A

Care Study

ON

CESAREAN SECTION WITH CHORIOAMNIONITIS

Submitted to:

Ms. Rhysyl M. Gealon

BSN II Clinical Instructor
VICENTE SOTTO MEMORIAL MEDICAL CENTER- OB Ward

In Partial Fulfilment
Of the Requirements of the Subject:
NCM 102
Care of Mother, Child,
Family and Population Group at –Risk

Submitted by:

Junard C. Roa
Student
BSN II-E

February 20, 2010

 TABLE OF CONTENTS PAGE

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

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

III. HEALTH ASSESSMENT

A. HEALTH HISTORY

A1. History of Present Illness-------------------------------------------------- 4

A1.1 Biological data

A1.2 Reason for seeking Consultation

A1.3 Current Health Status

A2. Past Health History--------------------------------------------------------- 4

A3. Family History--------------------------------------------------------------- 6

B. PHYSICAL EXAMINATION

B1. Review of Systems----------------------------------------------------------- 11

B2. Psychosocial Profile--------------------------------------------------------- 13

IV. REPRODUCTIVE ANATOMY AND PHYSIOLOGY---------------------- 14

V. CONCEPTUAL FRAMEWORK OF THE PHYSIOLOGY OF

PREGNANCY (for normal conditions) or CONCEPTUAL
FRAMEWORK OF THE PATHOPHYSIOLOGY OF
PREGNANCY (for abnormal condition) ----------------------------------------- 19

VI. THEORETICAL FRAMEWORK OF THE PHYSIOLOGY OF

PREGNANCY or PATHOPHYSIOLOGY
OF PREGNANCY------------------------------------------------------------------- 21

VII. CLINICAL MANAGEMENT

A. MEDICAL MANAGEMENT

A1. LABORATORY AND DIAGNOSTIC EXAMINATIONS----------- 22

 A2. TREATMENT AND PROCEDURES------------------------------------ 23

A3. MEDICATIONS (Drug Study Format) ---------------------------------- 24

A4. DIET--------------------------------------------------------------------------- 24

B. NURSING MANAGEMENT

B1. NURSING CARE PLAN -------------------------------------------------- 24

B2. DISCHARGE PLAN-------------------------------------------------------- 24

VIII. CONCLUSION AND RECOMMENDATION-------------------------------- 25

IX. IMPLICATIONS OF THE STUDY TO:

A. NURSING EDUCATION------------------------------------------------------- 26

B. NURSING PRACTICE---------------------------------------------------------- 26

C. NURSING RESEARCH--------------------------------------------------------- 26

X. APPENDICES: ----------------------------------------------------------------------- 27

APPENDIX A: PERMIT LETTER

APPENDIX B: DRUG STUDY

APPENDIX C: NURSING CARE PLAN

APPENDIX D: DISCHARGE PLAN

XI. BIBLIOGRAPHY---------------------------------------------------------------- 28

I. INTRODUCTION
 Chorioamnionitis is a condition that can affect pregnant women in which the chorion and
amnion (the membranes that surround the fetus) and the amniotic fluid (in which the fetus floats)
are infected by bacteria. This can lead to infection in both the mother and fetus, and, in most
cases means the fetus has to be delivered as soon as possible. Chorioamnionitis is caused by a
bacterial infection that usually starts in the mother’s urogenital tract. Specifically, the infection
can start in the vagina, anus, or rectum and move up into the uterus where the fetus is located.
Certain factors might create a higher risk for chorioamnionitis, including: premature birth and
fetal membranes that are ruptured (the water has broken) for a prolonged time.

Although chorioamnionitis does not always cause symptoms, some women with the
infection might have the following: high temperature and fever, rapid heartbeat (The fetus might
also have a rapid heartbeat.), sweating, a uterus that is tender to the touch, a discharge from the
vagina that has an unusual smell. Chorioamnionitis is most often diagnosed by physical exam
and the findings listed above. Other clues can be found by taking a blood sample from the
mother and checking for bacteria.

In addition, the doctor might take samples of the amniotic fluid to look for bacteria. The
doctor might also use ultrasound to check on the health of the fetus. If your doctor diagnoses
chorioamnionitis, he or she will treat you with antibiotics to help to treat the infection. However,
the treatment is to deliver the fetus. In addition, if the newborn has an infection, he or she will be
given antibiotics, as well. If the mother has a serious case of chorioamnionitis, or if it goes
untreated, she might develop complications, including: infections in the pelvic region and
abdomen, endometritis (an infection of the endometrium, the lining of the uterus), blood clots in
the pelvis and lungs. The newborn might also have complications from a bacterial infection,
including sepsis (infection of the blood), meningitis (infection of the lining of the brain and the
spinal cord), and respiratory problems.

The most common risk factors for chorioamnionitis include: young age (e.g., less than 21
years old); low socioeconomic status; first pregnancy; long labor; prolonged rupture of the
membranes (bag of waters); rupture of membranes at an early gestational age; multiple vaginal
examinations during labor (only in women with ruptured membranes); pre-existing infections of
the lower genital tract (bacterial vaginosis and group B streptococcal infection); and internal fetal
and uterine monitoring. The more of these risk factors you have, the more likely you are to
develop chorioamnionitis. Because chorioamnionitis is a serious condition with a high risk of
complications in the mother and her baby, pregnant woman needs to do every effort to prevent
this infection from developing in the first place. This is done in several ways, including: be
screened for bacterial vaginosis in your late-second trimester, and be screened for group B
streptococcal infection at 35 to 37 weeks' gestation.

1
II. GENERAL DATA
NAME : M.R.C.

PATIENT NUMBER : 111256-2010

ADDRESS : Sto. Niño, Guizo, Mandaue, Cebu

ROOM/ BED NUMBER : Ward 1- Bed # 11

BIRTHDATE : May 19, 1993

BIRTHPLACE : Mandaue City, Cebu

AGE : 16

SEX : Female

CITIZENSHIP : Filipino

SERVICE : OB (Obstetrics)

STATUS : Single

RELIGION : Roman Catholic

HEIGHT : 5 feet and 1 inch

WEIGHT : 55 kilograms

LANGUAGE SPOKEN : English, Tagalog, Cebuano-Bisaya

OCCUPATION : None

DATE OF ADMISSION : January 23, 2010

TIME OF ADMISSION : 2:00AM

ADMITTED BY :Jeffrey Carubio & Julie Libusan

HOW ADMITTED :Ambulatory

ATTENDING PHYSICIAN : Dr. Maglasang

2
OB SCORE : G1 T1 P0 A0 L0 M0
 LMP : April 12, 2009

AOG : 40 weeks and 8 days

EDC : January 19, 2010

ADMITTING DIAGNOSIS : PUFT, 40-41 weeks AOG, CEPH,

prolonged labor G1P0

PRINCIPAL DIAGNOSIS : Pregnancy uterine delivered

cephalic female live birth secondary
to CPD

OTHER DIAGNOSIS : Chorioamnionitis

3
III. HEALTH ASSESSMENT
A. HEALTH HISTORY

A1. History of Present Illness

A1.1 Biological Data

This is the case of Ms. M.R.C., 16 year old, single, female,

Filipino, Roman Catholic, from Sto. Niño, Guizo, Mandaue City, Cebu.
Admitted at Vicente Sotto Memorial Medical Center last January 23, 2010
at 2:00 AM. Received by Dr. Maglasang with a diagnosis of PUFT, 40-41
weeks AOG, CEPH, prolonged labor, G1P0.

A1.2 Reason for seeking consultation

Ms. M.R.C. came in due to failure of deliver from LHC. 18 hrs.

PTA, noted sudden gush of vaginal water. Thus went to LHC where I/E
was done by a MW, which reveals 3-4 cm cervical dilatation. Patient was
admitted and progress of labor was monitored. 7hrs. PTA, patient
claimed that she has asked to bear down with fundal pushing done and
failure to deliver prompted referral then admission.

A1.3 Current Health Status

Patient doesn’t have any other health problems except her

chorioamnionitis. She is experiencing mild pains on her incision site at
pain scale of 6/10 as 10 as the highest level of pain. She is given some
medications to be taken.

A2. Past Health History

Ms. M.R.C. is a non-smoker and occasional alcoholic beverage

drinker. She has no history of any food and drug allergies. During her
childhood she commonly acquires common childhood illnesses like
common colds, coughs, and fever. She was able to receive all the needed
immunizations like BCG (May 1993), Hep B-1 (May 1993), DPT1 (June
1993), OPV1 (June 1993), Hep B-2 (June 1993), DPT2 (July 1993),
OPV2 (July 1993), DPT3 (August 1993), OPV3 (August 1993), Hep B-3
(August 1993), and the measles vaccine last February 1994. Ms. M.R.C.
had her menarche at 14 years old with a regular monthly interval lasting

4
for 5 days. During puberty she experienced dysmenorrheal and other
common illnesses like colds, coughs and fever. She did not experience
 any psychiatric illness. During her childhood and adolescence she was
not able to experience any form of injuries. She was not able to undergo
any other operations except the 2010 cesarean section she had to deliver;
on the other hand this is also her first hospitalization. Her usual sleeping
pattern is 8-10 hours every day, but sometimes it’s just 6-7 hours due to
some events she don’t have any control of. Her usual habits and activities
done at home is watching TV, texting and doing some household choirs.

5
A3. Family History
 MOTHER SIDE FATHER SIDE

GM _____ GF GM _____ GF
OA OA TB OA

yy yy yy yy M F xx xx xx xx
ASTH ASTH HPN ACC

B B G B G G
G B

ASTH

Legend:
GM GF -Deceased grand father and mother GM - living grand mother
Or

yy M
Or xx - dead father and mother sisters or brothers -mother

F - father - patient ACC- accident

G
Or B - brother and sister ASTH- asthma HPN-hypertension

-baby who died OA- died due to old age

Ms. M.R.C’s grandparents in her mother side had died before she was able to
know them. On the father’s side her grandfather died because of old age, on the other
hand her grandmother is still living but with tuberculosis. In her mother’s side they were
five in the family, two of her aunt and uncle died due to asthma. Her mother is
hypertensive. In her father’s side, they were also five, one of her uncle died due to an
accident. In her father’s side no heredo familial diseases was noted.
In their family they are nine, all of them a living, she is the sixth in the family. In
her brother and sister, her sister (fifth in the family) is the only one with asthma.
Unfortunately the patient’s baby died 18 hours after delivery due to severe complications.

6
B. PHYSICAL EXAMINATION
 Some of the purposes of the physical health examination are to obtain
baseline data about the client’s functional abilities; to supplement, confirm, or repute data
contained in the nursing history; to obtain what will help the nurse establish nursing
diagnosis and plan the client’s care; to evaluate physiologic outcomes of health care.

 GENERAL APPEARANCE AND MENTAL STATUS

 awake, responsive, afebrile

 with ease respiration
 with D5LR @30 gtts/min infusing well @ Right hand
 with FBC-urobag draining well
 clean and neat
 body odor not noted, halitosis is noted
 guarding the incision site in the abdominal area
 height is symmetrical to built (ht. 5’1”; wt.121lbs.)

 VITAL SIGNS

 Temp: 37.1ºC
 HR: 78 beats/ min.
 RR: 12 cycles/min
 BP: 120/90 mmHg
 Pain scale @ 6/10 as 10 is the highest level in the pain scale

 SKIN AND APENDAGES

 Skin
-dark in colour uniform in all body parts
-lesions are noted at the left and right lower extremities
-dry, warm,
-good turgor
 Hair
-evenly distributed
-slight dryness noted
-no presence of lice and dandruff
 Nails
-long
-pinkish nail beds
-capillary refill time less than 2 seconds

7
 HEAD AND NECK
 Head
-symmetrical in size and shape
-no signs of lesions and nodules
-no flakes
-no rashes

 Face
-symmetrical both in shape and movements
-scars are noted
-some reddened papules are noted
- (-) edema
- (-) tenderness

 Eyes and Vision

-patient is not wearing an eyeglasses or contact lenses
-eyelids closed symmetrically
-pupils are black and reactive to light
-eyebrows have even distribution of hair
-pale conjunctiva

 Ears and Hearing

-colour same as facial skin
-symmetrical in size, shape and alignment
-no exudates noted and presence of cerumen
-able to hear on both ears
-patient cleans her ears twice a week

 Nose and Sinuses

- (-) discharges
-nares are patent for breathing
-no tenderness and masses noted

 Mouth and Pharynx

>Lips:
- dry, cracked lips
- dry mucous membrane
- no sores noted

>Tongue:
- dry
- pinkish in colour
- able to classify tastes

8
 Neck
-symmetrical in size and shape
 -no nodules and lesions noted

 THORAX AND CHEST

 has an equal chest expansion

 has no cough
 no difficulty in breathing
 no abnormal breath sounds upon breathing
 chest moving up and down normally
 RR= 12 cycles/minute

 CARDIOVASCULAR SYSTEM

 Heart
-has distinct heart sounds and regular rhythm
-no palpitations
-no history cardiovascular problems
-BP: 120/90 mmHg

 BREAST AND AXILLAE

 Breasts
-rounded
-slightly unequal in size
-areola is rounded and bilaterally the same; darken
-no masses noted
-nipples are round and protrude; everted and equal in size; no
discharges and lesions
-tenderness in noted due to inability to breastfeed

 Axilla
-axilla has no tenderness, nodules and lesions
-dark brown in color
-with odor
-presence of fine and thin hairs

 ABDOMEN
 uniform in colour
 big and flabby abdomen
 has tissue trauma secondary to caesarean section transverse
incision
 pain is noted, pain score of 6/10, as 10 is the highest in the pain
scale
9
 MUSCULOSKELETAL SYSTEM
  Muscles
-equal in both sides of the body
-muscle weakness is noted in the abdominal area

 Bones
-normal structure
-no deformities
-no swelling

 Joints
-no swelling
-no tenderness
-able to move freely

 NEUROLOGIC SYSTEM

 Motor Function
-has slought posture
-may sway slightly
-inability to move too much due to the incision
-repeatedly and rhythmically touches the nose

 Sensory Function
-light tickling or touch sensation
-able to discriminate sharp and dull object
-able to discriminate between hot and cold sensations
-can readily determine the position of fingers and toes
-can distinguish a one-point stimulus from two-point stimulus

 FEMALE GENITALIA AND INGUINAL LYMPH NODES

 has no episorraphy and episiotomy

 no tenderness on the inguinal area
 dark brown colour in the inguinal area
 pain not noted

 ELIMINATION PATTERN

 patient is used to move bowel everyday probably in the morning

 patient experienced a change in bowel movement after the surgery
 has no haemorrhoids
 with an FBC-urobag and as a urine output of 25-30mL/hour
 no history of kidney/ bladder dysfunction
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 HYGIENE
  patient is dependent in doing self-care
 needs a lot of assistance in changing her sanitary napkins
 has altered hygiene due to inability ambulate after the surgery

 NEUROSENSORY

 patient reported dizziness

 had a good vision and hears well
 no epistaxis noted

 PAIN/DISCOMFORT

 patient felt pain located in the incision site with scale of 6/10 as 10
as the highest level of pain in the pain scale
 manifested a guarding behaviour on the abdominal area
 BP is 120/90 mmHg and HR is 83beats/min.
 appears pale

 ACTIVITY AND REST

 patient was not able to sleep well the night after delivery because
of discomfort and pain in the incision site
 lying in bed
 need help in doing perennial care and self-care
 has limited movements

B1. Review of Systems

Data for Ms. M.R.C. organized according to Gordon’s Functional Health Patterns:

 Health Perception/Health Management

 Patient is aware of having a surgical incision on her

abdomen, caesarean section.
 Her live-in partner and her sister-in-law look after the health
care needs of the patient.

 Nutritional/Metabolic

 Able to eat any kinds and forms of foods

 Usual eating pattern: Full diet
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 Elimination
 Elimination is usually every day.
 Bowel movement is altered due to the surgery.
 Urinary output is about 25-30mL/hour via FBC-urobag.

 Activity/Exercise

 Patient has a limited movement, altering her activities and

exercise.
 Usually lying o n bed.

 Cognitive/Perceptual

 Patient is oriented to time, place and persons.

 Sleep/Rest Patterns

 She usually sleeps at night with disturbance due to noise of

the baby and pain occurrence.
 She taking a nap during day time to ease her short sleeping
time.

 Self-perception/Self-concept

 Patient cannot do self care, thus assistance in doing self

care is needed

 Role/Relationship

 Patient lives with her mother together with her other

brothers and sisters, including her cousins.
 She is the sixth in family with nine members.

 Sexuality/Reproductive

 Sexual abstinence due to the surgery and inability is

observed by the patient.

 Coping/Stress Tolerance

 Patient expresses coping mechanism through conversing

with her relatives during visiting hours and to the student
nurse in her bedside.

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 Value/Belief
  The patient and her husband often time attend mass every
Sunday.
 She is Roman Catholic, believing to God and giving her
future to God.

B2. Psychosocial Profile

She usually enjoyed watching TV and texting, as what a usual teen is doing.
She usually walks together with her friends that serve as her simple exercise. She
is also funned of watching teen ager who is playing basketball during afternoon.
She is not very particular with her diet and she usually eats any form and kinds of
food to be eaten.

As a teen ager, she also has some important experiences. She was raced by
her mother and father together with her other brothers and sisters. Because they are
many in the family, she was not given that focus in the process of upbringing. She
stopped schooling due to financial in capabilities, and is not employed in any way
due to her very young age of 16. On the other hand she doesn’t have any guts to
apply for an y jobs because she know that she lack the main requirement which is
schooling or studies. Their financial situation is not that suited for them because
there are a quite number of them living together. She is not yet married and is
currently living-in with her partner.

She is a Roman Catholic, with a very deep faith in God, thus she let God do
anything about her health, and her future. Their type of family is an extended type
because her brother’s and sister’s family lives with them. Their home is located in
a populated area of Sto. Niño, Guizo, Mandaue City, Cebu, where many people
flock together and live in a hot area. Her family owned the house where they are
living. In their location, patient admitted that drainages are not working properly
and their garbage disposal is not properly disposed, leading some people to throw
their garbage anywhere. Their water supply is good and their source is ground
water from the artesian well which is for her safe and clean. Transportation in their
area is not a problem because the main mode of transportation there are jeepneys,
which are common in the area. In her recreational and substance abuse she
occasionally drinks alcohol, do not smoke and most of all do not use any
prohibited drugs. Being a 16 year old mother she still don’t know a lot of things
about motherhood. In her sexual history, she prefers the opposite sex and is
currently in an active relationship. She had her first sexual intercourse at the age of
16 with her live in sole sexual partner. Because they are both unknowledgeable
about contraceptives, they were not able to protect themselves. As of the moment,
she do not have any other idea of what protection they will use, but according to
her, they prefer the normal one which is the sexual abstinence.

13
IV. REPRODUCTIVE ANATOMY AND PHYSIOLOGY
 FIGURE 1

The female reproductive organs consist of the ovaries, uterine tubes (fallopian
tubes), uterus, vagina, external genitalia, and mammary glands. The internal
reproductive organ of the female are located within the pelvis, between the urinary
bladder and the rectum. The uterus and the vagina are in the midline, with an ovary to
each side of the uterus. The internal reproductive organs are held in place within the
pelvis by a group of ligaments. The most conspicuous is the broad ligament, which
spreads out on both side of the uterus and to which the ovaries and uterine tubes attach.

A. External Structures:

 Mons Veneris/Pubis – is a pad of fat which lies over the symphysis pubis
where dark and curly hair grow in triangular shape that begins 1-2 years
before the onset of menstruation. It protects the surrounding delicate
tissues from trauma.

 Labia Majora – Two (2) lengthwise fatty folds of skin extending from
mons veneris to the perineum that protects the labia minora, urinary
meatus and vaginal orifice.

14
 Labia Minora – 2 thinner, lengthwise folds of hairless skin extending from
clitoris to fourchette.

o Glands in the labia minora lubricates the vulva

o Very sensitive because of rich nerve supply
o Space between the labia is called the Vestibule

 Clitoris – small, erectile structure at the anterior junction of the labia minora
that contains more nerve endings. It is very sensitive to temperature and
touch, and secretes a fatty substance called Smegma. It is comparable to the
penis in its being extremely sensitive.

 Vestibule – the flattened smooth surface inside the labia. It encloses the
openings of the urethra and vagina.

 Skene’s Glands/Paraurethral Glands – located just lateral to the urinary

meatus on both sides. Secretion helps lubricate the external genital during
coitus.

 Bartholin’s Gland/Vulvovaginal Glands – located lateral to the vaginal

opening on both sides. It lubricates the external vulva during coitus and the
alkaline pH of their secretion helps to improve sperm survival in the vagina.

 Fourchette – thin fold of tissue formed by the merging of the labia majora
and labia minora below the vaginal orifice.

 Perineum – muscular, skin-covered space between the vaginal opening and

the anus. It is easily stretched during childbirth to allow enlargement of
vagina and passage of the fetal head. It contains the muscles (pubococcygeal
and levator ani) which support the pelvic organs, the arteries that supply
blood and the pudendal nerves which are important during delivery under
anesthesia.

 Urethral meatus – external opening of the urethra. It contains the openings

of the Skene’s glands which are often involved in the infections of the
external genitalia.

 Vaginal Orifice/Introitus – external opening of the vagina, covered by a thin

membrane called Hymen.

15
 FIGURE 2

B. Internal Structures:

 Fallopian tube /Oviduct – 4 inches long from each side of the uterus (fundus).
It transports the mature ova form the ovaries to the uterus and provide a place
for fertilization of the ova by the sperm in it’s outer 3rd or outer half. Parts:

 Interstitial – lies within the uterine wall

 Isthmus – portion that is cut or sealed in a tubal ligation.

 Ampulla – widest, longest portion that spreads into finger like

projections/fimbriae and it is where fertilization usually occurs.

 Infundibulum - rim of the funnel covered by fimbriated cells

(hair covered finger like projections) that help to guide the ova
into the fallopian tube.

 Ovaries – Oval, almond sized, dull white sex glands on either side of the
uterus that measures 4 by 2 cm in diameter and 1.5 cm thick. It is
responsible for the production, maturation and discharge of ova and
secretion of estrogens and progesterone.

16
 Uterus – hollow, pear-shaped muscular organ, 3 inches long, 2 inches wide,
weighing 50-60 grams held in place by broad and round ligaments, and
abundant blood supply from the uterine and ovarian arteries. It is located in
the lower pelvis, posterior to the bladder and anterior to the rectum. Organ
of menstruation, site of implantation and provide nourishment to the
products of conception.

 Layers:

 Perimetrium – outermost layer of the uterus comprised of

connective tissue, it offers added strength and support to the
structure.

 Myometrium – middle layer, comprised of smooth muscles

running in 3 directions; expels fetus during birth process then
contracts around blood vessels to prevent hemorrhage.

 Endometrium – Inner layer which is visibly vascular and is

shed during menstruation and following delivery.

 Divisions of the Uterus:

 Fundus – upper rounded, dome-shaped portion that can be

palpated to determine uterine growth during pregnancy and the
force of contractions and for the assessment that the uterus is
returning to its non-pregnant state following child birth.

 Corpus – body of the uterus.

 Isthmus – area between corpus and cervix which forms part of

the lower uterine segment. It enlarges greatly to aid in
accommodating the fetus. The portion that is cut when a fetus
is delivered by a caesarian section.

17
 Cervix – lower cylindrical portion that represents 1/3 of the total uterus. Half
of it lies above the vagina; half of it extends to the vagina. The cavity is
termed the cervical canal. It has 2 openings/Os: internal os that open to the
uterine cavity and the external os that opens to the vagina.

 Vagina – a 3-4 inch long dilatable canal located between the bladder and the
rectum, it contains rugnae which permit considerable stretching without
tearing. It acts as a organ of intercourse/copulation and passageway for
menstrual discharges and fetus. Doderlein’s bacillus is the normal flora of the
vagina which makes the pH of vagina acidic, detrimental to the growth of
pathologic bacteria.

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V. CONCEPTUAL FRAMEWORK OF THE PATHOPHYSIOLOGY OF
PREGNANCY

Production of viable Sperm Production of viable oocytte

Transport down the male duct system Ovulation

Deposited in the female vagina Capture of the oocyte by the uterine tube

Meeting of sperm and oocyte in the fallopian tube

Union of sperm and egg {fertilization}

Abnormal bacterial Pregnancy

colonization in of the
rectum and anus

abnormal vaginal and cervical Implantation in properly

microbial environment prepared endometrium

Mitotic cellular Replication

Morula

infection in the chorion, Blastocyst

amnion and the amniotic fluid

Germinal Tissue Layers

19
Intrauterine infection Fetal Development
 Maternal fever Labor

Delivery

Due to CPD caesarean delivery NSVD

Postpartum Period

Legend:
- path to normal child bearing
- path to child bearing with chorioamnionitis

20
VI. THEORETICAL FRAMEWORK OF THE PATHOPHYSIOLOGY
OF PREGNANCY
 Abnormal bacterial colonization of the rectum and anus during pregnancy may
create an abnormal vaginal and cervical microbial environment.  More than 2 decades ago,
rectovaginal colonization with GBS during pregnancy was found to be associated with this
GBS infection of the fetus or newborn. Studies have demonstrated that other types of
bacteria residing in the vagina, cervix, or both ascend through intact or ruptured fetal
membranes and initiate amniotic fluid infection.

Urinary tract infection during pregnancy can bathe the vagina with bacterial
pathogens and is a recognized risk factor for neonatal sepsis. This observation is
particularly true for untreated asymptomatic GBS-related bacteriuria. A high maternal body
mass index increases the risk of EOS caused by GBS.

Bacterial vaginosis has been recognized as an important cause of premature labor,

although overt infection of the neonate with microbes causing bacterial vaginosis is
uncommon. Screening for and treatment of bacterial vaginosis and other genital infections
may prevent preterm birth, although recent Cochrane reviews conflict regarding
the effectiveness of therapy. 

Many interesting associations related to infection and preterm birth have been
made; however, the mechanisms of these relationships are not necessarily
understood. Although controversy exists about its role, periodontitis has been linked to
prematurity, low birth weight, and fetal growth restriction.   Blood types A and O are also
associated with an increased risk for chorioamnionitis. The same researchers found
relationships between alcoholism, prolonged rupture of membranes, and maternal
anemia as factors related to preterm birth. Obesityduring pregnancy has been related to
chorioamnionitis in several reports. 

In the mid trimester of pregnancy, ultrasonographic evidence of a short cervix may

be the only clinical finding in intraamniotic fluid infection.  Cervical insufficiency,
regardless of bacterial culture results in amniotic fluid, is associated with intraamniotic
inflammation, preterm birth and other adverse outcomes of pregnancy.   Related issues to
cervical insufficiency are mechanical methods of cervical ripening that are also suspected
of increasing maternal and neonatal infections.  Each of these factors may be associated
with altered host defenses that allow ascending infection from the urogenital tract to
placental tissues and amniotic fluid.

21

VII. CLINICAL MANAGEMENT

A. MEDICAL MANAGEMENT

A1. LABORATORY AND DIAGNOSTIC EXAMINATIONS

 HEMATOLOGY

TESTS RESULT UNIT REFERENCE

LEUKOCYTE 25.5 10^9/L 4.0-10
HEMOGLOBIN 121 g/L Female: 120-160
HEMATOCRIT 0.372 % Female: 0.37-0.49
PLATELET Adequate 10^9/L 150-450
COUNT
Neutrophil 86.5 %
Lymphocite 6.0 %
Monocyte 6.2 %
Eosinophil 1.0 %
Basophil 0.5 %

 URINALYSIS

Color Yellow
Transparency Cloudy
Reaction 6.0
Sugar Negative
Protein +++

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A2. TREATMENT AND PROCEDURES
 Vital signs taking

Closely monitored because this serves as a baseline data of the patient and
will indicate whether the patient’s condition is progressing or reclining. It is a
routine taking of the patient’s temperature, pulse rate, respiration rate and blood
pressure and even the fifth vital sign which is pain is also assessed.

 Intravenous fluid monitoring

This is important to prevent overloading and under loading of fluids on the

patient’s body. This is also prescribed or given to replace the patient’s fluid and
electrolytes loss during the labor and delivery process even if she underwent a
cesarean section.

 Administering oral medication

Oral medicines are administered or given to the patient as ordered by their

physician such as multivitamins with iron—this is to replenish the decreased
iron in her blood due to the delivery, antibiotics—this is to prevent infection
related to the surgical incision and analgesic—to relieve pain from the surgery.

 Health teaching

This is to provide the patient some information about the procedure she
underwent and on the things she will be required to do. this is also one way to
effectively communicate to the patient, and to provide her some knowledge
regarding her medications for her to be aware of its effect and functions in her
current situation.
  Bedside care

This is to monitor the patient closely, to assist the patient whatever things
she needs to do. And to closely monitor the patient in every activity she will be
doing. This is also one way of attaining her needs whenever her significant others
are not yet in the bedside.

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A3. MEDICATIONS

 Cefuroxime Sodium
 Celecoxib
 Gentamicin Sulfate
 Metronidazole hydrochloride
 Paracetamol
 Vitamin A

(see APPENDIX B p. 25)

A4. DIET

My patient Ms. M.R.C underwent a cesarean section and was given a diet
most appropriate for her. After 24 hrs. post-op, her doctor ordered her to have a soft
diet- taking only those soft kinds of food most preferable soup and “lugaw”. She was
also allowed to drink water.48 hrs. post –op she finally given a DAT(diet as tolerated)
diet. She was encouraged to eat vegetables and fruits to supplement her lost nutrients.
She was also encouraged to increase protein rich foods such as meats and fishes to aid
in her tissue repair. Other protein she was also encouraged to take in more iron rich
foods such as liver, and some dark leafy vegetables to aid in her iron loss during
delivery and the operation she underwent. She is now allowed to eat any foods she
wants as long as it will not harm her or may can an allergic reaction to her.
 B. NURSING MANAGEMENT

B.1 NURSING CARE PLAN

(see APPENDIX C p. 33)

B.2 DISCHARGE PLAN

(see APPENDIX D p 40)

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VIII. CONCLUSION AND RECOMMENDATION

A. CONCLUSION

Being a second year nursing student, my knowledge about this profession is

not yet that complete and not yet that stable and concrete to be able to perform
interventions without any assistance. As we are exposed to different areas in a very
early time as expected, I can assure myself that I am capable of doing simple yet
important nursing interventions based in our level of knowledge.

As a student nurse with enough maturity and competitiveness it is my priority

and responsibility to render care to my patient whatever ailment they have and
whoever they are in the broad society. This responsibility tied on me does not mean
that my actions are limited in just rendering care but it goes beyond it. As a student
nurse it is also my duty to be essential and sensitive in performing nursing
interventions and properly educate my patient which I did during my care to her. As a
student nurse it is also my role to stress some important facts she needs to know and to
empower her awareness necessary to promote her health both with and without the
presence of any health care members.
 My patient has this very rare condition which occurs seldomly on pregnant
mothers. As her student nurse for four (4) days I really did my best to converse to her
to get some information about her. On the other hand I also did my best to give her the
factual information about her current health condition. As her student nurse I was also
able to help her in alleviating her feeling she felt about her first daughter’s unexpected
death few days after birth. Having her as my patient is a big pleasure for me, because
at 16 years of age, she was able to stress many experiences about herself and her life.
Her situation is one of a kind and it is really a great opportunity for me to have it.

B. RECOMMENDATION

With this conclusion I have given I will recommend that as student nurses,
we need to be ready with all our intelligence, physically, and emotionally to face the
different experiences we are going to face in the areas. We need to fully understand the
purpose of our interventions and we must heartily perform it to our patients. As
student we need to fully understand the condition of patient to properly scrutinize what
kind of care is needed by them. We should also remember that in the profession we are
going through it is not a competition of grades, but a competition of skills and quality
of care rendered to our patients. We should not inculcate in our minds that what we are
doing is just for our grades, but we need to inculcate in our hearts the deep meaning of
the care we’ve rendered to them.

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IX. IMPLICATIONS OF THE STUDY TO:

A. NURSING EDUCATION

The implication of this study to nursing education is that is imparts

knowledge and information on how to properly care and promote health and
wellness to our patients with enough knowledge, proper skills and pleasing
attitudes to render care to post operative patients and to those patients with a
unique disease such as Chorioamnionitis. With this care study in which I give
most of my time with, I learned that being a student nurse does not limit us to do
only chosen things but we can also do more than what we expect. I also learned
that we are not only focusing on our patient but we are dealing a wide variety of
persons around us for us to collaborate. With this study also, I learned that we
nurses also serves as a teacher to our patients by educating them in factual
informations.

B. NURSING PRACTICE

Nursing practice is a wide continuum comprising many skills needed to

render the most appropriate care to our patients. As nurses we practice not only in
a limited area but in different areas we are usually unfamiliar of, this way of
 exposure enhances our fields of practice and capabilities. The focus of all nursing
practice is the client, who may be an individual, a family or a community. In this
situation I am focused to a client with a unique illness. I am very glad to have this
patient under my care for I can give other form of care and interventions needed.
Since her illness is unique I also need to widen my field of practice to be able to
compensate with her needs, and I did this by focusing to my patient and attending
her needs by bedside care.

With this study I made I was able to conclude that I did something very
helpful to me patient and this is educating her. Nursing practice should not be
limited in any parts but, it should be improved through different experiences to
widen its coverage.

C. NURSING RESEARCH

As what I had stated in nursing practice, we need to widen it, and nursing
research is one of those ways to be able to widen the coverage of our nursing
practice. Nursing research improves our individual capabilities which are very
useful for our patients. As years passed by, nursing research has also improved in
many ways. As one of the health practitioners, we also need to update ourselves
through some simple researches.

I consider this care study I made as one of my researches because I was

dealing with a unique patient that needs deeper focus and some researches.
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APPENDIX D:

DISCHARGE PLAN

Patient’s Name: M.R.C Hospital No. : 111256-2010

Age : 16 years old Room No. : Ward 1-Bed # 11
Impression/ Diagnosis: Chorioamnionitis Physician : Dr. Maglasang

PATIENT’S OUTCOME CRITERIA NURSING ORDER

As soon as the patient is discharged in the hospital,

the patient and her family will be able to:

ASSESSING:

 Assess patient’s to eat the right kind of food
necessary for her condition.
 Assess patient’s and family’s ability to
 Teach the patient’s significant others
regarding the benefits the patient can get in
eating the right kind of food. (Lippincott;
3rd ed.; p. 647)
 comply with the necessary medication
given upon discharge such as:
- Celecoxib
- Bromochriptine
 Assess patient’s ability to perform activities
of daily living without any superversion.
PLANNING:
 Planned to have discussion to the family
about the nature of the current condition.
 Plan to have a list of nutritious meals which
is affordable and within the budget.
 Provide family’s understanding in the
importance of treatment compliance.
(Lipincott, 3rd ed.;p.647)
 To be able to inform other family member
to keep an eye to the patient if needed.
(Lipincot, 3rd ed,;p.647)
 Teach the family the basic information
about the condition and informing them as
to what to do when the disease occurs
again.(Lipincott,3rd ed.;p.647)
 Teach the family other way of preparing not
just a healthy meal but also an appealing
presentation of foods.
(Lipincott,3rd ed.;p.647)
IMPLEMENTING:
 Medication
- Advise patient to continue
medications per physician’s order:
Celecpxib- 2x aday
Bromochriptin- 3x a day
- Encourage patient to follow the
medication’s timing and dosage
strictly.
 Execise/ Environment
- Encourage patient to perform
passive exercise like walking.
- Advise patient to stay in a
comfortable environment at home.
 Treatment
- The family and the patient will be
able to know the purpose of the
treatment.
 Hygiene/ Health Teaching
- Encourage patient to perform
proper hygiene by bathing daily to
promote self wellness.
 Out- patient/ Follow-up
- Advise patient to revisit the
hospital after 7 days for the
follow-up check-up.
 Diet
- Encourage patient to include
high protein foods such as meat
and poultry, fruits and
vegetables as the source of
dietary fibers.
- Inform patient the importance of
continuing the medications even at home.
- Teach the patient the importance of correct
timing and accurate dosage upon taking
the medication.
- Early ambulation will help in early healing,
this also boosts the confidence to perform
ADLs.
- Environment factors are important coping
mechanisms, taking environmental stimuli
positively will aid in patient’s early healing.
- Provide family understanding in the
importance of treatment compliance to allow
for faster recovery from the present condition.
- Proper hygiene contributes in maintaining
body wellness; educate the patient that it is
one factor in defending one’s self from
illnesses.
- Inform patient that follow-up check-up is
important to find out the underlying side
effects.
- Encourage patient to eat protein rich foods
to aid her in tissue repair and dietary fibers for
easy stool evacuation.
  Spirituality
- Patient and family will be able to - In this way they can strengthen their faith
hear mass every Sundays. to God, and to thank him in every blessing He
has given to them.

EVALUATION

 Evaluate the family’s and patient’s - Encourage the patient and the family
understanding on the previously given follow and adhere the given informations for it
discharge information. also benefits them.
APPENDICES:

APPENDIX A: PERMIT LETTER

APPENDIX B: DRUG STUDY

APPENDIX C: NURSING CARE PLAN

APPENDIX D: DISCHARGE PLAN

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Kozier, Barbara E., et al. Fundamentals of Nursing. 5th ed. 23-25 First Lok Yang Road
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Marieb, Elaine N. Essential of Human Anatomy and Physiology. 6th ed. 23-25 First Lok Yang
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http://en.wikipedia.org/wiki/Chorioamnionitis

http://emedicine.medscape.com/article/973237-overview

http://my.clevelandclinic.org/healthy_living/Pregnancy/hic_Chorioamnionitis.aspx

http://nursingcrib.com/news-blog/female-reproductive-system/

http://www.scribd.com

http://www.medonline.com

http://www.healthline.com/yodocontent/pregnancy/infections-chorioamnionitis.html

http://en.wikipedia.org/

http://www.healthline.com/yodocontent/pregnancy/complications-delivery-amnionitis.html

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