case study of pregnancy uterine full term

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					I. Introduction
We the Group A3 of College of Nursing-Norzagaray College with our beloved Clinical Instructor in OB-ward, Ms. Airies L. Borromeo, RN, was conducted an interview in Norzagaray Municipal Hospital at OB-ward as part of our case study. The significance of the study is for us third year student to apply the principles and concept that we have learned in the NCM (maternal and child Nursing) in our rotation in NMH with the following objectives:  To be able to review concept on theories in maternal and child nursing.  To be able to describe the development, physiology and nursing care of a client who has undergone normal spontaneous vaginal delivery (NSVD) and episiotomy procedure.  To be able to design a nursing care plan for the patient who has undergone NSVD and episiotomy procedure.  To be able to provide information and health teaching to the patient of the post-partum period.  To be able to establish a good working relationship with the patient and hospital staff.

II. Biographic data:
Name: Age: Sex: AA 19 y/o female

Date of birth: June 11, 1990 Place of birth:Tondo, Manila Civil status: living in Address: blk 26 lot 13 ph 2 FVR1

Occupation: housewife Spouse: Religion: RR Roman Catholic

Citizenship: Filipino

Date and time admitted: 8-19-09/1:30 am Hospital no.: 00103

III. Present History
As the interview was conducted, patient AA told us that since august 17, 2009, she was experiencing on and off pain in her lower abdomen and she can’t sleep because of the pain. August 19, 2009 at 1:30 in the morning, Patient AA was admitted in the OB ward with the chief complaint of labor in pain. Around 4:30 in morning the patient brought to the delivery room because the bag of water was ruptured. Almost 5:35am, she was delivered an alive, 7 lbs and 53 cm in length baby boy with this statistics:

Head circumference: 33 cm Chest circumference: 34 cm Abdominal circumference: 32 cm Patient AA’s placenta was expelled simultaneously by 5:45 am with blood pressure of 120/90 mmHg. After her delivery, she was admitted to the OB ward with repaired episiotomy. Post partum doctor’s orders were as follows which was carried out:         DAT (diet as tolerated) Ice pack over hypogastrium Perennial care Syntocinon 10 units infused to IVF Amoxicillin 500 mg 1 capsule TID Mefenamic 500 mg 1 capsule TID Methergin tablet 1 tablet TID Ferosulfate tablet 1 tablet OD



T = 36.7 c RR= 24 cpm PR= 61 bpm BP= 130/70 mmHg

IV. Past History
Upon interview the patient was asked about her menstrual history, she told us that at the age of 13, she had her 1 st menstrual period or menarche. Her menstrual cycle was regular, in her 28 day menstrual cycle; she had her period for 5 days.

V. Anatomy of the female reproductive system

Our overview of the reproductive system begins at the external genital area or vulva which runs from the pubic area downward to the rectum. Two folds of fatty, fleshy tissue surround the entrance to the vagina and the urinary opening: the labia majora, or outer folds, and the labia minora, or inner folds, located under the labia majora. The clitoris, is a relatively short organ (less than one inch long), shielded by a hood of flesh. When stimulated sexually, the clitoris can become erect like a man's penis. The hymen, a thin membrane protecting the entrance of the vagina, stretches when you insert a tampon or have intercourse.


The Vagina
The vagina is a muscular, ridged sheath connecting the external genitals to the uterus, where the embryo grows into a fetus during pregnancy. In the reproductive process, the vagina functions as a two-way street, accepting the penis and sperm during intercourse and roughly nine months later, serving as the avenue of birth through which the new baby enters the world.

The Cervix
The vagina ends at the cervix, the lower portion or neck of the uterus. Like the vagina, the cervix has dual reproductive functions. After intercourse, sperm ejaculated in the vagina pass through the cervix, then proceed through the uterus to the fallopian tubes where, if a sperm encounters an ovum (egg), conception occurs. The cervix is lined with mucus, the quality and quantity of which is governed by monthly fluctuations in the levels of the two principle sex hormones, estrogen and progesterone. When estrogen levels are low, the mucus tends to be thick and sparse, which makes it difficult for sperm to reach the fallopian tubes. But when an egg is ready for fertilization and estrogen levels are high the mucus then becomes thin and slippery, offering a much more friendly environment to sperm as they struggle towards their goal. (This phenomenon is employed by birth control pills, shots and implants. One of the ways they prevent conception is to render the cervical mucus thick, sparse, and hostile to sperm.)

The uterus or womb is the major female reproductive organ of humans. One end, the cervix, opens into the vagina; the other is connected on both sides to the fallopian tubes. The uterus mostly consists of muscle, known as myometrium. Its major function is to accept a fertilized ovum which becomes implanted into the endometrium, and derives nourishment from blood vessels which develop exclusively for this purpose. The fertilized ovum becomes an embryo, develops into a fetus and gestates until childbirth.

The Fallopian tubes or oviducts are two very fine tubes leading from the ovaries of female mammals into the uterus. On maturity of an ovum, the follicle and the ovary's wall rupture, allowing the ovum to escape and enter the Fallopian tube. There it travels toward the uterus, pushed along by movements of cilia on the inner lining of the tubes. This trip takes hours or days. If the ovum is fertilized while in the Fallopian tube, then it normally implants in the endometrium when it reaches the uterus, which signals the beginning of pregnancy.

The ovaries are the place inside the female body where ova or eggs are produced. The process by which the ovum is released is called ovulation. The speed of ovulation is periodic and impacts directly to the length of a menstrual cycle. After ovulation, the ovum is captured by the oviduct, where it travelled down the oviduct to the uterus, occasionally being fertilised on its way by an incoming sperm, leading to pregnancy and the eventual birth of a new human being. The Fallopian tubes are often called the oviducts and they have small hairs (cilia) to help the egg cell travel.

Uterine Full Term

Mechanism of Labor

VI. Physiology
Labor process
Pain in the abdominal tract Pressure Uterine contraction Increment Decrement Effacement Uterine relaxes

Cervical dilatation begins

Increase the diameter of the cervical canal

Fluid filled membranes press against the cervix

Cervical dilatation occur more rapidly

Increase vaginal secretions and perhaps spontaneous rupture of the membrane

Contractions reach their peak of intensity

Causing maximum dilatation

They will rupture as a rule of pull dilatation Sensation in abdomen maybe so intense

Contractions change from the characteristics crescendo-descrecendo

Fetal presenting part as its widest diameter reaches the level of the ischial spine of the pelvis

Downward movment of the biparietal diameter of fetal head until it reaches the pelvic inlet

Shortest head diameter passes through the pelvis Fetal head reaches the pelvic floor Fetus enter the pelvic inlet to the maternal pelvis Fetal head passes beneath the symphysis pubis Shoulder rotate internally to fit the pelvis Expulsion occurs first as the anterior

Then the posterior shoulder passes under the symphysis pubis After the shoulder delivery rest of the body follows

Folding the separation of the placenta occur

Active bleeding on the maternal surface of the placenta begins and separation

Separation completed

The placenta sinks to the lower uterine segment of the upper vagina

The placenta is delivered either by the natural bearing down effort of the mother or by gentle pressure on the contracted uterine fundus by the physician

Stages of Labor
FIRST STAGE: THE DILATATION STAGE DURATION Primigravida: 1st stage 12 ½ hr (average) CHARACTERISTICS Latent Phase: (1 -4 cm. Uterine contractions, which may follow a regular pattern & may be accompanied by: Abdominal cramps Backache Rupture of membranes Show (blood-tinged) Mucoid vaginal discharge Passage of mucous plug

Active Phase: (4-8 cm)Uterine contractions become stronger, longer (40-45 seconds) more frequent and may

be accompanied by pain

Transition: (8-10 cm) Uterine contractions stronger, longer (5060 seconds) and may be accompanied by amnesia b/w contractions. Generalized dis-comfort. Hiccoughing. Irritable abdomen. Abrupt changes in behavior (ie: Don't touch me) Marked restlessness, Sudden n/v,, Perspiration on upper lip and forehead, Profuse dark, heavy show, Rupture of membranes, Severe low backache, Shaking of legs. Stretching sensation deep in pelvis. SECOND STAGE: THE EXPULSIVE STAGE Primigravidas: ½ to 2 hours (average) Full dilatation of Cervix, accompanied by: Contractions which may be 1-2 minutes apart, becoming increasingly expulsive in nature. Expulsive grunt when exhaling Rectal bulging with flattening of perineum. Increased amnesia between

contractions. Gradual appearance of presenting part at vaginal opening

THIRD STAGE: THE PLACENTAL STAGE Primigravida: 10 to 20 minutes (average) Contractions temporarily cease upon birth of baby. When they resume, they usually are painless and may be accompanied by a rising of the uterus in abdomen; Uterus assuming globular shape. Visible lengthening of umbilical cord as placenta moves into vagina. Trickle or gush of blood.

FOURTH STAGE: IMMEDIATE POSTPARTUM PERIOD Duration is variable. Minimum of 1 hour up to 12 hours, depending on condition and/or complications Uterus - Firm, midline, initially halfway between sym-pubis and umbilicus, then raises 1-2 cm above the umbilicus by 12 hrs. Lochia - Rubra, heavy-mod. *continuous oozing should not occur episiotomy - clean and dry bladder - may distend and need to void/catheterize. patient may experience shaking chill due to vasomotor/nerve reaction

VII. Physical assessment:
The skin is normally brown in color, no areas of increased vascularity. No evidence of lesions and presence of birthmark at the right arm. The skin is not too dry with a minimum perspiration and slightly cooler in temperature than the rest of the body. There is a presence of edema in the lower extremities and presence of linea negra in the center of the abdomen vertically.

The head is normocephalic and symmetrical. The skull is smooth, non-tender and no palpable masses. The color of the hair is dark black and it is thick, slightly curl and shiny. There are presences of few lice. The scalp is shiny, intact and no lesions. The general features of the face are symmetrical and the face is oval in shape.

Neck and Shoulders:
The muscles of the neck are symmetrical and no palpable masses. The lymph nodes are not visible or inflamed upon inspection. The lymph nodes are palpable but not exceeded to 0.5cm in diameter. The shoulders are symmetrical.

The eyes are symmetrical, the pupil are deep black in color and round in shape. Pupils constrict briskly to direct light accommodation. The conjunctiva is pink and moist and no swelling, lesions and foreign bodies. The corneal surface is moist and shiny and no discharge, cloudiness, opacity and irregularity. The lens is transparent in color. The eyelids are symmetrical and no infectious and tumors upon inspection and palpation and the patient can raise both eyelids symmetrically. The eyebrows are present bilaterally, symmetrical and without lesions and scaling.

The breath smell fresh, the lips and membranes are pink and moist, no evidence of lesions on inflammation. The tongue is in the midline of the mouth and the teeth are yellowish in color and there are presences of dental caries.

The chest expansion is symmetry, respiratory rate is normal, the breath sounds are normal, the heart sounds is normal. The breast and axilla are flesh colored, and the areola areas and nipples are darkened. The breast is symmetrical and slightly large. No palpable masses in breast, axillary, areolas and nipples and presence of yellowish discharge.

There is presence of linea negra in the center. The abdomen is bilaterally symmetrical and no palpable masses or nodules.

Both upper and lower extremities are symmetrical in length and size. The number of fingers and toes are complete. There is a presence of edema in the lower extremities and the temperatures are slightly cooler.

VIII. Significance health pattern
a. The patient’s sleep pattern was normal, she was sleeping 7-8 hours a day her bedtime rituals are watching TV and sometimes reading books, magazines or newspapers. b. The patient actually and exercise during pregnancy walking while In pain and she just do the households. c. The patient food preferences were vegetables, rice, mat, and fish. She eats three times a day in normal amount. d. The frequency of the patient bowel pattern was 1-2 a day, hard in consistency, slightly black in color and aromatic odor. The frequency of urinary pattern was 5-8 times a day, the consistency was transparent, clear and ammonia like odor.

XI. Discharge plan
M- Medication to take  Amoxicillin  Mefenamic acid  Ferosulfate Instruct the client about the way of taking her medicines. Explain the proper measurement and time of intake. E- Exercise Encourage the client to do some exercise every morning such as simple walking. T- Treatments Advice the client not to engage in any house chores that might jeopardize her health. H- Health teaching Encourage and explain the importance of breast feeding to the client. Breastfeeding especially the first milk, “colostrums”, can reduce postpartum bleeding/hemorrhage in the mother, and to pass immunities and other benefits to the baby. Advice client to let her child expose to mild sunlight in order to balance and avoid excess bilirubin in the body. Instruct and teach the client about proper bathing of the baby. O- Out patient follow up Instruct the client to go back for the follow up check ups. D- Diet Advice client to eat proper diet. Encourage her to eat more vegetables and frequent intake of liquids. Advice her to eat food which are rich in protein, iron and vitamin C. protein helps to repair body tissues, iron provides formation of Red Blood Cells and Ascorbic Acid for helping absorption of iron.


Case Study

Pregnancy Uterine Full Term
Prepared by: GROUP A3 Ocampo, Marlon Openia, Rosemarie Oribiada, Clariver Paloma, Ronie Pascual, Angelie Pascual, Genalyn Sales, Jonson Samson, Aiza Santos, Mark francis Talaue, Tyrone Jig Tanseco, Ma. Shiela Tolentino, Ryan Joe

Resurreccion, Carls Burg A. Prepared to:

Ms. Airies L. Borromeo, RN

(C.I. in OB-ward)

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