Introduction

Pregnancy, the state of carrying a developing embryo or fetus within the female body. This

condition can be indicated by positive results of 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 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 two options of delivery: Cesarean section and

NSVD or normal spontaneous vaginal delivery. A cesarean section is a surgical incision through

the mother’s abdomen and uterus to deliver one or more fetuses. NSVD or normal spontaneous

delivery is the delivery of the baby through vaginal route. It can also be called NSD or normal

spontaneous delivery, or SVD spontaneous vaginal delivery, where the mother delivers the baby

with effort and force exertion.

Normal labor is defined as the gradual subjugation and dilatation of 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 into four stages thereby explaining this continuous process.

Stage 1: It is usually the longest part of labor. It begins with regular uterine contractions and ends

with complete cervical dilatation at 10 centimeters. This stage is broken down into three phases:

The Early phase, where the contractions are usually very light and maybe approximately 20

minutes or more apart from the beginning, gradually becoming closer, possibly up to five minutes

apart; the Active phase, where contractions are generally four or five times apart, and may last up

to 60 seconds long. Cervix dilates with 4-7 cm and initiates a more rapid dilatation. It is known
that to get through active labor, mobility and relaxations are done to increase contractions; and the

Transition phase, where it is definitely known as the shortest phase but the hardest, contractions

maybe two or three times apart, lasting up to a minute and a half, about approximately 8-10 cm of

cervical dilatation. Some women will shake and may vomit during this stage, and this is regarded

as normal. Most of the time, women would find a comfortable position to acquire complete

dilatation.

Stage II: This stage lasts for three or more hours. However, the length of this stage depends upon

the mother’s position(e.g.; upright position yields faster delivery). Once the cervix has completely

dilated, the second stage had begun. This stage ends with the expulsion of the fetus.

Stage III: This stage focuses on the expulsion of the placenta from the mother. Placenta expulsion

is much more easier than the delivery of the baby because it includes no bones and this is during

this stage that the baby is placed on top of the mother’s womb.

Stage IV: No more expulsions of conception products for this stage as this is generally accepted

as POST PARTUM juncture. This phase is from the placental delivery to full recovery of the

mother.

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 increase 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 to 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 rate may also occur. This happens as a response to the increase in

blood supply in order to increase also the oxygen intake.

Braxton Hick’s contractions, also known as false labor or practice contractions. Braxton Hick’s

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.

With delivery imminent, the mother usually placed supine with her knees bent (e.g. the dorsal

lithotomy position). An episiotomy ( an incision continuous with the vaginal introitus) may be

performed at this time. Episiotomy may ease delivery of the fetal head and allow some control over

what may otherwise be an uncontrolled perineal laceration. However, many providers no longer

perform routine episiotomy, since it may increase risk of rectal injury and are larger than the

spontaneous laceration.

The labor and birth process is always accompanied by pain. Several options for pain control are

available, ranging from intramuscular or intravenous doses of narcotics, such as Meperidine

(Demerol), to general anesthesia. Regional nerve blocks, such as a pudendal block or local

infiltration of the perineal area can also be used. Further options include epidural blocks and spinal

anesthetics.

Nursing Health History

Nursing health history is the first part and one of the most significant aspects in case studies. It is

a systematic collection of subjective and objective data, ordering and a step-by-step process

inculcating detailed information in determining client’s history, health status, functional status and

coping pattern. These vital information’s provide a conceptual baseline data utilized in developing

nursing diagnosis, subsequent plans for individualized care and for the nursing process application

as a whole.

In keeping the private life of my patient and in maintaining confidentiality, let me hide for with the

pseudonym of Patient D.
Patient D was born on December 19, 1992. She was born to parent from Agusan del Sur, but she

didn’t actually live with them. She was technically abandoned to the relatives, but those people

could not essentially foster her. She stayed at the Department of Welfare and Social Development

or DSWD and spent her 15 years of existence. Her education was funded mainly by volunteers and

charitable foundations. At the same time, she compensated for it by means of helping in chores and

accomplishing tasks in the said foundation. She grew up with other abandoned children with

questions in her mind. But to that, she never completely disclosed herself. Patient D is a victim of

sexual abuse. She was raped and was unable to resist because of her innocence. She doesn’t talk

that much. Often times, she paces back and forth inside the ward, sits silently on her bed and

sometimes quietly stares outside the window. When tried to ask about what she knows of her

family, she could only turn silent, and somehow implies to ask the next question to her. But when

chance punched, I grasped it and coiled directly to my point. Unfortunately, hesitancy was felt from

the kind of thing that was wanted to be discussed. The issue was not forced until her watcher, which

has no relation to her, revealed the reason behind her pregnancy.

According to Patient D’s watcher, it was on a cold night in October 2018, when Patient D came

home from school: Upon nearing the center, a man, which she identified as a newcomer to the

center, blocked and harassed her brutally. She struggled to let go from the ruthless hands of the

unaccustomed man. Patient D was threatened that if she’d make any noise, she’d get killed. Ill-

fatedly, she was held powerless to the man, and the crime had happened. Fortunate enough that she

wasn’t killed, she thanked the Lord for sparing her life. Although alive, she felt very much unfair

about her situation. She could only tell, “Kabata pa kaayo nako nahimong inahan, nganong

nahitabo man pud ni..” . Patient D conceived the baby and bore it for 9 months. For the first

trimester, she couldn’t believe and accept her fate, and sometimes thought of slight curses to the
person who did the crime. But somehow, she felt a lot of excitement of a having a baby

unexpectedly. She even verbalized, “Wa naman koy mabuhat. Nahitabo nato. Basin makasala pa

kog ipalaglag nako ang bata.. Wala man siya’y sala.”

According to Erik Erikson’s Developmental Task of adolescence, from the age of 10 to 18 years

old, Patient P belonged to the IDENTITY versus ROLE CONFUSION, which proposes that the

adolescent is newly concerned with how he or she appears to others. Development mostly depends

upon what is done to us. From here on out, development depends primarily upon what we do. And

while adolescence is a stage at which we are neither a child nor an adult, life is definitely getting

more complex as we attempt to find our own identity, struggle with social interactions, and grapple

with moral issues.

On June 18, 2019, Patient D complained of extreme abdominal pain. On the same date was her

EDC or expected date of confinement. The age of gestation is 39 weeks by LMP. Her LMP was

October 2018, exact date unrecalled. She was admitted to Butuan Medical Center at around 2:40am

with blood pressure of 140/90 mmHg. She was examined by Esmerlina Ortezuela, RM and found

out that she was fully dilated. By 2:45am, 5 minutes after her admission, doctor’s orders(MHO)

through phone were carried out:

• #1 D5LR I Liter started @ 20 gtts/min

• TPR q 4°
• NPO
• CBC blood typing;
• Labor watch

By 2:55am, she was endorsed to DR wheelchair. With the next 5 minutes, she was accompanied
by the staff, positioned on the DR table with final preparation done.
Around 3:36 am, she delivered an alive, 6 lbs 13 oz and 49 centimeters in length baby girl with
these statistics:
  Head Circ: 32 cm
 Chest Circ: 30 cm
 Abd Circ: 20 cm
Extemporaneously, the baby cried with the same breathing time of 3:36am. Patient D’s

placenta was expelled spontaneously by 3:47am with blood pressure of 130/80. Oxytocin 10 units

was infused to IVF; Methergine I amp IVTT; her uterus was firm and contracted and was

admitted to ward via stretcher. During her labor, she was anesthetized with Lidocaine HCl 5cc.

After her delivery, she was admitted to the Ob ward with repaired episiotomy. Post partum

doctor’s orders were as follows which was carried out:

• DAT (Diet as Tolerated)

• Ice pack over hypogastrium

• Perineal care

• Oxytocin 10 U infused to IVF and;

• Methergine I amp IVTT.

• Cephalexin I amp IVTT

• Mefenamic Acid 500mg I cap TID

• May room in

• Breastfeed per demand

The staff continued to monitor her vital signs and administered prescribed medications. As a student

nurse, I also did my assessment towards my patient’s condition. Upon assessing, I was able to take and

record her vital signs:

 T = 37.3°c

 82 bpm

 21 cpm

 120/70 mmHg
Patient D wasn’t able to take a bath because of her beliefs. Since she has an episiotomy wound,

she is at risk for infection. I made my independent nursing interventions. I explained to her the

importance of proper hygiene to prevent the occurrence of infection. Emphasis on eating foods

rich high protein to promote wound healing was imparted. She verbalized, “Sakit man akong

totoy mam.” So, I encouraged her to let her baby continuously suck to both breasts when

received back from NICU, that is to relieve her engorgement. Also, I instructed her to increase

fluid intake at least 8 oz per hour to facilitate increase in milk production, and to eat nutritious

foods such as fruits and vegetables to nourish her baby well.

On June 20, 2019, doctor’s orders were noted:

• Continue meds

• Repeat hemoglobin

• MGH after IE and if hemoglobin is OK By 1:25 pm:

• Defer MGH

• Secure and transfuse 4 units FWB/wg (fresh whole blood) properly crossmatched

• Antamine I amp 10,000 units

• BT (blood transfusion)