TAGUM DOCTORS COLLEGE INC.

Mahogany St., Rabe Subd., Visayan Village Tagum City, Davao Del Norte

Bachelor of Science in Nursing

In Fulfillment of the Requirements in

RLE 107:

Case Study: NORMAL SPONTANEOUS VAGINAL DELIVERY

Submitted to:

Aileen P. Crisostomo, RN

Submitted by:

Amodia, Hannah Mae

December 2023
Amoguis, Stephanie Marie Bartolome, Richard David

Ardenio, Angelo Mark Bayubay, Icy Claire

Ausejo, Mark Christian Bejerano, Marian

Bacena, Conrad Ven Cabarrubias, Chin Cindy

Balignot, Lovenelle Cabuyadao, Ava Niña

Balud, Marielle Cose, Angelica

 ii. TABLE OF CONTENTS

i. Cover Page

ii. Table of Content

iii. Acknowledgement

I. Introduction

II. Objectives

III. Patient’s Data

IV. Developmental Data

V. Definition of Complete Diagnosis

VI. Physical Assessment

VII. Anatomy and Physiology

VIII. Etiology and Symptomatology

IX. Physiology of Labor and Delivery

X. Doctor’s Order

XI. Drug Study

XII. Nursing Theories Applicable to the Case Presented

XIII. Nursing Care Plan

XIV. Discharge Plan

XV. Recommendation

XVI. References / Bibliography

 iii. ACKNOWLEDGEMENT

In the solemn embrace of gratitude, we commence by rendering our

outmost praise and appreciation to the Divine Providence, the Almighty,

whose benevolent showers of blessings sustained and guided us through the

intricate trajectory of our case study, culminating in its successful completion.

May His majesty and boundless strength continue to illuminate our collective

journey.

A profound debt of gratitude is owed to our esteemed CI, Mrs. Aileen

P. Crisostomo RN, whose benevolence and sagacity have indelibly shaped

our intellectual and professional growth. Her imparted knowledge and

profound understanding shall serve as a perennial lighthouse, guiding us

through the vicissitudes of the years to come. To all our Clinical Instructors,

we are honored for your continued guidance in our subsequent clinical

rotations, as your mentorship bestows upon us the requisite knowledge and

wisdom to evolve into adept and compassionate nurses in the unfolding

chapters of our careers.

Our expressions of gratitude extend to Mrs. Anabel V. Franada, RN,

MN, the venerable Dean of the Nursing Department, whose unwavering

commitment, patience, and diligent efforts have been instrumental in nurturing

and molding us into aspiring paragons of nursing excellence.

In a heartfelt acknowledgment, we turn to our revered parents,

guardians, and cherished loved ones, whose steadfast support, unwavering

trust, boundless love, earnest prayers, and selfless sacrifices have been the

bedrock upon which our educational pursuits and future aspirations have
been built. Through the undulating tapestry of our experiences, encompassing

both triumphs and tribulations, and enduring even the pervasive challenges

posed by the global pandemic, their enduring support remains an

unassailable pillar in our collective journey toward academic and professional

fulfillment.

Furthermore, we extend our profound appreciation to the collaborative

efforts of our project group, whose collective investment of time, concerted

effort, and diverse talents has contributed indispensably to the fruition of this

endeavor. The moments spent in the genesis of this intellectual endeavor

shall forever be etched in the annals of our memories, and the collaborative

spirit manifested therein is an enduring testament to the strength derived from

unity. To each member of the group, our sincere thanks for your unwavering

support and cooperative spirit. This venture has been a transformative

experience, and the realization of this completed work stands as a testament

to the collective synergy of our hard work and dedication.

In summation, our heartfelt appreciation extends to one and all who

have played an integral role in this journey of scholarly and professional

development. It is through the harmonious convergence of diverse

contributions that this opus has been brought to fruition, and for this, we

collectively express our deepest gratitude.

 I. INTRODUCTION

The condition of a developing embryo or fetus inside a female body is

known as pregnancy. This condition can be indicated through a positive result

on an over-the-counter urine test and confirmed through an X-ray, blood test,

ultrasound, or detection of a fetal heartbeat. Approximately, pregnancy lasts

nine months, counting from the date of the woman's last menstrual period

(LMP).

Following the completion of gestation, the developed fetus is expelled

from the mother's womb during a procedure known as delivery. It can be

delivered through a cesarean section or NSVD (normal spontaneous vaginal

delivery). A cesarean section is when the mother's abdomen and uterus are

surgically cut open to deliver a baby. This can be made when they believe it is

safer for the mother's and the child's health. Normal spontaneous vaginal

delivery (NSVD) is the term used to describe situations in which a woman

goes into labor naturally, without the use of drugs or other labor-inducing

techniques, and delivers the baby without the need for medical assistance via

cesarean section, vacuum extraction, or forceps.

Globally, it accounted for 80% of natural spontaneous vaginal births in

2021; rates ranged from 45% in the Caribbean to 95% in sub-Saharan Africa.

In the United States, 70% of all birth rates include NSVD and CS deliveries. In

2021, the global birth rate decreased by 1.13% from 2020 to 17.873 births per

1000 people. In 2022, there were 17.668 births per 1,000 people, a 1.15%

decrease from 2021. In 2023, the global birth rate is 17.464 births per 1,000

people, which is 1.15% less than in 2022.

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 Nationally, according to the findings of the National Demographic and

Health Survey (NDHS) for 2022, the percentage of live births that were

delivered in a medical facility in the two years prior to the survey went from 83

percent in 2017 to 88 percent in 2022, including the natural spontaneous

vaginal delivery. Of the live births that were performed in a medical facility, 32

percent were performed in a private facility, and over half (56%) were

performed in a public setting. The percentage of live births performed at home

fell from 14% in 2017 to 11% in 2022.

Urban areas had a higher percentage of live births delivered in a health

facility in 2022 (92%) compared to rural areas (85%). Regionally, Central

Luzon (97%) and Central Visayas (95%), followed by the Ilocos Region

(98%), had the highest percentage of live births delivered in a medical facility.

Alternatively, the lowest percentage of live births delivered in a medical facility

was found in the Bangsamoro Autonomous Region in Muslim Mindanao

(39%), followed by the MIMAROPA Region (77%) and the Zamboanga

Peninsula (76%). This includes the NSVD and CS live birth.

Locally, in 2021 statistics over 17 regions in the Philippines, Davao

Region had a total of 5.1% of live births registered, including natural birth

deliveries as well as caesarean section deliveries. Ranked in 8 out of 17

regions, Calabarzon has the highest overall percentage rate, at 14.3-15%

birth rate.

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 II.OBJECTIVES

General Objectives
Within the three (3) days of our rotational duty, our fundamental goal for the
study is to response to the treatment among the pregnant women presenting
Normal Spontaneous Vaginal Delivery (NSVD) and conduct a comprehensive
case study of the illness, and most especially, to provide a holistic and
effective nursing care to the client by relating and putting to use the
knowledge that we have acquired.

Specific Objectives
The student nurses would be able to:
 Defines Normal Spontaneous Vaginal Delivery (NSVD) and be review
concepts and purpose of the study.

COGNITIVE
 Understand the theoretical background of Normal Spontaneous
Vaginal Delivery.
 Compare and contrast the data gathered and prioritize problems raised
by
concerned patients.
 Recognize the anatomy and physiology involved to the patient's
condition.
 Identify the etiology and symptomatology of the problem.
 Trace down the physiology of the condition; and
 Relate the medication taken by the patient to her condition.
 Select the most effective independent nursing interventions to minimize
or

PSYCHOMOTOR
 Gather data and comprehend the patient's data, family background,
health history and present health condition.
 Student nurses will select a patient who will be the main subject of the
case. presentation.
 Follows instructions given by the clinical instructors for making this
paper, and able to perform the knowledge and skills from the learned
experiences.

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  Responds effectively to changes suggested by the clinical instructors
during the case presentation.

AFFECTIVE
 Establish good rapport with the patient to gain their trust and
cooperation
 Show respect, genuine concern, and empathy to the patient by giving
care and attention. Provide the best quality of care along with the
principles of nurse-patient relationship.
 Accepts responsibilities as student nurses for the enhancement of the
knowledge and skills throughout the making of this study.
 Characterizing: Shows reliance to do the tasks independently and
cooperates in group activities.

4
 III. PATIENT’S DATA

A. BIOGRAPHICAL DATA

Patient Code Name: Mrs. EB Gender: Female

Birthdate: November 17, 1983 Age: 40

Birthplace: Maragusan

Address: B1 Lot 17 Esmeralda Phase 2 Purok La,Filipina City of

Tagum

Religion: Catholic

Nationality: Filipino Status: Married

Ward or Unit Room: WING A3 RM 305 -B

Date/Time of admission: November 30, 2023 @ 5:12am

Vital Signs Upon Admission

Height: 157cm Weight: 55kg

Temperature 36.6c

Blood Pressure: 130/70 mmHg SPO2: 95%

Pulse Rate: 98 bpm

Respiration Rate: 20cpm

FHT: 138 bpm LR Fundal Height: 35cm

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B. Chief Complaints: Labor in Pain

Brief History of present illness: 1 day Prior to Admission (PTA),

onset of labor pain, persistence prompted for consultation, hence

admitted.

Admitting Diagnosis: Gravida 3 Parity 2 (3002) Pregnancy Uterine 37

weeks and 6days age of gestation.

Surgical Operation Done: Natural Spontaneous Vaginal Delivery

(NSVD), with repair of 2nd defuse perineal laceration

Final Diagnosis: Gravida 3 Parity 3 (3003) pregnancy uterine 37

weeks and 6 days, Cephalic Presentation.

Resident of Duty: Magallanes, Jomar C., MD

Attending Physician: Lascima, Chiara Mae

Source of information/ Informants: Client’s chart

C. Family Background/ Health History

Chief Complaints: Labor in Pian

Present Illness:1 day prior to admission (PTA), patient experienced

the onset of labor pain, persistence prompted for consultation, hence

being admitted on November 30, 2023, at Medical Mission Group

Hospital. Within the physical assessment the patient has fully dilated at

10 cm and was sent to the delivery room at 5:17 am. The doctor’s

order is Plain Lactated Ringers (PLR) 1 Litter at 30 cc/min.. At 5:30,

6
 Mrs.EB delivered a live baby girl via natural spontaneous vaginal

delivery. APGAR Score:8-9

Past Illnesses, Surgery and Operations:

Obstetrical History: Gravida 3 Parity 2, Last Menstrual Period (LMP)

was March 3, 2023. Age of gestational 38 weeks 8 days. Expected

date of confinement (EDC) is November 11,2023.

History of previous delivery: The patient had two children delivered

via viginal deliveries.

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 IV. DEVELOPMENTAL DATA

1. Piaget's Stages of Cognitive Development

STAGE ACTUAL JUSTIFICATION

FINDINGS

Formal Operational Stage This stage was The patient was able
successfully to show the ability to
Age: 12 years old and up achieved by the respond to some
Patient. questions. It was also
Adolescents and adults in this noted that despite
stage demonstrate abstract and having a different
hypothetical thinking abilities.This perspective than
stage allows for advanced others, she was
problem-solving and the encouraged to learn
development of higher-order through her own
thinking skills. They are able to desire to gain
examine their own thought knowledge and
processes, assess their own understanding.
capacity for thought, and change
as necessary.

2. Freud's Theory of Psychosexual Development

STAGE ACTUAL FINDINGS JUSTIFICATION

The Genital Stage This stage was Mrs. B has the ability to
achieved by the patient. form and maintain
Age: Puberty to Adult healthy, mature, and
fulfilling relationships
During this stage, the with her husband and
young person has their family was growing
beaten inactivity, made as she gave birth to their
relationships with one third child this November
orientation or the other, 2023.
and starts to seek out
pleasure through sexual
contact with others.

8
3. Erik Erikson’s “Theory of Developmental Stages”

STAGE ACTUAL JUSTIFICATION

FINDINGS

Generativity vs. Stagnation The generativity According to Mrs. B,

stage was during this stage of her
achieved by the life,she can find
Age:Middle adulthood (40 to 65 patient. fulfillment from seeing
years old) their children happy
and healthy. She also
feels happiness
Middle-aged adults strive to through participating
create or nurture things that will any activities in the
outlast them,often by raising community that may
children or fostering positive help the younger
changes that benefit others. generation in the future
Contributing to society and
doing things to promote future
generations are important
needs.

V. DEFINITION OF COMPLETE DIAGNOSIS

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 According to Zoey N. Pascual and Michelle D. Langaker that pregnancy

is a state of having implanted products of conception located either in the

uterus or elsewhere in the body. It ends through either spontaneous or

elective abortion or delivery. During this time, the mother’s body goes through

immense changes involving all organ systems to sustain the growing fetus.

According to Dr. Liji Thomas, MD that Pregnancy is the period in which

an egg cell is fertilized by a sperm to form a new cell, called the zygote, that

eventually develops into a new human organism, to be born.

According to Charles Patrick Davis, MD, PhD that the state of carrying a

developing embryo or fetus within the female body. This condition can be

indicated by positive results on an over-the-counter urine test, and confirmed

through a blood test, ultrasound, detection of fetal heartbeat, or an X-ray.

According to Dr. Irfana Koita, a fertility specialist, that pregnancy is the

physiological condition of a woman, starting from the moment of conception of

the fetus, including the baby’s growth, until birth. Pregnancy is usually

categorized by weeks (for a total of 40) and lasts around 280 days.

According to John W. Huffman Pregnancy, process and series of

changes that take place in a woman’s organs and tissues as a result of a

developing fetus.

According to William C. Lloyd III, MD that Pregnancy is a condition in

which a woman carries a developing baby, called a fetus, in her uterus.

Pregnancy normally lasts about 40 weeks or a little more than nine months,

and is divided into three 13-week trimesters. Most pregnancies involve one

10
fetus, but pregnancies involving multiple fetuses, such as twins or triplets, can

occur as well.

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 VI. PHYSICAL ASSESSMENT
Physical Assessment is an organized systematic process of collecting
objective data based upon healthy history and head to toe or general system
examination. A Physical Assessment should be adjusted to the patient based
on his needs. It can be a complete physical assessment, an assessment of a
body system or an assessment of a body part. By completing this
assessment, a medical professional can gather important data that allows
them to evaluate your health and identify any problems or concerns.

Measurement of Vital Signs

Name: Mrs. EB Sex: Female Age: 40 years
old
BP: 110/80 mmhg
PR: 71 bpm
RR: 18 cpm
TEMP: 36 C
O2. SAT: 97%

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 PHYSICAL NORMAL FINDINGS ACTUAL IMPLICATION
ASSESSMENT FINDINGS
 Alert  Able to Aware in the
 Aware of communic environment and
NEUROLOGIC environment ate and alert include being
SYSTEM  Able to response. oriented to person,
communicate . And also place, time, and
she is situation, displaying
aware to appropriate
her attention and
surroundin responsiveness to
gs. stimuli, and being
able to follow
Communication commands and
Device: vocal engage in
conversation with
appropriate
responsiveness.

INTEGUMENTARY  No edema, No  Skin color

 SKIN abrasions and is uniform Intact and
COLOR other lesions; except to symmetrical skin
 TEXTURE Moisture in those skin except to those skin
 TURGOR skin folds in that that exposed to
 TEMPERAT axillae (varies expose to sun, appropriate
URE with sun and skin turgor
 HAIR environmental warm to
(elasticity), absence
DISTRIBUTI temperature touch. The
and humidity, texture is of lesions or
ON abnormal growths,
 LESION body smooth
temperature, and intact. and normal hair and
 STOMA
and activity);  The nail condition
 FINGER
when pinched patients without signs of
NAILS AND
skin back to hair are infection or
TOENAILS
previous state. evenly abnormalities.
distributed.
 STOMA
not
applicable
 Finger
nails and
toenails
are pinkish
with and u-
shape,
thick and
convex.

HEAD  Rounded  Head is Absence of

13 abnormal growths
(Normocephali normocep
c and halic, with or lesions, intact
symmetrical, no and appropriately
Nursing Diagnosis:
1. Risk for infection related to perineal incision as evidenced by invasive
procedure ( episiotomy ).
2. Acute pain related to muscle contraction as evidenced by facial grimace
and with a pain scale of 7/10.
VII. ANATOMY AND PHYSIOLOGY

A. External Structure

The female external genitalia, also known as the vulva, is the collective
term for the external organs of the female reproductive system. It is located at
the front of the body, between the thighs, and includes the mons pubis, labia
majora, labia minora, clitoris, urethra, and vaginal opening, anus, and the
perineum.

● Mons pubis: The mons pubis is the fatty, triangular mound of skin that
covers the pubic bone. It is covered with hair after puberty.

● Labia majora: The labia majora are the two large, fleshy folds of skin
that surround the vulva. They are covered with pubic hair after puberty.

● Labia minora: The labia minora are the two smaller folds of skin that
lie inside the labia majora. They are usually hairless.

● Clitoris: The clitoris is a small, sensitive organ that is located at the top
of the vulva. It is covered with a hood of skin called the prepuce. The

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 clitoris is highly sensitive to touch and is the main source of sexual
pleasure for women.

● Urethra: The urethra is the opening through which urine is excreted

from the body. It is located between the labia minora, just below the
clitoris.

● Vaginal opening: The vaginal opening is the opening to the vagina,

which is the muscular tube that connects the uterus to the outside of
the body. It is located between the labia minora, just below the urethra.

● Anus: The anus is the opening at the end of the digestive tract through
which stool leaves the body. It is located at the end of the rectum,
which is the last part of the large intestine. The anus is made up of
muscles and skin.

● Perineum: The perineum is the area of the body between the anus
and the pubic symphysis. It is made up of muscles, skin, and
connective tissue. The perineum supports the pelvic organs, including
the bladder, uterus, and rectum. It also plays a role in childbirth.

B.Internal Reproductive Structure

● The Vagina: The vagina is a muscular canal that extends from

the vulva to the neck of the uterus (cervix). The vagina is where
the lining of the uterus is shed during menstruation, where
penetration can occur during sex and where a baby descends

15
 during childbirth. During pregnancy, the vagina undergoes
several changes to accommodate the growing baby. These
changes include:

1. Increased blood flow: The vagina receives more blood flow

during pregnancy, which can make the walls of the vagina
softer and more elastic.

2. Increased vaginal discharge: The vagina produces more

discharge during pregnancy, which is typically clear or white. This
discharge is caused by increased hormones and helps to keep the
vagina clean and lubricated.

3. Softening of the cervix: The cervix, which is the opening to the

uterus, softens and becomes more elastic during pregnancy. This
softening is necessary for the cervix to dilate during childbirth.

 Shortening of the pelvic floor muscles: The pelvic floor

muscles, which support the bladder, uterus, and rectum, can
weaken during pregnancy. This weakening can lead to
incontinence, which is the loss of bladder or bowel control.

● Cervix: Your cervix is a muscular, tunnel-like organ. It's the

lower part of your uterus, and it connects your uterus and
vagina. Sometimes called the “neck of the uterus,” your cervix
plays an important role in allowing fluids to pass between your
uterus and vagina.

The cervix is the lower part of the uterus that connects to the vagina. It
is a small, muscular canal that plays a vital role in the female
reproductive system. Here are the main functions of the cervix:

 Passage for sperm and menstrual flow: The cervix acts as

a gatekeeper, allowing sperm to enter the uterus during
sexual intercourse and menstrual blood to flow out of the
uterus during menstruation.

 Protection against infection: The cervix produces mucus

that helps to protect the uterus from infection. This mucus
becomes thicker during ovulation to help prevent sperm from
entering the uterus too early.

 Dilation during childbirth: During childbirth, the cervix

softens and dilates to allow the baby to pass through the
birth canal.

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  Maintaining pregnancy: Once a fertilized egg implants in
the uterus, the cervix closes to protect the developing baby.

 Protection against preterm labor: The cervix also plays a

role in preventing preterm labor. The cervix shortens and
softens as a sign of impending preterm labor.

● Uterus: The uterus is a hollow muscular organ located in the

female pelvis between the bladder and rectum. The ovaries
produce the eggs that travel through the fallopian tubes. Once
the egg has left the ovary it can be fertilized and implant itself in
the lining of the uterus.

During pregnancy, the uterus undergoes dramatic changes to

accommodate the growing baby. It enlarges to about 500 times its
original size and becomes more muscular. The walls of the uterus
thicken to support the weight of the baby and amniotic fluid. The lining
of the uterus, called the endometrium, also changes. It becomes
thicker and more glandular to provide nourishment for the developing
embryo and fetus. Here are some of the specific functions of the uterus
during pregnancy:

 Provides a protective environment for the developing

embryo and fetus. The uterus is a thick-walled, muscular organ
that protects the developing baby from injury and infection.

 Nourishes the developing embryo and fetus through the

placenta. The placenta is an organ that develops during
pregnancy and attaches to the wall of the uterus. It exchanges
nutrients and oxygen between the mother and the baby.

 Produces hormones that support pregnancy. The uterus

produces hormones such as estrogen and progesterone, which
are essential for maintaining pregnancy.

 Expands to accommodate the growing fetus. As the baby

grows, the uterus stretches and enlarges to accommodate the
extra space.

 Contracts during childbirth to expel the baby. When labor

begins, the muscles of the uterus contract to push the baby
down the birth canal and out of the vagina.

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 ● Oviduct (Fallopian Tube): The oviduct, also known as the
Fallopian tube, plays a crucial role in the early stages of
pregnancy. It is a thin, muscular tube that connects the ovary to
the uterus. The oviduct is where fertilization typically occurs, and
it also provides a nurturing environment for the fertilized egg as
it travels to the uterus. Here are the main functions of the
oviduct during pregnancy:

• Transport of the egg from the ovary to the uterus:

During ovulation, the ovary releases an egg, which is
then captured by the fimbriae, the finger-like projections
at the end of the oviduct. The egg is then transported
through the oviduct by cilia, tiny hair-like structures that
line the oviduct.

• Fertilization: Fertilization, the fusion of sperm and egg,

typically occurs in the ampulla, the middle section of the
oviduct. The oviduct provides a suitable environment for
sperm to meet and fertilize the egg.

• Nurturing environment for the fertilized egg: The

oviduct produces a fluid that nourishes and protects the
fertilized egg as it travels to the uterus. This fluid contains
nutrients and growth factors that support the
development of the early embryo.

• Transport of the zygote to the uterus: The fertilized

egg, now called a zygote, continues to travel through the
oviduct by cilia and muscle contractions. It takes about 3-
5 days for the zygote to reach the uterus.

• Implantation: Once the zygote reaches the uterus, it

implants in the lining of the uterus. Implantation is the
process by which the zygote attaches to the uterine wall
and begins to develop into an embryo.

After implantation, the oviduct plays a less important role in pregnancy.

The placenta, which develops during pregnancy, takes over the role of
providing nutrients and oxygen to the developing baby. The oviduct
remains closed until the next menstrual cycle.

● Ovaries: The ovaries play a crucial role in the early stages of

pregnancy. They are responsible for producing the egg that is
fertilized to create the embryo, as well as hormones that support
pregnancy, such as estrogen and progesterone.

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 • Egg production: During each menstrual cycle,
one of the ovaries releases an egg in a process
called ovulation. If the egg is fertilized by a sperm,
it will implant in the lining of the uterus and begin
to develop into an embryo.

• Hormone production: The ovaries also produce

the hormones estrogen and progesterone. These
hormones are essential for maintaining a
pregnancy. Estrogen helps to thicken the lining of
the uterus, making it more receptive to
implantation. Progesterone helps to support the
growth of the embryo and fetus.

• After implantation: Once implantation has

occurred, the ovaries continue to produce
progesterone for the first trimester of pregnancy.
After this time, the placenta takes over the
production of progesterone. The ovaries then
become relatively inactive for the rest of the
pregnancy.

● Urethra: During pregnancy, the urethra, the tube that carries

urine out of the body, undergoes some changes. These
changes are caused by the growing uterus putting pressure on
the urethra and by the hormonal changes of pregnancy.
Changes in the urethra during pregnancy include:

 Increased length: The urethra can lengthen by up to 50%

during pregnancy.

 Increased width: The urethra can also widen during pregnancy.

 Decreased closure pressure: The muscles that control the

urethra can relax during pregnancy, making it more difficult to
control urination.

C.Vaginal Delivery

Vaginal delivery, also known as childbirth or vaginal birth, is the process of

giving birth through the vagina. It is the most common type of delivery, and it
occurs in about 75% of all births.

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There are three stages of vaginal delivery:

Stage 1: Dilation and effacement

The first stage of

labor is the longest stage, and it can last anywhere from a few hours to
several days. During this stage, the cervix, which is the opening to the uterus,
dilates and effaces. Dilation means that the cervix is opening wider, and
effacement means that the cervix is thinning out.

There are three phases of the first stage of labor:

● Early labor: During early labor, the contractions are mild and irregular.
They may be felt as cramps or menstrual-like pain.

● Active labor: During active labor, the contractions become stronger,

longer, and more regular. They may be felt every 3-5 minutes and last
for 30-60 seconds.

● Transition: The transition is the shortest phase of the first stage of

labor. It is characterized by very strong, frequent contractions and rapid
cervical dilation.

Stage 2: Descent and expulsion

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 The second stage of labor is the pushing stage. During this stage, the
baby moves down the birth canal and is born. The pushing stage typically
lasts from a few minutes to an2 hours.

Stage 3: Delivery of the placenta

The third stage of labor is the delivery of the placenta, also known as
the afterbirth. The placenta is the organ that attaches the baby to the wall of
the uterus during pregnancy. The placenta is delivered within 15-30 minutes
of the baby being born.

D. Types Of Vaginal Lacerations

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 Vaginal lacerations, also known as perineal tears, are common injuries
that occur during childbirth. They are caused by the stretching and tearing of
the perineum, the area between the vagina and the rectum.

Vaginal lacerations are classified into four degrees based on the extent
of the tear:

First-Degree Lacerations:

These are the most common type of vaginal laceration and involve superficial
tears of the skin and skin lining (mucosa) of the vagina and perineum. They
typically heal within a few weeks without any complications.

Second-Degree Lacerations:

Extend deeper into the perineal muscles, but do not involve the anal sphincter
(the muscle that controls bowel movements). They usually require stitches to
close the wound and heal within a few weeks.

Third-Degree Lacerations:

Involve the anal sphincter and can extend up into the rectum. They require
more extensive suturing and may have a longer healing time. Third-degree
lacerations can lead to bowel incontinence (lack of control over bowel
movements) if not properly treated.

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Fourth-Degree Lacerations:

Are the most serious type of vaginal laceration and extend beyond the anal
sphincter into the anal canal and surrounding tissues. They require immediate
surgical repair and can lead to both bowel and urinary incontinence.

VIII. ETIOLOGY AND SYMPTOMATOLOGY

Patient X is a 40-year-old pregnant women. Gravida 3 Para 2 ( 2003)

pregnancy uterine 38 5/7 weeks Age of Gestation
ETIOLOGY
PREDISPOSING PRESENT ABSENT IMPLICATION JUSTIFICATION
FACTORS
/ Pregnancy is Patient is
SEX: FEMALE a natural female.
process that
occurs
exclusively in
women. This
is because
women
possess the
necessary
reproductive
organs and
hormones
needed to
support the

23
 progression
and
maturation of
a new life until
the moment of
delivery.
Age / Women have Patient is 40
the ability to years old.
conceive a
child starting
from the time
they reach
puberty, which
is when their
menstruation
begins. This
ability can
continue until
menopause,
which is when
their ovaries
no longer
release eggs.
On average, a
woman's
reproductive
years span
from the age
of 12 to 51.
PRECIPITATING
FACTORS
Coitus / Intercourse Patient had
allows the coitus with her
sperm to enter partner.
the cervical
canal and
travel to the
fallopian tube,
where it
encounters
the egg and
undergoes
fertilization.
Fertility / During the Patient had
days when a coitus with her
woman is partner during
most fertile, her fertile days.
an egg is
released and
begins to grow

24
 on the lower
part of the
lining of the
uterus. This
area provides
enough blood
and is a
suitable
environment
for the
development
of a fetus.

Symptoms

List of Symptoms Actual Findings Effect to the Patient/

Implication
Cramping (Afterpains) Patient experienced The most prevalent
abdominal pain as reason for experiencing
evidence by a pain scale cramping is the
of 7/10. contraction of the uterus
in order to return to its
original size. As the
uterus contracts, the
body also engages in
the process of
constricting blood
vessels within the uterus
to mitigate excessive
bleeding.
Vaginal Changes Patient experienced After giving birth, the
vaginal soreness and pelvic floor goes through
perineal discomfort. a lot of changes. The
muscles and nerves in
the pelvic area have
stretched to make way
for the baby's arrival.
Usually, the muscles
bounce back without any
issues. However, some
women have felt a slight
looseness and reduced
sensation. Pelvic floor

25

Vaginal Discharge Lochia in a postpartum
(Lochia) mother typically
progresses through
distinct phases, starting
with bright red discharge
(lochia rubra) for the first
few days.
Skin Changes Changes in skin tone or
pigmentation, especially
around the nipples and
around the areola, are
noted.
26
physical therapy can be
really beneficial in
activating and
strengthening those
muscles.
Lochia is the vaginal
discharge that occurs
after you give birth. It
contains a combination
of blood, mucus, and
uterine tissue. It may
have a slightly
unpleasant odor similar
to menstrual period
discharge and can last
for a few weeks. In the
beginning, itis quite
heavy but gradually
becomes lighter until it
eventually stops. This
process can take a few
weeks. Lochia is a
natural part of the
healing process after
giving birth and usually
does not cause any
complications.
Increased hormones in
the body can lead to
various changes in the
pigmentation of the skin,
which is completely
normal and natural.
These changes may
manifest in areas of the
body that already have a
darker pigmentation,
such as freckles, moles,
nipples, and areolas,
resulting in an even
darker appearance.
 IX. PHYSIOLOGY OF LABOR AND DELIVERY

Components of labor

Passage: I.E 10 cm, Suboccipitobregmatic

Passenger: Vertex, Cephalic Presentation

Power: True Labor

Psyche: Self-esteem and has a support

person

Stages of labor

First Stage of Labor Second Stage of Labor

Pushing Uterine Contraction

Increase oxytocin
concentration
Descent

Uterine Contraction Forces fetus down in

occiput

Increase pressure on
cervix Resistance of cervix, walls
of pelvis and pelvic floor
increase the pressure on
Dilation of cervix
baby’s cervical spine

Latent Phase: 0 cm – 4 cm
Flexion
Active Phase: 5 cm – 7 cm
Vertex presentation
Transition Phase: 8 cm – 10 cm changed to smallest
diameter

Desire to Push

27
Fetal head meets the pelvic Third Stage of Labor
floor

Continued Uterine
Internal Rotation
Contraction
Occiput turns anteriorly
towards the pubic
symphysis in occiput Detachment of placenta
anterior position from uterine wall

Extension Disruption of uterine

Gush of blood
vessels
Head extends outside pubic
symphysis as chin lifts. Head
Lengthening of cord
passes through vaginal Placenta gets closer to
outlet cervix
Rise of fundus

Restitution Expulsion of placenta

Delivered head externally
rotates to its original Fundus becomes
Contraction of uterus more globular
position to be in line with
the rest of the body

Expulsion Activation of
coagulation
Anterior shoulder passes cascade
beyond the pubic
symphysis, posterior
shoulder presses against
perineum internally, rest of Involution of the Cessation of
baby follows uterus bleeding

Baby Out

Cord Care

28
 X. DOCTORS ORDER

DATE DOCTOR’S ORDER RATIONALE REMARKS

ORDERED

To monitor the
11-30-23 Admit to room (Labor progress of labor,
Pain) provide necessary
DONE
care, and ensure a safe
environment for both
the mother and the
baby.

It is essential to
respect a person’s DONE
autonomy and ensure
they are informed
Secure consent to care
about and agree to any
medical treatment or
intervention.

To reduce the risk of

NPO aspiration. DONE
(once active labor)

It refers to the
IVF: PLR 1L @ 30 administration of
fluids directly into the

29
 gtts/mins. bloodstream through DONE
a vein.

Labs: To test the urine for

• UA any unusual results DONE
such as UTI.

To monitor the fetal

CTG/ EFM heart rate and uterine DONE
contractions during
pregnancy and labor.

To provide medical DONE

Refer to Pedia care specifically
tailored to infants,
children, and
adolescents.

To monitor a patient’s DONE

VSQ4 physiological status
and detect any
changes or
abnormalities in their
vital signs over time.

To support the DONE

Postpartum Order mother’s recovery,
monitor her health,
and provide
appropriate care
during the postpartum
period.

To detect the presence DONE

DAT of antibodies or
complement proteins
attached to red blood

30
 cells.

To closely monitor a DONE

VS q15 mins x 1hr, q30 patient’s vital signs
mins x 1 hr., q hourly x 2 during a critical or
hrs., q4
unstable period.

To support uterine DONE

PLR 1L to 10 units contractions and
oxytocin. prevent excessive
bleeding after
childbirth. PLR helps
maintain hydration
and electrolyte
balance, while oxytocin
is a hormone that
stimulates uterine
contractions.
Meds:
To promote effective
● Oxytocin 10 unit uterine contractions DONE
during labor or to
prevent postpartum
hemorrhage by helping
the uterus contract
and reduce bleeding.

To provide sedation
● Midazolam ½ am and promote a calm DONE
IVTT – given state, particularly
before certain medical
procedures or
surgeries.

To provide an effective
● Cefuroxime 5mg treatment against DONE
BID susceptible bacteria
and help resolve the
infection.

To provide a source of DONE

31
 ● FESO 1-tab OP iron supplementation.
Ferrous sulfate is
commonly used to
treat or prevent iron
deficiency anemia, a
condition
characterized by low
level of iron in the
body.

To prevent postpartum DONE

hemorrhage.
Keep uterus well
contracted

To provide pain relief

9:02 a.m. Mefenamic Ponstan and reduce DONE
SF TID inflammation in
conditions such as
menstrual cramps or
other sources of pain.

To aid in uterine DONE

12-01-23 Methergine 1-tab TID PO contraction, reduce
bleeding, and prevent
postpartum
hemorrhage.

32
 LABORATORY DEPARTMENT

HEMATOLOGY

11-30-2023 (6:58 A.M.)

TEST RESULT UNIT NORMAL REMARKS RATION

RANGE
HEMOGLOBIN 12.7 g/L 12.1 – 15.1 NORMAL To ensure
CONC. the individ
blood carri
adequate
amount of
oxygen to
body’s tiss

HEMATOCRIT 49.3 % 36-44 HIGH To ensure

the propor
of red bloo
cells in the
blood is wi
the expect
range.
LEUKOCYTE 9.14 x1 5.00 - 10.00 NORMAL To assess t
0ˆ body’s imm
9/ response a
L detect any
abnormaliti
in the whit
blood cell
count.

ERYTHROCYTE 9.11 Cel 5.00 - NORMAL The platele

ls/ 10.00 count asse
mc the numbe
l platelets in
blood and
diagnose
bleeding
disorders a
monitor th
body’s abil
form blood

33
 clots.
NEUTROPHIL 0.62 x10ˆ9/L 0.40-0.60 HIGH A high
neutrophil
count, kno
as neutrop
in a labora
test may
indicate an
ongoing
bacterial
infection,
inflammati
tissue dam
or other
conditions
as stress,
smoking, o
certain
medication
LYMPHOCYTE 0.310 Cells 0.250- NORMAL To evaluat
0.350 number an
proportion
lymphocyt
the blood.

MONOCYTE 0.050 Cells 0.010- NORMAL To assess t

0.060 number an
proportion
monocytes
the blood.

To assess the
number and
EOSINOPHIL 0.020 Cells 0.010- NORMAL
proportion in
0.040
blood.

34
MCV 96.4 fL 80.0-100.0 NORMAL MCV meas
the averag
of red bloo
cells. It hel
classify ane
types and
provides
informatio
about the
production
lifespan of
blood cells
MCH 32.7 pg 27.0-34.0 NORMAL MCH meas
the averag
amount of
hemoglobi
red blood c
It helps
evaluate th
oxygen-car
capacity of
blood cells
MCHC 33.9 g/L 320-360 NORMAL MCHC
measures t
average
concentrati
of hemoglo
in red bloo
cells. It
provides
informatio
about the
and densit
red blood c
and helps
diagnose a
classify
different ty
of anemia.

EXAMINATION RESULT RATIONALE

35
Blood Group O+ To ensure compatibility
for blood transfusions.

RH POSITIVE Helps identify the RH

status of the individual,
allowing healthcare
providers to take
appropriate measures
to prevent or manage
Rh incompatibility.

Hepatitis B Surface NON-REACTIVE To screen for hepatitis

Antigen (Qualitative) B infection.

12-01-23
1:00 a.m.

Na + K + Ca +
Sodium 139.3 135 – 155 mmol/L NORMAL
Potassium 4.56 3.4 – 5.3 mmol/L NORMAL
Calcium 1.250 1.203-1.32 mmol/L NORMAL

36
 XI. DRUG STUDY

Date Name of Drawing Classification Dosage/ Indication Mechanism of Side Effects Nursing
Drug Time/ Action Responsibilitie
Route s
Dec. Generic Ergot Dosage: Prevent and A partial agonist or  Headache Assess history
01- Name: Alkaloid 1TAB treat post antagonist at alpha  Nausea of allergy to
23 Methylerg 0.2mg partum receptors; as a  Vomiting the drug..
ometrine hemorrhage result, it  Dizziness
Time: caused by increases the Monitor
uterine atony strength, postpartum
Brand 6-12-6 or duration, and women for
Name: subinvolution frequency blood pressur..
Methergin Route: of uterine
e Contraindicati contractions
Oral ons: Avoid
prolonged use
Contraindicat of the drug.
ed with
allergy
To
Teach client to
methylergono
vine, report difficulty
hypertension, breathing,
toxemia, headache,
lactation, numb or cold
pregnancy. extremities,
severe
abdominal
37 cramping
Date
Date DateName
Name
Nameof
ofof Drawing
Drawing
Drawing Classification
Classificatio
ClassificatioDosage/
Dosage/
Dose/ Indication
Indication Mechanism
Mechanism
Mechanisofof Side Side
Side Effects
EffectsNursing
Nursing
Drug
Drug
Drug n n Time/
Time/
Time/Rou Action
Action
m of Effects Responsibiliti
Responsibilities
Responsib
Route
Route
te Action es ilities
Dec.
11 - 01
30
11- BRAND
Generic
Generic Non-
Therapeutic
Therapeitic Dosage:
Dosage:
Dose: Preoperative
ATo Medication
induce or Anti-
Causes
May potent CNS: CNS:
-Dizziness 1.Confirm
BEFORE:
1. Confirm
23
- 23 30- NAME:
Name:
Name: Steroidal
Class:
Class: 500
10 IUmg to stimulate
relieve
sedation (to inflammatory,
andpotentiate
selective of oversedati
-Headache patient's
Subarachno patient's
23 Anti-Anxiolytics Capsule
1/2 pain
labor and analgesic,
uterine
the eefects
andand on,id -DrowinessidentityCheck and doctor’s
induce identity
PITOCIN
Mefinami
MIDAZOL Inflammatory
Oxytocics Time:
ampule reduces or antipyretics
mammary
of GABA, drowsiness
- Nausea verify orders.
sleepiness hemorrhage andtheverify
c AM
Acid DrugsPharmacoloTime: IVTT inflammation.
To reduce and activities
drowsiness gland
depress
smooth
related , amnesia,
,-Vomiitng
seizures, medication
the
Check patient’s
GENERIC
HYDROC Pharmocolo
gic Class; 6-12-6 It postpartum
is
relieve used to to
muscle.
inhibition
the CNS, of headache,
- Skin
coma, rash order.
medication
rights upon
NAME:
HLORIDE gic Class: Route: treat
bleeding prostaglandin
and seizures,
- Stomach Inform the
apprehension order.
medication
Brand BenzodiazeRoute:
IVTT headaches,
after synthesis.
suppresss involuntary
discomfot patient about
CV:
Inform the
administration.
OXYTOCI
Name: Exogenous
pines menstual
expulsion of
Moderate the spread movementarrythmias, the drug its
N Brand hormones Oral cramps,
placentabefore of seizure s, hypertensiopurpose, patientand
sedation Obtain a
Ponstan
Name: dentaldiagnostic
pain activity. nystagmus side about
effectsthe
short n, PVC, medication
SF andIncomplete, , hiccups, drug its
or endoscopic hypotensionandticket.respect
postoperative
Inevitable, or paradoxica refusal. purpose,
procedures ,
surgeries.
elective l behavior, 2.Have and side
tachycardia. Prepare the
abortion
To inudce or oxygen and
effects
medication,
Contraindicat
sleepiness and excitemnet
GI: nausea,resucutation
and labels,
check
ions:
Contraindic
amnesia and to vomiting equipment
respect date
expiration
Inflammatory
ation:
relieve CV: available
refusal.in
intestinal GU:
variations case of
Assess patients
apprehension
Contraindica
disease. in abruptio
blood severe
who develop
before
ted when
Active peptic pressure
placentae, respirratory
severe diarrhea
anesthesia
vaginal or
ulcers. and pulse 2. Monitor
depression
tetanic and
before
deliveryandisn’t
Hypersensitiv rate. fetal heart for
vomiting
3.Contiunuos
uterine dehydration and
during
ityadvised
toaspirin rate and
contractionsly monitor
electrolyte
procedures
or(placenta
other non- GI:, uterine
patient, for
imbalance.
contraction
steroidal
previa, vasa nausea, life
Contraindication postpartum
inflammatory vomiting, s before
threatening
s:previa, hemmorhagrespiratory
agents.
invasive augmentin
DURING:
Renal failure. e, uterine
Respirator depression.
cervical
Contraindicated g and
y: rupture, Prepare
inducing the
Monitor
incarcinoma,
patients impaired blood
apnea, medication.
labor.
hypersensitive
genital to uterine
decreased presssure,
drug or its Explain
herpes, blood flow, heart
respiratory rate, to the
components and
when rate,
pelvic andsorhythm,
the purpose
incephalopelv
those with 3.
of Monitor
the drug.
oxygen
hematoma, respirations,
acute angle fluid intake
oc dissaturati
increased airway
closure AFTER:
and and
disproportio on,uterine integrity,
glaucoma, 38 output. for any
n is present, coughing,
motility pulseObserve
shock, coma, or
or when Anti- effects or
oximetry
side
acute, alcohol
HEMATOL during
diuretic effects.
adverse
 Dat Name
Dat Name
of ofDrawi
Drug Drawin Classification
Classificati Dose/ Dose/
Indication Indication
Mechanism of Mechanis
Side SideNursing
Effects Nursing
e e Drug ng gon Time/ Time/ Action m of Effects Responsibilit Responsibilities
Route Route Action ies
11- Generic
11- Generic TherapeitiTherapeitic
Dose: Dose:
Iron DeficiencySerious lower theInhibits
Elevates CNS: CNS CNS:Check
phlebitis,
the Check doctor’s
30- Name:
30- Name: c Class: Class: respiratory
serumtract
iron cell wall
toxicity, thrombophlebitsi,
doctor’s orders.
2323 FERRO Antibiotics
1 TAB PO 5mg BID infection,
Contraindications: UTI,
concentration, synthesis,
acidosis, order.
USCEFUROXIM Iron Contraindicated skin-structure
andis then promotingcoma and GI: diarrhea, Check patient’s
E SODIUM
SULFAT Suppleme infection,
with allergy to any bone or toosmotic
converted death withpseudomembran
verify rights upon
E nt joint infection,
ingredient; sulphite Hgb or instability;
overdoseous colitis,
patient’s
medication
allergy; septicemia,
trapped in the usaulay
GI: GI nausea, identity
administration.
Brand hemochromatosis, meiningitis, and
reticuloendoth bactericida
upset, anorexia,
Name: hemosiderosis,gonorrhea elial cells forl anorexia,vomiting.
administer Obtain a
haemolytic Perioperative
storage and nausea, the right medication
prophylaxis
anemiasPrecaution eventual vomiting, Hematologic:
drug in the ticket.
:Use cautiouslyMild toconversion toa constipatio Hemolytic
rightdose
with normal iron moderate acuteform of n,
usable anemia,
and route at Prepare the
balance; pepticbacterial iron diarrhea,thrombocytopeni
the right medication,
ulcer, regional exacerbations of dark a, transient
time check labels,
chronic bronchitis
enteritis, ulcerative stools, neutropenia, expiration date
colitisInteractions:> temporary eosinophilia
do not and compare
drug-drug: Contraindicatio staining of crush, chew
decreased nti- n: teeth Skin:or cut the medication
infective response (liquid maculopapular,
tablets and to the
to ciprofloxacin,Contraindicated preparatioand erythmatous
capsules medication
in patient
norfloxacin,ofloxaci ns) rashes, urticaria
n; decreased hypersesitive to pain, in duration, ticket for the skin
absorption withdrug or other steril abscesses, test.
cephalosporins
antacids,cimetidine temperature
Contraindicated elevation, tissue, Wash hands
; decreased effects
in patients
of levodopa if taken sloughing at IM DURING:
hypersensitive to
with iron; increased injection site.
serum iron levelspenicillin Prepare the
with because of medication.
chloramphenicol> possibility of
drug-food: cross-sensitivity Explain to the so
decreased with ither beta- the purpose of
absorption withlactam antibiotics the
antacids,eggs or drug.
milk, coffee and
tea; avoid Be aware of
39
concurrent changes in
administration of urinary
any of these
40
 XII. NURSING THEORIES

A. Roy Adaptation Theory

Sister Callista Roy is a dynamic nursing theorist who developed the
adaptation model theory. The Roy Adaptation Model (RAM) by Sister Callista
Roy focuses on how individuals adapt to changes in their environment
through a process involving stimuli and responses. It examines how
individuals, as adaptive systems, respond to various stimuli to maintain
equilibrium. Changes in stimuli can lead to changes in adaptive responses
within this framework.
Adaptation of Roy's Adaptation Models:
Physiological mode: refers to aspects related to the physical functioning
and adaptation of an individual in response to internal and external stimuli.
Self Concept Mode: involves considering how the surgical procedure might
affect her self-perception, body image, and emotional well-being.
Role Function Mode: involves considering how might impact her ability to
perform her roles and functions, especially those related to motherhood and
self-care
Interdependence Mode: focuses on the relationships and interactions
individuals have with others in their social environment. It emphasizes the
importance of social support, relationships, and the influence of the
environment on an individual's adaptation

B. FLORENCE NITANGLE’S ENVIRONMENTAL THEORY

The Environmental Theory encompasses the nurse's proactive role in setting
appropriate environmental conditions to facilitate the patient's gradual
recovery. It acknowledges that external factors surrounding the patient
influence their biological, physiological processes, and overall development.
This theory emphasizes the nurse's responsibility in creating a supportive
environment that fosters the patient's well-being and aids in their healing
process.
During the postpartum period, women who undergo perineal incisions, such
as episiotomies or tears during childbirth, face an increased risk of infection.
This risk is inherent due to the invasive nature of the procedure and potential
exposure of the incision site to bacteria from the vaginal and fecal areas.
Factors such as poor perineal hygiene, delayed wound care, and
compromised immune responses can further contribute to this susceptibility.
Applying Florence Nightingale’s Environmental Theory to nursing care for
postpartum mothers who have undergone perineal incisions maintains a focus

41
on creating an optimal healing environment conducive to the mother's
recovery and adaptation after childbirth and a perineal incision.

C. Virginia Henderson's Nursing Need Theory

The Need Theory emphasizes the importance of increasing the patient’s
independence and focusing on basic human needs so that progress after
hospitalization will not be delayed.
In the context of a postpartum mother experiencing acute pain, this theory
directs nurses to address her fundamental needs while prioritizing strategies
to alleviate discomfort. Nurses using the Need Theory would assess the
mother's pain levels, considering them a barrier to meeting her needs for rest,
comfort, and recovery. They would prioritize interventions aimed at pain
management, utilizing appropriate pharmacological and non-pharmacological
methods, such as medication administration, positioning techniques,
relaxation exercises, or heat therapy.
Overall, applying Henderson's Need Theory to a postpartum mother
experiencing acute pain, nurses focus on enabling her to regain
independence despite her discomfort. The approach involves holistic care,
encompassing physical, emotional, and educational aspects to support her
recovery, promote self-care, and ensure a positive transition to motherhood.

42
 XIII. NURSING CARE PLAN

CUES NEEDS NURSING DIAGNOSIS/ OBJECTIVE OF CARE NURSING EVALUATION

INTERVENTION
Objective: Health Risk for infection related Before 8 hours of nursing Established rapport After 8 hours of
VS: Perception to perineal incision as intervention the client will To develop trust and nursing intervention
Temp = 36 and Health evidenced by invasive be able to: cooperation from the the client is able to:
BP = 110/80 Management procedure. patient
RR = 16 by Gordon’s  remain free of  Maintain normal
PR = 96 11 health infection, as Checked vital sign vital signs and
evidenced by To assess the patient’s show absence
O2sat = 98% pattern.
normal vital signs physical health of sign and
and the absence of symptoms of
Body weakness signs and Noted risk factors for infection and
Episiotomy area is symptoms of the occurrence of remain free
swollen and reddish in infection. infection. from infection
color  Understand the To evaluate any  Verbalized her
WBC importance of presence or characters understanding
Neutrophils 62 knowing the signs of infections about the
[40-60] (HIGH) of occurring importance of
infection Provided education identifying the
 Understand the on symptoms. early signs of
importance of Nurses should educate infection
proper hand patients at discharge  Demonstrate
washing and on signs and and understand
proper hygiene in symptoms of infection proper hand
healing process and when to seek washing and
 Demonstrate prompt treatment proper hygiene

43
 techniques,  Perform proper
lifestyle changes to Reviewed hygiene and
promote safe environmental family members
environment factors perform a safe
 Take antibiotics as To assess if there is and clean
prescribed by the any need of avoidance environment
physician or modification of  Use the
 Demonstrate the environment to reduce prescribe
proper perineal incident of infection antibiotics with
care and inform the assistance
the importance of DEPENDENT of the nurse
proper hygiene. Administered and  Verbalize that
instruct precaution proper perineal
regarding medication care can
regimens and noted prevent the
client responses growth of
To determine the microorganism
effectiveness of 
therapy and if there is
a presence of
Side effect

Emphasized
necessity of taking
antibiotic, as directed
To inform the risk of
discontinuation of
treatment.

44
 CUES NEEDS NURSING OBJECTIVE OF CARE NURSING EVALUATION
DIAGNOSIS/ INTERVENTION
Subjective Cues Cognitive- Acute pain related to Before 8 hours of nursing Established rapport After 8 hours of
‘’sakit pa tarugon Perceptual muscle contraction as intervention the client will To develop trust and nursing intervention
akong puson dy’’ Pattern by evidence by facial be able to: cooperation from the the client is able to:
verbalized by the Gordon’s 11 grimace and pain scale patient
patient health of 7/10.
pattern.  Verbalize Checked vital sign  Verbalize
decrease pain To assess the patient’s decrease pain
Objective cues: . intensity using from a scale of
VS physical health
pain scale. From 7/10 to 2/10
Temp = 36 7/10 to 3/10
BP = 110/80 Assess abdomen  demonstrates
RR = 16  Use visual firmness relaxations
PR = 96 presentation to To monitor for any signs skills and
O2sat = 98% show relaxations of bleeding technique like
skills and changing in a
Pain scale: 7/10 diversional Encouraged and helped comfortable
Facial Grimace activities as the client in position position
Limited movement indicated for the change
Protective Gesture to situation For client to find
 voided at least
avoid more pain. comfortable position
 Void every 1-3 once in every 4
hours to promote hours
Encouraged the client to
comfort and verbalize feelings about
identify uterine pain.  Used the
firmness prescribed pain
Rationale: Allow the
client to verbalize her reliever as
 Follow prescribed guided by the
perceptions about pain

45
 analgesics and acknowledge the nurse
pain experience. Pain is a
subjective experience  Sleep with no
and cannot be felt by signs of facial
 Rest and show no
facial grimace others. Convey grimace and
acceptance of the complains
client’s response to pain.

Taught and
demonstrated proper
relaxation techniques
and position.
Rationale: relaxation
techniques and position
are used to promote
comfort.

Encouraged the use of

pain scales for the
patient to communicate
pain intensity.
Rationale: Pain scales
help healthcare
providers assess the
effectiveness of pain
management
interventions overtime

46
Instructed the patient
on proper wound care,
including hygiene and
the importance of
keeping the incision dry
and clean
Rationale: proper wound
care can help minimize
inflammation at the
incision site. Keeping the
incision clean and dry
helps manage
inflammation and
supports a more
comfortable recovery

Administered analgesics
as ordered by the
physician
To relive pain of the
patient

47
 XIV. DISCHARGE PLAN

M- Medication  Direct the patient to adhere to the physician's prescription

for prompt recovery by taking the designated home
medication.
 Inform the patient to take their medication at precise time
and in the recommended amount.
E-Exercise  Instruct patient to avoid extreme activities and lift any heavy
objects
 Promote range of motion as tolerated
 Encourage the patient to take adequate rest
 Advise patient to skip intercourse with her partner until the
time she have totally recovered
T- Treatment  Tell the client the importance of treatment to be done.
 Encourage the client to continue complying with diagnostic
examination to ensure that they do not have any
complications.
 Advice the mother to take a bath every day. In washing the
vagina, don’t use soaps or any feminine wash to avoid
irritations
H- Health Breastfeeding:
Teaching Cleanse the breasts daily using lukewarm water for hygiene. After
each feeding, allow the nipples to air dry. If experiencing breast
engorgement, use warm packs and express milk. Follow on-
demand feeding practices.
Uterine Changes:
Postpartum cramps or afterpains are a typical occurrence. These
cramps indicate that the uterus is contracting to resume its pre-
pregnancy dimensions. It usually takes 5-6 weeks for the uterus to
fully return to its non-pregnant size.
Vaginal Discharge:
Typically persists for a duration of 10 days to 4 weeks. The color
of the discharge will transition from bright red to a brownish or tan
hue and should resolve in approximately 6-8 weeks, unless
breastfeeding. Ensure proper perineal and personal hygiene by
taking a daily bath.
Care of Episiotomy:
Sitz Bath: Soaking in a warm water bath for 15 minutes, 2-3 times
a day, can alleviate discomfort. Ensure the area remains clean
and dry to expedite the healing process. Stitches are expected to
dissolve within 1-3 weeks.

Out-Patient  Advise to visit and have follow up checkups to attending

physician

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Diet  Diet as tolerated
 Increase fluid intake
 Instruct to take low-salt and low-fats
 Instruct to avoid alcohol beverages and smoking

49
 XV. RECOMMENDATIONS

TO THE CLIENT:
Eat a balanced diet.
Advice the client to eat healthy foods that are rich in Iron, etc.
Advice the patient to increase fluid intake to stay hydrated every day.
Advice the client to take vitamins, as recommended by a physician.
Take your medicines as prescribed.
Take adequate rest and have good hygiene to lessen the infections and
complications from afterbirth.
Encourage patient to always maintain a safe and clean environment.
Advice the client to lessen the intake of sugary and unhealthy foods.
Advice the patient to initiate breastfeeding as soon as possible after birth,
ideally within the first hour. Early breastfeeding helps establish a good latch
and stimulates milk production.

Advice the patient to practice skin-to-skin contact with your baby. This not
only helps with breastfeeding but also promotes bonding and regulates your
baby's temperature and heartbeat.

FELLOW STUDENTS:
Allowing ourselves to open up and share ideas to complete a specific task.
Encourage others to think about themselves and maintain a healthy
relationship with other people.
Make the most of your passions.
Set a high standard in everything.
Enjoy every little thing.
Explore and educate yourself more.
Make an effort to study more and motivate yourself to do the things that
makes you feel happy.

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SCHOOL:
Student should always be considered and involved in any planning that are
related to academics to broaden their sense of knowledge and to achieve a
more effective implementation in such works.
Offer a wide variety of learning resources and research on the many online
platforms that are accessible.
Establishing a creative learning environment for students and providing
them with access to resources like PowerPoint presentations, etc.
Encourage students to read and to reflect what they had learned.
Give students the freedom to select their own learning goals and resources,
which will encourage them.
Encourage students to create pleasant experiences.

51
 XVI. BIBLIOGRAPHY
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24). https://psa.gov.ph/statistics/vital-statistics/node/1684041483

| Philippine Statistics Authority | Republic of the Philippines. (2023b, September

14).

https://psa.gov.ph/statistics/national-demographic-health-survey/node/

1684061044

Cesarean section. (2023, November 3). Johns Hopkins Medicine.

https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/

cesarean-section#:~:text=Cesarean%20section%2C%20C%2Dsection

%2C,and%2Ddown%20(vertical).

Medical definition of pregnancy. (2021, March 29). RxList.

https://www.rxlist.com/pregnancy/definition.htm

NSVD (Normal Spontaneous Vaginal Delivery). (2023). NYE Partners in Women’s

Health. Retrieved December 5, 2023, from

https://nyepartners.com/nsvdserv/#:~:text=When%20a%20woman%20goes

%20into,spontaneous%20vaginal%20delivery%20(NSVD).

Professional, C. C. M. (n.d.). Vaginal delivery. Cleveland Clinic.

https://my.clevelandclinic.org/health/articles/23097-vaginal-delivery

World Rate Birth Rate 1950-2023. (2023). Mactotrends. Retrieved December 5,

2023, from https://www.macrotrends.net/countries/WLD/world/birth-

rate#:~:text=The%20current%20birth%20rate%20for,a

%201.13%25%20decline%20from%202020.

52
https://www.healthgrades.com/right-care/pregnancy/pregnancy

https://www.rxlist.com/pregnancy/definition.htm
https://pubmed.ncbi.nlm.nih.gov/32644730/
https://www.britannica.com/science/pregnancy
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Aggarwal, N. (2022, November 7). This Is What Really Happens to Your Vagina After Birth.
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Cleveland Clinic (2022, March 11). Lochia (Postpartum Bleeding).

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Cleveland Clinic (2018, January 1). Pregnancy: Physical Changes After Delivery

Marcin, A. (2020, August 28). Postpartum Cramps: Causes and How to Get Relief. Healthline
Media. https://www.healthline.com/health/postpartum-cramps

Aggarwal, N. (2022, November 7). This Is What Really Happens to Your Vagina After Birth.
The Bump. https://www.thebump.com/a/will-my-vagina-ever-be-the-same-after-delivery

Cleveland Clinic (2022, March 11). Lochia (Postpartum Bleeding).

https://my.clevelandclinic.org/health/symptoms/22485-lochia

Cleveland Clinic (2018, January 1). Pregnancy: Physical Changes After Delivery
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delivery

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