ST.
MARY’S COLLEGE OF BALIUAG
Nursing Department
NCM 109
CARE OF MOTHER & CHILD AT RISK
(GYNE)
A CASE STUDY ABOUT
PRE-TERM LABOR
Prepared by:
Rosella Joy Dela Cruz
Clinical Instructor/s:
Mrs. Rhodora Sulit
Mrs. Raquel Bautista
Mrs. Jeniffer Calma
March 2023
INTRODUCTION
Preterm labor is defined as labor that begins before 37 full weeks have passed. The uterus
consistently contracts throughout labor, and the cervix thins and begins to open. Thus, fetus can
now enter the birth canal. Last March 03, 2003, the student nurse had been able to meet and talk
to Mrs. Erika Gabrielle Valdez-Lopez, a patient in the OB-Gyne Ward at The Medical City. In this
case study, the student nurse specifically investigates the prior health conditions of the patient
mentioned, and applies the following nursing principles and skills of the following:
1. History Taking
2. Physical Assessment
3. Pathophysiological Review
4. Medical Management
5. Nursing Care Plan Formulation
This paper mainly consists of the data gathered by the student nurse from the patient
herself, the patient’s husband, and her Electronic Medical Record (EMR). Moreover, this serves as
a reference paper for her Case Presentation to her Clinical Instructor as her Performance Task
under the subject Care of Mother & Child at Risk (Gyne).
CHAPTER 1
NURSING HISTORY
The patient’s data was collected by March 03, 2023, through an interview and as based on the
patient’s EMR. Her delivery happened last March 01, 2023 at 2:01AM. The data are as follows:
Chief Complaint: Watery Vaginal Discharge
Admitting Diagnosis: G1P0 pregnancy uterine 34 4/7 weeks of gestation, cephalic, in preterm
labor, early fetal growth restriction, premature, preterm rupture of membranes.
PERSONAL DATA:
• Name: Erika Gabrielle Valdez-Lopez
• Birthday: August 04, 1989
• Age: 33 years old
• Residence: Pasig NCR, 2nd District Philippines 1604
• Civil Status: Married
• Religion: Roman Catholic
• Occupation: Lawyer
PAST MEDICAL / SURGICAL HISTORY
• Atopic Dermatitis (1995)
• Asthma (2017)
• (+) COVID (2022)
• Allergic to dark chocolate
PERSONAL SOCIAL HISTORY:
• Post graduate, Lawyer, work from home since December 2022. Denies vices and expose to
COVID, symptomatic individual
FAMILY HISTORY:
• Hypertension (Maternal and Paternal)
• Diabetes (Maternal and Paternal)
• Hypothyroidism (Paternal)
PRESENT ILLNESS:
• The patient is a 33-year-old, G1P0, at 34 4/7 weeks age of gestation, who came in for watery
vaginal discharge.
• 4 hours prior to admission (1AM), the patient had watery vaginal discharge, irregular
perceived contractions and good fetal movements. She had no vaginal bleeding. Persistence
prompted consult and subsequent admission.
MATERNAL HISTORY:
• First trimester
— at 5 weeks AOG, vaginal spotting, given Progesterone OD (until 12 weeks) and was advised
bed rest for 10 days.
• Second trimester
— at 23 weeks AOG, had COVID infection with symptoms of colds. Isolated for 7 days. No
medication.
• Third trimester
— at 31 2/7 weeks AOG, EFW was 1284g 1st percentile AOG which was compatible for IUGR
— at 33 4/7 AOG, had preterm labor and was given Betamethasone 12mg 924 x 2 doses (last
was February 5, 2023) and was prescribed Nifedipine 200mg twice a day intravaginally
— at 34 4/7 weeks AOG, sudden gushing of watery discharge hence consult which was
determined as ruptured bag of water hence admission.
— During admission, she was given Azithromycin 500mg/tab, 2 tablet for 1 dose and started
on Ampicillin 2g every 6 hours. Bag of water ruptured on February 27, 4AM
OBSTETRIC HISTORY:
• The patient delivered her first baby through cesarian section where she had a GTPAL score
1,0,1,0,1.
• LMP: June 30, 2022
• EDD: April 6, 2023
• Menarche: 13 years old
• Interval: 29 days
• Duration: 5 days
• Amount: 2 – 3 pads per day (moderately soaked)
CHAPTER II
PHYSICAL ASSESSMENT
• Weak in appearance
• Voiding freely
• With bowel movement
• With pain on incision site
• Unable to ambulate
• Soft and non-tender abdomen, well contracted uterus
• Incision wound is dry and well-coaptated, no discharge or erythema
Blood Pressure: 120/80
Pulse Rate: 64 bpm
Respiratory Rate: 20 bpm
Temperature: 36.8°C
Pain Scale: 6/10
CHAPTER III
PATHOPHYSIOLOGY
The mechanisms of labor are comparable during term and preterm labor, but during term
labor the mechanisms are activated physiologically, whereas during preterm labor the
mechanisms are activated pathologically. When local uterine factors are prematurely aroused or
when the factors that keep the uterus quiescent are prematurely withheld, preterm labor is likely
to develop.
Progesterone hormone acts to suppress uterine activity and cervical alterations during
pregnancy by reducing upregulation of the proteins linked with contractions and prostaglandin
activity. How labor starts in a human term pregnancy is unknown. Similar to the commencement
of premature labor, the precise mechanisms are unknown, although it is believed to be a
heterogeneous process. Both in term and preterm pregnancy, intricate mechanisms come
together to cause cervical softening and dilatation, membrane activation and rupture, and
increased uterine contractility, which result in the ultimate process of labor.
Four major factors leading to preterm labor are intrauterine infection, decidual
hemorrhage, excessive uterine stretch and maternal or fetal stress. In our patient’s case, the
factor that causes her preterm labor is the intrauterine infection due to urinary tract infection.
Urinary tract infections (UTIs) during pregnancy can increase the risk of intrauterine
infections, which can, in turn, lead to preterm labor. This is how it happens:
• Bacteria from the urinary tract can travel up to the uterus: A UTI can occur when bacteria
from the rectal area enter the urinary tract and cause an infection. If the infection is not
treated, the bacteria can travel up to the uterus and cause an intrauterine infection.
• Infection can cause inflammation: The presence of bacteria in the uterus can trigger an
immune response that leads to inflammation. This inflammation can cause the cervix to
soften and dilate prematurely, leading to preterm labor.
• Bacteria can produce toxins: Some types of bacteria that cause UTIs can produce toxins
that can damage the membranes surrounding the fetus. This can lead to premature
rupture of membranes (PROM), which is a common cause of preterm labor.
• Infection can cause contractions: Intrauterine infection can cause the uterus to contract,
which can lead to preterm labor. These contractions may be regular or irregular and can
lead to premature cervical dilation and effacement.
• Infection can affect fetal development: Intrauterine infection can also affect fetal
development leading to growth restriction and other complications that can increase the
risk of preterm labor.
One predisposing factor that can cause preterm labor is stress. The HPA axis is engaged
when someone is under stress, which causes stress hormones like cortisol to get released.
Inflammation brought on by high cortisol levels may result in preterm labor due to cervical
changes and contractions that may follow. The number of prostaglandins in the body might also
rise during stress. The beginning and development of labor is assisted by the hormones known as
prostaglandins. Cervical contractions and ripening brought on by high prostaglandin levels may
result in preterm labor.
DISEASE PROCESS:
Cause:
PRETERM INTRAUTERINE
Predisposing factors:
LABOR INFECTION UTI & STRESS
Clinical Manifestation:
PRETERM
PREMATURE
RUPTURE OF
MEMBRANES
CHAPTER IV
MEDICAL MANAGEMENT
Laboratory Test Results and Interpretation
The following table shows the results of the tests that was made to the patient. The highlighted
parts indicate abnormal results.
C-Reactive Protein (CRP) Test is a test that measures the level of c-reactive protein (CRP) — a
protein that our liver makes in a sample of our blood. It is a test used to find inflammation in our
body. It has been studied extensively as an adjunct in the diagnosis of subclinical infection among
pregnant women with preterm labor or preterm premature rupture of membranes.
C-REACTIVE PROT 4.61 1.00 – 3.00 mg/L H
Complete Blood Count with Platelet Count (CBC) Test is a test that can help diagnose a variety of
health problems such as anemia, clotting disorders and infections.
HEMOGLOBIN 132 120 – 160 g/L N
HEMATOCRIT 0.39 0.36 – 0.47 N
RED BLOOD CELL 4.12 4.20 – 5.40 x10 12/L L
WHITE BLOOD CELL 10.68 4.50 – 10.00 x10 9/L H
MCH 32 27 – 32 pg N
MCHC 0.34 0.32 – 0.36 - N
MCV 96 80 – 96 fl N
RDW 13.5 11.5 – 16.0 N
THROMBOCYTE 155 140 – 440 x10 9/L N
BAND 0.75 0.02 – 0.05 - N
NEUTROPHIL
0.15 0.56 – 0.66 - H
(BLOOD)
LYMPHOCYTE
0.06 0.22 – 0.40 - L
(BLOOD)
MONOCYTE (BLOOD) 0.01 0.04 – 0.06 - N
EOSINOPHIL 0.00 0.01 – 0.04 - N
BASOPHIL 0.00 – 0.01 - N
ERYTHROCYTE
-
MOPHOLO
REMARKS -
Routine Urinalysis is a test that can assess many different aspects of health with urine sample.
It's used to detect and manage a wide range of disorders, such as urinary tract infections, kidney
disease and diabetes.
COLOR Light yellow
TRANSPPARENCY Clear
REACTION 7.0
SPECIFIC GRAVITY 1.007
BLOOD Positive (+++)
PROTEIN Negative
GLUCOSE Negative
LEUCOCYTES Negative
KETONES Negative
UROBILINOGEN Negative
BILIRUBIN Negative
NITRATES Negative
RED CELLS 8 (H) 0–2
WHITE CELLS 0 0–3
EPITHELIAL CELLS 1 0–3
CASTS 0 0–3
BACTERIA 73 (H) 0 – 50
Surgical Procedure/s
Low Transverse Cesarian Section I
A cesarean section is a surgical procedure in which one or more incisions are made
through the mother’s abdominal wall and uterine wall to deliver one or more babies. This type of
delivery is generally avoided before 39 weeks of pregnancy so the child has proper time to
develop in the womb. Sometimes, however, complications arise and a cesarean delivery must be
performed prior to 39 weeks.
Low Transverse Cesarean Section is also known as the “bikini incision” or “bikini cut”
because the C-section cut curves horizontally across the bikini line (lower abdomen). This cut is
ideal because it causes the least amount of pain and gives the healthcare provider the best view
of the lower uterus. This type of cesarean section incision creates a strong scar that heals well.
DRUG STUDY
Nursing
Name of Drug Dosage Action Indication Contraindication Side / Adverse Effect
Responsibilities
Generic Name: 200mg / Tab BID • Bactericidal Preoperative antibiotic • Patients with known • Urticaria • Perform rights of
Cefixime • Cefixime exerts its prophylaxis to reduce allergy to the • Dyspepsia drug administration
bactericidal activity the risk of post- cephalosporin • Nausea • Monitor patient for
by interfering with operative bacterial group of antibiotics. • Vomiting signs and symptoms
Brand Name: the synthesis of the infections. • Hypersensitivity to • Dizziness of allergic response
Tergecef bacterial cell wall. penicillin. • Headache and other adverse
• Restlessness reactions, such as
rashes.
Route:
Oral
Name of Drug Dosage Action Indication Contraindication Side / Adverse Effect Nursing Responsibilities
Generic Name: 25mg / Tab q8° A propionic acid Management of • Hypersensitivity to • Dizziness • Advise patient to take the
Dexketoprofen derivative with moderate to severe dexketoprofen, • Vomiting medicine on an empty stomach.
Trometamol analgesic, anti- pain and aspirin, or other • Nausea • Monitor blood counts, renal and
inflammatory, and inflammation. NSAIDs • Stomach pain hepatic function regularly; and
antipyretic properties. • History of bronchial • Weakness any signs of gastrointestinal
Brand Name: It is an NSAID that asthma or asthma • Gastrointestinal bleeding and hypersensitivity
Ketesse reduces prostaglandin attacks bleeding reactions.
synthesis by inhibiting • Hypersensitivity
the cyclooxygenase reactions
Route: pathway.
Oral
NURSING CARE PLAN
Cues Nursing Diagnosis Scientific Explanation Nursing Objectives Nursing Intervention Rationale Evaluation
Subjective: Acute pain related The patient had given At the end of the shift, • Assess quality, • To know what After conducting the
“Masakit yung incision to surgical incision cesarean birth which led the patient will be able characteristics, and interventions to do; nursing interventions,
site kapag gumagalaw her to feel the pain of to experience lesser severity of pain. to establish baseline the patient:
ako lalo na pag umuubo. incision closure after the and above tolerable data for comparison
And hindi ko rin talaga cesarean delivery. level of pain as in making evaluation. • Decreased pain in
kaya yung pain kapag manifested by: tolerable level as
tumatayo para pumunta Pain is an unpleasant manifested by pain
• Assist patient in a • To decrease
sa comfort room.” sensory and emotional • Pain scale of at scale of 3/10.
experience associated comfortable position. discomfort
least 3/10 • Had no any subjective
Objective: with actual or potential • No facial grimace
• Advise and encourage • complaint related to
• Facial expression of tissue damage, or • Ableness to
To promote healing of
patient to do breathing surgical wounds. extreme pain
pain / grimace describe in terms of such
ambulate. • Had no facial grimace
• Irritability damage. It is a sudden or exercises by
slow onset of any intensity demonstrating how to do noted
• Discomfort
from mild to severe with it. • Is calm and
• Unable to ambulate
an anticipated or cooperative
• Pain score of 6/10 predictable end. • Encourage gradual • To stimulate • is able to ambulate
ambulation such as contractions of the with assistance of her
walking within individual intestines and husband.
limits prevent post-
operative
complication.
• Administer analgesic as • To relieve pain.
ordered by physician
Cues Nursing Diagnosis Scientific Explanation Nursing Objectives Nursing Intervention Rationale Evaluation
Subjective: Readiness for Readiness for enhanced Within 2 – 4 hours of • Perform physical • To promote parent’s After conducting the
“Nurse, ano ba yung mga enhanced parenting parenting includes the effective collaborative assessment of the knowledge on nursing interventions,
dapat namin gawin sa as evidenced by knowledge and skills a nursing intervention, the newborn with infant’s physical the patient:
pag aalaga ng new born? expressed desire to person needs in order to patient will be able to: parents present, and characteristics and
First baby kasi namin sya learn about fulfill roles and show typical behavior. • Expressed
and hindi pa kami aware parenting. responsibilities related to • Express confidence in newborn confidence and
enough sa mga dapat parental identity, taking care of their new characteristics. responsibility for
namin gawin at iwasan.” potential, and skills. In born. emotional and
other words, the ability to • Verbalize all the advice • Encourage parent • To promote physical care and
Objective: provide appropriate care and knowledge acquired participation in care familiarity with well-being of the
• Declaration of desire and guidance for children. behaviors such as behaviors and newborn.
to learn proper This is a core competency bathing and putting a decrease parental • Verbalized the advice
parenting for any person who is to diaper on. anxiety and to acquired.
• Exhibits eagerness to assume the care of a enhance parental • Swaddle the infant
learn by initiating child. It is also beneficial feeling of under the nurse’s
in determining safe and contribution as watch.
questions
appropriate practices for newborn’s primary
• Verbalizes feeling of young children’s health caretakers.
inadequacy and well-being.
