
antibiotic
medication to the
patient as
ordered by the
physician to
reduce the risk for
infection.
Rationale:
Administration of
antibiotics helps
ease the feeling
of the patient and
reduce the risk for
infection.

61
Collaborative:

10. Refer the

client for
individually
appropriate
diagnostic
procedures or
screenings
Rationale:
This helps in
further
assessment of
the patient’s
health as well as
to detect
complications and
other conditions
that can put the
patient at risk.

62
 DISCHARGE PLAN

Diet

- Recommend the patient to drink plenty of water.

- Encourage the patient to eat more fruits and vegetables.
- Inform the patient to not reduce weight until after postpartum
- Teach the patient the benefits of having a healthy lifestyle and diet.

Treatment

- Remind the patient that she should take the drug at the exact time.
- Instruct the patient not to stop drinking the medication unless the doctor stated

Medication

- Take medication as ordered

- Take 1 tab of Ferrous Sulfate, 500mg mefenamic acid and 500mg cefuroxime daily.
- Instruct patient to take medication at the route, prescribed, time and dosage
- Explain to the patient the indication, side effects, and adverse effects of the drug she
needs to take.

Spiritual Care

- Listen to the patient's thoughts and patients

- Open a peaceful setting for relaxation and meditation.
- Encourage the patient to pray and talk to God whenever she wants to talk to someone
and no one is around.

Exercise/Environmental

- Encouraged deep breathing exercises and relaxation techniques.

- Instruct the patient to balance physical activities with adequate rest periods.
- Discourage the patient from doing any strenuous activities and heavy lifting or excessive
stair climbing.
- Instruct the patient to perform Kegel exercise to help heal perineal tissues and improve
bladder control.

Health Teachings:

- Educate about family planning

- Encourage the patient to take Hot Sitz Bath
- Advise the patient to rest as much as possible.
- Teach and help the patient to catch up to new life changes.
- Remind the patient to change sanitary pads every 2 - 4 hours
- Instruct the patient to do proper hygiene especially perineal care

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 - Inform the husband or any family members to assist the patient in taking care of her
baby.
- Instruct the patient not to skip her meals and start eating a well balanced diet as well as
increasing the fluid intake.
- Remind to do the proper breastfeeding techniques and breastfeeding cues for her baby
- Teach and remind the patient how to assess the color and odor of lochia.

Out-Patient:

- Remind the patient to monitor her lochia.

- Teach the patient how to clean the umbilical cord.
- Remind the patient not to forget the baby’s immunizations.
- Remind the patient to make a follow-up checkup for about 4 to 6 weeks after delivery.
- Remind the patient not to forget the schedule of their checkups as ordered by their
doctor.
- Inform the patient to report to her physician when she feels sick or changes to prevent
further complications.

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