OBSTETRICAL CASE STUDY

SUBMITTED TO: Mrs. Neva Mae Tiangha, RN SUBMITTED BY: Lauo, Sheila Mae Lo, Marjorie Loloy, Maebelle Faith Mandolado, Maridel BSN 3J/ GROUP 39

I. Reproductive Health Case Study II. Introduction Definition of Terms

1. Mitosis responsible for growth and development of all humans through the division, replacement and addition of somatic cells. 2. Meiosis involved in gametogenesis which is the process of formation and development of the specialized male (spermatozoon) and female (ovum) germ cells (gametes) for fertilization. 3. Spermatogenesis- maturation of the sperm cells 4. Oogenesis maturation of the ovum 5. Ovum female gamete; life span: 12-24 hrs 6. Sperm produced starting at age 17; life span after ejaculation: 48-72 hrs 7. Fertilization/Fecundation/Conception/Impregnation refers to the union of the two gametes (mature egg cell and sperm cell) 8. Product of fertilization a. ovum from ovulation to fertilization b. zygote from fertilization to implantation c. embryo from 2 weeks to 8 weeks d. fetus from 9 weeks until birth 9. Blastomere when zygote subdivides into 2-4-8 daughter cells 10. Morula when zygote subdivides into 16 daughter cells and begins to leave the tube to go into the uterine cavity for 3-4 days

Physiology of Pregnancy Mature Sperm Cell Mature Egg Cell

FERTILIZATION (1st 24 hours) First cell division (cleavage) Zygote (haploid)

MORULA

goes to the uterus; Morula becomes blastocysts IMPLANTATION (Development of fetus) INVASION: settlement at the soft sites of the endometrium

Aposition: brushes away the thick and rich endometrial lining

ATTACHMENT (adhesion)

OBJECTIVE OF THE CASE STUDY Within 45 hours of exposure at TLJPH at OB, we will be able to: A. Knowledge: 1. Formulate appropriate nursing care plan for the patient. 2. Determine the appropriate nursing interventions for an antepartal, intrapartal and post partal patient. 3. Explain the corresponding rationale for the nursing interventions given. B. Skills 1. Render perinatal nursing care guided by the nursing process. 2. Conduct thorough assessment of the patient with the use of the Systemic Approach and Gordons Functional Health Pattern Approach. 3. Monitor the patients status and progress objectively. C. Attitude 1. Respect confidentiality of the patient. 2. Demonstrate sincere interest when attending to patients needs. 3. Manifest empathy towards the patient. 4. Assume nursing responsibilities with commitment and enthusiasm.

III. Patients Profile Personal Profile Name: Panaga, Joyce Age: 31y.o Status: Married Occupation: Housewife Religion: Roman Catholic Residence: Calasa, Silay city LMP: 03-06-08 EDC: 12-13-08 Gordons Functional Health Pattern: Health Perception Health Management Pattern Client has not experienced common colds, cough & fever in the past. If not that severe, the client takes over-the-counter drugs such as paracetamol & cough syrup. Moreover, if the signs and symptoms are not relieved by the OTC drugs, then the client visits the Health Center. Nutritional Metabolic Pattern Client eats a regular diet, 3 meals a day. She also takes ferrous sulfate once a day as a supplement. Daily water intake ranges from 8-10 glasses. The clients weight before she got pregnant was 110 lbs. She gained more or less 20 lbs when she got pregnant. They were no skin lesions and skin is not dry. The client showed no signs of mental problems. Elimination Pattern The bowel elimination pattern of the client varies. Prior to The client because of had her also iron was experienced supplement. to void able constipation Gravida: 2 Para: 2

delivery,

patient

freely. The color of the urine was light yellow and the volume was approximately 30-45 cc. During

the delivery, the client felt an urge to void but cant void freely. Straight catheter was inserted.

Activity Exercise Pattern

A. Perceived Activities Feeding 0 Bathing 0 Toileting 0 Bed mobility 0 Dressing 0 II Functional Level Code Level 0 Independent Level I Requires equipment or device. Level II Requires assistance and supervision from another person. Level III Requires assistance or supervision from another person and use of equipment or device. Level IV Dependent and unable to participate Sleep and Rest Pattern The client did not have any sleep problems during the course of her pregnancy. She always has her noontime nap. Cognitive Perceptual Pattern The client has no sensory problems. She had only experienced intense labor pains which started 6 am on July 30,2008. Self Perceptual \ Self Concept Pattern The client has disturbed body image because of the physiological changes of pregnancy. She sometimes during claimed time. Role- Relationship Since the client is married,she lives with the husband and the kids. Sexuality Reproductive Pattern her to feel last stay that ugly in she unattractive. of bed might because deliver Moreover, she some of of trimester pregnancy, ahead Grooming 0 General Mobility Cooking II Shopping II Home Maintenance

apprehensions

Her menstrual period started when she was 12 yrs. old. She has a regular menstrual cycle. Coping - Stress Tolerance Pattern Since the client have had given birth many times, she didnt have any hard time coping with stress. Value Belief Pattern The client is a Roman Catholic but says she seldom goes to church. Patients Health History Record The client mentioned she had asthma though it is not that severe. Present Health Status

BOOKVIEW Physiologic Changes Local Changes a.) Uterus Increase in size in 1 3

rd st

OBSERVATION

RATIONALE

Clients uterus has increased its size. to

Formation of few new muscle fibers in the uterine myometrium.

trimester

b.) Height of Fundus Increase starts at 12 wks. To 28 wks.

Clients fundus has increased its height.

Increase in the height of the fundus is due to the increase in the size of uterus.

Clients cervix is edematous c.) Cervix Becomes vascular and edematous

Increased fluid between cells cause the cervix to soften in consistency and increase in vascularity causes it to darken from

pale pink to violet hue. Cervix becomes soft compared to Softening of the Cervix ( Goodells Sign) Chadwicks sign was noted. d.) Vagina Chadwicks Sign (changes the color of vaginal walls from bright pink to deep violet) e.) Ovaries Ovulation stops with pregnancy Clients LMP was february 3, 2008. After that, the she did not have menstruation anymore indicating that there is also no ovulation. Active feedback mechanism of estrogen and progesterone produced by corpus luteum early in pregnancy and placenta later in pregnancy. The client has experienced f.) Changes in the Breasts Feeling of fullness, tingling or tenderness in her breasts Breast size increases The breasts of the patient have increased its size. It is visible in Vascularity of the Hyperplasia of the mammary alveoli and fat deposits. fullness, tingling, and tenderness in her breasts Increased stimulation of breast tissue by the high estrogen level in the body. Increased circulation to the vagina butter-soft lips. Due to increased level of circulating estrogen.

Blue veins may become prominent over the surface of the breasts

clients breasts.

breast increases.

It was not seen on clients abdomen.

As the uterus increases in size, the abdominal wall must stretch to accommodate it. The stretching can cause rupture and atrophy of small segments of the

g.) Skin Changes Striae Gravidarum

It was not observed. Diastasis It was seen on clients abdomen. Linea Nigra

connective layer of the skin.

The abdominal wall has difficulty stretching enough to accommodate the growing fetus.

These were not Vascular Spiders noted on patients thighs

Increased level of estrogen in the body

Systematic Changes Respiratory System Oxygen demands are increased

Clients O2 demand has increased

The pregnant woman breathes more deeply and more frequently to maintain 02 for herself and the fetus.

PR: 92 bpm

Increased blood volume

Circulatory System

Pulse increases The client felt nauseated and sometimes vomits during the 1st Nausea and Vomiting The client had experienced flatulence Reduction in gastric acidity, growing uterus and smooth muscle relaxation. trimester. Elevation in hormones, emotional stress, fatigue

Gastrointestinal System

Gastric acidity decreased, heartburn and flatulence

The client feels bloated and Bloating and Constipation sometimes constipated.

Delayed gastric emptying and decreased intestinal motility.

The client always goes to the CR Urinary System Urinary Frequency Weight Weight gain The clients weight has increased about 20 lbs.

Bladder is compressed by enlarging uterus. Weight gain is due to fluid accumulation in the body

MINOR DISCOMFORT DURING PREGNANCY BOOKVIEW OBSERVATION 1. Nausea, Vomiting, and Pyrosis The client has experienced abdominal discomfort, nausea and vomiting.

RATIONALE Elevation in hormones, decrease in gastric motility, and emotional factors

2. Constipation

The client has

Increased

experienced constipation during pregnancy

progesterone causes bowel sluggishness, as the weight of the growing uterus presses against the bowel and peristalsis slows.

3. Fatigue

It is seen in clients face that she lacked rest and sleep The client felt dizzy when she abruptly rises from bed.

Increased metabolic requirements

4. Postural Hypotension

The uterus presses on the vena cava, impairing blood return to the heart when she lies on her back.

5. Varicosities Few varicose veins were visible on clients legs The weight of the distended uterus puts pressure on the veins returning blood from the lower extremities. 6. Muscle Cramps The client has complained of muscle cramping. Decreased calcium levels, increase serum phosphorous levels and interference with circulation. 7. Hemorrhoids The client hasnt complained of hemorrhoids 8. Dyspnea The client Pressure of rectal veins from the bulk of growing uterus The expanding

sometimes complained of dyspnea during exertion.

uterus puts pressure on the diaphragm, causing some lung compression, shortness of breast may occur.

9. Frequency of Urination The client urinates frequently 10. Palmar Erythema There were redness and itching on palms during early pregnancy as the client stated. 11. Braxton Hicks Contraction According to client, she was able to experience painless uterine contractions 12. Gingivitis during her pregnancy. The client didnt complained of gingivitis during the course of pregnancy. Four basic hormones vital to the continuation of pregnancy are produced in large quantities during the gestation period. This hormonal increase exaggerates the way the gum tissues react to the bacteria in plaque, resulting in an increased likelihood that a pregnant woman will develop gum disease if her daily plaque control is not adequate. Increased placental perfusion Increased estrogen levels Pressure of the gravid uterus on bladder in 1st and 3rd trimester.

13.Vaginal problem

It has not been observed.

The changes of pregnancy promote growth of bacteria because of obstruction of free flow of urine by the pressure of the uterus on the ureters and the relaxing effect of progesterone on smooth muscle. The bladder may contain residual urine, and the ureters loop and dilate.

IV. Physiology of Labor and Delivery Labor Phenomena Labor/Parturition a series of physiologic and mechanical processes by which the products of conception ( baby, placenta, and fetal membranes) are expelled from the birth canal. Preliminary/ Prodromal Signs of Labor 1. Lightening the settling of the fetal head into the pelvis a. Results of lightening: 1. Relief of abdominal tightness 2. Increase in the amount of vaginal discharge 3. Increase in urinary frequency b. ENGAGEMENT occurs when the presenting part has descended into the pelvic inlet. 2. Loss of weight - of about 2-3 lbs. 1 to 2 days before labor onset, probably due to decrease in progesterone production, leading to decrease in fluid retention. 3. Increase in activity level due to increase in epinephrine secreted to prepare the body to the coming work ahead. 4. Braxton Hicks Contractions painless, irregular contractions 5. Ripening of the cervix from Goodells sign, the cervix becomes butter soft 6. Rupture of the Membranes (Bag of Water) 7. Show is due to pressure of the descending presenting part of the fetus which causes rupture of minute capillaries in the mucous membrane of the cervix B. Signs of True Labor 1. Uterine contractions The pain in uterine contractions results from:

A.

a. Contraction of uterine muscles when in an ischemic state. b. Pressure on nerve ganglia in the cervix and lower uterine segment. c. Stretching of ligaments adjacent to the uterus and in the pelvic joint. d. Stretching and displacement of the tissues of the vulva. Three Phases of Uterine Contractions a. Increment/Crescendo b Acme/Apex c . Decrement/Decrescendo 2. Effacement 3 .Dilatation 4.Uterine changes a. Upper uterine segment becomes thick and active to expel the fetus. b. Lower uterine segment becomes thin-walled, supple and passive so that fetus can be pushed out easily. LENGTH OF NORMAL LABOR STAGES First stage Second stage Third stage TOTAL PRIMI 12 hours 80 mins/ 1 hr., 20 mins 10 mins 14 hrs. MULTI 7 hrs., 20 mins 30 mins 10 mins 8 hrs.

DIFFERENCES BETWEEN FALSE AND TRUE LABOR PAINS FALSE LABOR PAINS 1. Remain irregular. TRUE LABOR PAINS 1. May be slightly irregular at first but become regular and predictable within a matter of hours. 2. First felt in the lower back and sweep around to the abdomen in a girdle like fashion. 3. Increase in duration, frequency and intensity. 4. Continue no matter what the womans level of activity. 5. Accompanied by cervical effacement and dilatation.

2. Generally confined to the abdomen. 3. No increase in duration, frequency and intensity. 4. Often disappears if the woman ambulates. 5. Absent cervical changes.

Components of Labor 1. Passage (Womans Pelvis) 2. Passenger (The Fetus) 3. Powers (Uterine factors) 4. Psyche

4 Stages of Labor a. First stage (Stage of Dilatation) - begins with true labor contractions and ends with complete dilatation of the cervix. Three phases: 1. Latent phase (Preparatory phase) - begins at the onset of regularly perceived uterine contractions and ends when rapid cervical dilatation begins. - contractions are mild and short - cervical dilatation : 0-3 cm - phase lasts approximately: * 6 hrs - nullipara * 4.5 hrs - multipara 2. Active phase - cervical dilatation: 4-7 cm - contractions are stronger lasting to 40-60 secs and occurring approximately every 3-5 mins. - phase lasts approximately: * 3 hrs. - nullipara * 2 hrs. - multipara - show (increased vaginal secretions) and perhaps spontaneous rupture of membranes may occur. 3. Transition phase - cervical dilatation: 8-10 cm - contractions reach their peak of intensity, occurring every 2-3 mins. with a duration of 60-90 secs. b. Second stage (Expulsion Stage) - from full dilatation of the cervix up to the delivery or expulsion of the baby Mechanism (Cardinal Movements) of Labor a. Descent b. Flexion c. Internal rotation d. Extension e. External rotation f. Expulsion c. Third stage (Placental Stage) - begins with the birth of the infant and ends with the delivery of the placenta. - Two separate phases are involved: a. placental separation b. placental expulsion Signs of Placental Separation: 1. Change in the shape of the uterus; from discoid to round/globular (Calkins sign)

2. It rises to the level of the umbilicus the earliest sign 3. Lengthening of the umbilical cord 4. Sudden gush of vaginal blood. Types of Placental Delivery: 1. Schultz Shiny, fetal membrane surface 2. Duncan Dirty, irregular maternal surface d. Fourth stage (Postpartum stage) - refers to the 6 week period after childbirth - this is a time of maternal changes that are: 1. Retrogressive (involution of the uterus and vagina) 2. Progressive a. Production of milk for lactation b. Restoration of the normal menstrual cycle c. Beginning of a parenting role.

VII. Discharge Plan PROBLEM DIET: DAT, high caloric diet, Iron rich diet, High protein diet is recommended for tissue repair (episiotomy) , Vitamin C rich foods for resistance against infections FOOD SOURCES: a. Iron rich foods: organ meats, legumes, green leafy vegetables b. Protein: egg, legumes, beans, dairy products (milk and cheese) c. Vitamin C rich foods: citrus fruits such as orange, pineapple, watermelon, guyabano; green leafy vegetables, pechay, cabbage, kangkong HYGIENE: a. Daily bath (eye, ear, hair, 1. Recurrence of pain at perineal area LEVEL OF CARE Promotive HEALTH TEACHING/ACTION/PL AN - Encourage patient to do light exercises only such as stretching exercises, breathing exercises, walking, internal and external rotation of joints such as the ankles, wrists, elbows and shoulders. - Advise patient to resume ADL as tolerated. - Emphasize to patient the importance of doing things gradually to prevent stress to the episiotomy. - Instruct patient to avoid doing strenuous activities/exercis es such as jogging, lifting heavy objects and those that require great amount of force as it may induce pain at the site of episiotomy. - Instruct patient to avoid sexual activity within the 1st 2 weeks after delivery. Sexual activity can be resumed 2-4 weeks after delivery. - Instruct the

Preventive

Curative

Promotive 2. Risk for infection R/T episiotomy

Preventive

Curative

nail and skin care) b. Routine oral care (3x a day or after every meal) c. Changing of perineal pads/ diaper when fully soaked. d. Breast and nipple care prior to breastfeedin g. ACTIVITIES: a. ADL as tolerated (eating, bathing, walking, writing, reading, going up and down the stairs, cooking, breastfeedin g the baby) b. Exercise as tolerated: Simple exercises such as stretching exercises, breathing exercises, walking, internal and external rotation of joints such as the ankles, wrists, elbows and shoulders. c. Sexual activity: 24 weeks after delivery

Rehabilitati ve

Promotive/ Preventive 3. Risk for ineffective breastfeedi ng due to lack of knowledge and experience

patient, SO and family that in case of recurrence of pain at the perineal area, administer mefenamic acid 500 mg 1 tab PRN po - Encourage intake of Vitamin C rich foods and high protein diet - Discuss to patient the importance of good personal hygiene especially in the perineal area - Explain to patient the importance of changing perineal pads/ diaper if it id already soaked to prevent infection at the site of episiotomy - Instruct patient not to touch the suture with her bare hands for it can also lead to infection. - Discuss to patient, SO and family the importance of compliance to medication: amoxicillin 250 mg 1 cap TID 7 days postpartum po 8am 1pm 6 pm - Instruct patient that if after 2 weeks, the episiorrhaphy still causes discomfort, seek medical attention at the VCHO - Teach patient of the proper positioning of the baby when

MEDICATIONS: a. amoxicillin 250 mg 1 cap TID 7 days postpartum po 8am 1pm 6 pm b. mefenamic acid 500 mg 1 tab PRN po APPOINTMENT: a. To come back everyday for the daily cord dressing of the baby b. Follow up check up of the episiotomy 2 weeks after (April 24,2006) @ VCHO

breastfeeding. The chin of the baby must rest on the lower portion of the mothers breast. The baby must suck the nipple and the areola. - Encourage the patient to breastfeed the baby 1-2 hrs. after birth because the colostrums is highly beneficial to the baby. - Discuss to patient the importance of cleaning ones nipples before breastfeeding to protect the baby from ingesting dirty particles that may cause certain health problems to the baby. - Instruct the patient of the proper burping methods for the baby after breastfeeding to prevent aspiration. 2 Methods: 1. let the baby lie on his stomach on top of the mothers lap and lightly stroke the back of the baby. 2. hold the baby in vertical position, facing the mother, his stomach against the shoulder of the mother and lightly

stroke the back of the baby.

VII. Summary A. Patients Progress We have performed our assessment of the patient before, after delivery. But we have not really observed the patients progress during the entire postpartum period because we had not enough time to interact with the patient. As far as we are concerned, during the few hours that we were able to assess the patient after delivery, we have not seen any signs of complications such as profuse vaginal bleeding, subinvolution and the like. The patient was in fair condition when she was transferred,only that the patient felt weak. B. Achievement of student objectives Before we started working on our case study, we have set objectives for us to meet. Now that we are done with our case study, we can objectively say that we have met our objectives satisfactorily. We were able to assess our patient during labor, delivery and several hours after delivery. We were also able to formulate an appropriate nursing care plan for the patient and have explained the rationale for each nursing interventions rendered. We were also able to evaluate the patients progress. Lastly, we were also able to deal with the patient in a prudent and tactful manner.

VIII. Bibliography Maternal and Child Nursing by Adele Pillitteri Fundamentals of Nursing by Potter and Perry Maternal-infant nursing care by Dickason Maternal-infant nursing care plan by Luxner Nursing Care Plan by Murr NANDA by Deosi