Father Saturnino Urios University

NURSING PROGRAM
Academic Year 2019 - 2020

INDIVIDUAL
CASE STUDY
Butuan Medical Center, Delivery Room
Tiniwisan, Butuan City

Jean Vivien Navarra │ Nikki Caryl Zafra

N-21
Mrs. Mary Lois Charity C. Elicano
Clinical Instructor
INTRODUCTION

Normal Spontaneous Vaginal Delivery is the simplest delivery process, compared

to various delivery processes. It is a natural occurring vaginal delivery in which the
attending physician or midwife does not use tools to aid the baby from coming out of the
mother’s vagina.
A laboring mother who is possibly about to undergo normal spontaneous vaginal
delivery (NSVD) has the following signs and symptoms: The cervix has completely
effaced and dilated up to 10 cm, Contractions increase in frequency and duration, The
mucous plug has already been passed, The fetus has already engaged on the mother’s
ischial spine, Back pains and contractions can be felt by the mother and she will
experience a sudden burst of energy.
Although Normal Spontaneous Vaginal Delivery provides a lot of benefits, not all
laboring mother can undergo the process. Mothers who undergo natural spontaneous
vaginal delivery should meet the following criteria in order to have a higher possibility of
a successful delivery. First is that the delivering mother has normal range values of vital
signs, she is neither hypertensive nor diabetic as it poses a risk during delivery. Also, the
fetus is not in any form of distress and is ideally in a cephalic presentation. If presenting
head is larger than vaginal opening, episiotomy is performed.

The latest statistics show from the year 2018, Worldwide the total fertility rate or the
average birth per woman over their lifetime has decreased to 2.4 compared to the
preceding years. In the Philippines, the latest data offered by the Philippine Statistics
Authority (PSA) was 1, 700, 618 live births of the year 2017 which is equivalent to a rate
of 16 births per population of a thousand. An observable decreasing trend from the year
2012 – 2017
 In the local setting, 23.1% of the births were from Mindanao. In CARAGA region
5.7% live births alone were from teenage mothers.

For a pregnant mother to undergo normal spontaneous vaginal delivery she is

required to have the following laboratory and diagnostic results:

When a mother is about to deliver the fetus, the duration and frequency of the
contractions are measured during labor watch. When the cervix is fully dilated and
effaced, the contractions increase in duration and frequency and the mother is finally
ready to bear down, she is then transferred to the delivery room. From here, An Assistant
nurse will the assist her to a lithotomy position and her blood pressure is taken before
delivery. Perineal Preparation then is performed on the mother and she is draped. She is
then encouraged to push either by the Handle Nurse, Midwife, or Attending Physician.
After the baby and placenta is delivered, the Handle nurse then clamps the cord and cuts
it. The Cord Care nurse then thoroughly dries the baby and performs cord care, measure
vital signs and statistics, and then administers eye ointment, vitamin K and Hepatitis B
Vaccine. Meanwhile, the Handle Nurse cleans the mother’s uterus from any remaining
blood clots and placenta fragments to avoid bleeding. The mother is then assisted to a
stretcher and is moved to the OB Ward.

Before labor, the mother should already have the following laboratories and
diagnostic tests:
In the Early Pregnancy Stage, the mother should have her Complete Blood Count
(CBC), which evaluates and measures the cells that make up her blood. Blood Typing to
determine what blood group the mother belongs to. Urinalysis which evaluates for the
presence of bladder or kidney infections, dehydration, diabetes, and pre-eclampsia.
Ultrasound to check on the baby’s health and development and lastly, screening test for
certain infections and diseases such as Rubella, Hepatitis B and C, Sexually Transmitted
Infection (STI), Human immunodeficiency Virus (HIV), and Tuberculosis (TB).
During Late Pregnancy, the mother will then have to perform a repeat CBC,
Rh antibody test, Glucose Screening Test and Group B Streptococci Test.
All these laboratories and diagnostics provide a baseline data in order to help in
determining the appropriate procedure for the mother and the child during birth.

The significance of the case that made the students to choose the case primarily it
caters to the development and enhancement of the students’ knowledge, skills and
experience in field of delivery. It provides a setting where the students can apply and
appreciate the principles learned in the academic setting. Secondly this study can
contribute to the present body of knowledge available and may be of use for future
studies with a related topic. Lastly, the case had a unique aspect to it especially in the
psychological aspect of the laboring mother since the mother has a status of Gravida 2
but the first child died 3 months later due to cardiovascular problems.

OBSTETRIC HISTORY AND ASSESSMENT

Obstetric history and assessment is the first part and the most significant aspect of
the nursing care process and case study. It is a systemic collection of subjective and
objective data of the client ordering by step by step process inculcating the detailed
information of the client’s history, coping strategies, health status and functional status.

In keeping private and maintaining patient’s confidentiality, the patient is hidden

behind the name Patient G.

Patient G with case no. 2019-07-0155, is 22 years old, unemployed and married to a 30-
year-old member of Armed Forces of the Philippines (AFP). The couple is currently
living in Dulag, Butuan City. The mother is a Gravida2 but the first child died 3 months
later due to cardiovascular problems.

According to the husband, during the first delivery the wife delivered via normal
spontaneous delivery and delivered a very quiet baby boy when the baby was out of the
womb. The attending physician explained to the couple that the baby was having
cardiovascular complication and will only live for less than three months and if above 3
months then the baby can survive. Yet, during the third month the couple thought that the
baby was going to survive unfortunately, the baby boy died.

Moreover, throughout Patient G’s second pregnancy, she went to the clinic to
have herself immunized and got a Tetanus Toxoid and Hepatitis B vaccine. However,
during her antenatal period, she got a urinary tract infection (UTI). Thus, the doctor
prescribed her medications and vitamins to intake. The vitamins are ferrous sulfate and
calcium, also, antibiotic for UTI.

On July 3, 2019, Patient G complained of extreme abdominal pain. Yet it did not
match on her EDC or expected date of confinement, since her expected date of
confinement was last week of June. The age of gestation is 39 weeks based on her LMP
(Last Menstruation Period). Patient G’s LMP was October 2018, exact date unrecalled.
Patient G was direct admitted to delivery room of Butuan Medical Center at around
11:55pm, position on the DR table with 1L of D5LR regulated at 30 gtts/min at level of
1000 ml hooked at the left metacarpal vein. Patient G was examined by midwife Valdez
and found out that she was 6cm dilated then performed a straight catheter due to full
bladder observed during palpation.

At 12:01 pm, Patient G delivered a live baby, 6.4 lbs and 51 cm in length baby
girl with these statistics:

Head Circ: 33 cm

Chest Circ: 34 cm

Abd Circ: 31 cm

Extemporaneously, the baby cried with the same breathing time 12:01 pm. Patient
G’s placenta was expelled by 12:09 pm with blood pressure of 120/90 mmHg. Then she
was injected an Oxytocin 20 units with 15 gtts/min and a Methergine 1 ampule IVTT;
and was admitted to ward via stretcher.

On the same day, at exactly 3 pm,physical assessment was performed on Patient

G and an interview regarding her brief history about her case. Upon visitation, Patient G
was cooperative and awake and was holding her baby warmly while trying to breastfeed
her in a side-lying position. However, Baby Girl G refuses. Patient G had the following
vital signs: temperature of 36.4 ℃ , pulse rate of 64 bpm, respiratory rate of 24 breaths
per minute, blood pressure of 110/70 mmHg and a pain rating of five out of ten. Patient
G was also negative for homan’s sign and has increased skin turgor indicating no sign of
dehydration.

Patient G’s BUBBLE-SHE Assessment was noted as the following:

B-soft and palpable

U-abdominal contour noted

B-did not urine yet

B- did not defecate

L-red discharge

E-without episiotomy

S- returns within 2 seconds

H- absence of edema and pain in the calf

E-taking in phase
 Patient G’s Physical Assessments were also noted as follows:

PHYSICAL ASSESSMENT
Body Build is proportionate and has
BODY BUILD mesomorph type of build.
HYGIENE AND GROOMING Patient has good hygiene; Clean and neat.
ATTITUDE Patient is awake and cooperative
AFFECT/MOOD Patient is weak due to delivery
QUANTITY AND QUALITY OF Patient’s speech is comprehensive and
SPEECH logical.
Patient’s lines of thought are organized and
RELEVANCE OF THOUGHT logical. Able to answer questions
appropriately.
Hair is evenly distributed at the head with
HAIR no patches of hair loss. No hirsutism
evident.
Skull is smooth and round with symmetric
SKULL features and movement. Absence of
nodules upon inspection and palpation.
Eyebrows are evenly distributed and are
symmetric in movement.
Eyelids close symmetrically and are
uniform in color with no presence of
EYES edema, lesions, ptosis.
Eyes are parallel aligned and symmetric in
movement and are able to move in six
directions. Sclera is white.
Nose has similar color with the face and
externally symmetric. There was no
NOSE AND SINUSES presence of flaring, discharges, lesions,
swelling and redness.
Nasal septum is intact and in midline.
Lips are uniform in color, free from lesions
MOUTH and are symmetric externally and in
movement. Patient is able to purse lips.
Neck and trachea are at midline. No
NECK masses. Lumps. Lesions were noted.
Thyroid Gland is not visible during
 inspection.
Chest is symmetric in appearance and
THORAX movement.
No abnormal pulsations noted.
HEART Jugular Vein not visible.
Breast is symmetric and even with chest
BREAST wall. Enlarged due to lactation. No
swelling or redness noted.
UPPER EXTREMITIES Arms are symmetric with no deformities.
ABDOMEN Abdomen is free of lesions.
Fundus is palpable and observable at
umbilical level.
Striae Gravidarum is noted on lower right
abdomen.
Legs are symmetric with no deformities.
No swelling of veins noted.
LOWER EXTREMITIES No pain on calf when dorsiflexed; Patient
is negative for Homan’s Sign.
PERINEUM Perineum is free of episiotomy. No
lacerations evident.

From the gathered assessment it can be inferred that Patient G did not experience
any complications in delivery, has a positive bond with the baby as evidenced by holding
the baby warmly and maintaining eye contact. Patient G is now in the Taking-In Phase
of the Post Partum period.

REPRODUCTIVE SYSTEM ANATOMY

The female reproductive system is generally compromised of the internal and

external genitalia. In which, both also compromise of varied organs with each having
various functions that all work together to help in the process of reproduction.

Internal Reproductive System

The Internal Genitalia is compromised

of the Ovaries, Fallopian Tubes, Uterus,
Cervix, and the Vagina. Mostly the
mechanisms of menstruation and ovulation
happen here due to the interaction of various
hormones produces by the ovaries. Fertilization also occurs in the internal genitalia
specifically in the fallopian tube which then the fertilized egg moves to the uterus to
develop and grow.

Vagina

The vagina is an elastic, muscular canal with a soft, flexible lining that provides
lubrication and sensation. The vagina connects the uterus to the outside world. The vulva
and labia form the entrance, and the cervix of the uterus protrudes into the vagina,
forming the interior end. Also, vagina receives the penis during sexual intercourse and
also serves as a conduit for menstrual flow from the uterus. During childbirth, the baby
passes through the vagina (birth canal).

Cervix

The cervix is a cylinder-shaped neck of tissue that connects the vagina and uterus.
Located at the lowermost portion of the uterus, the cervix is composed primarily of fibro
muscular tissue. There are two main portions of the cervix:

The part of the cervix that can be seen from inside the vagina during a gynecologic
examination is known as the ectocervix. An opening in the center of the ectocervix,
known as the external os, opens to allow passage between the uterus and vagina.

The endocervix, or endocervical canal, is a tunnel through the cervix, from the external
os into the uterus.

Uterus

A hollow muscular organ located in the female pelvis between the bladder and rectum.
The ovaries produce the eggs that travel through the fallopian tubes. Once the egg has left
the ovary it can be fertilized and implant itself in the lining of the uterus. The main
function of the uterus is to nourish the developing fetus prior to birth.

Oviducts

The oviduct consists of several segments: the infundibulum, which contains fimbriae and
is located adjacent to the ovary, the ampulla, the isthmus, and the pars interstitialis. The
first two of these regions have a characteristic appearance that is dominated by an
elaborate mucosa that is thrown into numerous branched folds, surrounded by a relatively
thin layer of smooth muscle. As the tube moves away from the ovary and toward the
uterus, these folds become smaller and the smooth muscle dominates.

Ovaries
The female pelvic reproductive organs that house the ova and are also responsible for the
production of sex hormones. They are paired organs located on either side of the uterus
within the broad ligament below the uterine (fallopian) tubes. The ovary is within the
ovarian fossa, a space that is bound by the external iliac vessels, obliterated umbilical
artery, and the ureter. The ovaries are responsible for housing and releasing ova, or eggs,
necessary for reproduction. At birth, a female has approximately 1-2 million eggs, but
only 300 of these eggs will ever become mature and be released for the purpose of
fertilization.

External Reproductive System

The overview of the external genetalia –runs from the pubic area or vulva down to
the anus. The two fatty fleshy folds that surrounds the vagina and urinary opening known
as labia majora and the inner fold also known as labia minora. Inside of these folds,
clitoris is located at above the urethra orifice. This clitoris serves as sensation during
intercourse. And the hymen, it serves protection of the entrance of the vagina and it
stretches when you insert tampons or have intercourse.

REPRODUCTIVE SYSTEM PHYSIOLOGY

Oogenesis

Oogenesis is the physiological process in which the ovaries produce female

gametes or ova. This is produced about once in every four weeks.
Ovulation

Ovulation is a phase in which after oogenesis, the ovaries releases an egg or ovum
to be fertilized. It is dependent on the interplay of the hormones of the female. It occurs
generally two weeks before the start of menstruation.

Menstruation

Menstruation occurs when the ova or ovum released by the ovaries was not able
to be fertilized, signals the thickened uterine lining to shed. It is vaginal bleeding that
occurs in a woman’s monthly cycle. The blood partly contains the uterine tissue that exits
the body through the vagina. The duration and pattern of menstruation varies among
women.

Pregnancy

After fertilization occurs during the ovulation period in which it is the most fertile
period for women, the fertilized egg will then move from the fallopian tube to the uterus
for it to grow and be nourished for the next 38 – 42 weeks.

LABOR AND BIRTH PROCESS

The Labor and Birth Process generally come in 3 phases, although some books
claim that there are four.

The First Stage occurs during the first four (4) hours in which initiation of true
labor contractions is felt by the mother and it takes about twelve (12) hours to complete.
In this stage, the cervix is now fully effaced and dilated up to 10 cm. During this stage,
the laboring mother also undergoes Three Phases, namely Latent Phase, Active Phase,
and Transition Phase.

On the Second Stage, the infant is born. At 3+ to 4+ station, the fetal head pushes
against the vaginal introitus and the fetal scalp appears. This instance is termed crowning.
The attending midwife or physician then assists in delivering the baby utilizing the
DFIRERE mechanism: the descent, flexion, internal rotation, external rotation and
expulsion.

Lastly during the Third Stage, it involves the delivery of the placenta. It has 2
separate phases, The Placental Separation and Placental Expulsion. Placental Separation
is characterized by the sudden lengthening of the cord and gush of blood. Three to Five
minutes later, the placenta will be delivered out of the mother’s vagina.
NEWBORN ASSESSMENT

On July 3, 2019 Patient G gave birth to a healthy baby girl. Baby Girl G born at a
gestational age of 39 weeks on July 3, 2019 at 12:01 noon weighed 6.4 lbs and 51 cm in
length had the following vital statistics:

 Head Circ: 33 cm
 Chest Circ: 34 cm
 Abd Circ: 31 cm

Baby Girl G also had an APGAR Scoring during the first minute of birth and five
minutes after as scored by the cord care nurse.

APGAR Scoring one minute after birth:

SCORE 0 1 2
Appearance Blue Acrocyanotic Pink All over 2
Pulse Absent Below 100bpm Over 100bpm 1
Minimal Prompt 2
Grimace Floppy response to Response to
stimulation Stimulation
Flexed arms Active 1
Activity Absent and legs
Slow and Vigorous cry 2
Respiration Absent irregular
Total Score: 8

APGAR Scoring five minutes after birth:

SCORE 0 1 2
Appearance Blue Acrocyanotic Pink All over 2
Pulse Absent Below 100bpm Over 100bpm 2
Minimal Prompt 2
Grimace Floppy response to Response to
stimulation Stimulation
Flexed arms Active 2
Activity Absent and legs
Slow and Vigorous cry 2
Respiration Absent irregular
Total Score: 10
SCORE:

0-4 –prognosis of newborn is grave

5-7 –infant need specialized, intensive care

<7-infant doing well

DRUG STUDY

For this case, the only drug administered to the Patient G is Oxytocin and methergine.
NAME OF
DRUG DATE DOSE MECHANISM SIDE NURSING
GENERIC ORDER CLASSIFICATION FREQUENCY OF ACTION SPECIFICATION CONTRAINDICATIONS EFFECTS PRECAUTIONS
(BRAND) ED
Oxytocin July 3, Pharmacologic 20 units, 15 Causes potent To induce or hypersensitive to drug Nausea and  Continuously
2019 Class: Exogenous gtts/ min and selective stimulate labor. when vaginal delivery is Vomiting monitor contractions,
hormones stimulation of To reduce post- advised- cephalopelvic Severe fetal and maternal
uterine and partum bleeding disproportion is present- Allergic heart rate, and
Therapeutic Class: mammary after expulsion when delivery requires Reactions maternal blood
Oxytocics gland smooth of placenta. conversion as in Bleeding after pressure and ECG.
muscles by For complete or transverse lie Child Birth Discontinue infusion
producing inevitable Abnormal if uterine
sustained abortion. Heart Beats hyperactivity occurs.
contractions High Blood
Induces labor Pressure  Monitor patient
and milk Rupture of extremely closely
ejection and Uterus during first and
reduces post- second stages of
partum labor because of
bleeding risk of cervical
laceration, uterine
rupture and
maternal and fetal
death.
 Assess fluid
intake and output.
Watch for signs and
symptoms of water
intoxication.
 Monitor and
record uterine
contractions, heart
rate, BP,
intrauterine
pressure, fetal heart
rate, and blood loss
q15.
 Be alert for
 adverse reaction
 Monitor I/O.
Antidiuretic effect
may lead to fluid
overload, seizures,
and coma
 Never give
Methergine July 3, PC: Ergot Alkaloid IV-0.2 mg Stimulates Prevention and Hypersensitive to Cardiovascula oxytocin
2019 and derivative after delivery uterine treatment of methylergonovine or r: simultaneously by
TC: oxytocic, of anterior smooth postpartum and any other component of hypertension; more than one route.
lactation Stimulant shoulder muscle post abortion, formulation. increased  have 20% solution
producing hemorrhage Potent inhibitors of heart rate, magnesium sulfate
sustained caused by uterine CYP3A4(azole systemic available for
contraction atony or sub- antifungal, venous return, relaxation of the
thereby involution hypertension, toxemia, and cardiac myometrium
shortens the pregnancy output,  If contractions are
rd
3 stage of andarrhytmias less than 2 minutes
labor CNS: apart, if they’re
seizures, above 50mm Hg ,or
coma from if they last
water 90seconds or
intoxication longer, stop
Gastrointestin infusion, and turn
al: Nausea, patient on her side,
vomiting, and notify
GU: titanic prescriber
uterine
contractions,
abruption
placentae,
impaired
uterine blood
flow, pelvic
hematoma
Hematologic:
afibrinogenem
ia
Respiratory:
anoxia,
asphyxia
NURSING CARE PLAN

During Labor
Date: July 3, 2019
CUES NURSING OBJECTIVES/ NURSING RATIONALE EVALUATION
DIAGNOSIS CRITERION INTERVENTIONS

Subjective: Normal Spontaneous Within 3 hours of > Provide and maintain > To avoid After 3 hours of nursing
“Ma’am gusto nako mu Vaginal Delivery intervention will be sterile environment for contaminating the birth intervention
utong.” able to deliver the fetus the mother to deliver the canal during the
Objective: through Normal baby. delivery that may cause
>Pt. lies in stretcher Spontaneous Vaginal infection to the mother
with IVF of D5LR Delivery without any or even worse, sepsis.
hooked at left complications.
metacarpal vein. > Encourage breathing >To conserve oxygen
>Pt. has fast shallow techniques. and prevent mother
breathing due to pain. from hyperventilating.
>Pt. holds abdomen and
grimaces due to pain >Monitor Patient’s vital >Serves as baseline
during contractions signs before and after data and monitoring for
> Pt has blood pressure giving birth. any signs of
of 120/90 mmhg before complications.
delivery. >Assess for distended >Distended Bladder can
bladder; Insert straight cause complications
Chief Complaints: catheter if present. due to force of the fetus
Labor Pains head exerting on the
bladder.
>Encourage mother to >To conserve and focus
push and discourage her mother’s energy into
to shout. pushing.

>Thoroughly dry baby >To provide effective

once out of vagina. thermoregulation;
prevents evaporation.
>Promote skin to skin >Provides initial
contact of newly born mother-child bonding.
fetus with mother.

> Administer Oxytocin

after birth.
Post Partum
Date: July 3, 2019
CUES NURSING OBJECTIVES/ NURSING RATIONALE EVALUATION
DIAGNOSIS CRITERION INTERVENTIONS
S-“sakit pa akong pus-on Acute pain related to Within 8 hrs of nursing *asses for the v/s -To check if there is the After 8 hrs of nsg.
tungod sa panganak normal spontaneous intervention the pt. will sign for hemorrhage Intervention the patient is
nako” delivery be able to use diversional *use PQRST method - assessing the pt’s pain able to demonstrate
O-limited movement activities and relaxation * use BUBBLESHE -to assess the postpartum diversional activities and
noted skills. technique mother relaxation skills to ease
-Guarding behavior *Advise to do deep - help your breathing, the pain from 5 to 2
noted breathing exercise clear your lungs, and ‘salamat kayo,dili na
-drowsy as observed lower your risk of kaayo sakit”.
v/s taken as ff: pneumonia.
T-36.4 C *encourage to do hot - Heat decreases pain
RR- 24 breaths/min compressed at the through improved blood
PR-64 bpm epigastric area blow to the area and
BP- 110/70 mmHg through reduction of pain GOAL PARTIALLY
Postpartum assement: reflexes. MET.
B-large and engored *position pt. at a -to make the pt. relaxed
U-have abdominal comfortable position and prevent bed sore.
contour *instruct to do - increasing the release
B-did not urinate diversional activities of endorphins, boosting
B-did not deficate yet such as listening to the therapeutic effects of
L-red music, reading books, pain relief medications.
discharge”serosa”(1st etc.
day) *encourage to drink 6-8 -prevent dehydration
E-none glasses a day
S-returns within 2 secs. *advise to take frequent -to regain energy.
H-Absence of edema and rest period when not
pain in the calf doing breastfeed.
E-Taking-in Phase *provide quiet -provides continuation of
Pain assessment: environment sleep without
P-moderate pain upon disturbances
positioning
Q-moderate pain as
described
R-localized pain at
epigastric area
S-5 out of 10 as
verbalized
T-continuous Pain;
 CUES NURSING OBJECTIVES/ NURSING RATIONALE EVALUATION
DIAGNOSIS CRITERION INTERVENTIONS
S-“ Gikapoy pako sap Fatigue related to normal Within 8hrs. of nsg. Restrict environmental -Vivid lighting, noise, After 8 hrs. of nsg.
ag-utong nako atong spontaneous vaginal stimuli, especially during visitors, numerous intervention the pt. will
Intervention the pt. will
nanganak ko” delivery planned times for rest distractions, and litter in be able to identify the
O-limited movement be able to identify and sleep. the patient’s physical intervention and
-Exhausted surroundings can limit technique to prevent
interventions and
-Disinterest in relaxation, disturb rest or exhaustion.
surrounding technique to prevent sleep, and contribute to
Vital signs as follows: fatigue.
exhaustion.
T-36.4 C
P-64 Bpm Aid the patient with -A plan that balances
R-24 breaths/mins developing a schedule periods of activity with
BP-110/70 mmhg. for daily activity and periods of rest can aid
Postpartum assessment: rest. Emphasize the the patient complete
B-larged and engorged importance of frequent preferred activities
U-linea negra @lower rest periods. without contributing to
abdomen levels of fatigue.
B-did not deficatel yet
B- did not excrete urine
L- lochia is red (serosa, 3 Teach energy -Organization and time
hrs of postpartum) conservation methods. management can help the
E-None Collaborate with patient conserve energy
S- normal within 2 secs. occupational therapist as and reduce fatigue. The
H-none needed. occupational therapist
E-taking in phase can offer the patient with
assistive devices and
educate the patient
energy conservation
methods.
Assist the patient with
setting priorities for
preferred activities and
role responsibilities
Promote sufficient
nutritional intake.
Encourage verbalization
of feelings about the
impact of fatigue.
Stay away from topics
that annoy or disturb
patient. Converse ways
to react to these feelings.
-Setting priorities is one
sort of an energy
conservation method that
permits the patient to
utilize available energy
to complete important
activities.
-The patient will need
properly balanced intake
of fats, carbohydrates,
proteins, vitamins, and
minerals to provide
energy resources.
-Acknowledgement that
living with fatigue is
both physically and
emotionally challenging
helps in coping.
-Increased irritability of
the CNS can make the
patient become easily
excited, agitated, and
prone to emotional
outburst.
Educate the patient and -Organization and
family about task management of time can
organization methods assist the patient save
and time organization energy and avoid fatigue.
methods.
-Changes in heart rate,
Make the patient aware oxygen saturation, and
about the signs and respiratory rate will
symptoms of reflect the patient’s
overexertion with tolerance for activity.
activity.

-These may reduce

Provide comfort such as nervous energy that lead
judicious touch or to relaxation.
massage, and cool
showers.
 CUES NURSING OBJECTIVES/ NURSING RATIONALE EVALUATION
DIAGNOSIS CRITERION INTERVENTIONS
S- Risk for fluid volume Within 8 hrs of nursing >Note client’s level of - to evaluate the ability to After 8 hrs of nsg.
O- deficit r/t uterine atony. intervention the pt. will consciousness. express needs Intervention the patient is
>Pt. is sweating be able to maintain fluid > Review the client’s -to identify medications able to maintain fluid
(diaphoresis) volume at a functional medications including that can alter fluid and volume at a functional
>Pt. skin turgor is level as evidenced by prescription, OTC drugs electrolyte balance. level as a evidenced by
moderately elastic. individually adequate Herbs and nutritional maintain intake of fluids
>v/s taken as ff: urinary output with supplements. and monitored urine
T-36.4 C normal specific gravity, >Review laboratory data -to evaluate fluid and output has normal
RR- 24 breaths/min stable v/s, moist mucous by collaborating with electrolyte status. specific gravity value,
PR-64 bpm membranes, good skin other healthcare and pt. has retained
BP- 110/70 mmHg turgor and prompt personnel. normal v/s.
Postpartum assement: capillary refill >Compare current fluid -to ensure an accurate
B-large and engored intake. picture of fluid status.
U-without abdominal >Monitor I/O Balance
contour > Assess skin and oral- -to check for signs of
B-did not urinate mucous membranes. dehydration. GOAL PARTIALLY
B-did not stool yet >Offer a variety of food -to increase client’s daily MET.
L- Moderate red (water-rich) and water. fluid intake
discharge”serosa”(1st >Remind pt. to drink
day) fluids as needed
E-none >Discuss individual risk -to reduce risk of
S- Skin returns to normal factors, potential dehydration.
at moderate rate problems, and specific
H-Absence of edema and interventions
pain in the calf >Provide client teachings -to educate and promote
E-Taking-in Phase about importance of client cooperation
hydration
 CUES NURSING OBJECTIVES/ NURSING RATIONALE EVALUATION
DIAGNOSIS CRITERION INTERVENTIONS
S-
O- Readiness for enhanced Within 8 hrs of nursing > Assess client’s -to determine client’s After 8 hrs of nsg.
>Pt. asks significant self-care r/t exhaustion intervention the pt. will knowledge and learning knowledge and learning Intervention the patient is
other to change clothes. from child birth. be able to demonstrate needs for post partal self- needs. able to demonstrate and
>pt. asks significant and understand various care. understand various self-
other for other self-care teachings and >consider hazards in the -to determine hindrances care teachings and
information regarding eventually maintain care setting or home and in environment where pt. planned to achieve self-
OB history during responsibility for other environment performs self-care care goals and general
assessment. planning and achieving >promote perineal self -to enhance integrity of well-being as evidenced
>pt. asks assistance from self-care goals and care perineum and promote by verbalization of
significant others general well-being. >promote perineal healing proper perineal care,
> v/s taken as ff: exercise proper breast hyiene, and
T-36.4 C - kegel’s is now able to rest ina
RR- 24 breaths/min -squatting regular pattern.
PR-64 bpm >promote rest throughout -to regain energy lost
BP- 110/70 mmHg post partal period and during childbirth
Postpartum assement: avoid heavy activities GOAL PARTIALLY
B-large and engored >promote breast hygiene -to avoid risk for MET.
U-without abdominal infection for both mother
contour and child.
B-did not urinate >provide accurate and -to enable client to
B-did not stool yet relevant incorporate into self care
L-red informationregarding plans.
discharge”serosa”(1st current and future needs
day) >encourage client to ask -to assist patient in
E-none for assistances managing a wide range
S-returns within 2 secs. >assist client to set of stressful conditions
H-Absence of edema and realistic goals for the
pain in the calf future.
E-Taking-in Phase >identify reliable -to reinforce patient’s
Pain assessment: references sources learning and promotes
regarding individual self-paced review
needs and strategies for
self-care
LEARNING OUTCOME

The case had catered the learning development of the students holistically.
Physically it had taught the students to be quick and alert on preparing and participating
during the delivery. Psychologically it had reached empathy from the students to the
mother to what she is going through. Socially it had taught the students to establish
rapport with the laboring mother and the significant others to develop better patient –
nurse interaction and provide quality nursing care.

The students also have learned that the principles of sterile technique is very
important despite the limited resources, it is the nurse’s duty to provide modifications and
to conserve resources while still able to provide quality and safe nursing care to the
patients.

From this case, time was also an important variable. An extended time frame
would have been a good opportunity to extend the quality nursing care to the mother by
gathering a variety of quality data that could be of comparison. These comparisons would
have contributed in drafting a quality Nursing Care Plan. Also a longer time frame would
have yielded a better case study.

Nevertheless, the case was a great opportunity to broaden our knowledge and
develop our skills in the Delivery Room Setting. This experience will certainly be a
reminder for our future duties in the delivery setting.

It is of greatest gratitude to our Clinical Instructor Mrs. Mary Lois Charity C.

Elicano and The Staff of Butuan Medical Center Delivery Room for the guidance they
have provided during the delivery operation which had taught us a lot.
DEFINITION OF TERMS
To further and better understand this case study, some terms are initially defined.
Antenatal- Prenatal care, also known as antenatal care, is a type of preventive
healthcare. Its goal is to provide regular check-ups that allow doctors or midwives
to treat and prevent potential health problems throughout the course of the
pregnancy and to promote healthy lifestyles that benefit both mother and child.
Antibiotic- type of antimicrobial substance active against bacteria and is the most
important type of antibacterial agent for fighting bacterial infections.
Dilation- Cervical dilation is the opening of the cervix, the entrance to the uterus, during
childbirth, miscarriage, induced abortion, or gynecological surgery. Cervical
dilation may occur naturally, or may be induced by surgical or medical means.
Effacement - the process by which the cervix prepares for delivery. After the baby has
engaged in the pelvis, it gradually drops closer to the cervix. The cervix will
gradually soften, shorten and become thinner.
Fetus- is the unborn offspring of an animal that develops from an embryo. Following
embryonic development the fetal stage of development takes place. In human
prenatal development, fetal development begins from the ninth week after
fertilisation and continues until birth.
Gravida- describes the total number of confirmed pregnancies that a woman has had,
regardless of the outcome.
Intranatal- occurring chiefly with reference to the child during the act of birth
an intranatalaccident — compare intrapartum — neonatal, perinatal, postnatal,
prenatal.
Para- Para or parity is defined as the number of births that a woman has had after 20
weeks gestation
Postpartum- begins immediately after the birth of a child as the mother's body, including
hormone levels and uterus size, returns to a non-pregnant state.
Vaccines- a biological preparation that provides active acquired immunity to a particular
disease.
Vitamins- an organic molecule that is an essential micronutrient that an organism needs
in small quantities for the proper functioning of its metabolism.