University of Baguio

School of Nursing

A Delivery Room Write-Up

Presented to the Faculty of the

School of Nursing

In

Partial Fulfillment of the

Requirements for the subject

NCENL01

By:

Peralta, Rusell Fernandez

NBA-5

Submitted to:

Nellie C. Palgue RN, MAN

Clinical instructor

December 2014
 TABLE OF CONTENTS

I. Introduction …………………………………………………………………………………………………………………3

II. Biographical Data …………………………………………………………………………………………………6

A. Patient’s Profile …………………………………………………………………………………………6

B. Patient’s Medical History ……………………………………………………………………6

B.1 Present Health History …………………………………………………………………6

B.2 Past Health History …………………………………………………………………………6

B.3 Family Health History ……………………………………………………………………7

B.4 Socio-economic History …………………………………………………………………7

B.5 Obstetric History ………………………………………………………………………………7

III. Anatomy and Physiology …………………………………………………………………………………8

A. Female Reproductive System …………………………………………………………………8

B. Physiology of Pregnancy ………………………………………………………………………12

B.1 Physiological Changes …………………………………………………………………12

B.2 Psychological Changes …………………………………………………………………13

C Fetal Development ………………………………………………………………………………………..14

IV.. Instrumentation ……………………………………………………………………………………………………26

V. Nursing Care Management …………………………………………………………………………………35

A. List of Identified Problems

A.1 Actual Nursing Problems ……………………………………………………………35

A.2 Potential Nursing Problems ……………………………………………………35

B. Nursing Care Plan for the Mother ………………………………………………….36

VI. Partograph ………………………………………………………………………………………………………………………40

VII. Bibliography ………………………………………………………………………………………………………………41

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 I. INTRODUCTION

A. Brief Introduction

Cesarean delivery is defined as the delivery of a

fetus through surgical incisions made through the abdominal wall

(laparotomy) and the uterine wall (hysterotomy).

Rusell Fernandez Peralta, member of NBA-5, supervised

by clinical instructor, Nellie C. Palgue, exposed in the

Delivery Room of Baguio General Hospital and Medical Center,

Baguio City last November 27, 2014. He was able to assist

Patient X in a Normal spontaneous delivery. Then that was the

opportunity of him to interview the patient about health

status, past and present and even her socio-economic status.

He is also collaborated to the doctors and nurses on duty for

further information, such as the DR nurse who revealed some

information about the mother’s pregnancy, partograph and vital

signs; the nursery nurse who revealed the APGAR, BALLARD

Score, initial vital signs, anthropometric measurements of the

baby. And lastly he was able to acquire knowledge about

delivery room, NSD, instruments from the different books that

can be found in the bibliography.

B. GOALS & OBJECTIVES

GOALS:

After the completion of the write up, he shall be able

to: Enhance his knowledge and Skills in Delivery Room, the

process done such as Normal Spontaneous Delivery, D&C and

other. The nursing care management to the mother, assisting in

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NSD, using instruments, Dr charting, doing aftercare and

others.

OBJECTIVES:

They enhance his knowledge and skills in the Delivery Room by:

1. Providing comprehensive information about Delivery room,

Normal spontaneous delivery, D & C, delivery instruments and

others.

2. Assisting the process of NSD and D&C.

3. Listing nursing problems of the mother and his baby.

4. Planning appropriate nursing interventions that is related

to the problem of the client.

5. Proper writing of the Dr chart, following Focus-Data-

action-response (FDAR).

6. Doing proper preparation of instruments and at the end is

doing the aftercare, by chlorinating and cleaning of the

instruments used.

II. BIOGRAPHICAL DATA

A. Patient’s Profile

Name: Patient X

Age: 18 y/o

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Gender: Female

Civil status: Single

Address: 52 Lower Fairview, Baguio City, Benguet

Birthday: November 21, 1996

Birthplace: Baguio City

Nationality: Filipino

Religion: Roman Catholic

Admission date and time: November 27, 2014 / 11:40 AM

B. Patient’s Medical History

B.1 Present Health History

Two hours prior to admission, patient felt painful

contractions lasting 40 to 60 seconds and occur approximately

every 3 to 5 minutes. The clerk on duty performed internal

examination and cervical dilatation was at 4 cm; thus, she was

brought to labor room. And her admission diagnosis was G1P0

Pregnancy uterine, 39 1/7 weeks Age of Gestation

B.2 Past health history

Last September, Patient had cough and colds but she

didn’t sought for medical intervention. According to her, she

hasn’t hypertensive, with diabetes mellitus and any infection

on the past few months, this is revealed in her chart.

B.3 Family Health History

The family has history of asthma on the father side

while in the mother side has the history of hypertension,

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Diabetes mellitus, and heart diseases. Presently her

grandmother has Diabetes mellitus.

B.4 Socio-Economic History

The patient communicates well and answers immediately

the questions that he asked. He is cooperative to the

therapeutic regiment or care management done. She was still

living with her parents in the reason that he acclaimed that

she doesn’t have husband, and no one can support except her

family. The family support her during the hospitalization.

They live in a bungalow house is a bit near to the highway. In

their backyard they have bayabas, and some flowering plants.

B.5 Obstetric History

The patient is primigravida. Her first menstruation

period or menarche is when she is 13 years old. Mother

partially immunized with the First tetanus toxoid. TPAL termed

as term, preterm, abortion, and live revealed (1,0,0,0). She

acclaimed that her last Menstrual Period was February 26,

2014. She also consults to the near local health unit for

prenatal check-up, that according to her, she done 5 times

before she admitted to the labor room

III. ANATOMY AND PHYSIOLOGY

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 A. Female Reproductive

System

Vagina

 a muscular

passageway that leads from

the vulva (external

genitalia) to the cervix.

Cervix

 a small hole at the end of the vagina through which

sperm passes into the uterus. Also serves as a

protective barrier for the uterus. During childbirth,

the cervix dilates (widens) to permit the baby to

descend from the uterus into the vagina for birth.

Uterus

 hollow organ that houses the baby during pregnancy.

During childbirth, the uterine muscles contract to push

out the baby.

Ovaries

 two organs that produce hormones and store eggs, that

was then fertilized with sperm cells from males.

Fallopian tubes

– muscular tubes that eggs are released from the ovaries

and must be transverse to reach the uterus.

B. Physiology of Pregnancy

B.1 Physiological Changes

a. Uterine Changes

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 The length is ranges from 6.5 to 32 cm, the depth

ranges from 2.5 to 22 cm, width would be from 4 to 24 cm; and

it can weighs from 50 to 1000 g. The uterine wall thickens

early pregnancy from 1 cm to 2cm; thins in pregnancy about6.5

cm thick. The uterine volume can ranges from 2ml to more than

1000 ml. The uterus can hold 4000 g.

The uterine increases it’s size, the blood flow;

before preganancy is 15 to 0 ml/in and end of pregnancy will

become 500 to 750 ml. Other changes will be Hegar’s sign

(softening of the cervix); ballottement (rebound that

occur)and Braxton hicks contractions (false labor

contractions)

b. Cervical Changes

The cervix become edematous and vascular cause by the

increase circulating estrogen; Goodell’s sign (soft

consistency in the earloebe or “ripe” cervix just befor

labor—butterlike.

C. Vaginal Changes

The pinkish or violet discoloration of the vagina

known as Chadwick’s sign; secretes white vaginal discharges

composed of loosen epithelial cells and connective tissues.

The vaginal environment will become acidic from 7 pH to 4 or

5 pH—this is to favor the growth of Candida Albicans.

d. Breast Changes

Tenderness, fullness, tingling (about 6 weeks) can be

present; increase in breast size; areolas darkens and

increase in diameter. There is also increase in the

vascularity of the breast, there will be prominent veins.

Montgomery’s tubercles enlarge and become protuberant. In the

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16th week—colostrums (thin, watery, high-protein fluid that

is a precursor to the breastmilk) can be expelled from the

nipples.

e. Integumentary System

There will be the presence of Striae gravidarum (pink

or reddish streaks); linea nigra—-a narrow, brown line

running from the umbilicus to the symphysis pubis; melasma

usually appears in the face caused by the increase in

melanocyte stimulating hormone secreted by pituitary gland.

There is also vascular spiders (small, fiery red and

branching spots); increase in perspiration; scalp hair growth

and palmar erythema.

f. Respiratory System

There is nasal stuffiness due to increased production

of estrogen; acute sensation of shortness of breath; and

breathing rate is more rapid than normal causes by the

hormonal changes.

g. Temperature

Body temperature increases (the temperature which

increased at ovulation remains elevated) temperature usually

ranges to 36.5 to 37 above.

h. Cardiovascular System

Blood volume increases by atleast 30% up to 50%; at

the end of 1st trimester, blood volume increases gradually;

28th to 32nd will be the peak level. False anemia

(Pseudoanemia)can also happen this is when the concentration

of Hgb and erythrocytes decline because Plasma volume is

greater than RBC production. In NSD, blood loss can be 300 to

400 ml. Cardiac output becomes 35% to 50% increase; heart

9
rate will become 80 to 90 bpm. Blood pressure decreases in

2nd trimester, prepregnancy level in 3rd trimester.

There is also impaired blood flow to the lower

extremities. Supine Hypotension Syndrome can be happen to

pregnant women when they lies on their back; the weight of

the uterus compresses the vena cava, trapping blood in the

lower extremities which causes decreased CO and hypotension.

This can be manifested with lightheadedness, faintness and

palpitations.

i. Gatrointestinal System

There will be slow intestinal peristalsis and the

emptying time of the stomach; decreased gastric acid

secretions. The pregnant can also experience heartburn

(reflux of gastric content); constipation and flatulence

cause by the misplacement of stomach; hemorrhoid or pressure

of uterus affect the anal canal. There is also nausea and

vomiting. Lastly, gingival hypertrophy or enlargement of gums

and hypertyalism or increased salive formation.

j. Urinary System

Women can experience fluid retention caused by the

production of progesterone; increased urine output and

specific gravity decreases. There is also increased GFR

(Glomerular Filtration Rate). Urinary frequency increase; the

ureter’s diameters increases and bladder capacity. There can

be pressure on the right ureter.

k. Skeletal System.

There is gradual softening of the woman’s pelvic

ligaments and joints this is caused by the ovarian hormone

relaxin and placental progesterone. There is also wide

10
separation of symphysis pubis makes the pregnant woman

difficulty in walking because of the pain waddling gait.

l. Endocrine System

There is slight enlargement of the thyroid gland and

hormone cause the increase production of BMR and 02

consumption; in early pregnancy, there is decreased insulin

because of heavy metal glucose demand. After 1st trimester,

increased production of insulin due to antagonist action of

estrogen, progesterone and others. In placenta there is

estrogen and progesterone produced.

m. Immune System

There is decreased IgG (immunoglobulin G) will cause

the mother prone to infection. There’s also increased in WBC

to help counteract the decrease in IgG response.

B.2 Psychological Changes

The pregnant women can experience the following:

a. Ambivalence – interwoven feelings of wanting and not

wanting the pregnancy. Patient X experienced this kind of

feeling though, she’s young, and acclaimed that she has no

husband, that will support her.

b. Grief – the feeling of sadness or melancholy that may

arise vague sense of want or loss, there is assuming of new

roles.

c. Narcissism – also known as the self-centeredness; an early

reaction to pregnancy. According to patient, she is the

center in the family, all of her needs was given by her

family.

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d. Body image – the way the women appears theirselves.

Patient X feels shy when she go out, because she’s pregnant.

e. Stress – this can make the women difficult to make

decisions, awareness to the surrounding as usual or maintain

time management with her usual degree or skill.

f. Mood swings – mood changes; emotional imbalance; the woman

finds acceptable one week, she may find intolerable the next

week.

g. Changes in Sexual Desire – there can be decrease or

increase of sexual desire. During ovulation, sexual hormones

will increase. During 1st trimester, libido decreases.

Psychological tasks to adjust for pregnancy are the

following:

a. 1st Trimester (Accepting the Pregnancy)

Making the woman feel “more pregnant”. Promoting the

reality of the pregnancy.

b. 2nd Trimester (Accepting the Baby)

Helps her realize that not only she is pregnant but

also there is child inside her.

c. 3rd Trimester (Parenthood Preparation)

“Nest-building activities” such as planning the

infant’s sleeping arrangements, buying clothes and choosing

names for the infant.

C. Fetal Growth and Development

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Milestone of fetal growth and development in the mother’s

womb:

a. End of 4th Gestational Week

The embryo’s length is 0.75 cm weighs 400 mg. The

spinal cord is fused and formed at the midpoint. Head is

about one third of the entire proportion. Heart appears as

prominent bulge on the anterior surface. Arms and legs are

bud-like structures. Eyes, ears and nose are rudimentary.

b. End of 8th Gestational Week

Fetal length is 2.5 cm and weighs about 20 grams.

Organ formation is complete; heart is with septum and valves,

beating rhythmically. Facial feature are discernible. Arms

and legs are developed genitalia are forming, but sex cant

determine yet. And abdomen bulges forward.

c. End of 12th gestational Age

Fetal length becomes 7-8 cm, and weighs about 45 g.

Nailbeds are reforming on fingers and toes. Spontaneous

movements are possible. Babinski reflex is elicited. Bone

ossification begin to form. Tooth buds are present, the sex

is now distinguishable.

d. End of 16th Gestational Week

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 Fetal length becomes 10-17 cm, and weighs about 55-120

g. Lanugo is well formed. Liver and pancreas are functioning.

Urine is present in the amniotic fluid.

e. End of 20th Gestational Week

Fetal length is 25 cm, weighs 223 g; spontaneous

movement can be sensed by mother; hair including eyebrows,

forms on the head. Vernix caseosa begisnd to cover the skin.

Meconium is presnt in the upper intestine. Passive antibody

transfer fro mother to fetus begins

f. End of 24th Gestational Week

Fetal length is 28 to 36 cm, weighs 550g. There is

active production of surfactant. Hearing can be demonstrated

by sudden sounds. This is the age of viability.

g. End of 28th Gestational Week

Fetal length is 35 to 37 cm and weighs 1200g. lung

alveoli are almost mature. Testes begins to desecend from

lower admoninal cavity; blood vessels of retina are formed.

h. End of Gestational Week

Fetal length is about 38 to 43, weighs 1600g.

Subcutaneous fat begin to deposited. Moro reflex is elicited.

Iron storage begins; Fingernails reach the end of fingertips.

i. End of 36th Gestational Week

Fetal length is 42 to 48 cm, weighs 1800 to 2700. Sole

of foot has only one to two crisscross creases. Amount of

lanugo begins to diminish.

j. End of 40th Gestational Week

Fetal length becomes 48-52 cm and weighs 3000g. Fetus

kicks actively, hemoglobin convert to adult hemoglobin.

14
 Vernix caseosa is fully formed. Creases on the sole of the

feet cover atleast two thirds of the surface.

IV. STAGES OF LABOR

The process of labor and birth is divided into three stages:

 FIRST STAGE begins with having contractions that cause

progressive changes in the cervix and ends with cervix

that is fully dilated.

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 This stage is divided into two phases:

Latent Phase : your cervix gradually effaces (thins out)

and dilates (opens).

Active Phase: the cervix begins to dilate more rapidly, and

contractions are longer, stronger, and closer together.

People often refer to the last part of active labor as

transition.

 SECOND STAGE begins once you’re fully dilated and ends

with the birth of your baby. This is sometimes referred

as the “pushing stage”.

 THIRD STAGE begins right after the birth of the baby and

ends with the delivery of the placenta.

***Every pregnancy is different like the length of labor.

For primigravidas, labor often takes between ten to twenty

hours. For some women, it lasts longer. Labor generally

progresses more quickly for women who’ve already given birth

vaginally.

FIRST STAGE: Cervical Stage

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First stage of labor is divided into three phases; the

latent, the active and the transition phase.

LATENT PHASE

It begins with the onset of regular contractions,

effacement and dilation of the cervix to 0-3 cm. It lasts

an average of 6.4 hours for nulliparas and 4.8 hours for

multiparas. Contraction ecome increasingly stronger and

more frequent. A woman should continue to walk and make

preparations for birth.

ACTIVE PHASE

Dilation continues from 3 to 4 to 7 cm. Contractions

becomes stronger, more frequent and more painful, lasting

40 to 40 seconds and occur approximately 3-5 cm. it can be

the frightening time because the labor is progressing and

contractions continue to become stronger.

TRANSITIONAL PHASE

The culmination of the first stage; cervix dilates

from 8 to 10 cm. Intensity, frequency and duration of

contractions peaks and there is now an irresistible urge to

push.

SECOND STAGE: Fetal Stage

17
 Begins with complete dilation of the cervix and ends

with delivery of the newborn. Duration may differ among

primiparas whis is longer and multiparas –shorter, but this

stage should be completed within 1 hour after completing

dilation. Contractions are severe at 2-3 minutes interval,

with duration of 50-90 seconds. There is now the mechanisms

of labor. “Crowning” occurs when the newborn’s head or

presenting part appears in the vaginal opening. Episiotomy

may be done to facilitate delivery and avoid laceration of

the perineum.

THIRD STAGE: Placental Stage

Begins with delivery of the newborn and ends with

the delivery of the placenta. It occurs in two phases; the

placental separation and expulsion.

PLACENTAL SEPARATION – when the uterus contracts down on an

almost empty interior, there is disproportion between

18
placenta and contracting wall of the uterus that folding

and separation of placenta occurs. Signs are: globularity

of the uterus, fundus rising in the abdomen, lengthening of

the cord and increased bleeding.

PLACENTAL EXPULSION – after the separation of placenta, it

will now delivered either by natural bearing of mother or

gentle pressure on the contracted uterus.

Contraction of the uterus controls uterine

bleeding, oxytocic drugs are administered to help uterus to

contract.

FOURTH STAGE: Recovery and Bonding Stage

It lasts from 1 to 4 hours after birth. Mother and her

baby both recover from the physical process of birth;

maternal organs undergo initial readjustments to the

nonpregnant state. The newborn body system begin to adjust

to extrauterine life and stabilize. Skin to skin contact or

mother-child dyad happens. Mother can breastfeed her baby

to acquire the colustrum that contains antibody that can

protect her baby from disease in atleast 2 months.

V. MECHANISMS OF LABOR

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1. DESCENT

The fetus head is pushed deep into the pelvis in

sideways position, face is to left and the occiput is to

the right.

- in primigravidas, this may occur two weeks before

delivery. This referred to as “lightening”. Lay people

Might call this “dropping”

20
 - in multiparas, this may not occur until dilatation

of the cervix.

2. FLEXION

As fetus head descends, the chin is flexed to come

into contact with the infant’s sternum. Occiput position

allows the occipital bone in the back of the head to laed

the way (smallest diameter of the head).

3. INTERNAL ROTATION

The amount of internal rotation depends on the

position of the fetus and the way the haed rotates to

accommodate itself to the changing diameters of the pelvis.

Enables the fetal head to progress through the

maternal pelvis. The largest diameter of the fetal haed

aligns with the largest diameter of the pelvis.

4. EXTENSION

Occurs when the occiput passes under the symphysis

pubis. This bony structure acts as stable point and

provides leverage, enabling the head to leave the pelvis.

Actual delivery of the head is done by extension.

5. EXTERNAL ROTATION (RESTITUTION)

Occurs as the shoulders and body move through th birth

canal, using the same maneuvers as the head. Shoulders are

delivered similarly to the head, with the anterior shoulder

pressing under symphysis pubis.

After shoulders are delivered , the delivery of the

fetus ends with expulsion.

6. EXPULSION

The top of the anterior shoulder is seen next just

under pubis; gentle downward pressure by the physician

21
delivers the anterior shoulder; the head is gently raised

to deliver the posterior shoulder; the rest of the body

follows the head, which then completes expulsion. The fetus

remains completely passive as it moves through birth canal.

22
 VI. PRODUCTS OF CONCEPTION

The aggregate of tissues present in a fertilized gestation

; in a pregnancy that has been terminated or aborted or

deivered, chorionic villiand/or fetal tissue must be present i

n a specimen to make a definitive diagnosis of intrauterine–

1. FETUS

The passenger is the fetus; the part of the fetus that

has the widest diameter is the head, so this part least

likely to be able to pass through the pelvic ring. The

fetus delivered via NSD 38-40 weeks is appropriate Age of

Gestation, if least or greater, there is possible

complications.

2. FETAL MEMBRANE

The membranous structure that surrounds the developing

fetus and forms the amniotic cavity is derived from fetal

tissue and is composed of two layers; the amnion (inner

layer) and the chorion (outer layer). The amnion is a

translucent structure adjacent to the amniotic fluid, which

provides necessary to the amnion cells. The chorion is more

opaque that is attached to the decidua (maternal tissue

that lines the uterus during pregnancy)

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 The amnion and chorion are separated by the exocelamic

cavity until approximately three months gestation, when

they become fused. Intact, healthy fetal membranes are

required for an optimal pregnancy outcome.

3. FUNIS (Umbilical Cord)

Also known as birth cor or furnicularis umbilicalis,

is the connecting cord from the developing embryo or fetus

to the placenta. During prenatal developmet, umbilical

cordis physiologically and genetically part of the fetus

normally conatins 2 arteries and one vein, buried within

Wharton’s jelly.

4. PLACENTA

The placenta is an organ that connects the developing

fetus to the uterine wall to allow nutrient uptake, waste

elimination and gas exchange via mother;s blood supply.

It forms from both embryonic and maternal tissues, and

hosts an astonishing array of hormonal, nutritional,

respiratory and immunological functions. It is expelled

after the baby is delivered.

5. AMNIOTIC FLUID

This fluid is clear, slightly yellowish liquid that

surrounds the unborn baby (fetus) during pregnancy. It is

contained in the amniotic sac.

While in the womb, the baby floats in the amniotic

fluid. The amount of amniotic fluid is greatest at about 34

weeks (gestation) into the pregnancy, when it averages 800

ml. approximately 600 ml of amniotic fluid surrounds the

baby at full term (40 weeks gestation)

24
 VII. INSTRUMENTATION

The following instruments are used during Normal

Spontaneous Delivery

1. MAYO SCISSOR

-Used for cutting heavy

fascia and sutures sush as

the perineum during

episiotomy

2. STRAIGHT KELLY FORCEP

- Used for grasping anything

which would be inconvenient or

impracticable to graso with

fingers, such as clamping the

cord.

3. TISSUE FORCEP

- a forcep without teeth, designed

for handling tissues with minimal

trauma during surgery such as

episiotomy and perineal repair.

4. CURETTE

- Designed for scraping

biological tissue or

debris in a biopsy,

25
 excision or cleaning procedure such as the evacuation of

the blood clots after the delivery of the baby and

placenta.

5. METZ SCISSORS

- surgical scissors designed

for cutting delicate tissue and

blunt dissection. The scissors

come in variable lengths and

have a relatively long shank-

to-blade ratio. They are constructed of stainless steel and

may have tungsten carbide cutting surface inserts. Blades

can be curved or straight.

6. MAYO BASIN

- used as the storage of the

sterile instruments, and for

the placenta.

7. NEEDLE HOLDER

- also called needle

driver, is a surgical

instrument, similar to

a hemostat, used

by doctors and surgeons to hold suturing needle for closing

wounds during suturing and surgical procedures.

26
 VIII. NEWBORN ASSESSMENT

A. Vital Statistics

Weight: Baby girl weighs 3.16 kilograms. (Normal range

is 2.5 to 3.5 kg.)

Legth: 50 cm (Normal Range: 46-56 cm)

Head Circumference: 35 cm (Normal Range: 33-35 cm)

Chest Circumference: 33 cm (Normal Range: 31-33cm)

Abdomen circumfernce: 33 cm (Normal Range: 33-35cm)

Arm Cercumference: 12 cm (Noram range: 8- 12 cm)

B. Vital signs

Temperature: upon birth baby has the temperature of

36.60c (Normal range: 36.5 – 37.40c)

Respiratory rate: ranges to 55-60 breathes per minute

(Normal range: 30-60)

Cardiac rate: ranges from 125-130 beats per minute

(Normal range: 120-140)

C. Gastrointestinal System

Baby girl is breastfed by her mother immediately after

delivery. He didn’t pass out stool after birth.

D. Urinary System

Baby girl was voiding colorless and odorless urine

immediately after the delivery.

E. Neuromuscular system

The baby girl elicited the following reflexes:

- Blink reflex. Protect the eye from any object coming

near by rapid eyelid closure, and also the use of bright

light.

27
 - Rooting reflex. Helps the newborn to find food. When

the mother holds the child and brrush her nipple to the

newborn’s cheek, the baby turn toward the breast.

- Sucking reflex. Helps also the newborn to find food.

When the newborn’s lips are touched, the baby suck.

- swallowing reflex – when the breastmilk reaches the

posterior portion of the tongue is automatically

swallowed.

- Gag, Sneeze and cough reflex. It usually maintain the

clear airway to the newborn.

- Palmar grasp reflex. Newborn grasps an object placed

in his palm by closing his fingers on it.

- Plantar grasp reflex. When an object touches the sole

of anewborns’s foot at the base of the toes, toes grasp

in the same manner as the fingers do.

- Placing rflex. It’s elicited by touching the anterior

surface of the newborn’s leg against a hard surface. The

newborn makes a few quik lifting motions.

- Tonic neck reflex. When newborn lie in his back, her

head usually turn to one side or the other. The arm and

the leg on the side toward which the head turns extend,

and the opposite arm and leg contract.

- Starle or Moro reflex. Can be elicited by startling

the newborn with loud noise.

- babinski reflex – when the side of the sole of foot is

stroked in an invertes “J” curve from heel upward,

newborn fans the toes.

F. SENSES

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 Hearing – baby girl is very calm in response to a

soothing noise, or silence, and start to startle if

there’s a loud noise.

Vision – she blinks in response to a bright light, such

as penlight and in the light of the radiant warmer.

Touch – she keeps quiet when he is touched. She cries

when I rubbed his bach or patted his sole of feet. He

also grasp when there is object in his hands or feet.

Smell – She turns towrd her mother’s brear party out of

recognition of the smell of breat milk.

Taste – She accepts the taste of milk, and he enjoyed

it.

G. SKIN

Skin and mucosa color was pinkish. Adequate vernix

caseosa that is white, cheese-like secretions in his

skin, mostly in back part. He has also fine and downy

hair known as lanugo found in her shoulders, back, upper

arms, forehead and ears

She has a good skin turgor, because it goes back

immediately when I pinche her abdomen.

H. HEAD

Her head appers proprortionally large. The forehead is

small. The chin appears to be receding, and it quivers

easily if the infant is startled or cries.

The posterior fontanelle is triangular in shape, while

her anterior was diamond ins hape and felt as soft spot.

I. EYES

When the baby cries normally there is no taers. Her iris

is gray. Eyes appear clear, without any redness or

29
 purulent discharges and the cornea appears round and

proportionate in size.

J. EARS

Her pinna found in the ear is recoiled after I bend it.

There is no discharges noted. Good hearing sense as he

elicited the startle reflex.

K. NOSE

The baby’s nose is small. There is a little amount of

secretions in his nose. There is no discomfort, or

distree noted when she is breathing.

L. MOUTH

Baby girl’s mouth open whenever he is crying. She tongue

is quite large in his mouth. The lips and palate is

intact.

M. NECK

Her neck is short and well flexed. Her can elicited the

tonic neck reflex, and he can rotates it easily.

N. CHEST

The chest is smaller than the head. Breast look

engorged. Clavicles are straight and the chest is

symmetric. Respiration is in normal range.

O. ABDOMEN

Her abdomen looks like slightly protubenrant. The stump

of the umbilical cord appears as white, gelatinous

marked with the red and blue streaksof the umbilical

vein and arteries.

P. GENITALIA

Both labia are present, clitoris is protuding and

slightly reddish. Urethra and vaginal orifice is noted.

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Q. ANUS

Anus is well patent as the tip of thermometer in

introduce.

R. BACK

Baby boy’s Spine appears flat in the lumbar and sacral

part.

S. EXTREMETIES

His arma and legs appers short and move symmetrically.

It is all well flexed. Fingernails are soft and smooth.

He has a good muscle tone. The sole of foot appears

flat. No extra fingers and toes noted.

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 IX. NURSING CARE MANAGEMENT

A. List of Identified Problems

A.1 Actual Nursing Problems

Acute pain on the lower back after labor or vaginal

birth

Acute Pain related to tissue trauma and edema after

childbirth, uterine contractions (after-pains), engorged

breasts.

Deficient knowledge to infant and self-care related to

experience and skill in providing infant care and self

care after giving birth.

A.2 Potential Nursing Problems

Risk for Deficient Fluid volume related to active

losses after childbirth (vaginal), inadequate intake

Risk for infection related to site for invasion of

microorganisms (specify: e.g episiotomy, lacerations,

catheterization).

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 X. Sample Delivery Room Charting For NSD

Date Focus-Data-Action-Response
Time
2:25 PM >Received from LR ambulatory with ongoing IVF of D5LRS 1l
+10 “U” Oxytocin at 700 cc level, infusing well on the R
hand accomapanied by NOD
>assisted and positioned comfortably lithotomy.
>oxygen inhalation administered at 2-3 lpmp per nasal
cannula.
>right-medio lateral episiotomy done by Clerk Flores
2:28 PM >Delivered an alive baby girl via NSD by Clerck Flores
>oxytocin 10 “U” given IM on the left deltoid.
2:29 PM >cord clamping and cutting done done by clerk Flores
2:31 PM >Placenta out by Schultz presentation done by clerk Flores
>BP taken and recorded as 110/70
>evacuation of blood clots and placental fragments done by
clerk flores
>episiorapphy done by clerk flores used 1 pc vicryl rapide
2.0
>perineal care and betadine swab done by clerk Flores.
>placed adult diaper and secured
>Brought to RR per stretcher accompanied by NOD with
ongoing IVF of D5LRS IL + 10 “U” oxytocin at 400 cc level,
infusing well.
>with minimal lochial discharge
>with firm and contracted uterus
>monitored for possible profuse bleeding
>advised to massage uterus as needed
>encouraged mother to breastfeed per demand and burp then
and after
>instructed to increase fluid intake and to eat food rich
in vit.c, iron and protein
>emphasized importance of drug compliance and daily
perineal care
>advised to report any untoward observation
3:57 PM >transout to ward per wheelchair with ongoing IVF D5LRS Il
+ 10 “U” oxytocin x 28 gtts/min at 300 cc level, infusing
well

Patient’s Name: Case #:

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 XII. BIBLIOGRAPHY

Pilliteri, A., Maternal and Child Health Nursing, 6th Ed.

Luxner, M. Maternal-Infant Nursing Care Plan, 2nd Ed., 2005

Tortora, G., Anatomy and Physiology, 11th Ed.

Biswas, A; Su, LL; Mattar, C (Apr 2013). "Caesarean section

for preterm birth and, breech presentation and twin

pregnancies.". Best practice & research. Clinical obsLiu S,

Liston RM, Joseph KS, Heaman M, Sauve R, Kramer MS (2007).

"Maternal mortality and severe morbidity associated with

low-risk planned cesarean delivery versus planned vaginal

delivery at termtetrics & gynaecology

Goldenberg RL, Culhane JF, Iams JD, Romero R (2008).

"Epidemiology and causes of preterm birth

Luo ZC, Wilkins R, Kramer MS (2004). "Disparities in

pregnancy outcomes according to marital status and

cohabitation status". Obstetrics and Gynecology

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