A

CARE STUDY

ON

NORMAL SPONTANEOUS VAGINAL DELIVERY

SUBMITTED TO:

MS. MARIA LOWELA V. ELOPREBSN LEVEL III CLINICAL INSTRUCTOR

CONSOLASCION LYING-IN

In Partial FullfilmentOf The Requirements In The Subject:

NCM 501201-A

SUBMITTED BY:

RICHARD B. TANUCOStudent

BSN Level III Section N

T A B L E O F C O N T E N T S

I. INTRODUCTION..............................................................................1

II. GENERAL DATA...............................................................................2

III.HISTORY OF PRESENT ILLNESS................................................22

IV. PAST HEALTH HISTORY...............................................................2

V. FAMILY, PERSONAL , SOCIAL AND ENVIRONMENTAL HISTORYA. MEMBERS OF THE FAMILY.....................................................4

B. PERSONAL AND SOCIAL HISTORY..........................................4

C. ENVIRONMENTAL HISTORY...................................................4

D. HEREDO-FAMIAL HISTORY......................................................4

VI. A. ANATOMY AND PHYSIOLOGY OF THE SYSTEM INVOLVED.........5-7

B.DISCUSSION OF THE PHYSIOLOGY.................8

C.SYMPTOMATOLOGY.............................................9.

VII. MEDICAL MANAGEMENT........................................10

A. TREATMENT AND PROCEDURES.......................10

B. MEDICATIONS.....................................................10

C.DIET.......................................................................10

VIII. NURSING MANAGEMENT....................................11A. ACTUAL GIVEN............................................11

B. PROBLEMS ENCOUNTERED DURING THE IMPLEMENTATION OF NURSING CARE.............................................................11

C. RESTORATIVE MEASURES USED.........................11

D. EVALUATION.................................................11

E. PATIENTS TEACHING..............................11

IX. A. CONCLUSION...............................................12. B. RECOMENDATION...........................................12

X. IMPLICATIONS OF THE STUDY TO:

A. NURSING EDUCATION.............................12

B. NURSING PRACTICE....................................12. C. NURSING RESEARCH .........................................12.

APPENDICES: APPENDIX A: PERMIT LETTER

APPENDIX B: NURSING CARE PLAN

APPENDIX C: DISCHARGE PLAN

APPENDIX D: DRUG STUDY

APPENDIX E: IVF STUDY

BIBLIOGRAPHY

I. INTRODUCTION:

Postpartum complicationsThe postpartum period is the time immediately after a woman delivers her baby. It is the time when the mother's body is changing back to the non-pregnant state. It lasts approximately 6 weeks or until the reproductive organs return to normal size. During the postpartum period, a woman can expect a variety of symptoms ranging from physical discomfort to emotional upsets.

Feeling overwhelmed with the responsibility of caring for an infant is a normal postpartum symptom. Other emotions may include sadness, feeling helpless, and a "let down" feeling. Discomfort in the perineum (area between the rectum and vagina) is expected and may cause difficulty with sitting or walking. It is common for the breasts to be swollen and painful. The new mother may feel tired, experience hot flashes and sweating, and may be constipated. A woman may also have a reduced interest in sex for up to 6 months after childbirth. All these symptoms are normal, a temporary reaction to childbirth.

There are symptoms that are not normal and may be considered postpartum complications. Contact your healthcare provider immediately if one of more of these symptoms develop:

temperature of 100.4 degrees Fahrenheit (38 degrees Centigrade) or greater chills nausea or vomiting moderate to strong abdominal or back pain that is more than just an ache increased pain, swelling, redness, or drainage from the episiotomy or C-section incision bleeding through more than one pad per hour blood clots the size of a plum a foul smelling vaginal discharge chest pains increasing tenderness in the lower abdomen red, warm to the touch, painful breasts burning when urinating or blood in the urine a severe headache in the forehead and behind the eyes, accompanied by extreme pain while

sitting or standing feeling depressed or blue for more than 3 days severe weakness extreme paleness or a rapid, racing pulse

Treatment for complications varies depending on the source of the problem. Infection usually responds to antibiotic treatment. Other special medications and procedures are available for treating postpartum problems.

A new mother who experiences one or more of these symptoms should contact her provider immediately.

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II. GENERAL DATA

HOSPITAL: Consolascion lying-in

PATIENTS NAME: Estrella Manatad

ADDRESS: Riles Basak, Mandaue City

AGE: 34

SEX: Female

OCCUPATION: Housewife

HUSBAND'S NAME: Crisroy Manatad

HUSBAND'S OCCUPATION: Constraction Worker

CIVIL STATUS: Married

RELIGION: Roman Catholic

CITEZENSHIP: Filipino

LMP: 11-16-08

EDC: 8-23-09

MENARCHE: 13 yrs.old

AOG: 38 weeks

HIGHEST EDUCATIONAL ATTAINMENT: High School Graduate

III. HISTORY OF PRESENT ILLNESS

Client X doesnt experienced any illness. Furthermore, the latter only experience pain of labor specifically, pain felt at the abdomen. Client was also experienced signs of true labor. According to her, she experienced frequent uterine contractions, breast enlargement and some discharges.

IV. PAST HEALTH HISTORY

Client had experienced fever. She had no past records in the hospital. Negative in allergies on foods and drugs. For her childhood illness she had experienced colds, cough and fever. Paracetamol are the usual drugs they used for treating fever. Client also didnt experienced any injuries in the past. She had been able to had immuniation when she was a child.

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V. NURSING REVIEW OF SYSTEM

CENTRAL NERVOUS SYSTEM

Client experienced headache after giving birth. She doesnt take any pain reliever because she stated that it is manageable. She just take a rest to diminished the pain felt in the head.

EENT ( EYES, EARS, NOSE & THROAT)

Client does'nt complain any abnormalities and pain in her eyes, nose , ears, and throat. She just felt itchy on her nose.

ENDOCRINE SYSTEM

Client does'nt had any complains . Hence, se does'nt had enlargement on her lymph nodes and does not had graveyards disease.

GASTROINTESTINAL SYSTEM

The client experienced thirst and hungry after giving birth to his baby. She felt stomace ache if she doesnt take her meals. She does not deficate after she give birth.

MUSCULOSKELETAL SYSTEM

Client just felt fatigue and pain felt at the lower extremities after a several minutes at lithotomy position while the delivery is n going. She was taking mefenamic acid to minimized the pan she felt.

GENITO-URINARY SYSTEM

Client had not urinating for an hour after she delivered. She started menstrating when she get 13 yrs. Old. And menstrate regularly without any dysmenorhea felt.

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VI. FAMILY,PRSONAL, SOCIAL AND ENVIRONMENTAL HISTORY

MEMBERS OF IMEDIATE FAMILY

NAME SEX AGE GEN. HEALTH STATUS

POSITION IN THE FAMILY

EDUCATIONAL BACKGROUND

CRISROY MANATAD

MALE 36 YRS. OLD

HEALTHY HUSBAND HIGH SCHOOL GRADUATE

CHRISTIAN MANATAD

MALE 5 YRS.OLD HEALTHY ELDEST SON KINDER 2

MARK JAY MALE 3 YRS.OLD HEALTHY 2ND SON NOT YET IN SCHOOL

JOHN CLIFFORD

MALE 2 YRS.OLD HEALTHY 3RD SON NOT YET IN SCHOOL

BABBY GIRL FEMALE 2DAYS OLD

HEALTHY YOUNGEST DOUGHTER

NOT YET IN SCHOOL

PERSONAL AND SOCIAL HISTORY

Client x is a married, 34 yrs.old and married. She was just a high school graduate and did not able to proceed in college. During his pregnancy, she was able to continue his usual activities and continue to met her friends and neighboor. She also send his eldest son to school and get her child from school. She oually get to sleep after she watched televesion and preparetheir foods. Before she get sleep she make sure that she is clean and maintain proper hygiene. She knows how to speak tagalog and speak mostly on cebuano and a little comprehension on english dialect

ENVIRONMENTAL HISTORY

Client house is located at Riles Basak, Mandaue City. The place is near the Fatima Parish. As the table shown above, she had 4 children. Their family lie in a semi-concrete house and not fully furnished, located near the highwa and about 3minutes walk going to the church. Regularly, they dispose their waste in the garbage can and collected by the bargy. Workers every week.

HEREDO-FAMILIAL HISTORY

Their common family illness is asthma. Her father had asthma until now.

VII.ANATOMY AND HYSIOLOGY OF THE SYSTEM INVOVLED:

FEMALE REPRODUCTIVE SYSTEM

The female reproductive system is designed to carry out several functions. It produces the female egg cells necessary for reproduction, called the ova or oocytes. The system is designed to transport the ova to the site of fertilization. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The next step for the fertilized egg is to implant into the walls of the uterus, beginning the intitial stages of pregnancy. If fertilization and/or implantation does not take place, the system is designed to menstruate (the monthly shedding of the uterine lining). In addition, the female reproductive system produces female sex hormones that maintain the reproductive cycle.

During menopause the female reproductive system gradually stops making the female hormones necessary for the reproductive cycle to work. When the body no longer produces these hormones a woman is considered to be menopausal.

What Parts Make-up the Female Anatomy?

The female reproductive anatomy includes internal and external structures.

The function of the external female reproductive structures (the genital) is twofold: To enable sperm to enter the body and to protect the internal genital organs from infectious organisms. The main external structures of the female reproductive system include:

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Labia majora: The labia majora enclose and protect the other external reproductive organs. Literally translated as "large lips," the labia majora are relatively large and fleshy, and are comparable to the scrotum in males. The labia majora contain sweat and oil-secreting glands. After puberty, the labia majora are covered with hair.

Labia minora: Literally translated as "small lips," the labia minora can be very small or up to 2 inches wide. They lie just inside the labia majora, and surround the openings to the vagina (the canal that joins the lower part of the uterus to the outside of the body) and urethra (the tube that carries urine from the bladder to the outside of the body).

Bartholin's glands: These glands are located next to the vaginal opening and produce a fluid (mucus) secretion.

Clitoris: The two labia minora meet at the clitoris, a small, sensitive protrusion that is comparable to the penis in males. The clitoris is covered by a fold of skin, called the prepuce, which is similar to the foreskin at the end of the penis. Like the penis, the clitoris is very sensitive to stimulation and can become erect.

The internal reproductive organs in the female include:

Vagina: The vagina is a canal that joins the cervix (the lower part of uterus) to the outside of the body. It also is known as the birth canal.

Uterus (womb): The uterus is a hollow, pear-shaped organ that is the home to a developing fetus. The uterus is divided into two parts: the cervix, which is the lower part that opens into the vagina, and the main body of the uterus, called the corpus. The corpus can easily expand to hold a developing baby. A channel through the cervix allows sperm to enter and menstrual blood to exit.

Ovaries: The ovaries are small, oval-shaped glands that are located on either side of the uterus. The ovaries produce eggs and hormones.

Fallopian tubes: These are narrow tubes that are attached to the upper part of the uterus and serve as tunnels for the ova (egg cells) to travel from the ovaries to the uterus. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The fertilized egg then moves to the uterus, where it implants to the uterine wall.

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Mammary Glands: Mammary glands, which are part of the breasts, are very high modified suderiferous (sweat) glands, which appear in mostly all vertebrates, but are developed in their own ways. The glands are also somewhat different from species to different animals. Each mammal may secrete milk in different ways when they produce it. All of these organs are major and critical parts of the female reproductive system. They are housed internally within the body. These organs work together to help the ovaries release the egg follicle which is then either implanted in the uterus or is sloughed out. Humans are the only mammal to have enlarged breasts when they are not lactating. This is due to the large content of fat (adipose tissue) contained in a breast surrounding the mammary gland.

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VII, PATHOPHYSIOLOGY OF THE PRESENT CONDITION

Ovulatory Phase

The ovulatory phase, or ovulation, starts about 14 days after the follicular phase started. The ovulatory phase is the midpoint of the menstrual cycle, with the next menstrual period starting about 2 weeks later. During this phase, the following events occur:

The rise in estrogen from the dominant follicle triggers a surge in the amount of luteinizing hormone that is produced by the brain.

This causes the dominant follicle to release its egg from the ovary. As the egg is released (a process called ovulation) it is captured by finger-like projections on the

end of the fallopian tubes (fimbriae). The fimbriae sweep the egg into the tube. Also during this phase, there is an increase in the amount and a change in the consistency of

mucus produced by the cervix (lower part of the uterus.) If a woman were to have intercourse during this time, this receptive mucus captures the man's sperm, nourishes it, and helps it to move towards the egg for fertilization.

Luteal Phase

The luteal phase begins right after ovulation and involves the following processes:

Once it releases its egg, the empty follicle develops into a new structure called the corpus luteum.

The corpus luteum secretes the hormone progesterone. Progesterone prepares the uterus for a fertilized egg to implant.

If intercourse has taken place and a man's sperm has fertilized the egg (a process called conception), the fertilized egg (embryo) will travel through the fallopian tube to implant in the uterus. The woman is now considered pregnant.

If the egg is not fertilized, it passes through the uterus. Not needed to support a pregnancy, the lining of the uterus breaks down and sheds, and the next menstrual period begins.

How Many Eggs Does a Woman Have?

During fetal life, there are about 6 million to 7 million eggs. From this time, no new eggs are produced.

The vast majority of the eggs within the ovaries steadily die, until they are depleted at menopause. At birth, there are approximately 1 million eggs; and by the time of puberty, only about 300,000 remain. Of these, 300 to 400 will be ovulated during a woman's reproductive lifetime. The eggs continue to degenerate during pregnancy, with the use of birth control pills, and in the presence or absence of regular menstrual cycles.

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IX.SYMPTOMATOLOGY

THIRD STAGE OF LABOR

Stage three begins with the birth of the baby and ends at the delivery of the placenta. A time frame of 5 to 20 minutes is considered as normal for both primi and multiparas. Signs that indicate that the placenta is separiting from the uterine wall consist of:

GUSH OF BLOOD

LENGTHENING OF THE UMBILICAL CORD

GLOBULAR SHAPE OF THE FUNDUS

The placenta is delivered spontenously of the two mechanisms. Expulsion by shultzes mechanism, indicates that the fetal or the shiny part delivered first. Delivery by duncan mechanism, specifies that the maternal or the roughy side delivered first.

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X. MEDICAL MANAGEMENT

A. TREATMENT AND PROCEDURES

VITAL SIGNS TAKING

Closely monitored to be able to have time to time basis of what our client been felt internally.

TEMPERATURE: PULSE RATE RESPIRATORY RATE:

BP. :

MOTHER 36.9 degree celcious 66 bpm. 22 cpm. 100/80 mmHg

BABY 36.7 degree celcious 138 bpm. 68 cpm

ADMINISTERING ORAL MEDICATION

Medication is given to the client as ordered by the physician. As to the setting, normally the midwife give medication that are independent , such as mefenamic acid, amoxicillin, ferrous sulfate and methergine. Each drugs has its own specific effects on the clients body.

PERINEAL CARE

Perineal care is done during the labor starts. Its the method that cleanse the perineum after the various obstetric and gynecologic procedures. It is practiced to removed secretion or dried blood and prevent contamination of urethral and vaginal areas.

We performed his procedures before doing internal examinaton and when there is gush of blood came out or even if theres feces also.

DIET

During the labor the client is instructed not totake anything by mouth (NPO- nothing per orem). This is so that the patient will not defecate as the labor goes on.

Right after the delivery, the client is allowed to eat so she can regain her energy.

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XI . NURSING MANAGEMENT

ACTUAL CARE GIVEN

As the student nurse to my client I was able to give proper nursing care such as getting vital signs every 15 mins for 2 hous and every 30 minutes for the following hours for both mother and baby. I assist her for ambulation and encourage her to take her medications exactlyand followed the instruction given. And lastly, I was able to teach my client the proper ways in breastfeeding her child so that she can performed it without any fear.

PROBLEM ENCOUNTERED DURING THE IMPLEMENTATION OF NURSING CARE

As far as my concern, my client does'nt encountered any problem as I give my nursing care for as long as she follow what is the proper care for both her and to the baby.

RESTORATIVE MEASURES USED

Client x delivered her child vaginallyand does'nt had any incisions. My restorative measures that I implemented was to check her vtal signs, monitor intake and output of her and to the baby, and to make sure that she take her medication accordingly.

EVALUATION

Client x is very thankfull to thestaff and to the student nurses that help her in managing herself and the baby in the hospital. She also appreciate the effort of the staff in providing her anything she wanted and giving her right medications. She learned a lot and willing to apply it outside the premises of the hospital.

PATIENT TEACHING

Client was able to learned proper breastfeeding technique. She was also tought on the pros and cons of the latter. She was also reminded on proper hygiene to her and to the child so that she can assure to be healthy for as long as she implemented what we taught to her. I also include to have regular consultation to the nearest health center to monitor the recovery and the come back of her normal vital signs.

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XII.CONCLUSION AND RECOMENDATION

CONCLUSION

In this study, it really proof that knowledge is a power for it really help individual to make appropriate actions and interventions that can be applied to each specific objectives with a specific rationale so that people whom gonna read this work will be able to comprehend and understand what im talking about especially caring this kind of client so that others will be guided on what to do and what would be the priority action to be done. May this work of mine can help us health care providers on what is the proper and exact ways on ealing our clients problem so that it is easy for us to make specific action for them.

RECOMMENDATION

The care study is a requirement for us nursing student to be able to proceed to the next level. I tell you this work is not easy to make and need enough time . We must put in our mind that we need to have this work be the best and give all of us in makingit. My recomendation is just, we must give enough time to make this and must have time management so that we can pass this work with confidence and to get high grades.

XII. IMPLICATION OF THE STUDY TO:

NURSING EDUCATION

This study implicates what are the proper ways on treating specific problem concerning to our patient and to promote good health among our client. Furthermore, this study is the best way to show our unique ability to solve those problem that are difficult to solve with the help of many resources.

NURSING PRACTICE

As a nurse in the future, this study that we conducted really a great tool for us to build more knowledge, skills and positive attitude towards our work.

NURSING RESEARCH

This study I made , i consudered it as a research becouse it show what are the common experienced pregnant mother had.

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APPENDIX

PERMIT LETTER

August 10,2009

MRS. MERCY MILAGROS B. APUHIN Chairman, BSN level 3University of Cebu- BaniladCollege of NursingBanilad, Cebu City

Dear Mrs. Apuhin,

In connection to the completion of the requirement of the subject, NCM 501201-A Related Learning Experience, may I ask permission from your good office to take the case of MANATAD, ESTRELLA, female, 34 years old, a resident of RILES BASAK, MANDAUE CITY, and is diagnosed of pregnancy uterine full-term delivered baby girl through normal spontaneous vaginal delivery, as a subject of nu MCN Care Study.

I am hoping for your kind consideration.

Thank you very much.

Very respectfully,

Mr. Richard B. TanucoBSN 3- A STUDENT

Noted By:

Ms. Maria Lowela V. ElopreClinical instructorConsolacion, Lying-In

Ms. Cindy PaoAdviser

Approved By:

Mrs. Mercy Milagros B. Apuhin

Chairman, BSN Level 3UC-Banilad, College of nursing

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