Mariano Marcos State University College of Health Sciences Department of Nursing Batac City

POSTPARTUM ASSESSMENT
(MOTHER)

Submitted by: Marianne Angelina R. Lorenzo BSN II-C, Group 3

Submitted to;

Mrs. Julie C. Damaso, R.N. Clinical Instructor

October 2011

POSTPARTUM PERIOD (MOTHER)

Name: Eden B. Agno Age: 22 Address: Bgy. 4 Paoay, Ilocos Norte Religion: Aglipayan Educational Attainment: College Graduate (Computer Technology) Occupation: None Date Admitted: September 12, 2011 Attending Physician: Dr. Ferraris/Dr. Mariano/Dr. La Cuesta Admitting Diagnosis: G1P0 (1000) pregnancy uterine 35 3/7 weeks AOG by LMP cephalic in active labor Final Diagnosis: G1P1 (1001) pregnancy uterine, cephalic delivered spontaneously baby boy (BW: 2.4 kg; BL: 46 cm), AF - clear Date of Delivery: September 12, 2011 at 2:20 AM Type of Delivery: Normal Spontaneous Delivery (NSD) OB Score: G1P1 (1 0 0 1)

I. Health History Ms. Agno claimed that she doesnt know the name of her grandparents both from the maternal and paternal sides. His father suffered from Diabetes Mellitus but doesnt know the medications that her father took. On the year 2001, she claimed that her father died at the age of 71but doesnt recall the cause of his fathers death. Her paternal aunts Andrea and Margarita were now dead but doesnt know the cause of death of both her aunt because both of them resided in Cagayan. On her maternal side, Ms. Agno claimed that her mother had suffered from a certain disease that she does not know and verbalized Agparparuar isuna ti dara nangrugi idi 2007. She said that her mother consulted to RHU Sarrat and was given some vitamins but couldnt recall it. As of now, her mother is still sometimes suffers from this. Her aunts Inday (60) and Dolores (58) and her uncle Monoy (45) were still alive and well. She doesnt have any information about her aunts and uncles about their health status because they were residing in Visayas. Her siblings, Luz (27), Arleen (26) and Ashley (24) were all alive and well.

Past Health History The patient claimed that she had experienced childhood illnesses such as chicken pox, measles, and mumps. She managed these through adopting folk practices. They practiced the wearing of black shirt for measles, bathing in warm bath with arutang (burnt hay) for chicken pox, and applying akot akot to the affected areas for mumps. Ms. Agno also suffers from fever, headaches, cough, and colds. She manages her fever and headache by taking in Paracetamol 500mg every four hours

until it disappears. She also manages this by taking enough rest and sleep. For her cough, she takes in Robitussin 400mg TID every after meal and Neozep 500 mg TID also every after meal for her colds. Aside from taking these drugs, she also accompany it by taking enough rest and sleep, increase fluid intake usually more than 9-10 glasses of water a day and eating nutritious foods. The client claimed that she has no food, drug and environmental allergies (dust, weather changes). She also claimed that she

doesnt engage herself in any vices such as alcohol drinking and cigarette smoking. When asked to name the immunizations she received, she said that she had her BCG, DPT and OPV. Analysis/Implication: On the family health history of Ms. Agno, only his father had acquired a disease (DM). Since she is still on her 20s, she may not have this disease for now but this is a genetically transmitted disease hence she may acquire this on the later years also with her baby.

II. Obstetric History Ms. Agno is on her first pregnancy. She visited Dr. Marasigans clinic on her first month of pregnancy and RHU Paoay for the following months for her prenatal check-up. She went there every month. She had received the first dose of Tetanus toxoid on her 6th months of pregnancy by Dr. Domingo followed by the second dose on her 7 th month. She had not taken any medications throughout her pregnancy even she experiences headache. She just managed it by taking a rest. Dr. Domingo prescribed her to take in Ferrous sulphate 1 tab OD and Nutri OB 1 tab OD. She has never ingested alcohol or

any other substance that will harm her pregnancy. She doesnt smoke also as she claimed that it would harm her baby. She doesnt have any exposure to radiations. She undergone ultrasound test when she was 7 months pregnant and it was resulted to a baby boy. As to her weight gain, when she was not pregnant, she weighs 40 kg. On her last weighing being pregnant, she weighs 50 kg. She gains 10 kg. As to her sexual activity, she and her partner have contact once a month because her pregnancy was really unplanned. They are having contact for about 30 minutes in a missionary position. But during her pregnancy, she claimed that they never had contact to her husband anymore because they are afraid that her baby would harm. Ms. Agno has a good nutritional status since she balances to eat vegetables, meat, fish and poultry products. She loves to ate ripe/unripe mangoes during her

pregnancy. She also drinks 1 glass of milk every morning. She doesnt have any health problems that would affect her pregnancy. She doesnt attended childbirth

preparation classes in preparation to her role as a mother and to her baby.

Analysis/Implication: The patient had followed a monthly pre-natal check-up which implies that she is aware and wanted herself and her baby safe from any complications since it is her 1st pregnancy and these check-ups served as acquiring some knowledge about the changes occurring on her body and proper caring for herself and the baby. She also had the first and second dose of Tetanus toxoid which implies that she is 80% protected wherein the infant born to the mother will be protected form neonatal tetanus and gives 3 years protection for the mother. The patient was prescribed vitamins to provide iron

needed by the baby to produce red blood cells. It is used to treat or prevent irondeficiency anemia, that occurs when the body has too few red blood cells due to pregnancy. She is also aware on the possible effects of alcohol drinking and smoking to her health and her baby. She had undergone ultrasound test also wherein the result of her ultrasound is congruent to what she had delivered, a baby boy. As to their sexual activity, they were not active on since they are both afraid that they would harm the baby. She had a good nutritional status since she had a balanced intake of proteins, calcium, iron, fats and fibers which is necessary for her and the development of the baby. The patient doesnt undergone into childbirth classes but acquired knowledge on and ideas on child bearing preparation from the shared experiences of other pregnant women, her mother, her would be mother-in-law and through her check-ups.

III. Labor and Delivery According to Ms. Agno, she experienced mild bleeding around 5:30 PM of September 11, 2011. She just managed this by bathing and resting. Around 11:00 PM, she experienced uterine contraction with a duration of 1-2 minutes, frequency of 10-15 minutes, interval of 3-5 minutes with an intensity of moderate to strong. Therefore, she had a labor of around 9 hours because she gave birth to an alive baby boy at 2:20 AM of September 12, 2011. She was not expecting to deliver this month because as to the computed expected date of confinement (EDC) will be on October 12, 2011 because her last menstrual period (LMP) was on January 7, 2011. Ms. Agno admitted at Mariano Marcos Memorial Hospital & Medical Center at 2:00 AM of September 12. In the internal examination done by Dr. la Cuesta, her cervix

was soft, fully dilated and 100% effaced in a cephalic presentation. It reached the station +1 with LOA position. She was attended by Dr. La Cuesta and delivered via She had a right mediolateral episiotomy

Normal Spontaneous Vaginal Delivery. (RMLE) with episiorraphy.

The placenta was delivered spontaneously by Brant-

Andrews maneuver at 2:27 AM in a Schultz presentation. No abnormalities were seen on the placenta and the cotyledons were complete. She had a blood loss of <500 cc due to the episotomy, episiorraphy and placental delivery.

Analysis/Implication: Since the patient is a primipara, her expected duration for labor is 14 hours however she only had around 9 hours but it is still normal because the factors that helped for an easier and faster labor and delivery of the baby. The power of the patient while pushing helped in the faster descent and expulsion of the baby. The position of the baby is LOA which is the best position for delivery. The psychological response of the client which was her self-esteem and awareness that resulted to a shorter labor. The client also delivered a month before her EDC which implies that the patient was really not aware of her LMP because it is still considered normal when the delivery is two weeks before or two weeks after the EDC. As to the blood loss of less than 500 cc, it is just normal because the normal blood loss during delivery is 300-500 cc, thus no postpartal bleeding or hemorrhage occurred.

IV. Beliefs and Practices During Postpartum

According to the mother of the partner of Ms. Agno, they have beliefs and practices related to postpartum care. She conversantly said that one should smile when the placenta is flowing onto the river so that the baby will smile also. They also placed to the container of the placenta a pencil and paper so that the baby would become intelligent. The patient should not also take a bath in cold water. For the mother, they practiced her to eat soup such us horse radish (malungay) and even bittergourd to increase the milk production of the mother. They also inhibit the mother in eating

dumadara (a kind of fish) because the mother would experience shivering. Eating the meat of carabao is also prohibited because the mother would experience easy fatigue. They also believed that the newborn should be slapped on the buttocks so that the baby would not be easily frightened. They also practiced tanggad and sidor. They also believed that after delivery, the postpartal mother should not engaged to walkingon her first day postpartum and she should stay on her bed for rest gain energy. They will also go to the manghihilot to massage the mothers uterus so that it will go back to its original position.

Analysis/Implication: As to the beliefs and practices that the patients would be mother-in-law had enumerated, some of these beliefs have no scientific evidence but she told that they still believed on these because this is part of their culture. This implies that these beliefs

and practices on postpartal care are still widely practiced. In not taking cold bath, it is more preferably that it is good to take lukewarm water for it can help to remove microorganisms from her body and would make her relaxed and would not feel exhausted. Eating malungay and ampalaya can also increase the production of milk. As to not engaging the patient in ambulation on her first day of postpartum, this is in contrast that a postpartal mother should be encouraged to ambulate early after 4 hours of delivery for an NSD as this can help in the faster involution of the uterus and draining of the lochia. Not ambulating for the first day of postpartum can also lead to

thromboplebitis or sub-involution of the uterus.

V. Physical Assessment General Survey

Mrs. Eden Agno is in 5 hours postpartum. She was in bedrest activity, dressed with the hospital gown with pajama, exhausted appearance, uncombed hair and with a low voice. Her vital signs were taken as follows: BT: BP: PR: RR: 36.8 oC 100/70 mmHg 81 beats per minute 33 beats per minute

Head to toe assessment:

Hair and Scalp hair is dry hair evenly distributed no masses, depressions and tenderness noted scalp intact, moist and with no scars noted scalp slightly lighter than the faces color Face fair complexion of face face slightly edematous Able to pop out cheeks Able to raise and lower eyebrows eyebrows black Able to bare teeth Able to smile broadly Eyes eyes are black with equal palpebral fissure (non protruding) Eyebrows are black and evenly distributed Eyelids are symmetrical with no ptosis (meets completely when eyes are closed)

 Eyelashes are black, curved outward and evenly distributed Both conjunctivae are pale, moist and smooth Sclera is white Cornea is clear and smooth ( with no irregularities and with positive corneal reflex) Iris is black PERRLA Ears parallel and symmetrical auricle is slightly higher 10 degrees with the outer canthus of the eye with no lesions, masses or abnormalities noted Ear canal has no discharges or lesions Able to repeat the whisper word mama NOSE Color is the same with the face No lesions, masses or tenderness noted No redness, swelling Slightly low nose bridge Able to distinguish odors like alcohol and perfume

 Patent nostrils MOUTH AND THROAT Lips are pinkish in color with no swelling or inflammation 30 pearly white teeth Pinkish gums buccal mucosa, no swelling, no lesions Symmetrical movement of the soft palate Uvula located at the midline, hangs free Rugae present on the hard palate No redness, no swelling, no lesions, no masses Neck Color similar to the face able to extend, hyperextend, and move neck on both sides no masses or tenderness noted Chest/ Breast erect nipples dark brown areola soft upon palpation with a RR of 33 breaths per minute Abdomen Round abdomen

 striae gravidarum present fundus of the uterus is located at the level of the umbilicus uterus is well contracted, globular, firm and located at the midline Perineum moderate amount of lochial rubra and fleshy odor presence of clots edematous Upper Extremities Symmetrical With short clean nails nails are hard With good capillary refill of 2 seconds No involuntary movements Temperature is warm and even With full ROM -able to abduct, adduct, flex and resist the force which the examiner applied Lower Extremities Symmetrical

 with dead nail (thumb finger) at the right foot With good capillary refill of 2 seconds No jerky movements No edema noted Skin Temperature is cool to touch body temperature of 36.8 degrees Celsius diaphoresis noted Analysis/Implication: As to the physical assessment, the patient doesnt exhibit abnormalities or any abnormal behavior. Some changes such as diaphoresis, edema on the perineum,

having a lochia and firmness of the uterus on the level of umbilicus are ust normal for a postpartum patient.

VI. Nutrition, Elimination, Comfort Measures As to the dietary intake of Ms. Agno, she is in DAT (Diet as Tolerated). She eats crackers suck as skyflakes and cup noodles. She also ate all the hospital ration. She drinks hot water of almost 250 ml from the beginning of pospartal period. An IV Fluid of D5LR 1L at 870 ml remaining with incorporation of 10 U oxytocin on the left hand. She had not yet voided and defecates. She felt pain on her abdomen specifically at the level of umbilicus with a rating scale of 8/10, 10 being the highest. She managed it by

massaging and having in a prone position. She also rest by taking a nap but she claimed that sometimes she has difficulty in resting and sleeping. As to medications, she had not yet taken Mefenamic acid 500 mg TID as pain reliever.

Analysis/Implication: The patient is in DAT as this would help her fight for postpartal fatigue. As to the IVF infused with incorporation of oxytocin, this contributes for the contraction of the uterus and the patient can also help in warding off dehydration since the mother used lots of fluids during the labor and delivery. The pain that the patient experienced are afterbirth pains brought about by the strong contractions in the uterus and this is just normal for the first day of postpartum. The patient had difficulty in sleeping, however according to Perry (2010), the excitement and exhilaration experienced after birth of the infant may make rest difficult.

VII. Psychosocial Assessment Ms. Agno is on her first day of post partum. The patient is slightly pale and exhausted during the interview. She has a very soft and low voice and is shy during the conversation. She said that Nagrigat ti aganak, nagsakit ngem makapabang-ar idi nakitakon a rimuaren. She is very dependent and passive when it comes to her needs. She has an encouraging husband accompanied with her very supportive would be mother-in-law. Some of her relatives and friends take turn in visiting and watching her.

Analysis/Implication: The patient is on Taking in or Dependent phase wherein she is self-centered when it comes to her needs. She is sharing her experiences during her delivery. As to Reva Rubins postpartal phases, the mother is talkative and verbalizes her experiences during the delivery. Her primary concerns are with her own needs. As to Mercers maternal role attainment, the patient is on anticipatory phase as she prepares her responsibility of being a mother to her child. The patient is starting to breastfeed the baby, changes the diapers and even trying to communicate with him. The presence of a support system like her husband, would be mother-in-law and other relatives is a great factor in gaining her self-esteem.