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. Stages of Labor ………………………………………………………………………………………………………17
V. Mechanisms of Labor ………………………………………………………………………………………………21
VI. Products of Conception ……………………………………………………………………………………24
VII. Instrumentation ……………………………………………………………………………………………………26
VIII. Newborn Assessment …………………………………………………………………………………………28
A. General Assessment……………………………………………………………………………………………28
B. APGAR Scoring…………………………………………………………………………………………………...33
C. Ballard scoring………………………………………………………………………………………………….24
IX. 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
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X. Sample Delivery Room Charting For NSD …………………………………………………39
XI. Partograph ………………………………………………………………………………………………………………………40
XII. Bibliography ………………………………………………………………………………………………………………41
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I. INTRODUCTION
A. Brief Introduction
Delivery Room is a part of the hospital wherein the
process of delivering a baby and other products of labor is
done. Normal spontaneous delivery is the process known which
is delivering a neonate and placenta vaginally and
spontaneously without use of delivery forceps, vacuum and any
other instrumentation. Another procedure done in a delivery
room is D&C or Dilation and Curettage, procedure to scrape and
collect the tissue which is the endometrium form inside the
tissue.
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.
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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
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.
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II. BIOGRAPHICAL DATA
A. Patient’s Profile
Name: Patient X
Age: 18 y/o
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
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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,
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
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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
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
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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
16th week—colostrums (thin, watery, high-protein fluid that is
a precursor to the breastmilk) can be expelled from the
nipples.
e. Integumentary System
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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 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
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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
separation of symphysis pubis makes the pregnant woman
difficulty in walking because of the pain waddling gait.
l. Endocrine System
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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.
d. Body image – the way the women appears theirselves.
Patient X feels shy when she go out, because she’s pregnant.
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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
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.
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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.
Vernix caseosa is fully formed. Creases on the sole of the
feet cover atleast two thirds of the surface.
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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.
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.
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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
First stage of labor is
divided into three phases; the latent, the active and the
transition phase.
LATENT PHASE
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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
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
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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
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.
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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”
22
- 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
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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.
VI. PRODUCTS OF CONCEPTION
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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)
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)
25
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)
VII. INSTRUMENTATION
The following instruments are used during Normal
Spontaneous Delivery
1. MAYO SCISSOR
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-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,
excision or cleaning
procedure such as the
evacuation of the blood clots after the delivery of the baby
and placenta.
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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 surgeon
s to hold suturing needle for closing wounds
during suturing and surgical procedures.
VIII. NEWBORN ASSESSMENT
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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.
- 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.
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- 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
Hearing – baby girl is very calm in response to a
soothing noise, or silence, and start to startle if
there’s a loud noise.
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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
purulent discharges and the cornea appears round and
proportionate in size.
J. EARS
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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.
Q. ANUS
Anus is well patent as the tip of thermometer in
introduce.
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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
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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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37
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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
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+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.
41
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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