College of Nursing
4400, Ateneo Ave., Bagumbayan Sur Naga City
RLE Group 1:
I.
INTRODUCTION
Pregnancy is a state which happens when an egg gets fertilized by the sperm, implants on the
uterus, then soon develops into the placenta, and embryo, and later into a fetus. It usually lasts for 38-40
weeks of gestation, thats starts from the first day of the last menstrual period (LMP), and is divided into
three trimesters, each lasting for three months. It can be indicated by positive urine test (PT), and can be
confirmed by blood test, ultrasound, fetal heart tone.
Delivery is defined as the extraction or expulsion of the fetal membrane at birth when gestation has
completed. We have two types of Delivery. The Cesarean Section involves the surgical incision of a
mothers abdomen and uterus to extract one or more fetuses; NSVD or Normal Spontaneous Vaginal
Delivery is the delivery of the fetus through the vaginal route.
The focus of this presentation is for a patient that has undergone NSVD with Right Mediolateral
Episiotomy (RMLE), the surgical incision of the mediolateral portion of the perineum during chilbirth to
facilitate delivery. As a requisite for the course, this aims to briefly discuss Pregnancy, Child Delivery
Process particularly with the case aforementioned, and the Nursing Process relative to OB clients.
In respect to the patients right to confidentiality, let us keep her name private and address her by
the pseudonym initials, AD.
To give a brief background on the client, AD is a 27 year old marketing associate currently residing in
Dayangdang Naga City. She is married for 9 years and was expecting to deliver her first child. Morning of
September 25, 2015 at exactly 9:33, Client AD was admitted to the hospital for the complaint of severe
abdominal cramps that radiates to the back down to the perineum. Records state that she was currently on
her 39-40 Gestation week whos about to give birth.
II.
Definiton of Terms
Suture - the line of junction or an immovable joint between two bones, especially of the skull. The process
of joining two surfaces or edges together along a line by or as by sewing. The surgical method used to
close a wound or join tissues.
Episiotomy also known as perineotomy , is a surgical incision of the perineum and the posterior vaginal
wall generally done by a midwife or obstetrician during second stage of labor to quickly enlarge the
opening for the baby to pass through.
Right Medio-lateral episiotomy begins at the vaginal opening in the midline with the incision directed
toward the right buttocks at a 45- degree angle the main advantage of the medio lateral episiotomy is
that it is less likely to extend into or involve the anal sphincter and the rectum.
Labor childbirth, the process of delivering a baby and the placenta, membranes and umbilical cord from
the uterus to the vagina to the outside world. During the first stage of labor ( which is called dilation), the
cervix dilates fully to a diameter of about 10cm (2 inches).
Spontaneous vaginal delivery- occurs when a pregnant female goes into labor without the use of drugs
o techniques to induce labor and delivers her baby in the normal manner, without forceps, vacuum
extraction, or a caesarean section.
III.
Patient AD was born on November 6, 1987 in Legazpi Albay. She no longer have patients, instead
shes living with her uncle who is her guardian. At the age of 17, she met her husband who was courting
her that time. When she was about to graduate from her two year secretarial course, he proposed
marriage to her at the age of 18. They had civil wedding, and then she continued her studies until she
graduated. On their first two and a half years of marriage, they still live in legazpi. When her husbands job
was no longer stable, theyve decided to move to Naga City. She was able to find a job at SM while her
husband move from one job to another. For almost seven years, they are living in Dayangdang renting a
place.
From the time they lived together, the couple used the calendar method and withdrawal as their
method of birth control. When she was 25 years old, they wanted then to have a baby but they were
having difficulties for almost 3 years.
Patient AD then applied to go to work in Kuwait, but during the time when she was about to have her
last medical examination, her husband wanted her to take a pregnancy test. It was her husbands way of
making sure that she wasnt leaving the country pregnant. She took his advice, and after taking the
pregnancy test she wasnt hopeful to get a positive result because theyve been trying to conceive a child
for almost 3 years and failed to do so. She was preventing herself from making any false hope regarding
her pregnancy. Patient AD then placed the pregnancy test kit on the table and left before seeing the result.
When it was her husbands turn to look at the pregnancy test, he saw red lines on the kit which
made him pause for a moment. He couldnt hide his feeling of being overjoyed right after finding out about
the result.
After 2 days of finding the positive result the couple wanted to be 100% certain so she visited an OBGyne last January 2015 for 1st check-up. It was confined by her OB-Gyne that shes indeed pregnant. On
her first month, however, she observed brown discharge and had another check-up. Her doctor was her
physician for the first two months of her pregnancy, then she changed to visiting BMC-OPD monthly during
her third month and onwards.
During her first trimester she had small frequent feeding. Patient AD dislikes eating rice and meat,
but she prefers eating fruits and vegetables.
IV.
Frameworks are used to accurately gage a patient health. They are a systematic way of collecting
objective and subjective data to establish a plan of care for the patient. Health care professionals must
continually observe the patients subjective and objective data in can act upon them to achieve the best
possible outcome for the patients wellbeing.
The categories of Gordons functional health patterns include health perception and health
management, nutrition and metabolic assessment, elimination, activity and exercise, and cognition and
perception. Additional areas of the assessment include sleep and rest, self-perception and self-concept,
roles and relationships, and sexuality and reproduction. The final categories of Gordons functional health
pattern assessment covers coping and stress tolerance and values and belief.
Assessment is the first step in the nursing process. It involves the collection, verification,
organization, interpretation and documentation of data collected during the process. Subjective data and
objective data are collected during the assessment process. Subjective data includes information such as a
clients feelings, perceptions and concerns. Objective data includes measurable variables obtained via
observation, physical examination and diagnostic tests.
Interviewing patients by asking questions is a common assessment tool. Open-ended questions are
used to collect detailed information about a problem or concern. Closed-ended questions are answered
with a yes, no or short answers. This questioning tactic provides specific and targeted information.
Assessment is the first step in the nursing process. It involves the collection, verification,
organization, interpretation and documentation of data collected during the process. Subjective data and
objective data are collected during the assessment process. Subjective data includes information such as a
clients feelings, perceptions and concerns. Objective data includes measurable variables obtained via
observation, physical examination and diagnostic tests.
Interviewing patients by asking questions is a common assessment tool. Open-ended questions are
used to collect detailed information about a problem or concern. Closed-ended questions are answered
with a yes, no or short answers. This questioning tactic provides specific and targeted information.
Gordons
Functional
Pattern
Before Hospitalization
During Hospitalization
Health
-Patient highly regards her health -Patient highly regards her health because she
Health
Perception- because she believes that if she believes that if she doesnt take care of herself
Health Management doesnt take care of herself it will it will reflect on the babys health but it has
Pattern
reflect on the babys health.
grown stronger because she is aware that shell
be giving birth to her first baby.
-The patient filed a maternal leave
because she believes that it would -The patient is still in a maternal leave.
be best for her state.
-Patient on the first trimester dont -Patient eats the rationed food in the hospital.
want to eat rice and meat rather,
Nutritional-Metabolic she prefers to eat fruits and
Pattern
vegetables only.
-She regained her appetite during
the mid-second trimester.
-Still diaphoretic
Elimination Pattern
-Diaphoretic
-Patients way of exercising is -Limited
movement
walking, more or less 1 hour per day contractions
ActivityPattern
due
to
frequent
Exercise
-Spends
spare
time
watching
television and surfing the internet
miscarriage
-The woman and her partner still
engage in coitus during second
trimester and early-third trimester.
-The woman and her partner
stopped engaging in coitus on the
third trimester because she has
limited ROM
Sleep-Rest Pattern
-The woman has an adequate rest -The patient wants to sleep and felt tired
because of the maternity leave she because of the contractions.
filed.
communication.
-Patient is still adjusting to her new
job
-Income of family is sufficient for
their needs, especially for the
delivery of the baby
- The woman saw changes in her - The patient saw changes in her body and she
Self Perception Self body and she positively accepted it
positively accepted it
Concept Pattern
-She is easily annoyed by the fact
that her husband gets stressed out
by his current job
-The woman easily and positively -The patient easily and positively accepted the
Coping
Stress accepted the fact that she is fact that she has a baby
Pattern
pregnant
-She again directed her attention in good
-She usually directs her attention in thoughts like having her first moments with her
good
things
whenever
shes baby whenever she feels the contractions
stressed
-The woman wears scapula because strongly believes that Mama Mary will be there
she strongly believes that Mama to guide her during the delivery of the baby
Mary will be there to guide her
during the delivery of the baby
V.
REVIEW OF SYSTEM
Physical examination allows a methodical head to toe format. This is done systematically using inspections
palpations, percussion, and auscultation.
The ears are symmetrical, without ear wax. She has no difficulty in hearing and no pain was felt upon
palpation of the ears. There is pinnal retraction.
G. Assessment of the throat:
The throat is at the midline, and there is no pain felt by the patient during palpation. There is an
absence of dysphagia.
H. Neurological Assessment :
Behaviour Patient seems agitated.
Reflexes - Blinking reflex is present
Sensory functioning- She was able to feel the touch and pain, and distinguish hot and cold.
I. Integumentary Linea negra is present, striae gravidarum at the abdominal are present.
VI.
Lab test
CBC
it
gives
information on a number
of
haematological
parameters,
but
generally in pregnancy
the most useful are the
haemoglobin,
platelets
and WBC count.
Result
A. RBC 4.77
cells/mm3
B. WBC
30.90
cells/mm3
C. PLATELET
338
D. HGB 11.8
Normal
Value
4-5.3
cells/mm3
Interpretation
Red blood cells carry oxygen from the lungs
to the rest of the body. If the RBC count is
low (anemia), the body may not be getting
the oxygen it needs. If the count is too
high\9a condition called polycythemia),
there is a chance that the red blood cells
will clump together and block tiny blood
vessels (capillaries).
20-30
cells/mm3
146-429
gm/dl
I.
Mrs. AD subjected herself to complete blood count as requested by the doctor. To serve as one of
the basis if the mother is set for delivery. This test will serve as a basis to determine the
implications of both positive and negative result and risk of disease transmission to the fetus.
II.
CBC it gives information on a number of haematological parameters, but generally in pregnancy
the most useful are the haemoglobin, platelets and WBC count.
A. Very low or high haemoglobin levels- This is associated with increased fetal risk. Gestational
age should be taken into account when assessing hemoglobin as levels decrease during
pregnancy. The lower limit for hemoglobin is usually 115 g/L, but for pregnant woman the
lower limit is usually 100g/L.
B. Iron deficiency anemia It is the most frequent haematological concern during pregnancy and
is usually characterized by decreased hemoglobin, mean cell volume (MCU) and mean cell
hemoglobin (MCH) levels.
C. Changes in platelet levels it is frequently seen during pregnancy. A decrease in the platelet
count is more common than an increase and must obvious in women who had low levels prior
to becoming pregnant. Plateletsuduslly decrease as a result of hemodilution , and this can
become pronounced as pregnance progressive from the second to third trimester. Elevated
platelets levels during pregnancy are generally a reactive response to the pregnancy and do
not usually suggest a clinical problem.
D. Total white cell number it will frequently be elevated in pregnancy due to increased numbers
of neutrophils. The total WBC can also be misleading in pregnant woman and should be
interparted with care.
VII.
DRUG STUDY
Medication Ordered,
Drug Classification,
Description
Oxytocin
Classification: Uterineactive agent
Description: Injection Of
oxytocin may be used to
strengthen uterine
contractions during labor,
to contract uterine muscle
after delivery of the
placenta and to control
postpartum hemorrhage. It
must be administered w/
care to avoid trauma to the
Indication, Action,
Dosage, and
administration
Action:
Contraction of the womb
(uterus) during childbirth. It
stimulates the uterine
muscles to contract and also
increases production of
prostaglandins which
increase the contractions
further.
Stimulate muscular
contractions of the uterus &
milk flow during nursing.
Side Effects,
Adverse Effects,
Contraindications
Nursing Considerations
Side Effects:
Uterine rupture, Fetal
death, Arrhythmias,
Anaphylaxis, H20
Intox.
Before administering
oxytocin to the parturient,
make sure that theres no
2nd baby still in the uterus
or all the baby or fetus is
expelled from the uterus.
Monitor Vital Signs; Nasal
form for breast feeding
only.
mother or infant by
hyperactivity of uterine
muscles during labor.
Oxytocin also may be
administered intravenously
by slow drip or applied to
mucous membranes of the
nasal cavity to be absorbed
into the bloodstream.
Dosage:
0.0005-0.001 units/min IV
inf; titrate 0.001-0.002
units/min q30-60 min.
Breast Feeding: 1 spray in
both nostrils 2-3 min before
feeding.
Administration:
Administered through IV
incorporation in D5Lr and IV
injection.
Date
09/25
Day
1
Time
9:00-9:50
Intervention
Pt wheezed to the DR
V/S taken
v/s- BP 110/90
Positioned
patient
in
dorsal lithotomy
Cleaned the perineal area
of the PT with antiseptic
solution
Encouraged
relaxation
technique
e.g. Deep breathing
Encourage PT. to push
simultaneous
to
the
contraction
Controlled
cord
traction
with
counter traction
IX.
Massage uterus
Prepared equipments for
episioraphy
Assisted in episioraphy
Washed perineum with
water
Changed patients clothes
and promote rest
The VAGINA
- The vagina is a muscular, ridged death connecting the external genitals to the uterus,
where the embryo grows into a fetus during pregnancy. In the reproductive system,
the vagina functions as a two-way street, accepting the penis and sperm during
intercourse and roughly nine months later, serving as the venue of birth through
which the new baby enters the world. Chadwicks sign is present.
The CERVIX
-
The cervix located at the lower portion or neck of the uterus has dual reproductive
functions. After intercourse, the sperm ejaculated in the vagina pass through the
cervix then proceed through the uterus to the fallopian tubes where if a sperm meets
an ovum, conception occurs. The cervix is lined with mucus 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,
making it difficult for the sperm to reach the fallopian tubes.
But when the egg is ready for fertilization and estrogen levels are high, the mucus then
becomes
thin
and
slippery, making it easier for the sperm to enter the ovum. A mucus plug called operculum is
formed
to
seal
out bacteria and prevent infection to the fetus and its membrane. Goodells sign is present.
The UTERUS
- The uterus or also known as the womb is the major female reproductive organs. 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 length of the uterus grows approximately 6.5cm to 32cm, the depth increases from
2.5cm to
1000g.
22cm, width expands to 4cm to 24cm, and weight increases from 50g to
The OVARIES
- 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
menstrual
cycle.
After ovulation, the ovum is captured by the oviduct, where it travelled down the
oviduct to the uterus, occasionally being fertilized on its way by an incoming sperm,
leading to pregnancy and the eventual birth of a new human being.
X.
PHYSIOLOGIC MECHANISM
LABOR
FIRST STAGE
SECOND
THIRD STAGE
EFFACEMENT
AND
BIRTH OF THE
PLACENTAL
DELIVERY
MECHANISM
OF LABOR
PLACENTAL
SEPARATION
PLACENTAL
EXPULSION
DESCENT
FLEXION
INTERNAL
EXTENSION
EXTERNAL
EXPULSION
XI.
Assessment
Subjective
Data:
Diagnosis
Acute pain
related to
Rationale
Unpleasant
sensory and
Planning
After 15 - 45
minutes of
Intervention
Independent
Rationale
Evaluation
After 15 -30
minutes of
Makulugon
sobrang kulog
halat lang po
ta makulugon
as verbalized
by the patient
Objective
Data:
Pain scale:
10/10
Facial
grimace
noted
Excessive
perspiratio
n observed
Moaning
heard.
disruption of
skin tissue
and muscle
integrity.
emotional
experience
arising from
actual
tissue
damage.
nursing
intervention the
patient would be
able to gain
optimism and
will demonstrate
use of relaxation
techniques and
other methods
to promote
comfort.
Teach focused
breathing.
Give positive
regard
This will
encourage the
patient to be
more focus and
reduce the level
of anxiety.
Teach proper
pushing.
nursing
intervention
the patient
was able to
gain optimism
and
demonstrated
use of
relaxation
techniques and
other methods
to promote
comfort such
as focused
breathing.
abdomen.
Perform uterine
massage
Dependent
Administer
analgesics as
ordered by the
doctor
Assessment
Subjective
Data: Pano po
Diagnosis
Knowledge
deficit
Rationale
To make
informed
Planning
After 15 30
minutes of
Intervention
Assess
patients
Rationale
Evaluation
To determine (Met) After 15
readiness to 30 minutes, the
pano po first
time ko po
kaya as
verbalized by
the patient.
Objective
Data:
Disturbed
attention
noted
G:1
T:1
P:1
A:0
L:0
M:0
related to
primigravida
.
choices
regarding
condition.
nursing
intervention the
patient would be
knowledgeable
about proper
techniques during
delivery.
ability to
focus during
delivery.
Teach patient
proper
breathing.
Teach pt to
push while
having hard
contraction
learn and
individual
learnings
during
delivery.
This will
provide
proper
ventilation
This will help
the patient
to have an
easy
delivery
patient gained
knowledge
about proper
techniques
about delivery.
Assessment:
Objective:
Normal
Spontaneou
s Delivery
with Right
Mediolatera
l Episiotomy
Diagnosis:
Risk for
infectio
n
related
to
episioto
my and
lacerati
on.
Rationale:
At risk for
being
invaded
by
pathogen
ic
organism
s.
Planning:
After a
day of
patient
stay in
the
hospital
,
the
patient
is risk
for
infectio
n
will
be
reduce
d.
Implementatio Rationale:
Evaluation:
n:
Noted
risk To
assess Met: after
factors
for
causative/contrib
a day of
occurrence
uting factors.
patients
To
reduce
of infection.
stay in the
Emphasized
hospital
existing
risk
the
proper
use
factors.
patients
To minimize the
of PPE.
risk
for
Recommend
transmission of
infection
ed
body
viral diseases.
was
reduce
shows or to To
reduced.
take a bath.
bacterial
Advised
infection and to
patient
to
alleviate
the
perform
healing process
perineal care
of laceration and
as often as
episitomy.
needed.
Advised
patient
to
use
betadine
feminine
wash.
XII.
BIBLIOGRAPHY
Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing & Childbearing Family Volume 1.
Lippincott William & Wilkins. 2014
www.yourhormones.info/hormones/oxytocin.aspx
medicaldictionary.thefreedictionary.com/oxytocin
nursingceu.com