A CASE

STUDY ON
PRETERM
LABOR
SUBMITTED BY:
DALUSAG, RAVEN SAMANTHA
BSN 2A
FEBRUARY 2016

INTRODUCTION

Patient JQJ, a 38 year old female was admitted in Jonelta Ward last January 15,
2016, 4:22 am at University of Perpetual Help DALTA Medical Center with a diagnosis
of G3P2 (2002) Pregnancy Uterine 36 2/7 weeks Cephalic in Preterm Labor, Prev. CS II
Primary for Arrest Indescent.

DESCRIPTION OF DISEASE:

Premature labor is also called preterm labor. Its when your body starts getting
ready for birth too early in your pregnancy. Labor is premature if it starts more than three
weeks before your due date.
This happens because uterine contractions cause the cervix to open earlier than
normal. Consequently, the baby is born premature and can be at risk for health problems.
Lots of different things can increase your risk of premature labor. Some of them
are smoking, being very overweight or underweight before smoking, being very
overweight or underweight before pregnancy, not getting good prenatal care, drinking
alcohol or using street drugs during pregnancy, having health conditions, such as high
blood pressure, preeclampsia, diabetes, blood clotting disorders, or infections, being
pregnant with a baby that has certain birth defects, being pregnant with a baby from in
vitro fertilization, being pregnant with twins or other multiples, a family or personal
history of premature labor, getting pregnant too soon after having a baby.

Warning signs and symptoms of premature labor include five or more uterine
contractions in an hour, watery fluid leaking from your vagina (this could indicate that
your water has broken), menstrual-like cramps in the lower abdomen that can come and
go or be constant, low, dull backache felt below the waistline that may come and go or be
constant, pelvic pressure that feels like your baby is pushing down, abdominal cramps
that may occur with or without diarrhea, increase or change in vaginal discharge.
Premature labor occurs in about 12% of all pregnancies. However, by knowing
the symptoms and avoiding particular risk factors, a woman can reduce her chance of
going into labor prematurely.

OBJECTIVES OF THE STUDY

Identify the expected outcomes of the patient related to the disease.

To gain better and clearer understanding on the nature, course, physical, and
emotional changes and signs and symptoms related to the disease.

To gain new facts and ideas about the disease.

Illustrate and explain the pathophysiology of preterm labor.

To be able to identify nursing interventions appropriate for the patients

conditions.

PATIENTS PROFILE
Clients name or Initials:

MRS. JQJ

Age:

38 YEARS OLD

Civil Status:

MARRIED

Religion:

CATHOLIC

Address:

804 SAN JOSE ST. MANUYO I, LAS

PINAS CITY, METRO MANILA 1740

Birth Date and Place:

JUNE 6, 1977 LAS PINAS CITY

Race/Nationality:

FILIPINO

Usual Source of Medical Care:

HOSPITAL

Chief Complaint:

LABOR PAINS

Attending Physician:

DR. MARITESS BLAS

Admitting Diagnosis:

G3P2 (2002) PREGNANCY UTERINE 36

2/7

PRETERM
PRIMARY FOR
DESCENT

WEEKS
LABOR,

IN

CEPHALIC

PREV.

ARREST

CS

II
IN

HISTORY OF PRESENT ILLNESS

The patient was amenorrheic for 4 weeks and did a pregnancy test 5 weeks that
revealed a possible result.
During the 1st trimester, she had her 1st prenatal check-up at Jonelta OPD at 6-7
weeks AOG. Transvaginal UTZ, CBC, urinalysis, FBS, VDRL, Hepa B were done. She
took multivitamins, folic acid, and calcium. She was diagnosed with SVI and Bacterial
Vaginosit. She took metronidazole and it resolved.
During the 2nd trimester, she felt quickening at around 5-6 months. No bleeding or
spotting. No watery discharge. No infections noted. she continued to take multivitamins,
FeSo4 (ferrous sulfate) and Calcium once a day.
During the 3rd trimester, no spotting or bleeding noted. No watery discharge. No
uterine contractions noted. With good fetal movement. She continued to take
multivitamins, FeSo4 and Calcium once a day.
2 days pain to admission, the patient noted abdominal pain with every fetal
movement, with a PS (pain scale) of 4/10. Then is associated irregular contraction. No
spotting/bleeding or watery discharge noted. Pain and contractions eventually resolve.
1 day prior to admission, abdominal pain reassured now with a PS of 6/10.
Contraction become frequent. No spotting/bleeding or watery discharge noted. Before
patient was about to sleep, the pain and contractions resolved.

In ans PTA, abdominal pain and regular contractions noted. There is also lower
back pain, no spotting or bleeding. No watery discharge.
Persistence of symptoms prompted consult. Upon IE, cervix is 1cm and with
regular contraction of 6 minutes interval. Hence, this admission.
The last time I handled the patient, shes still in abdominal pain with a PS of 5/10
due to (+) suture on abdomen in mediolateral, and using an abdominal binder.

MEDICAL HISTORY OF PAST HEALTH

As stated by the patient, she had a history of Asthma. Occasionally experienced
difficulty of breathing when she was young.
GORDONS FUNCTIONAL PATTERN OF ASSESSMENT
Functional Pattern
Nutritional Pattern

Before

Prior to admission, patient

During

stated that her usual meals;

during breakfast was milk

During admission, patient

was in SD (soft diet)

with bread, lunch and

Has an allergy with fish.

No allergy in medications.

dinner composed of
various foods and
vegetables.

She preferred vegetables

especially chopseuy and
pakbit.

Elimination Pattern

Before hospitalization,
Mrs. JQJ had an
elimination pattern of 2-3
times a day and her bowel

yellow colored urine.

elimination is usually
every morning before
taking a bath.

Usually had yellow

colored urine and dark
brown.

Activity/Exercise

Pattern

Mrs. JQJ was a wheeler

- She is in limited activity due

cart.

to CS (Caesarian Section)

Does household chores

- Walk with assistance

when off duty

Sleep/Rest Pattern

Mrs. JQJ stated that her - JQJ sleep and rest normally,
sleeping pattern is normal. but sometimes need to care
She usually sleeps 8-9 and breastfed her baby.
hours a day.

She normally goes to bed

around 9pm and wakes up
around 6am.

Cognitive/Perceptual
Pattern

Able to read and write

JQJ was able to finish

JQJ has a good perception,

she responses very well
and very cooperative.

college.
Self-perception/Self-

- Mrs. JQJ was a loving and caring person and seldom gets mad

concept pattern

at her children, she talks to them calmly during family

problems.
Role-relationship

Pattern

Mrs. JQJ is the second born among four siblings in her

family. She has a good relationship with her family. She has
a husband and two children. She has one son and one
daughter; her mother also lives with them.

Theyre always after the sake of each members of their

family by helping one another and they value the gift of
family very well. Shes the decision-maker for the family.

During confinement, JQJ receives care and support from

her family especially from her husband.

Sexuality-Reproductive - Upon interviewing the patient, she stated that she and her
Pattern

husband seldom engage in sexual activity before she get

pregnant.

Coping/Stress

- Upon interview, the patient stated that before confinement,

Tolerance Pattern

whenever they have a problem they talk about it and provide

choices or alternative to solve it. After the patient was confined
to the hospital, the husband stated that he is very much stressed
because her wife was in pain during labor.

Value/Belief Pattern

- According to the patient she seldom goes to church because of

his inconsistent time of working hours but she has a faith in
God and surely believes in Him.

PHYSICAL ASSESSMENT
GENERAL APPEARANCE
Area Assessed

Technique

Actual

Normal

Used

Findings

Findings

Analysis

Body built

Inspection

Proportionate

Proportionate

Normal

Posture and

Inspection

Coordinated

Coordinated

Normal

gait
Body odor

Inspection

and Slouched
No body odor

and erect
No body odor

No body odor

Signs of

Inspection

No distress

No distress

Normal

Effect of mood

Inspection

Cooperative

Cooperative

Normal

Speech

Inspection

Coherent

Coherent

Normal

distress

VITAL SIGNS during the assessment January 18, 2016, 8:00 am

Area Assessed

Technique

Actual

Normal

Analysis

Temperature

Used
Measured using

Findings
36.1 degree

Findings
36-37.5 degree

Normal

Pulse rate

a thermometer
Palpation

Celsius
90 bpm

Celsius
60-100 bpm

Normal

Respiratory

Inspection

20 cpm

12-20 cpm

Normal

110/70 mmHg

90/60 120/80

Normal

rate
Blood Pressure Measured using
a

mmHg

sphygmomano
meter and
stethoscope
SKIN

Area Assessed

Technique

Actual

Normal

Analysis

Color

Used
Inspection

Findings
Brown

Findings
Light brown

Normal

Symmetry of

Inspection

Symmetrical

to brown
Symmetrical

Normal

color
Edema

Inspection

Absent

Absent

Normal

Skin lesions

Inspection

No lesions

No lesion

Normal

Moisture

Inspection

Moist

Moist

Normal

Temperature

Palpation

Warm to touch

Warm to

Normal

Good skin

touch
Good skin

Normal

turgor

turgor

Skin Turgor

Palpation

NAILS
Area Assessed

Technique

Actual

Normal

Analysis

Nail curvature
Texture

Used
Inspection
Inspection and

Findings
Convex
Firm

Findings
Convex
Firm

Normal
Normal

Nail bed color

palpation
Inspection

Pinkish

Pinkish

Normal

Surrounding

Inspection

Intact

Intact

Normal

tissue
Capillary refill

Palpation

2 seconds

Less than 2-3

Normal

sec

HEAD
Area Assessed

Technique

Actual

Normal

Analysis

Shape

Used
Inspection

Findings
Normocephalic

Findings
Normocephalic

Normal

with smooth
Nodule/Masses

Palpation

Absent

contour
Absence of

Normal

nodule/masses

EYES
Area Assessed

Technique

Actual

Normal

Analysis

Pupils

Used
Inspection

Findings
Black, pupils

Findings
Black, pupils

Normal

equal, round,

equal, round,

reactive to light

reactive to light

accommodatio

accommodation

Inspection

n
Coordinated

(PERRLA)
Coordinated

Normal

Eyebrows

Inspection

Evenly

Evenly

Normal

Eyelids

Inspection

distributed
Intact skin,

distributed
Intact skin,

Normal

bilateral

bilateral blinking

blinking
Pinkish

Pinkish

Extra ocular
movement

Conjunctiva

Inspection

Normal

Cornea
Lacrimal

Inspection
Palpation

Clear
No tenderness

Clear
No tenderness

Normal
Normal

gland
Eye lashes

Inspection

Evenly

Evenly

Normal

distributed

distributed

EARS
Area

Technique

Actual Findings

Normal Findings

Analysis

Assessed
Pinna

Used
Inspection

Uniform in color,

Uniform in color,

Normal

Ear canal

Inspection

symmetrical
Presence of

symmetrical
Presence of

Normal

Inspection

cerumen/earwax
Responds when

cerumen/earwax
Responds when

Normal

called

called

Hearing
acuity

NOSE
Area Assessed

Technique

Actual

Normal

Analysis

External nose
Nasal cavity

Used
Inspection
Inspection

Findings
Symmetrical
Dark pink, dry,

Findings
Symmetrical
Dark pink, dry,

Normal
Normal

free of exudates

free of
Normal
Normal

Sinus

Palpation

No tenderness

exudates.
No tenderness

tenderness
Nasal mucosa

Inspection

Intact and

Intact and

midline

midline

PHARYNX
Area Assessed

Technique

Actual

Normal

Analysis

Uvula
Oropharynx
Gag reflex

Used
Inspection
Inspection
With the use of

Findings
In midline
Pink
Intact

Findings
In midline
Pinkish
Intact

Normal
Normal
Normal

a tongue
depressor
MOUTH
Area Assessed

Technique

Actual

Normal

Analysis

Lips
Teeth

Used
Inspection
Inspection

Findings
Symmetrical
Complete

Findings
Symmetrical
32 pearly

Normal
Normal

Gums

Inspection

Pinkish, moist,

normal teeth
Pink, moist,

Normal

Inspection

firm, intact
Midline and

firm, intact
Midline,

Normal

movable

pinkish,

Light pink,

movable
Light pink,

intact

intact

Tongue

Palate

Inspection

Normal

NECK
Area Assessed

Technique
Used

Actual Findings

Normal
Findings

Analysis

Muscles
Movement
Range of

Palpation
Inspection
Inspection

Symmetrical
Coordinated
Full

Symmetrical
Coordinated
Full

Normal
Normal
Normal

motion
Muscle

Inspection

Equal

Equal

Normal

strength
Lymph nodes
Trachea

Palpation
Inspection

Not palpable
In midline

Not palpable
In midline

Normal
Normal

CHEST AND LUNGS

Area Assessed

Technique

Actual

Normal

Analysis

Breathing

Used
Inspection

Findings
Regular

Findings
Regular

Normal

pattern
Symmetry
Spinal

Inspection
Inspection and

Symmetrical
Aligned

Symmetrical
Aligned, in

Normal
Normal

alignment
Skin

palpation
Inspection

Smooth, no

midline
Smooth, no

Normal

tenderness and

tenderness and

lesions
Clear

lesions
Clear

Normal

Breath sounds

Auscultation

HEART
Area Assessed

Technique

Actual

Normal

Analysis

Rhythm
Heart sounds

Used
Auscultation
Auscultation

Findings
Regular
S1 louder at

Findings
Regular
S1 louder at

Normal
Normal

apex, S2

apex, S2 louder

louder at base

at base

ABDOMEN

Area Assessed

Technique

Actual

Normal

Analysis

Skin integrity
Contour
Symmetry
Bowel sounds

Used
Inspection
Inspection
Inspection
Auscultation

Findings
Unblemished
Rounded
Symmetrical
High pitched,

Findings
Unblemished
Flat/Rounded
Symmetrical
High pitched,

Normal
Normal
Normal
Normal

irregular

irregular

gurgles, 5-35

gurgles, 5-35

times/min in all

times/min in all

quadrants
N/A

quadrants
Generalized

Has a suture on

tympanic

the abdomen

sounds
No tenderness

due to CS
Has a suture on

Percussion

Palpation

Percussion

Palpation

N/A

the abdomen
due to CS

BACK AND EXTREMETIES

Area Assessed

Technique

Actual

Normal

Analysis

Muscle size
Muscle tone
Muscle

Used
Inspection
Palpation
Inspection

Findings
Equal
Firm
Unequal

Findings
Equal
Firm
Equal

Normal
Normal
Due to pain

strength

associated with
a suture on the

Bones
Joints
Range of

Palpation
Palpation
Inspection

No tenderness
No tenderness
Full

No tenderness
No tenderness
Full

abdomen
Normal
Normal
Normal

motion

LABORATORY STUDY
Complete Blood Test (CBC)
January 16, 2016 (8:06 PM)
PROCEDU

INDICATION/PURP

NORMAL

RESULT

INTERPRETATI

RE

OSE

VALUES

ON

RBC

It is the count of the

4.50-

2.90

Low RBC may

actual number of red

5.50x10^12/

indicate presence

blood cells per volume

of iron deficiency,

of blood.
Hemoglobin

anemia, etc.

It is a protein used by

110.00-

red blood cells to

150.00g/L

83

Normal for a
pregnant woman

distribute oxygen to
other tissues and cells
in the body.
Hematocrit

It is traditionally
defined as the
percentage of RBCs per

0.37-0.47L

0.25 (2x

Low Hematocrit

done)

may indicate
anemia, a large

volume of whole blood.

number of WBC,
and vitamin or
mineral
deficiencies

WBC

These immune cells

4.50-

17.5

Leukocytosis

form in the bone

10.00x10^9/

Increased levels

marrow to help fight

may indicate

infection. High levels

presence of

may indicate infection.

infection

Low levels may result

from treatment or
disease.
Segmenters

Used to determine if

0.50-0.70

0.75

there is infection

High Segmenters
may indicate
infection

Eosinophils

A type of phagocyte

0.00-0.05

0.02

Normal

0.20-0.40

0.16

Low lymphocytes

that produces the antiinflammatory protein

histamine.Used to
diagnose allergy, drug
reactions, Parasitic
infections.
Lymphocytes

Include T-cells, B-cells,

and NK cells. Viral

may indicate

Monocytes

infections may increase

infections or

their number.

inflammation

It is a type of white

0.00-0.07

0.07

Normal

Helps to determine the

150.00-

239

Normal

presence of bleeding

400.00x10^

blood cell that is

produced by the bone
marrow and helps to
protect the body from
foreign invaders, such
as harmful bacteria and
viruses.
Platelets

9/L

Urinalysis
August 12, 2015 (11:17 am)
Color

Yellow

Transparency

Hazy

Reaction (pH)

6.0

Protein

Trace

Glucose

(+3)

Specific Gravity

1.030

RBC

8-12/HPF

Pus cells

3-6/HPF

Epithelial cells

Moderate

Bacteria

Moderate

CLINICAL FINDINGS
The patient was in abdominal pain with a pain scale of 5/10. Complete blood
count revealed that there was an elevation in the WBC count which may indicate
presence of infection, together with Segmenters, and a low count of Lymphocytes which

may indicate also an infection. CBC also revealed a low count of RBC and Hematocrit
which may indicate presence of iron deficiency and anemia.
Other tests includes: Urinalysis which has shown presence of glucose in the urine
(glycosuria) with a result of +3.

Signs and Symptoms before administration:

abdominal pain

- due to contraction

ANATOMY AND PHYSIOLOGY

UTERUS
The uterus (womb) is the part of the female reproductive system in which a baby
grows.
The female reproductive system is made up of internal organs, including the
vagina, uterus, ovaries and Fallopian tubes, and the external genital organs (the parts that
make up the vulva). All the internal organs are in the pelvis, which is the lower part of the
abdomen between the hip bones.

Structure
The uterus is a hollow, muscular organ that is shaped like an inverted pear. It has 3 parts:

fundus (top)

body (the main parts of the uterus, including the uterine cavity)

cervix (lower, narrow part)

The uterus is located above the vagina, above and behind the bladder and in front of the
rectum. It is about 7 cm long and 5 cm wide (at the widest point).
The wall of the uterus is thick and has 3 layers:

endometrium The inner layer that lines the uterus. It is made up of glandular

cells that produce secretions.

myometrium The middle layer, which is made up mostly of smooth muscle.

perimetrium The outer serous layer that covers the body of the uterus and part of

the cervix.

Function
The uterus receives a fertilized egg (ovum) and protects the fetus (baby) while it
grows and develops. The uterus contracts to push the baby out of the body during birth.
Every month except when a woman is pregnant or has reached menopause the
lining of the uterus is shed through the cervix, into the vagina and out of the body. This is
called menstruation.

DISCHARGE PLANNING
Medication

Should be taken regularly as prescribed, strictly follow exact dosage, time, &
frequency, making sure that the patient and relatives fully understand the
importance of taking medications.

Instruct patient and relatives to immediately report any side effects/adverse

reactions.

Exercise

ROM exercises.

Gradual back to basic daily routines.

Should be promoted in a way by stretching all body parts every morning. Patient
should be encouraged to keep active through light exercises.

Maintain rest periods in between activities.

Treatment
Discuss the purpose of treatments to be done and continued at home:

Cleaning and properly dressing of the suture.

Health Teaching
Discuss to the patient and family the importance of:

Bed rest

Proper Hygiene

Promote safety and comfort

Outpatient

Remind the patients family that frequent check-ups are important to improve
patients condition and improve optimum level of wellness.

Inform significant members to report any abnormalities as soon as possible to

prevent further complications.

Diet

Advise patient to control intake foods high in sugar.

Advise to eat foods containing iron such as liver, green leafy vegetables, and red
meat and high in fiber.

Spiritual counseling

Encourage client to take time examine his feelings and thoughts in search for
peace and harmony.

Advise patient to pray. A helpful way of promoting general well-being and sense
of connection with himself, or spiritual power.

Encourage patient and family to continue participating in desired religious

activities such as contact with minister, rosary, singing in choir. Family that shows

support and understanding of the patients condition strengthens bonds, faith in

God, and decreases occurrence of stress.

REFERENCE:
Books

Berman, A., Snyder, S. (2011). Kozier & Erbs fundamentals of nursing: concepts,
process, and practice (9th ed.). Philadelphia: Prentice Hall

Doenges, M., Moorhouse, M. F., Murr, A. (2010). Nurses pocket guide diagnoses,
prioritized interventions, and rationales (12th ed.). Philadelphia: F.A. Davis Company.

Karch, A. (2012). Lippincotts nursing drug guide (17th ed.). Philadelphia: Lippincott
Williams & Wilkins.

Smeltzer, S., Bare, B., Hinkle, J., et al. (2010). Brunner & Suddarths textbook of
medical-surgical (12th ed.). Philadelphia: Lippincott Williams & Wilkins.

Electronic Sources:

HTTP://WWW.CANCER.CA/EN/CANCER-INFORMATION/CANCER
TYPE/UTERUS/ANATOMY-AND-PHYSIOLOGY/?REGION=ON

HTTP://EMEDICINE.MEDSCAPE.COM/ARTICLE/167981-OVERVIEW