I.

Introduction

Pregnancy is the carrying of one or more offspring, known as a fetus or

embryo, inside the uterus of a female human came from Latin word graviditas. In

a pregnancy, there can be multiple gestations, as in the case of twins or triplets.

Human pregnancy is the most studied of all mammalian pregnancies. Obstetrics

is the surgical field that studies and treats pregnancy. Midwifery is the non-

surgical field that cares for pregnant women. Childbirth usually occurs about 38

weeks from conception approximately 40 weeks from the last menstrual period.

Pregnancy is divided into three periods and every period has three months each.

The first trimester is from conception to partial fetal development. The second

trimester is from 4 to 6 months this is the period when the first fetal movement is

observed. The third and last trimester is from 7 to 9 months and it is

characterized by popping out of abdomen, fetus can now move regularly.

After nine months of pregnancy it is now time to face the most crucial and

complicated stage of labor. It is the time when the woman faces chances

between life and death wherein a new form of life is to be given a chance to live.

Every woman undergoes pregnancy unless they don¶t want to have children.

Childbirth is the process whereby an infant is born. It is considered by many to be

the beginning of a person¶s life and age is defined relative to this event in most

cultures. A woman is considered to be in labor when she begins experiencing

regular uterine contractions, accompanied by changes of her cervix primarily

effacement and dilation. While childbirth is widely experienced as painful, some

women do report painless labors, while others find that concentrating on the birth

helps to quicken labor and lessen the sensations. Most births are successful

vaginal births, but sometimes complications arise and a woman may undergo a

c
caesarean section. A Primi-gravida woman fears what will happen during and

after delivery thinking about the pain, the deformities and life threats. A woman

undergoes many changes before reaching up delivery stage. This changes starts

from conception to full fetal formation. Physiological changes in pregnancy

include hormonal, musculoskeletal, cardiovascular, respiratory, physical,

metabolic, and renal.

Management on nutrition, weight gain, Immunological tolerance, and

psychological changes should be given focus.

During the time immediately after birth, both the mother and the baby are

hormonally cued to bond, the mother through the release of oxytocin, a hormone

also released during breastfeeding The first breast secretions contain colostrums

which can enhance anti-bodies of the baby for stronger immunity. Doing so can

maximize the purpose not only for the babies immune system but also for

bonding with the mother.

Upon this stage of pregnancy many questions will be raised not only by the

client but also from the family. Some of these questions may affect the view of

individuals upon labor. There is a need of giving right information to client so that

no misconception will happen. No matter what questions will be asked by the

relatives of client still only one thing is dearly shown and that is how much they

love the client.

c
II. Physiology of Labor

Labor is the series of events by which uterine contractions and abdominal

pressure expel the fetus and the placenta from the woman¶s body. Regular

contractions cause progressive dilatation of cervix and sufficient muscular force

to allow the baby to be pushed outside, It is time of change, both an ending and a

beginning for the woman the fetus and the family.


ori
 of Labor

‡ Low prog
t
ron
t
ory/ Prog
t
ron
d
privation t
ory

When progesterone (uterine muscle relaxant) decreases in late

pregnancy with the corresponding increase of oxytocin (uterine muscle

stimulant), labor starts.

‡ Oxytocin t
ory

The pressure of the fetal head on the cervix in the late pregnancy

stimulates the posterior pituitary gland to secrete oxytocin which causes

uterine contraction

‡ Etrog
nic, F
tal Hormon
and Protaglandin t
ori


All these have stimulating effect on uterine musculature uterine

motility.

c
 ‡ 
ory of Aging Plac
nta

As the placenta mature more and more pressure is exerted on the

fundal portion, the usual placenta site and the most contractile portion of

the uterus, it is believed that the resultant diminished blood supply to the

area causes contraction.

‡ Ut
rin
Myom
trial irritability/ Ut
rin
Str
tc
d 
ory

The most acceptable theory) as the uterine muscle get stretched

with fetal growth and increasing amniotic fluids, irritability and contractions

to empty the contents of the uterus are likely to result.

Compon
nt of Labor

A. Paag

Is the shape and measurement of maternal pelvis and dispensability of

birth canal.

F
tal Pr

ntation and Poition

Attitud
- describes the degree of flexion a fetus assumes during

labor the relation of the fetal parts to each other.

r ‰ood attitud
  is in complete flexion  the spinal column is bowed

forward, the head is flexed forward so much that the chin touches

the sternum, the arms are flexed and folded on the chest, the thighs

are flexed onto the abdomen, and the calves are pressed against

the posterior aspect of the thighs.

c
 r Mod
rat
fl
xion  if the chin is not touching the chest but is in

alert or military position.

Engag
m
nt - refers to the settling of the presenting part of a fetus

enough into the pelvis to be at the level of the ischial spines, midpoint of the

pelvis.

Station ² refers to the relationship of the presenting part of a fetus to if

level of the ischial spines.

r Station 0: when the presenting part is at the level of ischial spin

(Synonymous with engagement)

r Minu tation (-1 to -4)  if the presenting part is above the spines.

r Plu tation (+1 to +4)  at ÷3 to +4 station, the presenting part¶

at the perineum and can be seen if the vulva is separated (crowning)

F
tal Li
- is the relationship between the long (cephalocaudal) axis the

fetal body and the long (cephalocaudal) axis of a woman¶s body.

. Pa
ng
r

Is the fetus the body part of the fetus that has the widest diameter is the

head, so this is the part least likely to be able to pass through the pelvic ring.

r F
tal H
ad - usually the largest part of the body, it has found effect

on the birthing process.

c
 r on
 of t
Skull - are joined by membranous sutures, which

allow for overlapping or molding´ of cranial bones during birth

process.

r Ant
rior and Pot
rior Fontan
l ² are the pints of intersection

for the sutures and are important landmarks.

r Fontan
l ² are used as landmarks for internal examinations

during labor to determine position of fetus.

r F
tal  ould
r ² may be manipulated during delivery to allow

passage of one shoulder at a time.

r Molding ² is the change in shape of the fetal skull produced by

the force of uterine contractions pressing the vertex of the head

against the not-yelled- dilated cervix.

yp
 of pr

ntation

r C
p alic

Head is presenting part, usually the vertex (occiput), which is

the most favorable for birth. Head is flexed with chin on chest.

p o
rt
x Pr

ntation

† When the head is well flexed the

suboccipitobregmatic diameter and the parietal

diameter present. When the head is not flexed but

erect, the presenting diameters are occipitofrontal

and biparietal.

c
 p row Pr

ntation

† When the head is partial flexed, the brow or sinciput

becomes the presenting part.

p Fac
Pr

ntation

† When the head is extended to make the face the

presenting part.

p M
ntum Pr

ntation

† The head is completely hyperextend the head to

present the chin.

r r

c

Buttocks or lower extremities present first.

p Frank

† Thighs flexed, legs extended on anterior body

surface, buttocks presenting.

p Full or Compl
t

† Thighs and legs are flexed. Buttocks and feet (baby

is squatting position).

p Footling

† One or both feet are presenting.

r S ould
r

Presenting part is the scapula and baby is in horizontal or

c
 Transverse position. Cesarean birth indicated.

C. Pow
r (ut
rin
factor

a. Ut
rin
contraction (involuntary

r Fr
u
ncy ² timed from the beginning of one contraction to the

beginning of the next.

r Ñ
gularity ² discernable pattern  better established as pregnancy

progresses.

r Int
nity ² Strength of contraction; May be determined by the

³depressability´ of the uterus during a contraction. Describe as

mild, moderate or strong.

r uuration ² length of contractions. Contraction lasting more than

90 seconds without a subsequent period of uterine relaxation may

have severe implications for the fetus and should be reported.

r P a
 of contraction

p the increment, when the intensity of the contraction

increases

p acme, when the is at its strongest

p decrement, when the intensity decreases

r C
rvical C ang


p Effac
m
nt- shortening and thinning of the cervical canal.

Canal is approximately 1-2cm long.

c
 † Primipara ² effacement is accomplished before

dilatation begins.

† Multipara ² dilatation may proceed before

effacement is complete.

† uilatation- refers to the enlargement or widening of

the cervical canal from an opening a few millimeters

wide to one large enough (approximately 10cm) to

permit passage of the fetus.

b. ooluntary 
aring uown Effort

r After full dilatation of the cervix, the mother can use her abdominal

muscles to help expel fetus.

r These efforts are similar to those for defecation, but the mother is

pushing out the fetus from the birth canal.

r Contraction of levator and muscle

Pr
monitory Sign of Labor

r Lig t
ning- descent of the fetal presenting part into the pelvis

approximately 10-14 days before labor begins.

Sign of Lig t
ning:

p Relief of Dyspnea.

p Relief of abdominal tightness

c
 p Increase frequency of urination, varicosities, and pedal

edema because of pressure on the bladder and pelvic

girdle.

p Shooting pain down the legs because of the pressure on

the sciatic nerve

p Increase amount of vaginal discharge

r Incr
a
Mat
rnal
n
rgy- nesting behavior because of increase

level of epinephrine.

r raxton Hick Contraction- extremely strong which may interpret

as true labor contractions.

r Ñip
ning of t
c
rvix (‰ood
ll¶ Sign - becomes soft as butter

that is seen only on pelvic examination.

uiff
r
ntiation b
tw

n ru
and Fal
Labor Contraction

ru
Contraction Fal
Contraction

r Begin irregular but r Begin and remain

become regular and irregular

predictable. r Fell first abdominally

r Felt first from lower back and remain confined to

groin to abdomen in a the abdomen and groin

wave r Often disappear with

r Continue no mailer what ambulation and sleep.

c
 r the woman¶s activity r Do not increase in

r Increase in duration, duration, frequency, or

frequency and intensity intensity

r Achieve cervical r Do not achieve cervical

dilatation dilatation

M
c anim of Labor

Passage of fetus through the birth canal involves a number of

different position changes to keep the smallest diameter of the fetal head (in

cephalic presentation) always presenting to the smallest diameter of the birth

canal. These position changes are termed the cardinal movements of labor 

descent, flexion, internal rotation, extension, external rotation and expulsion.

r uESCEN - Is the downward movement of the biparietal diameter

of the fetal head to within the pelvic inlet. Full descent occurs when

the fetal head extrudes beyond the dilated cervix and touches the

posterior vaginal floor. Descent occurs because of pressure on the

fetus by the uterine fundus. The pressure of the fetal head on the

sacral nerves at the pelvic floor causes the mother to experience a

c
 pushing sensation. Full descent may be aided by abdominal muscle

contraction as the woman pushes.

r FLEXION ² as the descent occurs and the fetal head reaches the

pelvic floor, the head bends forward onto the chest, making the

smallest anteroposterior diameter (the suboccipitobregmatic

diameter) the one presented to the birth canal. Flexion is also aided

by abdominal muscle contraction during pushing.

r INEÑNAL ÑOAION ² The head flexes as it touches the pelvic

floor, and occiput rotates until it is superior, or just below the

symphysis pubis, bringing head into the best relationship to the

outlet of the pelvis. This movement brings the shoulders, coming

next, into the optimal position to enter the inlet. Putting widest

diameter of the shoulders in line with the wide transverse diameter

of inlet.

r EXENSION ² As the occiput is born, the back of the neck stops

beneath pubic arch and acts as a pivot for the rest of the head. The

head extends the foremost parts of the head, the face and chin, are

born.

r EXEÑNAL ÑOAION ² almost immediately after the head of

the infant is the head rotates back to the diagonal or transverse

position of the early part labor. This brings the after coming

c
 shoulders into an anteroposterior position which is best for entering

the outlet. The anterior shoulder is born first. Assisted perhaps by

downward flexion of the infants head.

r EXPULSION ² once the shoulders are born, the rest of the baby s

born easily and smoothly because of its smaller size. This

movement is the end of the pelvic division of labor.

Stag
 of Labor

A. Firt Stag

A first stage of dilatation, which begins with the initiation of true

labor contract and ends when the cervix is fully dilated. The first stage of

labor is divided into If phases  the latent, the active, and the transition

phase.

PÑIMI: 12 1/2 our

MULI: 8 our

a Lat
nt P a

The latent or preparatory phase begins at the onset of

regularly perceived uterine contractions and ends when rapid

cervical dilatation begins. Contractions during this phase are

mild and short, lasting 20-40 second cervical effacement

occurs, and the cervix dilates from 0-3cm. the ph lasts

c
 approximately 6 hours in a nullipara and 4.5 hours in a

multipara. Maternal behavior  talkative, less anxious, alert,

excited and the woman. This stage is excited with some

degree of apprehension but still with the ability to

communicate.

cccccccccccccccccc



c

i. Contractions  frequency, intensity, duration

ii. Membranes  intact, ruptured, color of fluid

iii. Bloody show, time of onset, cervical changes

iv. Time of last ingestion of food

v. FHR every l5mirts. Immediately after rupture of

membranes

vi. Maternal vital signs  temperature every 2 hours

membranes ruptured every 4 hours if intact

vii. Pulse and respirations every hour or when necessary

viii. Progress of descent

b Activ
P a

During the active phase of labor, cervical dilatation

occurs more rapidly. Increasing from 4-7 cm. contraction

grow stronger, lasting 40-60 seconds. and occur

approximately every 3-5 minutes. This phase lasts

approximately 3 hours in a nullipara and 2 hours in a

c
 multipara. Show (increased vaginal secretions) and perhaps

spontaneous rupture of membranes may occur during this

time. Maternal behavior  less talkative. More anxious; may

not want to be alone, fears of losing control, restless.

Increase anxiety. Maternal problem may hyper ventilate.

A
m
nt:

i. Cervical changes and increase bloody show

ii. Progress of descent

iii. Maternal and fetal vital sign

c ranition P a

During the transition phase, contractions reach their

peak of intensity. Occurring every 2-3 minutes with a

duration of 60-90 seconds and causing maximum dilatation

of 8-10 cm. by the end of this phase, both full

Dilatation (10 cm) and complete cervical

effacement(obliteration of the cervix) have occurred. If cervix

is intact, this period is marked by a sudden gush of amniotic

fluid as the fetus is pushed into the birth canal. Shows

become prominent. There is an uncontrollable urge to push

with contractions. The woman may experience intense

discomfort that may be accompanied by nausea and

vomiting. Maternal behavior  feeling of loss of control,

anxiety, panic and irritability.

cccccccccccccccccc



c

c
 i. Progress of labor and cervical changes

ii. Mood changes  if irritable or aggressive may be tiring or

unable to cope

iii. Signs of nausea, vomiting, trembling, crying, irritability

iv. Maternal and fetal vital signs

v. Breathing patterns, may be hyperventilating

vi. Urge to bear down with contractions

. S
cond Stag

The second stage of labor is the period from full dilatation and

cervical effacement to birth of the infant; with uncomplicated birth, this

stage about 1 hour. Contractions change from the characteristic

crescendo-decrescendo pattern to an overwhelming, uncontrollable urge

to push or bear down with each contraction as if to move her bowels.

Perineum bulges; grunting sounds. Increase bloody show with leg cramps

and bag of water ruptures. Maternal behavior  progresses from irritability

to participation, eagerness and excitement with need to bear down so she

pushes with uterine contraction spontaneously.

PÑIMI: 80 mm.

MULI: 30 mm

A
m
nt

i. Signs of imminent delivery

ii. Progress of descent

iii. Maternal and fetal vital signs

iv. Increase maternal pushing efforts

v. Vaginal distension

c
 vi. Crowning

vii. Birth of baby

C.  ird tag

The third stage of labor, the placental stage, begins with the birth of

the infant and ends with the delivery of the placental separation and

placental expulsion.

PÑIMI: 10 mm

MULI: 10 mm

Sign of plac
ntal S
paration:

r Lengthening of the umbilical cord.

r Sudden gush of vaginal blood

r Change in shape of the uterus

r Firm contraction of the uterus

r Appearance of the placenta at the vaginal opening

yp
 of Plac
ntal u
liv
ry:

r Schultz Mechanism  80% of the cases; fetal side, shiny clean and

inverted umbrella.

r Duncan¶s Mechanism  20% cases. maternal side. rough dirty and

umbrella shape.

A
m
nt

i. Signs of placental separation

c
 ii. Mechanisms of placental separation

iii. Completeness of the placenta

iv. Status of mother and baby  baby¶s apgar scores, blood

pressure, pulse, respirations, lochia and fundal status of the

mother.

C. Fourt Stag
(r
cov
ry tag


The first 1- 4 hours after birth of the placenta is sometimes termed

the fourth stage to emphasize the importance of the close observation

needed at this time. First two hours is the most crucial stage of the mother

due to unstable vital signs.

A
m
nt

i. Fundus  every 15 mm. for one hour and every 30 mm. for

the next four hours.

ii. Lochia  should be moderate in amount

iii. Bladder  full bladder is evidenced by the shifting of the

uterus to the right.

iv. Normally tender, discolored, edematous and intact

sutures

v. BP and HR  monitored closely 15 mm. during the 1 hour,

every 30 mm. for 2 hours.

vi. Rooming- in concept  the mother and the baby stays in

the same room in the hospital to promote the bonding and

encourage breastfeeding.

c
 vii. Firmness of the fundus and its position

viii. Lochia color and amount

Blood and cellular

Lochia Rubra Dark red 1-3 days debris from

decidua

Lochia Serosa Mostly serum,

Pinkish 4-10 days some blood,

tissue debris

Mostly, white

Lochia Alba Yellowish 11-21 days leukocytes with

deciduas,

epithelial cells,

ix. Perineum condition

x. Vital signs and medications and IV if any

xi. Infants pulse rate, respiration, appearance, reflexes and

vital measurements

xii. Palpate fundus every 15 mm. for the first 1-2 hours or

until stable

xiii. Monitor Mothers vital signs

xiv. Check vaginal discharges every 15 mm. for the first 1-2

hours

c
III. Profil

Name   Dona P. Villlegas

Address   Flores Compound, Calaanan, Canitoan, CDOC

Civil Status   Married

Sex   Female

Age   24 yrs. old

Height   162.6 cm

Occupation   Teacher

Educational status   College Graduate

Income   N/A

Religion   Roman Catholic

Nationality   Filipino

LMP   December 10, 2008

EDC   September 17, 2009

Time of delivery   2 38 pm

Type of delivery   Normal spontaneous delivery

Gravida  1

Parity  1

Term   full term

Premature  0

Abortion  0

Living  1

Name of Hospital   J.R Borja General Hospital

Name Physician   Dr. John Paul L. Oliveros, M.D.

c
A
m
nt

1st Visit 2nd Visit 3rd Visit 4th Visit

Assessment (July 28, 09) (Aug. 28,09) (Sept.26,09) (Oct. 2,09)

Temperature 36.5 C 36.3C 37.5C 37.4C

Pulse rate 76bpm 80bpm 82bpm 81bpm

Respiration rate 21cpm 19cpmc 21cpmc 21cpmc

Blood pressure 120/90mmHg 100/60mmHg 120/80mmHg 110/90mmHg

Height 162.6 162.6cm 162.6cm 162.6cm

Weight 58.9kgc 58.5kgc 58.9kgc 57.5kgc

Age of gestation 26weeks 30weeksc 34weeksc Weeksc

Fetal heart beat 128bpm 130bpm 135bpm 134bpm

Fundal height 26cm 30cmc 34cmc cmc

Immunization:

Type of dose date Place of

immunization immunization


tanu toxoid 1 do
Marc 29,2009 Canitoan

H
alt C
nt
r


tanu toxoid 1 do
April 26,2009 Canitoan

H
alt C
nt
r

Food or drug allergy  No known food and drug allergies

Heredo-Familial Disease  No known Heredo-Familial Disease

c
Received Blood in the past  she haven¶t received blood in the past

Io. Id
al Nuring Int
rv
ntion

A. Ant
partum

Nuring uiagnoi

p Fatigue related to effects of physiologic changes of

pregnancy.

Nuring Int
rv
ntion:

1. Explain to patient physiologic changes responsible for increased

feeling of fatigue during pregnancy.

r Information provides knowledge that can

motivate an individual to make lifestyle

changes that will enhance energy level by

promoting adequate rest.

2. Assist patient in developing a plan to increase amount of rest

and sleep.

r Mutually deciding on a plan increases the

likelihood that the patient will follow through

with the actions needed to successfully

implement the plan.

3. Instruct patient to limit fluid intake during the evening.

r To prevent frequent awakenings from nocturia.

4. Instruct patient to position self in bed for maximum comfort.

r Comfort promotes rest.

5. Assist patient in eliminating nonessential tasks from schedule.

c
 r To prevent fatigue from excessive demands

and to allow time for additional rest periods.

Nuring uiagnoi

p Pain related to urinary tract infection.

Nuring Int
rv
ntion:

1. Assess pain, noting location, intensity (scale of 0-10), and

urination

r Provides information to aid in determining

choice/effectiveness of interventions.

2. Recommend bed rest as indicated.

r Bed rest may be needed initially during acute

retention phase.

3. Suggest comfort measures, like backrub, deep-breathing

exercises, diversional activities and helping patient assume position

of comfort.

r Promotes relaxation, refocuses attention, and

may enhance coping abilities

4. Encourage use of sitz baths, warm soaks to perineum.

r Promotes muscle relaxation.

5. Administer medication as indicated 

r Narcotics like meperidine (Demerol)

p Given to relieve severe pain, provide

physical and ental relaxation.

r Antibacterial like methenamine hippurate

(hiprex)

c
 p Reduces bacteria present in urinary

tract as well as those introduced by

drainage system.

r Antiplasmodics and bladder sedatives like

flavorate (urispas), Oxybutynin (ditropan).

p Relieves bladder irritability.

Nuring uiagnoi

Risk for ineffective breathing pattern related to respiratory

changes during pregnancy..

Nuring Int
rv
ntion:

1. Investigate etiology of respiratory failure.

r Understanding the underlying cause of the

patient particular ventilatory problem is

essential to the care of the patient.

2. Observe overall breathing pattern.

r To identify if patient is experiencing

hyperventilation or hypoventilation.

3. Count patients respirations for one full minute and compare to

desired ventilator set rate.

r Respirations vary, depending on problem

requiring ventilator assistance.

4. Elevate head of bed or place in orthopedic chair if possible.

r Elevation of head is both physically and

psychologically beneficial.

c
 5. Keep resuscitation bag at bedside and ventilate manually

whenever indicated.

r Provides adequate ventilation when patient

problems require that the patient be

temporarily removed from the ventilation.

Nuring uiagnoi

p Imbalanced nutrition, less than body requirements related to

nausea, vomiting and knowledge deficit of nutritional needs

during pregnancy.

Nuring Int
rv
ntion:

1. Review 24-hour dietary intake and ask if this is typical of the normal

diet.

r To provide baseline information of patients

nutritional habits.

2. Determine current knowledge of nutritional needs during

pregnancy.

r To provide information needed to develop an

individualized teaching plan.

3. Use of food pyramid to teach patients to eat a nutritional diet;

provide them with a copy of the food pyramid.

r A healthy diet should consists of that can be

adapted to accommodate cultural preferences.

4. Teach patient to report excessive nausea and vomiting to health

care provider.

c
 r To allow for early intervention of alternative

forms of nutritional delivery if an oral diet

cannot be tolerated.

5. Avoid beverages with meals and foods that are spicy and greasy.

r These have noxious odors can increase

episodes of nausea and vomiting.

Nuring uiagnoi

p Knowledge deficit related to normal changes of pregnancy

versus illness complications.

Nuring Int
rv
ntion

1. Review avoidance of environmental risk factors.

r Reduces potential for acquired infection.

2. Identify specific activity limitations.

r Prevents undue strain on operative site.

3. Recommend planned progressive exercise.

r Promotes return of normal function and

enhances feeling of general well.

4. Schedule adequate rest periods.

r Prevents fatigue and conserves energy for

healing.

5. Review importance of nutritious diet and adequate fluid intake.

r Provides elements necessary for tissue

regeneration.

6. Identify signs and symptoms requiring medical evaluation.

c
 r Early recognition and treatment of developing

complications.

. Intrapartum

Nuring uiagnoi:

p Anxiety  mild related to excitement, of onset of labor and fear

of the birth.

Nuring Int
rv
ntion:

1. Support woman¶s knowledge of labor.

r To provide comfort measures to the mother

during labor and delivery process.

2. Explain all procedures performed or the process of labor.

r Explaining the process of labor or childbirth to

the patient minimizes patients apprehensions.

3. Answer all questions and provide information as needed.

r To provide reassurance to the mother and help

her to relax during childbirth.

4. Monitor VS, FHR and progress of labor.

r Monitoring mothers VS and fetal heart rate is

needed to take baseline data and to take note

for any patients reactions during labor process.

5. Support woman¶s preference for breathing and relaxation

techniques to be used at this time.

c
 r Supporting the mother¶s preference for

breathing and relaxation techniques helps us to

implement or provide comfort measures and

help the mother to expel the newborn properly.

6. Administer anti-anxiety or anxiolytic medications as ordered.

r Anxiolytic drugs or medications lowers level of

anxiety with the proper use of pharmacology.

Nuring uiagnoi:

p Fluid volume deficit related to decreased intake and

increased loss of fluid with the work of labor.

Nuring Int
rv
ntion

1. Explain to woman and support person why oral fluids are

restricted or stopped at this time.

r Explaining the necessary information

concerning fluid intake of the client was

necessary in order to gain cooperation from the

mother and to decrease urination during the 2nd

stage
of labor (delivery stage).

2. Start and maintain IV infusion.

r Intravenous infusion is necessary to maintain

adequate hydration during the labor process of

the client.

3. Provide ice chips or sips of clear fluids if allowed.

c
 r To prevent dry mouth during labor process and also to

increase mother¶s energy in doing the bearing down

technique during contractions.

Nuring uiagnoi:

p Pain related to increasing frequency and intensity of uterine

contraction

Nuring Int
rv
ntion:

1. Provide comfort measures (eg. back rub, change of position)

r Back rubbing could provide non-pharmacologic pain

management, thus reducing the pain felt by the mother

during her labor stage.

2. Encourage diversional activities (e.g. TV, radio, socialization

with others )

r Diversional activities are a mean of diverting patients

attention on others things, thus reducing the pain felt

by the mother during the labor process.

3. Eliminate additional stressors or sources of discomfort whenever

possible.

r Patients may experience an exaggeration in pain or

decreased ability to tolerate painful stimuli if

environmental, interpersonal factors are further

stressing them.

4. Instruct or encourage the mother to use of relaxation exercises,

such as focused breathing, or listening to music.

r Relaxation eases the painful sensation.

c
 5. Administer analgesics as ordered.

r Analgesics provide pain relief to the patient during

delivery stage of labor.

Nuring uiagnoi

p Ineffective individual coping, related to anxiety, fear and

decreased problem-solving capability.

Nuring Int
rv
ntion

1. Assess anxiety level.

r To identify appropriate comfort measures to be given

to the client during her labor process.

2. Assess behavior of support person and its effect on the woman.

r To help woman cope with increasing pain and anxiety

of active labor.

3. Provide information

r Information concerning labor process reduces

mother¶s feeling of fear or anxiety during labor

process.

4. Assist woman and support person in focusing on breathing and

relaxation techniques to maintain control.

r To Relieve from muscular aches

3. Give episiotomy Care

r To relieve discomfort

r To prevent further infection

4. Promote Perineal Exercises

c
 r Aids comfort by providing circulation to the area and

decreasing edema.

r To help regain her Pre-pregnant stage.

r To reduce episiotomy discomfort

5. Administer Hot and Cold Therapy

r To reduce perineal edema and possibility of

Hematoma formation.

r To increase circulation to the perineum, provide

comfort and promote healing.

6. Administer Sitz Baths

r To decrease inflammation by causing vasodilatation

in the area, and thereby effectively reduces

discomfort and promotes healing.

7. Provide pain management

r To reduce incision line pain

r To promote extra encouragement to try the pain

medications

r To relieve perineal pain

Nuring uiagnoi

p Risk for infection (uterine) related to lochia and episiotomy

Nuring Int
rv
ntion

1. Provide Perineal Care

r To remove transient microorganisms in the perineum

r To avoid further infection

r To promote hygiene

c
 2. Promote perineal self-Care

r To teach the patient how to carry out own perineal care

Nuring uiagnoi

p Disturbed sleep pattern related to exhaustion and excitement

from and excitement of childbirth

Nuring Int
rv
ntion

1. Promote rest in the early postpartal period.

r To encourage a period of rest to regain energy.

2. Listen to subjective reports of sleep quality.

r To evaluate pattern of sleep and dysfunction.

3. Assist individual to develop schedules that take advantage. of

peak performance times as identified in chronological order.

r To promote wellness.

Nuring uiagnoi

p Risk for bathing hygiene self-care deficit related to

exhaustion from childbirth.

Nuring Int
rv
ntion:

1. Determine current capabilities and barriers to participation in

care.

r Identifies need for/level of interventions required

2. Involve patient in formulation of plan of care at level of activity

r Enhances sense of control and aids in cooperation and

development of independence.

c
 3. Encourage self-care. Work with present abilities  do not

pressure patient beyond capabilities. Provide adequate time for

patient to complete task.

r Doing for one self enhances feeling of self-worth. Failure

can produce discouragement and depression.

Nuring uiagnoi

p Imbalanced nutrition, less than body requirements,

related to lack knowledge about postpartal needs

Nuring Int
rv
ntion:

1. Promote Adequate Fluid Intake

r Prevent dehydration

2. Emphasize importance of well-balanced, nutritious intake.

Provide information regarding individual nutritional needs and ways

to these needs within financial constraints.

r To promote wellness and knowledge about own

nutritional needs

3. Ascertain understanding of individual nutritional needs

r To determine what information to provide client.

4. Provide diet modification

r To establish nutritional plan that meets individual needs

Nuring uiagnoi

p Risk for impaired urinary elimination or constipation

related to of bladder and bowel sensation after

childbirth.

c
 Nuring Int
rv
ntion:

1. Promote Urinary Elimination

r To achieve normal elimination pattern

2. Adequate fluids and roughage

r To prevent constipation

3. Palpate bladder for retention

r To assess the degree of interference

Nuring uiagnoi

p Risk for ineffective peripheral tissue perfusion related

to immobility and increased estrogen

Nuring Int
rv
ntion:

1. Observe skin for pallor, redness. Manage with lotion, change

position frequently.

r Compromised peripheral circulation increases risk of skin

breakdown

2. Assess skin for coolness, pallor, diaphoresis, delayed capillary

refill, and weak, thread peripheral pulses.

r Vasoconstriction is a sympathetic response to lowered

circulating volume and/or may occur as a side effect of

vasopressin administration.

Nuring uiagnoi

p Pain related to primary breast engorgement

Nuring Int
rv
ntion:

1. Promote Breastfeeding

c
 r Prevent tenderness and soreness of primary breast

engorgement.

2. Promote Breast Hygiene

r To prevent possible infection when breastfeeding

Nuring uiagnoi

p Health-seeking behaviors related to client¶s desire to

return to pre- pregnant weight and appearance

Nuring Int
rv
ntion:

1. Teach methods to promote uterine involution.

r To promote fast return to pre-pregnant state

2. Promote using proper body mechanics, getting adequate rest,

and performing prescribed exercises.

r To help client¶s abdominal wall to return to good tone.

Nuring uiagnoi

p Attachment risk for impaired parent/infant! child

Nuring Int
rv
ntion:

1. Interview parents, noting their perception of situation. Individual

concerns

2. Evaluate parents ability to provide protective environment,

participate in reciprocal relationship.

r To provide a good environment to infant/child

3. Educate parents regarding child growth and development,

addressing parental perception. Helps clarify realistic expectations

r To enhance behavioral of infant/child

c
 4. Involve parents in activities with the infant/child that they can

accomplish successfully. Enhance self-concept.

r To enhance best functioning of parents

u. Imm
diat
N
wborn Car

Nuring uiagnoi

p Imbalance nutrition less than body requirement related

to poor sucking reflex

Nuring Int
rv
ntion:

1. Assess nutritional status continually during nursing care noting

energy level, condition of the skin, nails, hair and oral cavity.

r provides the opportunity to observe deviations from

normal

2. Weigh daily and compare with the admission date.

r Establish baseline, aids in monitoring effectiveness of

therapeutic regimen and alerts the nurse to inappropriate

trends in weight loss or gain

3. Always hold the infant when feeding and propping the bottle when

feeding.

r To promote bonding and gain trust of the infant

4. Feeding only breast milk or formula milk for the first year.

r Feeding only breast milk for the first year is given since it

is theft main source of nutrition consumption because

ingestion of solid foods is not appropriate for infants

aging 0-4 mos.

c
 5. Avoiding use of honey and corn syrup.

r Use of honey and corn syrup can make the infant

dependent on it with out taking new food preference that

contains more nutrition

Nuring uiagnoi

p Risk for ineffective airway clearance related to difficulty

establishing respirations and rapid respiratory rate

Nuring Int
rv
ntion:

1. Assess respiratory rate every 15 mm. for about 1 hr. report any

increase in rate, retractions or development of nasal flaring or

grunting

r Assessment provides a baseline foe evaluating changes.

Increase in respiratory rate and a retraction accompanied

by nasal flaring and grunting indicates respiratory

distress.

2. Position the newborn on his side with his head slightly lower

than the rest of the body

r Positioning in this manner facilitates drainage of

secretions from airway

3. Change the position of the newborn frequently

r Changing position frequently facilitates drainage of

secretions and thus promotes lung expansion

4. Suction mouth and nose with a suction bulb as indicated

r Suctioning removes secretions and suctioning from

mouth to nose prevents aspiration of oral secretions

c
 5. Monitor newborn temperature and keep him warm via radiant

warmer. Wrap the newborn loosely with a blanket and place a cap

on head

r Newborns have difficulty conserving body heat. Exposure

to cold environment increase metabolic rate, increasing

the need of oxygen and further increasing respiratory

rate.

Nuring diagnoi

p Risk for impaired parenting related to concerns about

skin color.

Nuring Int
rv
ntion:

1. Allow parents to verbalize their concerns about the

discoloration.

r Verbalization allows safe outlet for emotion and helps to

increase the parents awareness

2. Explain that Mongolian spats are normal variation to skin color

of the newborn. Inform them that the area usually disappears by

school age.

r Explanation as normal provides information to help allay

parents fears and concerns

3. Point out other positive normal attributes of the newborn

r Pointing out other positive areas helps the parents focus

on the uniqueness and special qualities of their child.

4. Encourage the parents to hold, talk and explore the newborn

c
 r Interaction and exploration help to promote bonding and

reassure the parents that their child is normal

Nuring uiagnoi

p Risk for infection related to newly clamped cord and

exposure of eyes to vaginal secretions

Nuring Int
rv
ntion:

1. Inspect and care for the newly clamped cord

r To be sure that the cord is being clamped securely

2. Asses the newly cut cord after few minutes

r To ensure that bleeding is not evident

3. Apply eye ointment as required by the agency policy

r Puffing eye ointment will help reduce infection due to

vaginal secretions during delivery

4. Keep the cord dry until it falls off after they return home

r Keeping the cord dry will promote fast wound healing ant

to prevent microbes to lodge in into the affected part.

5. Provide a clean, well ventilated environment.

r This is to reduce number of pathogens present on the

immune system and reduces possibility of the newborn

acquiring nosocomial infections

Nuring uiagnoi

p Risk for ineffective thermoregulation related to

newborns transition to extra uterine environment

c
 Nuring Int
rv
ntion:

1. Assess environmental temperature (78 ² 80F) and modify if

needed example providing warm and cooling blankets and increasing

room temperature.

r Assessing would maintain and stabilizes newborns

temperature

2. Monitor newborn temperature and keep him warm via radiant

warmer. Wrap the newborn loosely with a blanket and place a cap

on head

r Newborns have difficulty conserving body heat. Exposure

to cold environment increase metabolic rate.

3. Close doors and windows and regulate the cooling facility

r To provide warm environment for the newborn thus

preventing him from chilling

4. Prevent exposing the newborn¶s body for a long span of time

r Preventing sudden and long exposure of newborns body

to the environment reduces chance of chilling

c
cActual Nuring Int
rv
ntion

A. Ant
partum

During antepartal period, a pregnant woman may able to experience many

things related to her health such as headache, nausea, vomiting, and cramps

over the extremities. Due to this complication a pregnant woman may feel

depressed or may form a negative feeling towards her pregnancy. To solve

this complication or to prevent a pregnant woman to have further

complication, it is better for them to consult their physician or by visiting the

nearest health center in their town. The reason for visiting and consulting their

physician and health center is that they can monitor her condition. And so she

can understand why she¶s experiencing this condition.

During our assessment to our client, we were able to identify different

problems.

We were able to identify the following problems 

~ Improper breathing pattern while sleeping

~ Back pain

c
 Nuring A
m
nt (Syt
m Ñ
vi
w and Nuring A
m
nt

º
c cc
 c c
ccc

ccccccccc]cccccccccccccc
cccccccc
cccccccc c

 c! cccccccccccccccc
 c"

EEN:
R ] Impaired vision R ] blind
R ] pain redden R ] drainage
R ] gums R] hard of hearing R ] deaf c
R ] burning R ] edema R ] lesion teeth No problem
R ] assess eyes ears nose
R ] throat for abnormality Rx] no problem c
ÑESP:
R ] Asymmetric R ] tachypnea R ] barrel chest
R ] apnea R ] rales R ] cough
R ] bradypnea R ] shallow R ] rhonchi
R ] sputum R ] diminished Rx] dyspnea
R ] orthopnea R ] labored R ] wheezing
R ] pain R ] cyanotic
R ] assess resp. rate, rhythm, pulse blood Linea nigra
R ] breath sounds, comfort R ] no problem

CAÑuIOoASCULAÑ: Strae gravidarum

R ] arrhythmia R ] tachycardia R ] numbness
R ] diminished pulses R ] edema R ] fatigue
R ] irregular R ] bradycardia R ] mur mur
R ] tingling R ] absent pulses R ] pain
Assess heart sounds, rate rhythm, pulse, blood
Pressure, circ., fluid retention, comfort
Rx] no problem

‰ASÑOINESINAL ÑAC:
R ] obese R ] distention R ] mass
R ] dysphagia R ] rigidity R ] pain
R ] assess abdomen, bowel habits, swallowing
R ] bowel sounds, comfort [x] no probl
m

‰ENIO ± UÑINAÑ ANu ‰ NE

R ] pain R ] urine R ] color R ] vaginal bleeding
R ] hematuria R ] discharge Rx ] nocturia
Rx] assess urine frequency, control, color, odor, comfort
R ] gyne bleeding R ] discharge R ] no problem

NEUÑO:
R ] paralysis R ] stuporous R ] unsteady R ] seizure
R ] lethargic R ] comatose R ] vertigo R ] tremors
R ] confused R ] vision R ] grip
R ] assess motor, function, sensation, LOC, strength
R ] grip, gait, coordination, speech Rx ] no problem Back pain
MUSCULOSKELEAL and SKIN:
R ] appliance R ] stiffness R ] itching R ] petechiae
R ] hot R ] drainage R ] prosthesis R ] swelling
R ] lesion R ] poor turgor R ] cool R ] flushed
R ] atrophy R ] pain R ] ecchymosis R ] diaphoretic moist
R ] assess mobility, motion gait, alignment, joint function
R ] skin color, texture, turgor, integrity Rx] no problem
Varicosity

c

c c


 ccccc c c
cc cccc ccccccccccccccccccccccccccc
E6cc/ c c cccccccccccccccccccc!c
ccc ' 2cc/ c
 !c c"cc#$%cccccccccccccccccccccccccc#$%c
'$Fcc &'c()c#$%cccccccccccc'c!**c
92(!c2.cc " )c&""c
'5c
c

+,- cccccccccccccc c c

c .'c "' .)ccc"cc
c  /c .c E&$!c ' )c""cc1c cc
0000000000000000c / 7c !c/ c c
c c c15Fc ")cccc.c cc*cc
c 'c c92(!c )c*ccc.c cccc
c !c 2.cc'c c
c c

"
 cccccccccccccc c c

/c&c c".)ccccc
c&c E
2 !c /c!c c
2c *ccc / ccc/cc c
ccccc / c/ !cc &ccccccccc"!cc &ccc3c
c !c ' Fcc "ccccccccccccccc4ccccc4ccccc4cccccc5 c
92(!c2.cc ccccccccccccccc4ccccc4ccccc4cccccc5 c
'c  )cc'ccc''2c
c
c

" cccccccccccccccc c c
!cccccccc c
) cc E-/c/ cc c
cccccccc /' cc cccccccccccccccccc3cccccccc'ccccccccc1c'c
c 2Fcc
''ccccccccccccccccccccccccccccccccccccccccccccccc
c"ccc 92(!c2.cc  1ccccccccccccccccccccccccccccccccccccccccccccccc
cccc67c''c
'5c
c 1 1c
cccc **.c
c

 cccccccccccc  )cccccc 1c !)c

c2 1c'ccccccccccccccc.c*8.c cccccccccccccccccccccccccc
cc9.c1 c!.ccccccccccccc:cc'c!.c ccccccccccccccccccccccccc2! c  c
c cccccccccccccccccccccccccccccccccc&c. c
c ' cccccccccccccccccccccccccc.c cccccccccccccccccccccccccccccccccc
c?  7c .7c ! @c
cccc"!.ccccccccccccccccccccccccccccccccc!.c ccccccccccccccccccccccccccc
ccccccccccccccccccccccccccccccccccccccccccccccccccc cccccccccccccccccccccccccccccccccccccccc*c.ccc'Ac
c *cc
)ccccccccccccccccccccccc c
'5c;<7c;==>ccccccccccccccccccccccccccc' .c
c!ccccccccccccccccccccccccccccccccc* .cc'c
cccccccccccccccccccccccccccccccccc!!c

-5c 3ccBc c *.c!2cc'Dc2.c c*  1cc

c  cccccccccccccccccccccccccccccccccc!!c ?!7c!57c5@c* c >cc' 2c?c*c'@c
c c
 c ccccc'c!!c c'c.c c' 25c

&)c 5=C7c;==>c
c

c
c
/c.ccccccccccccccc c c
c .c c c!.cccccccccccccc !ccccccccccc'c
cc c*!cccccccc1c
c c c ccccccccccc. c
!!c cc
c ccccc"7c7c!2c?!2c(7c  7c
c !@c c* !c.c'!c/c.5c
c
c
9.G *.ccccccccccccc c c
c 9 c cc c!c  )c'cc1c
c!((c
c!c  c *cH c !c1cc!c!5c
c2c -)ccc6/cccccccccccccc c
cc*c ccccccccccccccc!.ccccccc!.0000000c
c c ccc .c!c  c cc*c c)c c
!!c cc"
c c
 * G 'G1/)c c
cc'c?  7ccccccccccccccccc c c*cc
ccccccccccccc*8.cc c!c
ccccccccccccc!@c c c cc *c'cc
cc c c!ccc* c!c?:=4c@c
'c!**c
c!!c

 ')c c
' )c c 29!c $92c29 )cccccccccc
c

2c *c  !)c<c c' c!cc' c2ccc2c!c.c

c'' 9c' )c c!c*c )c

&c&c3 "
 cc
cccccccccccGc .c1ccccccccccccccccccccccccccccccccccccccccccccccccccccccccccccGc&G c
cccccccccccGc&c8c*cccccccccccccccccccccccccccccccccccccccccccccccccccccccccccccccccGc! c
cccccccccccGcc c9ccccccccccccccccccccccccccccccccccccccccccccccccccccccccccccccccccccGc
cc
cccccccccccGc&G -5c"!ccccccccccccccccccccccccccccccccccccccccccccccccccccGc;%c c
c  c
c
cc !!c  G2  .c cc c cc !!c 5c3!G !c cc c
c
c c c c c c
c c c c c c
c
c

c
c
 #$%c#$&º'(c

! c cc'c !!c2.cc!  ccc
 c/c* c*cc!.c*c2/*c
c ~ !9c c! c'ccc
'' c* c2 c!c!9.5cc1c
ccc 9c'7c
2! 7c7c!c!c2/c!c
2c 9cc5c
~  cc'ccc
c* c!c*c' 2cc1c*  1c
c*1!5c
§  cc*  1c)c
r &9cc c'9c /c
r lcc1c
r cc
r  cc
r "2c*c
r  !cc
r lc2!c
r *cc
c c'c cc*!c/c cc
c1 !c2c!ccc c *c
 c*!5c
$'c "c/$'c cccc
/$'c
r 9.c!.c *cc1/c
r cc c2* c cc
cc c'c cc* !c/cc)c
r 3 !ccc' c
r 3 !cccc ccc/c
9c!c.5c
c

c
 Nuring A
m
nt (Syt
m Ñ
vi
w and Nuring A
m
nt

º
c cc
 c c
ccc

ccccccccc)*]cccccccccccccc
ccccccc"
cccccccc c

 ccccccc!ccccccccc
 c"

EEN:
R ] Impaired vision R ] blind
R ] pain redden R ] drainage
R ] gums R] hard of hearing R ] deaf c
R ] burning R ] edema R ] lesion teeth
R ] assess eyes ears nose No problem
R ] throat for abnormality Rx] no problem c
ÑESP:
R ] Asymmetric R ] tachypnea R ] barrel chest
R ] apnea R ] rales R ] cough
R ] bradypnea R ] shallow R ] rhonchi
R ] sputum R ] diminished R ] dyspnea
R ] orthopnea R ] labored R ] wheezing
R ] pain R ] cyanotic
R ] assess resp. rate, rhythm, pulse blood
R ] breath sounds, comfort R ] no problem
Lochia serosa
CAÑuIOoASCULAÑ:
R ] arrhythmia R ] tachycardia R ] numbness
R ] diminished pulses R ] edema R ] fatigue
R ] irregular R ] bradycardia R ] mur mur
R ] tingling R ] absent pulses R ] pain Itching
Assess heart sounds, rate rhythm, pulse, blood
Pressure, circ., fluid retention, comfort
Rx] no problem

‰ASÑOINESINAL ÑAC:
R ] obese R ] distention R ] mass
R ] dysphagia R ] rigidity R ] pain
R ] assess abdomen, bowel habits, swallowing
R ] bowel sounds, comfort [x] no probl
m

‰ENIO ± UÑINAÑ ANu ‰ NE

R ] pain R ] urine R ] color R ] vaginal bleeding
R ] hematuria R ] discharge R ] nocturia
R ] assess urine frequency, control, color, odor, comfort
R x ] gyne bleeding R ] discharge R ] no problem

NEUÑO:
R ] paralysis R ] stuporous R ] unsteady R ] seizure
R ] lethargic R ] comatose R ] vertigo R ] tremors
R ] confused R ] vision R ] grip
R ] assess motor, function, sensation, LOC, strength Back pain
R ] grip, gait, coordination, speech Rx ] no problem

MUSCULOSKELEAL and SKIN:

R ] appliance R ] stiffness R ] itching R ] petechiae
R ] hot R ] drainage R ] prosthesis R ] swelling
R ] lesion R ] poor turgor R ] cool R ] flushed
R ] atrophy Rx ] pain R ] ecchymosis R ] diaphoretic moist
R ] assess mobility, motion gait, alignment, joint function
R ] skin color, texture, turgor, integrity R ] no problem
No problem

c

c c


 ccccc c c
cc cccc ccccccccccccccccccccccccc cc
E6cc/ c c cccccccccccccccccccc! c
ccc ' 2cc/ c
 !c c"cc#$%cccccccccccccccccccccccccc# $%c
'$1Fcc &'c()c#$%cccccccccccc'c!** c
92(!c2.cc " )c&""c
'5c
c

+,- cccccccccccccc  c c

c .'c "' .)ccc"c c
c  /c .c E1cc/ c ' )c""cc1c c c
0000000000000000c ' 2cc c
c c / c ")cccc.c cc*c c
c 'c '15Fc )c*ccc.c ccc c
c !c c92(!c c
2.cc'c c
c

"
 cccccccccccccc c c

/c&c c".)ccccc
cc&c E
2 !c /c!c c
c2c *ccc / ccc/cc c
ccccc / c/ !cc &ccccccc cc"!cc &ccc3c
c !c ' Fcc "cccccccccccc ccc4ccccc4ccccc4cccccc5 c
92(!c2.cc ccccccccccccccc 4ccccc4cccc c4cccccc5 c
'c  )cc'ccc''2 c
c
c

" cccccccccccccccc c c
!cccccccc  c
)c cc E1cc/ c c
ccccccccc c ' 2cc/ c cccccccccccccccccc 3cccccccc'ccccccccc1c' c
c '/Fcc
''cccccccccc ccccccccccccc ccccccccccccccccccccccc c
c"ccc 92(!c2.cc  1cccccccccccccccccccccccccccccccccccccccccccccc c
cccc67c''c '5c
c 1 1c
cccc **.c
c

 cccccccccccc  )cccccc 1c !)c

c2 1c'cccccccccccccccc.c*8. c c c !c'c *c2! c !cccccccccccccc
c!.ccccccccccccccccccccccccccccccccc #cIc%ccc!.c ccccccccccccccccccccccccc 2! c  c
c cccccccccccccccccccccccccccccccccc &c. c
c ' ccccccccccccccccccccccccc c.c cccccccccccccccccccccccccccccccccc
c?  7c .7c ! @ c
cccc"!.ccccccccccccccccccccccccccccccccc!. c cccccccccccccccccccccccccc c
ccccccccccccccccccccccccccccccccccccccccccccccccc cc cccccccccccccccccccccccccccccccccccccccc *c.ccc'Ac
c *cc
)ccccccccccccccccccccccc  c
'5c;%7c;==>cccccccccccccccccccccccccc c' .c
c!ccccccccccccccccccccccccccccccccc* .cc' c
cccccccccccccccccccccccccccccccccc!! c

-5c 3ccBc c *.c!2cc'Dc2.c c*  1c c

c  cccccccccccc ccccccccccccccccccccc c!!c ?!7c!57c5@c* c >cc' 2c?c*c'@ c
c/ c cc/2 cc  c c
 cc&'c )c c ccccc'c!!c c'c.c c' 25c

&)c 5=C7c;==>c
c
cc
/c.ccccccccccccccc c c
c .c E/ cc c!.cccccccccccccc !ccccccccccc' c
cc / c c*!cccccccc 1c
c c Fcc c ccccccccccc.  c
c!!c 92(!c2.c cc
c c'c ccccc"7c7c!2c?!2c(7c  7c
c !@c c* !c.c'!c/c.5c
c
c
9.G*.ccccccccccccc  c c
c 9 c cc c!c  )c'cc1c
c!((c E/ /$
c!c  c *cH  c  /c'c !c1cc!c!5c
c2c / Fcc -)ccc6/cccccccccccccc  c
cc*c 92(!c2.c cccccccccccccc c!.ccccccc!.0000000c
c c c'c ccc .c!c  c cc*c c)c  c
!!c cc"
c  c
 * G'G1/)c c
cc'c?  7ccccccccccccccccc  c c*c c
ccccccccccccc *8.cc c!c
ccccccccccccc !@c E /cc/ c c cc *c'cc
cc c '$ Fcc c!ccc* c!c?:=4c@ c
c'c!**c 92(!c2.c
c!!c c'c

 ')c c
' )cc 29!c $92c29 )cc'c1c  c!c
 cccccccccc

2c *c  !)c:c c

c'' 9c' )c2!c c' c!cc' c2ccc2c!c.c

)cc
&c&c3 "
 cc
ccccccccccc Gc .c1cccccccccccccccccccccccccccccccccccccccccccccccccccccccccccc Gc&G c
ccccccccccc Gc&c8c*ccccccccccccccccccccccccccccccccccccccccccccccccccccccccccccccccc Gc! c
ccccccccccc Gcc c9cccccccccccccccccccccccccccccccccccccccccccccccccccccccccccccccccccc Gc
cc
ccccccccccc Gc&G -5c"!cccccccccccccccccccccccccccc cccccccccccccccccccccccc Gc;%c c
c  c
c
cc !!c  G2  .c cc c cc !!c 5c3!G !c cc c
c
c c c c c c
c c c c c c
c

c
Imm
diat
N
wborn Car

c, a postpartum client, del ivered a healthy baby girl in a

normal spontaneous vaginal delivery. Last October 2, 2009 , we went to their

home and conducted our last assessment. When we arri ved to their home, we

found her feeding her baby through a milk bottle . She told us that her b aby

has a good sucking reflex.

The mother is anxious about the red spot locate d at the lower

Right arm of the infant and we told her that the spot is n ormal for an infant. As

nursing intervention we advised the mother not to place pow der ointment or

baby oil on the baby¶s skin if rashes occur. Vital signs were taken during the

assessment and it was in normal range. We noted little diaper rashes on the

infant¶s inguinal area.

c
 H
alt 
ac ing

r Remind parents to hold infant properly when feeding and never

propping bottle when feeding.

r Instruct parents to limit infants water intake to ½ oz. ² 1 oz.

r Instruct the mother not to leave infant unattended on bed, tables, or

other surfaces without side rails.

r Encourage to sit comforta bly and hold baby in a semi upright position 

hold bottle so that fluids fills the nipples and the air in the bottle does

not enter the nipple.

r Encourage the parents to change position of the in fant alternately

during feeding; feed for half of feeding hold ing in 1 hour, and then

switch to the other arm.

c
oI. ÑEFEÑÑAL

We advised the mother to seek medical help when lochia

discharges after 14 days and above is still red and has a faulty smell, also we

emphasized to mother the importance of vaccines in the health of her

newborn child and immunization of the child should be religiously followed

with regards to the health of the mother we suggested her to eat iron reach

foods to replace blood lose during her delivery and also was advised to

perform postpartum exercises by following the required exercises per day and

also must eat foods that can help to stimulate for the production of her breast

milk like horse radish, fishes, shells, milk, tulya and fruit juices. Sin ce the

mothers give birth to her own home we advised her to go to any hospital for

consultation and to check for any abnormalities and also to repair the

laceration at her perineal area.

c
oII. Summary and Evaluation

Pregnancy represents a maturation crisis that requires an open

outlook, a pessimistic attitude that involves self awareness of the situation,

sense of preparedness and readiness. This event requires the involvement of

all family members.

The case studies itself was a great experience for everybody, for us, on

how to actually care and monitor childbearing woman until towards her post

partum care. It was a four months monitoring and studying. It gave way for all

of us the opportunity to incorporate the knowledge that we have learned in

school including the theories and principles behind the phenomenon called

pregnancy to the actual life experience in the persona of our client,

Mrs.Donna. In this way, the group was able to relate ideal nursing intervention

into actual nursing intervention during the said studies. Though along the

way there were undesirable moments that occurred, yet it did not stop the

group from this case studies.

As an overview, Ms. Donna Villegas was experiencing common

discomfort such as dyspnea in supine position, backache, fatigue and

frequent urination. She had a regular prenatal check up with her OB Gyne.

This is one advantage for pregnant women to be guided and be aware of their

conditions for the entire pregnancy months

c
 During our visit with Ms Donna Villegas, the group made sure that

we gave her health teachings related to her condit ion, such as antepartal

exercise and nutritional requirement to meet her day to day requirement

during the period of pregnancy. We also shared to her the importance of

prenatal check up and advised to have complete immunization to her children

and the group also discussed about family planning method, so that they will

know how they going to plan their family in the future. The group also

discusses or sites an example of danger sign of pregnancy if she will not be

careful.

With this case study, the group learned so much, we gained and

learned a lot from this, we get to have understanding and a good picture of

our goal and sticking to our objective on how to care, provide efficient and

effective care during antepartal period of pregnancy, but also the group

learned so much about themselves as individual person. A lot of drama

happened prior to the completion of this case study, we bonded together, we

laugh together, and we unite as one, agreed on one thing th ough there were

arguments that took place, some misunderstandings that leads to silent

moments.