Professional Documents
Culture Documents
In Partial Fulfillment in
Maternal and Child Health Nursing I
(Lecture)
Submitted by:
Mary Rose E. Melicor
2014-10525
Submitted to:
Prof. Ronnie M. Tiamson, RN, RM, MAN, MSN
Table of Contents
Title Page
Introduction
I. General Objectives
VII. OB History/Scoring
Labor is the series of events by which uterine contractions and abdominal pressure
expel a fetus and placenta from a woman’s body. Regular contractions cause progressive
dilatation (enlargement or widening of the cervical canal) and create sufficient muscular
force to allow a baby to be pushed from the birth canal (or vagina). It is a time of change,
both an ending and a beginning, for a woman, a fetus, and her family. (Maternal and Child
Childbirth is painful and stressful event in women’s life, a women that is undergoing
a labor and birth needs all the psychological and physical coping methods she has
available. Having a child is one of the most amazing and memorable thing a women could
have and experience. However, due to some prejudice and lack of knowledge about labor,
often prevents some women to enjoy the experience. Giving an adequate knowledge
about labor is a must so that they would now that different thing about signs of labor and
about labor and delivery in general, so that they will somehow know what to do when it
manifest.
is very crucial in having a successful labor. She will need all the support that she could
receive from her family, relative and medical professionals like nurses and physician.
Receiving emotional support from someone is very important for the woman in labor for
she comes to think that she is not alone and it also helps her to be strong and confident
because she is seeing that her loved ones is there for her. According to study, a woman
who are receiving emotional, physical, psychosocial and spiritual support are less pain for
they feel comforted by the received support, compared to the woman who doesn’t received
any.
Hearing encouragement and assurance from the people around her helps her to
alleviate the pain and help her have a speedy recovery. We can say and understand that
there are different factors in labor pain for it involves, emotional, sensorial, environmental
and existential factors. Our role as a nurse is to relieve the labor pain being experience by
the mother by encouraging her and keep on supporting her, in this case we can reduce
the use of riskier medication or analgesics to relieve the pain and potentially improved the
labor progress. Giving an holistic care as a nurse to the woman in labor helps a lot in
The case study aims to determine and identify the general health and
Specific Objectives:
nursing intervention.
Informant: Patient
Labor pain.
The patient said that she’s at home watching the television when she felt
discomfort and pain but didn’t bothered about it at first for it is still tolerable.
At around 6:30 am, she felt the pain more intensely and wasn’t able to tolerate
it anymore. She described that the pain is coming from her lower back and radiating
in front of her abdomen with the severity that she can’t tolerate and decided to go to
the hospital.
At 7:30 am, they arrived at the hospital with the positive signs of labor and a
The patient acquired illnesses such as chickenpox, mumps and measles during
childhood.
Diabetes and Pulmonary Tuberculosis. The patient has no allergy related to food, drug
and animals.
The female patient is 31 years old and second to the eldest of the four siblings.
They are 6 in the family. He has an older brother and 2 younger sisters. Her family is
still complete, and her mother and father is together with her husband accompanying
her. The patient has been married to her husband for 5 years already and said that
the baby girl that just been delivered is their first child.
VII. OB History/Scoring:
The patient’s pregnancy was planned and said that they’ve been expecting a
child because they aren’t getting any younger, that’s why they are very happy to finally
have a child especially a baby girl. Her last menstrual period is December 14, 2016
based on what se recall. The OB History of the postpartum woman before the delivery
is G1 P0 (T0 P0 A0 L0); gravida is 1, parity is 0, term is 0, pre-term is 0, abortion is 0
The patient was 12 years old when she had her first menstrual flow (menarche),
she stated that she have a regular period of menstruation and with an interval of one
month in every cycle, the duration of her period is 4-7 days. She uses 4 pads a day
during menstruation and she also stated that every period she’s experiencing
dysmenorrhea.
The patient’s skin is color brown, has now skin lesions, but some pigmented
area, due to production of melanocytes during labor that cause some pigmentation on
patient’s face and abdomen. Striae gravidadum is also present on the patient’s
abdomen.
patient and can move freely. The nails are symmetrical and short, it has a good
The patient’s hair is evenly distributed, thick and color black. No lesions on the
of masses or nodules palpated on the head. The patient’s eyes are even, no
canthus of the eyes. Has an even color same with the facial skin. No presence of
obstruction that can hinder the patient’s breathing. No tenderness when palpated, and
no presence of lesions.
The patient’s lips are essentially normal, pale pink in color, the patient’s teeth
The abdomen is slightly big however essentially normal, normal in color, but
has an uneven distribution of color due to pigmentation and there is presence of stretch
marks.
The patient’s genitals is slightly dark in color and has a few pubic hair for it has
been cut due to labor. There is lochia secretions. There is no pubic lice present.
IX. Review of Systems
The patient’s general status is that she experienced body malaise and a
shortness of breath because of the episiorrhaphy during the delivery. The patient is
coherent and well-oriented, but verbalized experiencing pain due as an effect of the
No skin lesion have been observed on the patient’s skin, except for the
presence of scar in the lower right leg due to injury. The patient also has a pigmentation
on the abdomen and striae gravidadum caused by the stretching of the skin in the
There is no other verbalized feeling of discomfort aside from the after pain
experiences because of the episiorrhaphy. The patient stated that she can hear clearly
and loud. There is no complications when it comes to the patient’s vision, there is no
as well.
There is no presence of edema in any part of the body. The breasts of the
patient are tender and engorge. She doesn’t experience chest pains, but experiences
shortness of breath.
The patient can move comfortably and does not experience any muscle pain,
stiffness or joint pain, however the patient stated feeling of pain and slight difficulty in
The first time that I saw the patient is on the second day of my duty, she
appears normal and looks like she already regained some of her strength however she
In my stay in the ward I was able to handle her for that particular day only for
we don’t have our duty after that day. First is that our CI introduced us to each of our
patient, and then she assigned us to different patients. Before I start gathering
information from her, what I did at first is introduced myself and tell her what I am going
to do. I build rapport first, between the patient and me, so that both of us won’t have a
hard time being uncomfortable with each other. After getting the patient’s trust I was
able to talk to her comfortably and it slightly become easier for me. What I did after
building rapport with my patient is that I took her vital signs as well as her baby’s vital
signs for 4pm, to have a baseline data. After taking their vital signs I plot the data
gathered as instructed by our CI. After that I let the patient to rest and for some time
let her feed her baby girl whenever she’s hungry. After 4 hours, I again took the
patient’s, as well as her baby’s vital signs for 8pm. And after that I plot the data
I interviewed her, but asked first if it would be fine if I used her case in my
case study and she said that it’s fine. So I started asking significant information
needed, and she answered it honestly. After I interviewed her, I happily say thank you
and say good bye to her for I won’t be seeing her again tomorrow for we don’t have
our duty. The next week after that, I wasn’t able to see her for she’s already been
discharge.
XII. Lab Results with Analysis
Ultrasound Report
EMBRYO/FETUS
CRL: 0.41 cm = 6 weeks 1 day
ADNEXA:
IMPRESSION:
Ultrasound Report
General Survey:
Number = Singleton
Presentation = Cephalic
SVP = 4.28 cm
Fetal Biometry
OFD = 7.43 cm =
Impression:
Normohydramnios
M 14-16 g/dl
Hematocrit F 0.37-0.47 0. 36
M 0.40-0.57
Segmenters 60-70% 75
Urinalysis
CLINICAL MICROSCOPY
Reaction 6 4.8-7.8
Microscopic
EXAMINATIONS RESULTS
RPR NON-REACTIVE
HIV 1. NON-REACTIVE
HIV 2. NON-REACTIVE