1

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

NCLNLM5

By:

Badecao, Kayla D.

Cruz, Nierisha Ann

Selga, Andrea Rose

Laranang, John Allester P.

Sumbad, Mark Bhen

NDA-1

Submitted to:

JENNIFER BALINSOY, RN

Clinical instructor
 2

February 2023

ACKNOWLEDGEMENT

Primarily, special thanks for their parents who authorized them to be lenient

and provide the necessary data needed for this Delivery Room Write-Up.

Without them, they will not be able to learn more about this Write-up.

To their Clinical Instructor, MS. Jennifer Balinsoy, for extending his patience

and for guiding them throughout their duty. They are truly grateful for having

her as their clinical instructor as he shared his knowledge and skills and

greatly motivated them throughout their struggles during their duty.

To their families and guardians, who supported them holistically and

encouraged them to finish their requirements. They are grateful for having

them as they were able to support and guide them to their success.

To their friends, who continually supported them morally and encouraged

them to study further.

 3

TABLE OF CONTENTS

Title Page . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.......... 1

Acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.......... 2

Table of Content . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.......... 3

Chapter I:

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. 5

Chapter II: PATIENT’S

PROFILE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Chapter III: ANATOMY AND

PHYSIOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Chapter IV: PHYSIOLOGY OF PREGNANCY

● Maternal Physiology Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . .. .. .. . .11
 4

● Fetal

Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

…….. . .15

● Labor and Delivery

a. Stages of Labor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . ..18

b. Mechanism of

Labor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . 21

● Products of Conception

a. Fetus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . 23

b. Placenta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . 23

c. Membrane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . .23

d. Amniotic

Fluid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .

23

Chapter V: ESSENTIAL NEWBORN CARE

● Newborn

Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . 24

Chapter VI: NURSING AND MEDICAL MANAGEMENT

 5

● Nursing Care Plan

a. Mother . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..

. . . . . ..27

b. Newborn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . 30

● Medical

a. Drug Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . 31

Chapter VII: SUMMARY AND

CONCLUSIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

Chapter VIII: RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . 40

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . 42
 6

CHAPTER I

INTRODUCTION

A. Brief Introduction

The BSN 4 group NDA-1 students had their duty last February 19-25, 2023
11:00pm - 7:00am shift under the supervision of their clinical instructor
Jennifer Balinsoy at Baguio General Hospital and Medical Center. They were
exposed in the Delivery Room to render their services and to expound their
knowledge on various situations in the area. The client they chose was
patient A who gave birth to a term baby girl via Normal Spontaneous Delivery
(NSD).

According to William C. Shiel "Pregnancy is 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.
Pregnancy lasts for about nine months, measured from the date of the
 7

woman's last menstrual period (LMP). It is conventionally divided into three

trimesters, each roughly three months long".

When gestation has completed, it goes through a process called delivery,

where the developed fetus is expelled from the mother’s womb. There are
options of delivery: Cesarean section, NSVD or normal spontaneous vaginal
delivery and an assisted delivery such as Forceps delivery. A cesarean section
is a surgical incision through the mother’s abdomen and uterus to deliver one
or more fetuses while NSVD or normal spontaneous vaginal delivery is the
delivery of the baby through vaginal route. It can also be called NSD or
normal spontaneous delivery, or SVD or spontaneous vaginal delivery, where
the mother delivers the baby with effort and force exertion. For forceps
delivery is in which forceps are inserted through the vagina and used to grasp
the head of the fetus and pull it through the birth canal; since the forceps can
injure the fetus this procedure has generally given way to cesarean
deliveries.

Labor and delivery of the fetus entails physiological effects both on the
mother and the fetus. In the cardiovascular system, the mother’s cardiac
output increases because of the increase in the needed amount of blood in
the uterine area. Blood pressure may also rise due to the effort exerted by
the mother in order expel the fetus. There could also be a development of
leukocytes or a sharp increase in the number of circulating white blood cells
possibly as a result of stress and heavy exertion. Increased respiratory may
also occur. This happens as a response to the increase in blood supply in
order to increase also the oxygen intake.
Normal labor is defined as the gradual subjugation and dilatation of the
uterine cervix as a result of rhythmic uterine contractions leading to the
expulsion of the products of conception: the delivery of the fetus,
membranes, umbilical cord, and placenta. Laboring cannot that be easy;
thereby implicating that there are processes and stages to be undertaken to
achieve spontaneous delivery. Through which, Obstetrics have divided labor
into four (4) stages thereby explaining this continuous process. During the
 8

first stage of labor this is the time of the onset of true labor until the cervix is
completely dilated to 10 cm, while the second stage of labor this is the period
after the cervix is dilated to 10 cm until the baby is delivered. The third
stage, delivery of the placenta entails. Lastly the fourth stage this is the hour
or two after delivery when the tone of the uterus is reestablished as the
uterus contracts again, expelling any remaining contents. These contractions
are hastened by breastfeeding, which stimulates production of the hormone
oxytocin.
Braxton Hicks (contractions, or also known as false labor or practice
contractions. Braxton Hicks are sporadic uterine contractions that actually
start at about 6 weeks, although one will not feel them that early. Most
women start feeling them during the second or third trimester of pregnancy.
True labor is felt in the upper and mid abdomen and leads to the cervical
changes that define true labor.

B. GOALS & OBJECTIVES

GOALS:

After the completion of the write up, she shall be able to: Enhance

her 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 her knowledge and skills in the Delivery Room by:
 9

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 are 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.

CHAPTER II

BIOGRAPHICAL DATA

A. Patient’s Profile

Name: Patient X

Age: 29 y/o

Gender: Female

Civil status: Single

Address: 371 Ananey St.tomas road Green valley Dontogan, Baguio city

Benguet

Birthday: February 21, 1994

Birthplace: Tanay Rizal

 10

Nationality: Filipino

Religion: Roman Catholic

Admission date and time: February 24, 2023 / 12:24 PM

Admitting diagnosis: G1P0 pregnancy uterine 39 1/7 week age of gestation,

cephalic in beginning labor, gestational hypertension, Controlled.

Final diagnosis: G1P0 pregnancy uterine 39 1/7 week age of gestation,

cephalic in beginning labor, gestational hypertension, Controlled.

B. History of present condition

Three days prior to admission the patient had irregular uterine

contractions every 1-3 hours with good fetal movement. No vaginal bleeding and

no watery vaginal discharge were noted. First Blood Pressure elevation at

140/100 - 160/90 38 1/7 weeks AOG at OB OPD, patient was advised admission

but refused. Workup was done , Patient was advised Blood Pressure monitoring

at home OD and started on Methyldopa 250mg 1 tab BID or twice a day.

C. History of past medical condition

The Patient states that she had a cough and colds but she didn’t seek

medical intervention. In 2008 she was diagnosed with Iron deficiency Anemia at

Tanay Community Hospital and was prescribed a medication of Ferrous Sulfate.

No other known comorbidities, no known allergies and no previous surgeries.

D. Family Health History

The family has a history of diabetes mellitus on the father's side while the

mother side has the history of hypertension, Diabetes mellitus, breast cancer

and heart diseases. Presently her grandmother has Diabetes mellitus.

E. Obstetric History
 11

Her first menstruation or menarche was when she was 14 years old. She

states that she has a regular menstrual cycle 28-32 days usually lasting up to 3-

4 days she claimed that her last Menstrual Period was last week of June 2022.

No dysmenorrhea reported. She also consults the nearby local health unit for

prenatal check-up.

CHAPTER III

ANATOMY AND PHYSIOLOGY

FEMALE REPRODUCTIVE SYSTEM

Vagina
 12

The vagina is a muscular tube-like structure that extends from the cervix

of the uterus to the outside of the body. It is located between the rectum and

the bladder. The vagina provides sexual sensation due to its many nerve

endings, especially in the outer third. It is three inches long when not aroused

and five to six inches long when aroused. The vagina produces fluid daily to

cleanse and lubricate itself and help sperm travel. The vagina serves as a

passageway for menstrual flow. It is very stretchy and can expand during sexual

arousal to receive the erect penis during intercourse, and during childbirth to

allow a baby to leave the body. This is where tampons can be inserted during

menstruation. A few days after the menstrual period ends, the secretions leave

the body as vaginal discharge. As the days go by, the amount of discharge

increases. Mid-cycle, after ovulation, the amount of vaginal discharge begins to

decrease until the next cycle.

Cervix

The cervix is the lower part of the uterus where it joins the vagina. The

cervix opens to allow passage of the baby out of the uterus during labor.

Different types of normal, healthy secretions are produced here. These

secretions change throughout the month. Sometimes they are white and sticky,

sometimes they are clear and stretchy. Through the opening of the cervix,

menstrual blood and other secretions pass from the uterus, into the vagina, and

out of the body. Cervical mucus is a healthy secretion and a sign of fertility. A

few days after the menstrual period ends, the genitals begin to secrete fluids. As

the days go by, the amount of wetness increases. After ovulation, the genital

wetness begins to decrease and dry up, until the next cycle. The pap test
 13

screens for cancer of the cervix. The test is done by swabbing cells on the

cervix. For best accuracy, the test should not be done during menstruation.

Uterus

The uterus (womb) is a hollow organ. A fallopian tube extends from

each side of the uterus. The uterus is made up of muscular walls, an inner lining

called the endometrium, and a cervix. It is located in the pelvis between the

bladder and the rectum. The uterus plays a role in three important functions:

menstruation, pregnancy, and childbirth. The endometrium, or lining of the

uterus, responds to changing hormone levels throughout a menstrual cycle. It

gets thicker to provide nutrients for a fertilized egg to implant and grow. If

implantation doesn’t happen, then the top layers of the endometrium shed as

menstrual bleeding, while the deeper layers remain to rebuild for the next cycle.

If the uterus receives a fertilized egg, it provides an environment for the

fertilized egg to develop into a fetus and then the fetus to grow throughout

pregnancy. Before the first pregnancy, the uterus is about the size and shape of

a pear, with the narrow portion directed down toward the vagina. After childbirth

the uterus is usually larger and it regresses after menopause.

Ovaries

Ovaries are where the egg cells (ova) grow and develop. There are two

ovaries, each about the size and shape of an almond. The ovaries are located in

the pelvis, one on each side of the uterus. Beginning in puberty, follicle-

stimulating hormone supports the growth of egg cells each month. About two

weeks before menstruation, ovulation occurs. Ovulation is the process of an egg

 14

leaving one of the ovaries. The ovaries produce estrogen, progesterone and

androgens. Estrogen regulates the menstrual cycle and supports the

development of secondary sex characteristics, such as breast development and

pubic hair growth. It also affects many other parts of the body, including the

musculoskeletal and cardiovascular systems, and the brain. Progesterone

readies the endometrium to support a fertilized egg, should conception occur. If

pregnancy does not occur, the progesterone levels in the body decrease, causing

menstruation. During pregnancy, progesterone prevents premature uterine

contractions and prepares the breasts for milk production.

Fallopian tubes

The fallopian tubes (uterine tubes or oviducts) connect the ovaries and the

uterus. If an egg is fertilized by a sperm cell within about 24 hours after

ovulation, the fertilized egg will travel along the fallopian tube for about seven

days until it reaches the uterus for implantation. If the egg is not fertilized, the

egg will dissolve in the fallopian tube. These are the tubes that are blocked when

female sterilization is performed. Scar tissue in the fallopian tubes can be caused

by chlamydia and gonorrhea infection. This can lead to infertility or ectopic

pregnancy. Ectopic pregnancies occur when a fertilized egg implants outside of

the uterine cavity, most often in a fallopian tube. This can be life-threatening to

a woman if not detected early.

 15

CHAPTER IV

PHYSIOLOGY OF PREGNANCY

Maternal physiology changes

1. Physiological Changes

a. Uterine Changes

The length 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 weigh from 50 to 1000 g. The

uterine wall thickens early pregnancy from 1 cm to 2cm; thins in pregnancy

 16

about 6.5 cm thick. The uterine volume can range from 2ml to more than 1000

ml. The uterus can hold 4000 g.

The uterine increases its size and blood flow; before pregnancy it is 15

to 0 ml/in and at the end of pregnancy it will become 500 to 750 ml. Other

changes will be Hegar’s sign (softening of the cervix); ballottement (rebound

that occur) and Braxton hick’s contractions (false labor contractions)

b. Cervical Changes

The cervix becomes edematous and vascular because of the increase

circulating estrogen; Goodell’s sign (soft consistency in the earloebe or “ripe”

cervix just before 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 darken and increase in diameter. There is also an increase

in the vascularity of the breast, there will be prominent veins. Montgomery’s

tubercles enlarge and become protuberant. In the 16 th week-colostrum (thin,

watery, high-protein fluid that is a precursor to the breastmilk) can be expelled

from the nipples.

 17

e. Integumentary System

There will be the presence of Striae gravidarum (pink or reddish

streaks); linea nigra -a narrow, brown line running from the umbilicus to the

symphysis pubis; melasma usually appears in the face caused by the increase in

melanocyte stimulating hormone secreted by pituitary gland. There are 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

caused by the hormonal changes.

g. Temperature

Body temperature increases (the temperature which increases at

ovulation remains elevated) temperature usually ranges to 36.5 to 37 above.

h. Cardiovascular System

Blood volume increases by at least 30% up to 50%; at the end of 1 st

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, pre-pregnancy level in 3rd trimester.

 18

There is also impaired blood flow to the lower extremities. Supine

Hypotension Syndrome can happen to pregnant women when they lie 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. Gastrointestinal System

There will be slow intestinal peristalsis and the emptying time of the

stomach; decreased gastric acid secretions. The pregnant woman can also

experience heartburn (reflux of gastric content); constipation and flatulence

caused 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 hyperptyalism 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.

 19

l. Endocrine System

There is slight enlargement of the thyroid gland and hormone cause the

increase production of BMR and 02 consumption; in early pregnancy, there is

decreased insulin because of heavy metal glucose demand. After 1 st 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 to be

prone to infection. There’s also an increase in WBC to help counteract the

decrease in IgG response.

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 from a vague

sense of want or loss, there’s assuming of new roles.

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

pregnancy. According to the patient, she is the center in the family, all of her

needs were given by her family.

 20

d. Body image – the way the women appear theirselves. Patient X feels shy

when she goes out, because she’s pregnant.

e. Stress – this can make the woman make decisions, be aware of the

surroundings 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 1 st trimester,

libido decrease

FETAL GROWTH AND DEVELOPMENT

Milestone of fetal growth and development in the mother’s womb:

a. End of 4th Gestational Week

 21

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

is discernible. Arms and legs are developed genitalia are forming, but sex can’t

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
 22

begins to cover the skin. Meconium is present in the upper intestine. Passive

antibody transfer from 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 begin to descend from the lower abdominal cavity; blood vessels

of the retina are formed.

h. End of Gestational Week

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

be 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 the foot has only

one to two crisscross creases. Amount of language is beginning to diminish.

j. End of 40th Gestational Week

 23

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

hemoglobin converts to adult hemoglobin. Vernix caseosa is fully formed.

Creases on the sole of the feet cover at least two thirds of the surface.

LABOR AND DELIVERY

Progress of Delivery

Every pregnancy is different, like the length of labor. Normal labor usually begins

within 2 weeks of the estimated delivery date. In a first pregnancy, labor usually

lasts 12 to 18 hours on average; subsequent labors are often shorter, averaging

6 to 8 hours. Labor generally progresses more quickly for women who’ve already

given birth vaginally.

a. STAGES OF LABOR

FIRST STAGE: Cervical Stage

First stage of labor is divided into three phases; the latent, the active

and the transition phase.

LATENT PHASE
 24

It begins with the onset of regular contractions, effacement and dilation of

the cervix to 1-3 cm. Contractions are mild and frequent. A woman should

continue to walk and make preparations for birth.

ACTIVE PHASE

Dilation continues from 3 to 4 to 7 cm. Contractions become moderate,

more frequent and more painful, lasting 30 to 60 seconds. It can be a

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

 25

Begins with complete dilation of the cervix and ends with delivery of the

newborn. Duration may differ among primiparas which are longer and multiparas

–shorter, but this stage should be completed within 1 hour after completing

dilation. Contractions are severe at 2-3 minutes intervals, with duration of 50-90

seconds. There are 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 a disproportion between placenta and contracting wall of

 26

the uterus that folding and separation of placenta. Signs are: globularity of the

uterus, fundus rising in the abdomen, lengthening of the cord and increased

bleeding.

PLACENTAL EXPULSION – after the separation of placenta, it will now be

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 the 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 begins to

adjust to extrauterine life and stabilize. Skin to skin contact or mother-child

dyad happens. Mother can breastfeed her baby to acquire the colostrum that

contains antibody that can protect her baby from disease in at least 2 months.

b. MECHANISMS OF LABOR

The cardinal movements that occur during the mechanism of labor describe the

movement of the fetus through the birth canal. These movements consist of
 27

engagement, descent, flexion, internal rotation, extension, restitution and

external rotation, and expulsion of the infant.

1. Engagement

During the few weeks before labor, the presenting part of the fetus will pass

through the maternal pelvic inlet and engages in the true pelvis. This mechanism

refers to engagement.

2. Descent

The descent of the fetus through the pelvis indicates the progressive movement

of the fetal presenting part through the pelvis to prepare for birth.

3. Flexion

When descent is complete and the fetal head meets the cervix, the fetal head

flexes to allow the chin to make contact with the fetal chest. This mechanism

allows a smaller diameter of the head to move through the outlet.

4. Internal Rotation

In order for the fetus to be able to exit the pelvic outlet, the fetal face rotates

posteriorly so that the occiput faces anterior.

5. ExtensionA

As the fetus moves through the vaginal opening for birth, the head extends

pushing the occiput out first followed by the face and chin.
 28

6. External Rotation (Restitution)

Once the head is outside of the vaginal opening, the fetus rotates to realign the

head with the shoulders and back allowing for the shoulders to move out of the

vaginal opening.

7. Expulsion of Infant

After the head and shoulders have exited the vaginal opening, the fetal head and

shoulders move upward allowing for the rest of the baby to be born.

PRODUCTS OF CONCEPTION

A) Fetus
 29

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

diameter is the head, so this part is 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 are possible complications.

b. 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.

c. FETAL MEMBRANE (CHORION AND AMNION)

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 opaquer 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.

d. AMNIOTIC FLUID
 30

This fluid is a 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).

CHAPTER V

ESSENTIAL NEWBORN CARE

NEWBORN ASSESSMENT

Each newborn baby is carefully checked at birth for signs of problems or

complications. The healthcare provider will do a complete physical exam that

includes every body system. Throughout the hospital stay, doctors, nurses and

other healthcare providers continually look at the health of the baby. They are

watching for signs of problems. Assessments may include the below APGAR

scoring.
 31

The APGAR score is a test given to newborns soon after birth. This test

checks for the baby's heart rate, respiratory rate, muscle tone, reflexes and

color and other signs to see if extra medical care or emergency care is needed.

The baby is checked at 1 minute and 5 minutes after birth. In the test, five

things are used to check a baby’s health. Each is scored on a scale of 0 to 2,

with 2 being the best score. 10 is the highest score possible, but few babies get

it. That’s because most babies’ hands and feet remain blue until they have

warmed up. Apgar scores of 6 or less usually mean a baby needs immediate

attention and care.

SIGN 0 1 2 1 min 5 min

COLOR Blue or Acrocyanotic Completely 1 1

pale pink

HEART RATE Absent <100 minute >100 minute 2 2

REFLEX No Grimace Cry or active 2 2

response withdrawal
IRRITABILITY

MUSCLE TONE Limp Some flexion Active motion 1 2

RESPIRATION Absent Weak cry; Good crying 2 2

hypoventilation
 32

TOTAL APGAR 8 9

SCORE

During the one minute of APGAR monitoring Baby X total score is 8 this

indicates Baby X is in good health. Low score does not mean that the baby is

unhealthy. It means that the baby may need some immediate medical care. At 5

minutes after birth the reassessment is given again Baby X total score is 9. The

baby’s score was higher than the first which is healthy. If the baby’s score was

low at first and hasn’t improved there are other concerns.

Vitals Signs

DATE/ CARDIAC RESPIRATORY TEMP O2 STOOL BREASTFEEDING

TIME RATE RATE . SAT

01/24/23 152 44 36.5 96 + 20 mins

8:15 PM

8:30 PM 140 42 36.7 97 26 mins

8:45 PM 158 55 36.9 98 25 mins

9:00 PM 155 45 36.6 97 22 mins

9:30 PM 132 44 37 97 30 mins

 33

10:00 PM 142 52 36.6 98 23 mins

11:00 PM 136 46 36.8 95 21 mins

PHYSICAL ASSESSMENT

BIRTHWEIGHT (kgs) 3.06 kg

LENGTH (cm) 49 cm

HEAD CIRCUMFERENCE (cm) 32 cm

CHEST CIRCUMFERENCE (cm) 33 cm

ABDOMINAL CIRCUMFERENCE (cm) 31 cm

ARM CIRCUMFERENCE (cm) 11 cm

CHAPTER VI

NURSING AND MEDICAL MANAGEMENT

A. NURSING CARE PLAN

Mother - Risk for infection as manifested by deficient knowledge in

perineal and wound care

ASSESSM INFEREN PLANNIN INTERVENT RATIONA EVALUATI

ENT CE G ION LE ON

SUBJECTI Risk for Short- - Monitoring - Short-

Infection term: of vital signs, Alterations term:
 34

VE: is defined After 3 lochia from Goal was

as at hours of (character, normal met. After
increased nursing amount, may be 4 hours of
“hindi ko risk for interventio odor, and signs of nursing
po alam being n, the presence of infection, interventio
paano invaded patient will clots) fundal retained n, the
maglinis ng by verbalize height, and fragments patient
sugat pathogeni understan status of or sub was able to
natatakot c ding of improvement involution verbalize
po ako organism health of the of the understand
maghugas” s. teachings sutured uterus ing of
as Infections and laceration present
verbalized occur present condition
by the when the condition - Monitor and shows
patient natural temperature, cooperatio
defense check for n on health
OBJECTIV mechanis redness, - Increased teachings
ms of an swelling, temperatur
E: individual increased e Long-
are Long- pain, or any accompani term:
inadequat term: abnormal ed by Goal was
- presence
e to After 2-3 drainage on redness, met. After
of perineal
protect days of the lacerated swelling 3 days of
wounds
them. appropriat site and pain appropriat
due to
Organism e nursing are signs e nursing
episiotomy
s such as interventio -Proper of infection interventio
bacterium ns, the perineal care ns, the
- with firm
, virus, patient will and hygiene patient
and
fungus, verbalize should be was able to
contracted
and other understan reinforced - verbalize
uterus
parasites ding of risk Appropriat understand
invade factors, e self-care ing of risk
- used
susceptibl achieve of the factors, is
single pad
e hosts timely perineum achieving a
for 12
through wound in timely
hours
inevitable healing, postpartum wound
injuries and patients healing,
VITAL
and continue to reduces and is free
exposure be free of the risk of of any
SIGNS:
s. People any pathogenic symptoms
have symptoms microorgan of infection
BP- 110/70 dedicated of infection ism
mmHg cells or during invasion.
T- 36.8 tissues postpartu Patient’s
PR- 82 that deal m period consciousn
bpm with the ess should
RR- 19 threat of be raised
bpm infection. and
SPO2- 96 These are knowledge
 35

% known as - Emphasize should be

the early reiterated
NURSING immune ambulation in order to
DIAGNOS system. and retain
IS: encourage information
- Risk for her in and to
infection as beginning promote
manifested post-partal practice
by deficient exercise with
knowledge resumption
in perineal of normal -
and wound activities Circulation
care of blood is
promoted
through
regular
movement
s thus this
it helps in
the healing
process,
prevents
constipatio
n, urinary
and
circulation
- Encourage problems,
to eat foods promote
that are rich rapid
in protein recovery,
and Vitamin and
C such as hastens
citrus fruits drainage of
and guava lochia

- Vitamin C
is known to
prevent
infection
- Advise and and
encourage to promote
have enough healing.
rest and Protein is
sleep needed for
tissue
repair and
regeneratio
n
 36

- This
promotes
healing by
reducing
- Intake of basal
antibacterial metabolic
medications rate and
as per allowing
doctor’s oxygen and
order and nutrients
advise to be
utilized for
tissue
growth,
healing,
and
regeneratio
n

-
Antibiotics
are used to
used to
treat and
prevent
infections
caused by
susceptible
pathogens
in skin
structure
infections

Newborn- Ineffective breastfeeding related to unsatisfactory feeding

process
 37

ASSESSM EXPLANAT PLANNI INTERVEN RATION EVALUAT

ENT ION OF NG TION ALE ION

THE

PROBLEM

Subjectiv First time Within 1 Independent After 1

e: “wala mothers hour of -Explain to hour of

-To
atang na may have nursing the patient nursing
promote
dede si some interventi and family interventi
breastfee
baby anxiety on and members on and
ding
walang around nursing the health

lumalabas breastfeedi education importance education

na gatas” ng that is the of the

as contributin patient breastfeedin patient

verbalized g to their will g demonstra

by the difficulties demonstr ted proper

patient. due to ate technique

-To detect
-Assess the
limited proper as
any
patient’s
experience, technique evidenced
abnormali
Objective breast and
knowledge and by Able to
ties and
: demonstrate
and skilling achieve find
prevent
breast care
CR: 100 providing effective feeding
contamin
before
infant care breastfee cues
ation
RR: 20
latching on
after giving ding as Demonstr
upon
Temp:
birth. manifeste ated
breastfee
36.5°C
 38

-Weak in d by: ding proper

appearanc position in
Able to -Inform the -
e breastfeed
find patient Recognitio
ing and
feeding about n of infant
burping
cues feeding cues hunger
Nursing
Proper such as promotes - GOAL
Diagnosi
position sucking, rewarding MET-
s:
of the licking and feeding
Ineffective
baby rooting
breastfeed
Infants
ing related
-To have
satisfacto
to
a
ry in
insufficien
successful
breastfee -
t
breastfee
ding Demonstrat
knowledge
ding and
e the
regarding
to satisfy
correct
breastfeed
infants
positioning
ing
feeding
of the
techniques
needs
mother and

-This will

educate

the

mother to

have a
-
 39

Demonstrat good

e to the burping

mother how position

to let the for the

infant burp infant to

after each prevent

feeding backflow

of milk

ingested

-To limit

fatigue

and

facilitate
-Encourage
relaxation
frequent
of feeding
rest period
times

-To

Interdepend promote

ent breastfee

ding
-Encourage
productio
the patient
n and
to eat
optimize
 40

nutritious infant

food growth

including and

green leafy developm

vegetables, ent

milk product

and citrus

food

B. MEDICAL

DRUG STUDY

Drug Mechanis Indication Side Effect/ Nursing

Name m of Adverse Effect Consideratio

Action n

Generic Direct Stimulation of ● Hypertensi ● Assess

Name: affects uterine
on vital
oxytocin neurorece contractions
signs for
ptor sites during the third ● Dysrhyth
Brand baseline
to stage of labor of mias
Name: data.
stimulate postpartum
 41

Pitocin contractio bleeding or ● Tachysyst ● Monitor

n of the hemorrhage.
Classificat ole frequenc
uterus
ion: y,
during ● Uterine
duration
Dosage:
labor hyperstim
,
10
especially ulation
strength
units/mL
toward
of
in 1
the end of
contracti
ampule
the
on
Frequency pregnancy

, helping ● Monitor
:

expel the for signs

Route:
baby. It Contraindicati of
I.M
also ons uterine
Adverse Effect
contracts rupture,
● Hypersen Hypertonicity
myoepithe which
may occur with
lial cells in sitivity to include
tearing of
the oxytocin. FHR
uterus,
breast, decelera
● Fetal increased
causing tions,
intoleranc bleeding,
milk to be sudden
e of labor abruption
expressed increase
placentae fetal
from the d pain,
● Anticipate
bradycardia
alveoli loss of
d non
into the Low APGAR uterine
 42

ducts so vaginal score at 5 min contracti

that the delivery ons,

baby can hemorrh

● Cephalop Prolonged IV
obtain it age, and
elvic infusion of
by rapidly
disproport oxytocin with
suckling. developi
ion excessive fluid
ng
volume has
hypovol
caused severe
emic
water
shock.
intoxication

with seizure, ● Maintain

coma, death. careful I

& O; Be

alert to

potential

water

toxicatio

n. Check

for

blood

loss.

● Report

changes
 43

in vital

signs

and

FHR,

specially

late

decelera

tion and

any

vaginal

bleeding

Drug Name Mechanis Indication Side Effect/ Nursing

m of Adverse Consideration

Action Effect
 44

Generic Analgesic ● Treatmen CV: ● Monitor

Name: and anti- t of mild Palpitations,
vital
celecoxib inflammato to flushing
signs
ry moderate tachycardia,
Brand and
activities hypertens peripheral or
Name: record
related to ion and facial edema,
Celebrex
inhibition angina. bradycardia, ● Assessed

Classificati
of the chest pain, patient
on:
COX-2 syncope, health

Dosage: enzyme, postural status

400mg which is hypotension.

● Explain
activated
Frequency: CNS: Light -
Contraindicati about
in
O.D headedness,
on the
inflammati
fatigue,
Route: P.O ● Hypersen importan
on to
headache.
sitivity to ce and
cause the
GI: Abdominal purpose
signs and amlodipin
pain, nausea, of the
symptoms e
anorexia, drug to
associated
constipation, patient
with
dyspepesia,
inflammati
● Assess
dysphagia,
on; does
skin
diarrhea,
not affect
color and
flatulence
the COX-1
lesions,
enzyme,
 45

which reflexes,

protects sensatio

the lining ns,

of the GI edema,

tract & has serum

blood electrolyt

clotting es

and renal
● Administ
functions.
er the

right

drug:

recheck

the label

● Administ

er drug

with food

or after

meals if

GI upset

occurs

● Provide

warmth,

positioni
 46

ng and

rest to

reduce

inflamm

ation

● Instruct

patient

to report

any

adverse

effect.

Drug Mechani Indication Side Nursing

Name sm of Effect/ Consideration

Action Adverse

Effect
 47

Generic Amlodipi ● Treatmen CV: ● Assessed

Name: ne is a t of mild Palpitations,
patient health
Amlodopi calcium to flushing
status
ne channel moderate tachycardia,

blocking hyperten peripheral or ● Explain about

Brand
agent sion and facial the
Name:
that angina. edema, importance
Norvasc
selectivel bradychardia and purpose
Classificat
y blocks Contraindicati , chest pain, of the drug to
ion:
calcium ons syncope, patient
Cardiovas
ion postural
● Hypersen
cular ● Monitor BP for
reflux hypotension.
sitivity to
agent; therapeutic
across
amlodopi CNS: Light-
calcium effectiveness,
cell
ne headedness,
channel BP reduction
membra
fatigue,
blocker is greatest
nes of
headache.
pregnanc after peak
cardiac
y GI: levels of
and
category: amlodopine
vascular Abdominal
C are achieved
smooth pain,
6-9 hours
Dosage: muscle nausea,
following oral
10 mg without anorexia,
doses.
changing constipation,
Frequenc
serum dyspepsia,
y: O.D ● Monitor for s/s
calcium dysphagia,
 48

Route: concentr diarrhea, of dose

P.O ations. flatulence, related

vomitting. peripheral or
It
facial edema
predomi Urogenital:
that may not
nantly Sexual
be
acts on dysfunction,
accompanied
the nocturia.
by weight
peripher
Respiratory
gain; rarely
al
: Dyspnea
severe edema
circulatio
Skin: may cause
n,
Flushing, discontinuatio
decreasi
rash, n of drug.
ng

peripher other: ● Monitor BP

al Arthralgia,
with postural
vascular cramps,
changes.
resistanc myalagia
Report
e and
postural
increase
hypotension,
s cardiac
monitor more
output.
frequently

ywhen

additional

antihypertensi
 49

ves or

diuretics are

added.

● Monitor heart

rate; dose

related

palpitations

(more

common in

women) may

occur.

Drug Mechanis Indication Side Effect/ Nursing

Name m of Adverse Effect Consideratio

Action n

Generic Ferrous Prevention and ● Monitor

Name: sulfate is treatment of
blood
Multivita CNS:seizure,dizzi
an iron iron vitamin and studies
ness,headaches,
mins dietary syncope
suppleme of
+FeSo deficiency
nt used patient
Brand anemias used in
to treat CV: ● observe
Name: anemia due to
hypotension,hyp
or proper
Mulvitron blood loss ertension,tachyc
 50

prevent during dosage

Classificat low blood menstruation, of

ion: ardia
of infection,surger medicati
levels
Category: y,delivery,intoxi on
iron
A cations,parasito ● verify
(e.g., for Dermatologic:
Dosage: sis or other flushing,urticaria
anemia the
1TAB causes and
patient’s
or during
Frequency anemias during
identity
pregnanc Respiratory:coug
: OD pregnancy.
h,dyspnea
● inform
Route: PO
y). Iron

is an patients

Others:staining about
importan
of
possible
t mineral teeth,anaphylaxi
s,sweating. adverse
that the
effects
body
that
needs to
may
produce
occur.

red blood

cells and
Contraindicati
keep you
ons
in good

health.
Hemochromato

sis,hemosiderosi

s or other
 51

evidence of iron

overload

anemias not due

to iron

deficiency some

products contain

alcohol,

tartrazine or

sulfites and

should be

avoided in

patients with

known

intolerance or

hypersensitivity.
 52

CHAPTER VII:

SUMMARY AND CONCLUSIONS

NARRATIVE FORM

A 29-year-old G1P0 mother was transferred from the labor room to the

delivery room on February 24, 2023, by 4:00 am, in preparation for a normal

spontaneous delivery. After being assisted to the delivery table and instructed on

pushing techniques to aid the baby's release from the womb, she received 10

units of oxytocin intravenously. The doctors then supported the mother's

perineum to prevent any tears from occurring as the baby delivered. The mother

received 10 units of oxytocin intramuscularly on her right deltoid at 4:58 after

the placenta was delivered. Then the umbilical cord was clamped and cut, and

the student nurse assisted the expulsion of placenta using a straight clamp as a

support and handle. By 4:58 am the placenta was out and placed in a placenta

bowl, Fundal massage was done. Then the mother was monitored every 15

minutes for the 1st hour and every 30 minutes for the 2nd hour. She then was

discharged from the Delivery room and sent to the Normal Spontaneous Delivery

ward/room in the Obstetric ward.

SUMMARY OF CARE RENDERED

A. Nursing

CARE DURING THE FIRST STAGE OF LABOR

Assessing the start of labor

 53

⮚ One of the most important aspects of management of labor. Signs of the

start of labor are:

- Painful contraction with a certain regularity, frequency and duration

- Effacement and/or dilatation of the cervix

- Leakage of amniotic fluid

- Bloody discharge

● Position and movement during the first stage of labor

● Vaginal examination

● Monitor the progress of labor

● Prevention of prolonged labor

● Intravenous infusion of oxytocin

● Intramuscular oxytocin administration

CARE DURING THE SECOND STAGE OF LABOR

● The onset of the second stage

● The onset of pushing during second stage

● Maternal position during the second stage

 54

● Care of the perineum

● Physiological background

● Perineal tear and episiotomy

● Perineal support

CARE DURING THIRD STAGE OF LABOR

● Prophylactic use of oxytocin

● Controlled cord traction

● Active versus expected management of the third stage

● Timing of the cord clamping

● Immediate care of the newborn

● Care of the mother immediately after the delivery of the placenta

B. Medical

DIAGNOSTIC PROCEDURES

URINALYSIS

MICROSCOPIC MUCUS THREADS RARE

 55

COLOR YELLOW CRYSTALS

TRANSPARENCY TURBID RARE

AMORPHOUS URATE
S/PO4

REACTION 5.0 CALCIUM OXALATE

SPECIFIC GRAVITY 1.020 URIC ACID

PROTEIN NEGATIVE TRIPLE PHOSPHATE

GLUCOSE NEGATIVE CAST

OTHERS FINE GRANULAR

COARSE GRANULAR

MICROSCOPIC WBC

RED BLOOD CELLS 0.2 /HPF

WHITE BLOOD 15.20 /HPF BACTERIA

CELLS

EPITHELIAL CELLS

SQUAMOUS MODERATE OTHERS

RENAL PREGNANCY TEST

 56

ROUTINE URINALYSIS

Color Dark CAST CRYSTALS

Yellow

Transparency Slightly Amorphous FEW

Turbid urates

Amorphous
PO4

Glucose Negative Ca oxalate

Protein Negative Pus 2-5 Uric Acid

cells/hpf

PH 7.0 RBC/hpf 0-3

Specific 1.005 Pregnancy

Gravity Test

Epithelial FEW Cast

Cells

Ketone Mucus FEW

Threads

Bile Yeast Cells

Nitrite OTHERS

Urobilinogen Bacteria +1

CHAPTER VIII

RECOMMENDATION

A. Student nurse

To our fellow student nurses, in order to improve our knowledge and

abilities in providing appropriate and effective nursing care. Making a write-up is

essential; it is a necessary tool for developing knowledge and skills competency

 57

in understanding specific cases. It is not only about developing a good nurse-

patient relationship, but also about having the opportunity to work with a fellow

student. Making a case study requires time, effort, and sacrifice in order to

achieve the goal of finishing the case study. Being willing to learn and work on

creating a case study can improve our knowledge and mind, allowing us to

achieve our goal for both our patient and ourselves.

B. Patient

To compensate for the fluids lost during delivery, the patient must

increase her fluid intake. Eating nutritious foods like fruits and vegetables, as

well as following a well-balanced diet, is essential. The patient must also take

iron and vitamin A-rich minerals, and post-natal visits are required to determine

her state of wellness after delivery. The patient must also practice and

understand the benefits of breastfeeding for both herself and the baby.

C. Health Provider

The patient's condition should be understood by the health care provider.

Understanding various post-partum cases is critical for assisting health care
providers in performing their duties and providing proper effective nursing care
 58

REFERENCES:

- https://my.clevelandclinic.org/health/articles/9675-pregnancy-types-of-

delivery

- https://www.msdmanuals.com/home/women-s-health-issues/normal-

pregnancy/stages-of-development-of-the-fetus

- https://www.mayoclinic.org/healthy-lifestyle/labor-and-delivery/in-

depth/stages-of-labor/art-20046545

- https://www.nichd.nih.gov/health/topics/labor-delivery/topicinfo/stages

- https://my.clevelandclinic.org/health/body/22999-ovaries

- https://www.mayoclinic.org/diseases-conditions/placental-abruption/

symptoms-causes/syc-20376458

- https://my.clevelandclinic.org/health/diseases/21512-retained-products-

of-conception

- http://www.simardartizanfarm.ca/pdf/Nurses%20Drug%20Handbook
%207E%20UnitedVRG.pdf