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INTRODUCTION

This is the case of a female patient, 25 years of age living at Lake Sebu, South
Cotabato She was admitted at August 21, 2019 at 10:00pm at South Cotabato Provincial
Hospital with the chief complaint of Difficulty of Breathing.
Pregnancy starts when a male’s sperm fertilizes a female ovum (egg), and the
fertilized ovum implants in the lining of the uterus. Because pregnancy changes a
woman’s normal hormone patterns, one of the first sign of pregnancy is a missed
menstrual period. Normal labor is defined as the gradual subjugation and dilation of the
uterine cervix as a result of rhythmic uterine contractions leading to the expulsion of the
products of conception, the delivery of the fetus, membranes, umbilical cord, and
placenta. Labor cannot be that easy; thereby implicating that there are process and stages
to be undertaken to achieve spontaneous delivery.
A spontaneous vaginal delivery is a vaginal delivery that happens on its own,
without requiring doctors to use tools to help pull the baby out. This occurs after a
pregnant woman goes through labor which opens or dilates her cervix to atleast 10
centimeters.
Study shows, 16 million women 15 – 19 years old give birth each year, about
11% of all births worldwide, 95% of these births occur in low and middle-income
countries. The average adolescent birth rate in middle income countries is more than
twice as high as those high-income countries, with the rate in low income countries being
five times as high. The proportion of births that take place during adolescence is about
2% in China, 18% in Latin America and the Caribbean and more than 50% in Africa.
Half of all adolescent births occur in just seven countries; Bangladesh, Brazil, Congo,
Ethiopia India, Nigeria, and United States. US teens are two and a half times as likely as
teens in Germany or Norway and almost 10 times in Switzerland.
In 2017, a total of 1,700,618 live births was registered which is equivalent to a
crude birth rate (CBR) of 16.2 or 16 births per thousand population. The number of
registered live births showed a decreasing trend, noticeably from 2012 to 2017. The
decrease in the last five years was 5.0 percent, from 1,790,367 live births in 2012 to
1,700,618 recorded births in 2017. More males (887,972 or 52.2%) were born than
females (812,646 or 47.8%) which resulted in a sex ratio of 109 males per 100 females.
On the average, there were about 4,659 babies born daily or about 194 babies
born per hour or approximately three babies born per minute. Of the total live births, 57.8
percent were born in Luzon, 19.1 percent in Visayas and 23.1 percent in Mindanao.
Among the regions of the country, the National Capital Region (NCR) recorded the
highest number of birth occurrences of about 14.0 percent. Second in rank was
CALABARZON (13.6%) and the third was Central Luzon (11.2%). Of the total number
of births in the country, 93.3 percent birth deliveries were attended by health
professionals which may either be a physician, a midwife or a nurse. The number of
births by place of occurrence and by usual residence of mother showed a remarkable
proportion on births attended by health professionals in the 16 regions. This is indicative
of improving health services in terms of maternal and child health care. Among regions,
only Autonomous Region in Muslim Mindanao (ARMM) showed a very low proportion
of medically attended births. More than half of the births that occurred in the region were
attended by traditional birth attendants (hilot/unlicensed midwife). More than half
(907,061 or 53.3%) of the total registered live births in 2017 were born out of wedlock.
The three regions that recorded the highest number of illegitimate children born in 2017
by usual residence of mother were CALABARZON (144,622), NCR (141,206), and
Central Luzon (100,956).
The proportion of illegitimate babies in ten regions of the country, as usual
residence of mother were more than half of its total births, including Eastern Visayas
(65.4%), NCR (64.9%), CALABARZON (58.2%), Davao (57.4%), Central Visayas
(56.7%), Bicol (55.7%), Caraga (55.6%), Northern Mindanao (53.6%), Central Luzon
(52.7%), and Ilocos Region (50.6%). Babies born to adolescent mothers (196,478) were
more than those babies sired by adolescent fathers (52,342). Moreover, babies sired by
fathers aged 50 years old and over (27,068) were far more than babies born to mothers of
the same age group (328). The modal age group of childbearing in 2017 was at 20-24
years old. The highest frequency of live births (471,356 or 27.7%) belonged to mothers in
this age group. On the other hand, fathers aged 25-29 were recorded to have sired the
highest frequency of live births (416,168 or 24.5%) The median age of mothers giving
birth was 26 and for fathers was 29 years old.
PERSONAL DATA
Vital Information
Patient’s Name: Mrs. Red
Age: 31
Sex: Female
Birth Date: September 15, 1987
Birth Place: Barangay Cacub, Koronadal City
Address: Santo Niño, South Cotabato
Occupation: Housewife
Tribe: Ilonggo
Citizenship: Filipino
Religion: Convert Muslim
Civil Status: Married
Educational Attainment: High School Graduate
Name of Institution: South Cotabato Provincial Hospital
Date and Time of Admission: July 27, 2019 @ 9:27pm
Chief Complaint: Increased Blood Pressure; vomit this
afternoon, Edematous both feet
Admitting Diagnosis: G5P4 (4004) Pregnancy uterine 40 weeks
Age of Gestation, Cephalic not in Labor TK
Preeclampsia
OB History: LMP: October 21, 2018
EDC: July 28, 2019
Attending Physician: Dr. White
Spouse Name: Mr. Blue
Age: 41 years old
Educational attainment: College Graduate
Occupation: Aircon Technician
Parent’s Name:
Father’s Name: Mr. Green
Age: 55 years old
Occupation: Farmer
Educational Attainment: High School Undergraduate
Mother’s Name: Mrs. Yellow
Age: 54 years old
Occupation: Housewife
Educational Attainment: High School Undergraduate

Siblings:
Name Age Educational Attainment
1. Mrs. Gray 36
2. Mrs. Brown 34
3. Mr. Black 29
4. Mr. Orange 27

Source of Information:
Patient
Patient’s Chart
FAMILY BACKGROUND
Mrs. Red is the seventh among twelve children of Mr. Green and Mrs. Yellow;
she is a T’Boli and a Catholic. She belongs to a nuclear type of family, which is
composed of father, mother and children.
Presently, they are residing at Purok Pioneer Santo Niño, South Cotabato with her
second Husband and her children. Mrs. Red’s mother is a housewife and her father is a
farmer. Mrs. Red has four siblings Mrs. Gray age 36, Mrs. Brown age 34, Mr. Black age
29 and Mr. Orange age 27. Mrs. Red herself is a housewife, she has three children from
her first marriage and one child from her second marriage. According to the patient, her
family has no family history of Asthma, Hypertension, Diabetes and Cancer.
The family experiences common illnesses such as fever, cough, colds and flu.
They utilize over the counter drugs such as paracetamol, decongestant, pain reliever and
sometimes they utilize also herbal medicines such as lagundi for cough. She added that
they don’t have any history of serious or viral diseases in both sides of their family.

HISTORY OF PAST ILLNESS


According to the patient she was delivered through Normal Spontaneous Vaginal
Delivery by a trained midwife at their house. She completed her vaccine such as one dose
of BCG, three doses of DPT, three doses of OPV, three doses of hepatitis B vaccine and
one dose of anti-measles.
The patient experienced nausea, vomiting and morning sickness in the past few
months especially during her first trimester. She did not undergo any blood transfusion
and surgery nor any accidents and denies of having allergies on foods and any of the
drugs.
Her menarche was at an early age with irregular succeeding menstrual cycle. She
also experienced common childhood illnesses such as colds, cough, fever and was treated
only with over the counter drugs depending on the illness experienced such as
paracetamol, neosep, etc. but also a fan of using herbal medicines. This is her fifth
pregnancy and her last menstrual period was on October 21, 2018.
She also said that during her childhood years, she encountered such diseases like
chickenpox and other common illnesses experienced by a normal child.
HISTORY OF PRESENT ILLNESS
Nine months prior to admission, the patient experienced probable signs of
pregnancy like amenorrhea and morning sickness. Upon admission she said she
experienced an Increase in Blood Pressure and that she vomited during the afternoon, and
that she also had edema on both feet.
According to the patient, she was diagnosed with preeclampsia, but she only got a
rise on her blood pressure when she was admitted already in the hospital, she was
internally examined by the midwife and was informed that she was 5cm dilated and that
she wasn’t experiencing any labor.
When she got to the delivery room she was internally examined again and
amniotomy was performed by the midwife therefore making her cervix fully dilated but
labor still she wasn’t going into labor she was returned to the labor room but shortly after
she gave birth inside the labor room, she gave birth to a baby boy, she said that she was a
little nervous and a bit scared because she wasn’t going into labor but after she gave birth
she said she was happy and a bit relieved.

EFFECTS OF ILLNESS TO SELF


For the patient when she knew she was pregnant she felt happiness
EFFECTS OF ILLNESS TO FAMILY
When the patient told her family that she was pregnant her family was very
supportive of it.
EXPECTATIONS TO SELF
She did not expect she would deliver the baby inside the labor room, but she was
glad that she was able to pull through. And she expects herself to consider family
planning because this is her fifth child already.
EXPECTATION TO FAMILY
She expects that her family will be glad that she got through the delivery and
delivered the baby by normal delivery and she expects her husband to be happy of the
delivery.
REVIEW OF SYSTEMS
Date: July 31, 2019
Time: 7:45pm
General:
The patient denies that she experienced any fever or chills during the admission but she
said she experienced Vomiting and dizziness before admission
Integumentary System:
Skin: Patient denies of having rashes and lumps, lesions and itching of the skin
Hair: Patient denies of having lice or dandruff
Nails: Patient denies of having long nails
Head: Patient denies of having head injury but claims of having experienced
headache and dizziness
Eyes: Patient denies of having blurred vision and Double vision she also does not
use eyeglasses
Ears: Patient denies of having hearing loss, pain in the ears, discharge in the ears
and cerumen impaction.
Nose: Patient denies of loss of smell and nasal obstruction.
Mouth and throat: Patient denies of having sore throat, sore tongue, gum
problems and difficulty in swallowing
Neck: Patient denies having goiter and stiffness of neck
Respiratory System: Patient denies cyanosis, having cough and dyspnea. And denies
smoking
Cardiovascular System: Patient denies of having chest pain and palpitations.
Musculoskeletal System: Patient denies of having joint stiffness, but claims of having
leg cramps and leg muscle weakness
Gastrointestinal System: Patient denies of having constipation and bowel irregularity
Endocrine System: Patient denies of having enlargement of thyroid glands and denies
that she has diabetis
Female Reproductive System: Patient said that there are no deformities about her
vagina
Breast: Patient denies of having breast sore and lumps
Genitourinary: Patient denies having dysuria, urgency and hematuria
Hematology: Patient denies of having any bruises in both extremities
Psychiatric: Patient claims of having mood changes sometimes but denies
difficulty of concentrating and suicidal thoughts.

PHYSICAL ASSESSMENT
Date: July 31, 2019
Time: 7: 50pm
GENERAL APPEARANCE:
The patient is female adult, hair is not fixed and she wears slight clean and
comfortable clothes. She does not have body odor; she is conscious and well oriented by
the time, place and people around her. She speaks well with clear and audible voice and
was able to understand instructions and health teachings. The patient is sitting on bed
with IVF of D5LR 1 L with 10 units of oxytocin at the level of 1000 cc and regulated @
30gtts/min. hooked @ right cephalic vein. No Facial grimace,

VITAL SIGNS:
BP: 130/90 mmHg
Temp. 36.7 C
PR: 71 Bpm
RR: 20 Cpm

Head/ Hair/ Scalp


Inspection: Head is proportional to the body and skull is rounded with symmetrical,
flaccid movement. No Dandruff noted, hair is black in color.
Face:
Inspection: No facial grimace noted as well as pimples noted. Also eyebrows and
eyelashes are equally distributed.
Palpation: no tearing of lacrimal sac during palpation, and smooth.

Ears:
Inspection: Ears are symmetrical to the head. No lesions noted, no deformities noted as
well as discharges. Client is able to hear whispered words from 1-3 feet inches. Vibration
was heard equally in both ears.
Nose
Inspection: External nose are symmetrical, uniform in color and no discharges noted.
No lesions noted. The patient can determine the smell good and bad odor; air is felt being
exhaled through opposite nares; noiseless.
Lips/ mouth/ teeth/ throat
Inspection: No Dry lips noted. Complete set of adult teeth. Yellow in color.. The gum is
pink in color, no retraction noted and no gum bleeding noted, the tongue’s position is in
the midline, pink in color and has white pigment and moves freely
Neck
Inspection: Jugular veins are not inflamed and no stiffness noted, neck muscles are equal
in size with head centered. Smooth, controlled movements;
Palpation: Trachea is in midline position, smooth, firm, and non-tender. Cervical Lymph
nodes is not palpable, soft mobile, discrete, and non tender.
Respiratory
Inspection: Intercostals spaces are even and relaxed, chest symmetry are equal, the
position of the trachea is at the level with the ribs, the position of the trachea is at the
midline and the client explanation is 7 inches w/ deep inspiration.
Auscultation: Respiration pattern is even, 12-20/ min. unlabored with a normal breathing
pattern.
Cardiovascular
Inspection: Small apical impulse (< 2.5 cm) at medial to left midclavicular line at fourth
or fifth ICS.
Breast
Inspection: Nipples are symmetrical to each other, black in color and increase in size.
The areolas on both breast are black in color, milk secretion noted.
Abdomen
Inspection: presence of linea nigra noted. Moles were also noted.
Genitalia
Inspection: No Vaginal discharge noted, perineal bulging noted. Perineum is shaved.
Extremities:
Upper:
Inspection: Arms are symmetrical and appropriate to body size, with normal tan skin
color. No swelling noted on both extremities, with IVF of D5LR 1 L at 1000cc regulated
at 30 gtts/min. hooked at right cephalic vein. Fingers are compute and no deformities
noted. Arms, elbows, shoulder are able to move in range of motion.
Palpations: No tenderness as well as lesions noted.
Lower extremities:
Inspection: Bone structure and bony landmarks are bilaterally symmetrical and equal,
joint structures are symmetrical & equal. Limited R.O.M of the hip, knee ankle, and toes.
Nails, skin
Inspection: fair skin complexion, no lesion noted, short nails and a little dirty.
DEVELOPMENTAL DATA
Name: Mrs. Red
Age: 31 years old
According to: Erickson’s Psychosocial Developmental Data
Theory: Psychosocial Development
Stage of the patient: Young Adult
Description of Theory
Erikson’s stages of psychosocial development are based on (and expand upon)
Freud’s psychosexual theory. Erikson proposed that we are motivated by the need to
achieve competence in certain areas of our lives. According to psychosocial theory, we
experience eight stages of development over our lifespan, from infancy through late
adulthood. At each stage there is a crisis or task that we need to resolve. Successful
completion of each developmental task results in a sense of competence and a healthy
personality. Failure to master these tasks leads to feelings of inadequacy.
Stage Task Age Justification Remarks
Intimacy vs Positive: 31 Patient is Separated Partially
Isolation Young Adult During years from first Husband. Achieved
Age: 19 – 40 this period, we begin to old And has a second
years old share ourselves more husband, they are
intimately with others living together. They
are striving to build a
Successful completion strong relationship
of this stage can result within the family.
in happy relationships
and

Negative:
Avoiding intimacy,
fearing commitment
and relationships can
lead to isolation,
loneliness, and
sometimes depression.
SIGMUND FREUD PSYCHOSEXUAL THEORY
Description of theory:
According to Freud’s theory of psychosexual development, the personality develops in
five overlapping stages of birth to adulthood. The libido changes, it’s location of
emphasis within the body from one stage to another. Therefore, a particular stage. The 1st
three stages ( oral, anal, phallic) are called pregenital stages. The culminating stage is the
genital stage. Ideally an individual progress through the task of each stage and balance is
achieved between the id, ego and sub ego. Conflict or stress, however can delay or
prolong progression through a stage or cause a person to regress to a previous stage.
Stage Task Justification Remarks

Stage 5 He did not formally continue At this age, Mrs.


genital his theory into adulthood. Red was starting to Achieved
(puberty This is a time of turbulence have her own
through when earlier sexual urges decision pertaining
adulthood). reemerge to be dealt with. to small things and
Freud believed that the task this time she started
of moving from sexual to have a
attachment to the parent of relationship.
childhood to the separation
and emotional independence
of the adult sexual partner is
difficult to achieve.
TEXTBOOK DISCUSSION

Complete Diagnosis

PREGNANCY – period of time between fertilization of the ovum (conception) and


birth, during which mammals carry their developing young in the uterus. The duration of
pregnancy in humans is about 280 days, equal to nine calendar months. After the
fertilized is implanted in the uterus, rapid changes occurs in the reproductive organs of
mother. The uterus becomes larger and more flexible, enlargement of the breasts begins,
and alteration of renal function, blood volume and blood cell count occur. Movement of
the fetus and fetal heartbeat can be detected early in pregnancy.
Reference: www.dictionary.com
HUMAN PREGNANCY – divided into three trimester periods, as means to simplify
reference to the different stages of fetal development. The first trimester carries the
highest risk of miscarriage. During the second trimester the development of the fetus can
start to be monitored and diagnosed. The third trimester often remarks the beginning of
viability, or the ability of the fetus to survive or without medical help, outside the
mother’s womb.
Reference: Mittenporf R. Williams MA, Berkeley CS Cotter PF. The length of
uncomplicated human gestation, OB Stet Gynesol – 1990
PREGNANCY – pregnancy brings both psychological and physical changes to the
woman and her partner. The physiologic changes of pregnancy occur gradually but
eventually affect all organ systems of the woman’s body. Psychological changes occur in
response not only to the physiologic alterations that are occurring but also to the
increased responsibility associated with welcoming new and completely dependent
person to the family. The changes occur in order for the woman to provide oxygen and
nutrients for the growing fetus, as well as extra nutrients for her own increased increased
metabolism during the pregnancy. They ready her body for labor and birth and for
lactation once the baby is born.
Reference: Maternal and Child Health Nursing
Adele Pillitteri
LABOR – is the series of events by which uterine contractions and abdominal pressure
expel the fetus and placenta from the woman’s body. Regular contractions cause
progressive dilatation of the cervix and sufficient muscular force to allow the baby to be
pushed to the outside.
Reference: Maternal and Child Health Nursing
Adele Pillitteri
THEORIES OF LABOR ONSET
Labor normally begins when a fetus is sufficiently mature to cope with extrauterine life,
yet not too large to cause mechanical difficulties with birth. In some instances, labor
begins before the fetus is mature (preterm birth). In others labor is delayed until the fetus
and placenta have both passed beyond the optimal point of birth (postterm birth).

SIGNS OF LABOR
Preliminary Signs
Lightening
The descent of fetal presenting part into the pelvis occurs approximately 10 to 14
days before labor begins. These changes the woman’s abdominal contour as the uterus
becomes lower and more anterior.
Increase in Level of Activity
The increase in activity is due to an increase epinephrine release that is initiated by a
decrease in progesterone produced by the placenta.
Braxton Hicks Contraction
This is true labor contractions. Contractions that begin irregularly but become regular and
predictable. Felt first in the lower back and sweep around the abdomen in a wave.
Continue no matter what the woman’s level of activity. Increase in duration, frequency
and intensity and it achieve cervical dilatation.
Ripening of the Cervix
This is seen only on pelvic examination. Throughout pregnancy, the cervix feels softer
than normal, like the consistency of an earlobe. At term the cervix becomes still softer.
Ripening is an internal announcement that labor is close at hand.

SIGNS OF TRUE LABOR


Uterine Contractions
The initiation of effective, productive, involuntary uterine contractions.
Show
As the cervix softens and ripens, the mucus plug
that filled the cervical canal during pregnancy is expelled.
Rupture of membranes
Labor may begin with rupture of membranes, experienced as either a sudden gush or
scanty, slow seeping of clear fluid from the vagina.

COMPONENTS OF LABOR
PASSAGE – route the fetus must travel from the uterus through the cervix and vagina to
the external perineum.
PASSENGER – the fetus
POWERS OF LABOR – supplied by the fundus of the uterus, are implemented by
uterine contractions, a process that causes cervical dilatation and then expulsion of the
fetus from the uterus.
PSYCHE – psychological state or feelings that women bring into labor with them.
STAGES OF LABOR

FIRST STAGE
THREE PHASES
LATENT PHASE
Begins at the onset of regularly perceived uterine contractions and ends when
rapid cervical dilatation begins. The cervical dilatation at this phase is 2-3.
ACTIVE PHASE
Cervical dilatation occurs more rapidly, going from 4cm to 7cm.
TRANSITION PHASE
Maximum cervical dilatation of 8 to 10 cm.
SECOND STAGE
The second stage of labor is the period from full dilatation and cervical effacement to
birth of the infant. Contractions change from the characteristic crescendo-decrescendo
pattern to an overwhelming, uncontrollable urge to push or bear down with contractions
as if she had to move her bowels.
THIRD STAGE
The placental stage begins with the birth of the infant and ends with the delivery of the
placenta. Two separate phases are involved: placenta; separation and placental expulsion.

ANATOMY AND PHYSIOLOGY

Female Reproductive Organ

Normal Delivery
PHYSIOLOGY

STRUCTURE LOCATION & DESCRIPTION FUNCTION

Upper chest one on each side


containing alveolar cells (milk
production), myoepithelial cells
Breasts Lactation milk/nutrition for newborn.
(contract to expel milk), and duct
walls (help with extraction of
milk).

During childbirth, contractions of the uterus


will dilate the cervix up to 10 cm in
The lower narrower portion of the
Cervix diameter to allow the child to pass through.
uterus.
During orgasm, the cervix convulses and
the external os dilates

Small erectile organ directly in


Clitoris Sexual excitation, engorged with blood.
front of the vestibule.
Extending upper part of the uterus Egg transportation from ovary to uterus
Fallopian tubes
on either side. (fertilization usually takes place here).

Thin membrane that partially


Hymen covers the vagina in young
females.

Outer skin folds that surround the


Labia majora Lubrication during mating.
entrance to the vagina.

Inner skin folds that surround the


Labia minora Lubrication during mating.
entrance to the vagina.

Mound of skin and underlying


Mons fatty tissue, central in lower pelvic
region

Provides an environment for maturation of


Ovaries (female Pelvic region on either side of the
oocyte. Synthesizes and secretes sex
gonads) uterus.
hormones (estrogen and progesterone).

Short stretch of skin starting at the


Perineum bottom of the vulva and extending
to the anus.

Urethra Pelvic cavity above bladder, tilted. Passage of urine.

Uterus Center of pelvic cavity. To house and nourish developing human.

Receives penis during mating. Pathway


through a womans body for the baby to take
Canal about 10-8 cm long going during childbirth. Provides the route for the
Vagina from the cervix to the outside of menstrual blood (menses) from the uterus,
the body. to leave the body. May hold forms of birth
control, such as an IUD, diaphragm, neva
ring, or female condom
Surround entrance to the
Vulva reproductive tract.(encompasses
all external genitalia)

The innermost layer of uterine Contains glands that secrete fluids that
Endometrium
wall. bathe the utrine lining.

Myometrium Smooth muscle in uterine wall. Contracts to help expel the baby.