General Objective: After 6 hours of case presentation at Lyceum of Iligan Foundation, we will be able to present our OB care assessment

to the whole class. Specific Objective: After 6 hours of case presentation at Lyceum of Iligan Foundation, we will be able to Know the assessment of our patient during and after pregnancy. Present and discuss to the class our OB care assessment. Encourage active participation of the class in regards to our OB case presentation.

ACKNOWLEDGEMENT
This case presentation is possible through the full cooperation and efforts of the members of the group. To our patient who opened her doors to us and who gave her time and participation during the assessment and interview. To our respected NCM Clinical Instructors, Mrs. Janet Tabar, RN., Mrs. Marissa Patalinghug, RN., and Mrs. Feliciana Mirando RN., MAN, who imparted their knowledge for the completion of this case presentation. To our Dear Parents, who patiently nurture us to become truly human persons and who have never ceases to guide us and financially helped us in our needs. And most of all, to our Holy Tribune God, from when the gift of life comes and who is the source of our inspiration In Body, In Soul, In Spirit. GROUP 3

INTRODUCTION
Pregnancy and its endpoint, labor, mark the start of parenthood, a new phase of life, for millions of women worldwide each year. During this exciting time, the baby develops from a fertilized egg into an infant ready to be born. After a gestation of approximately 40 weeks, labor begins the process of birth. On average, pregnancy lasts 40 weeks, although anything between 37 to 42 weeks is still considered normal. Pregnancy is often referred to in trimesters, with the first trimester being the first three months, the second trimester being months four to seven, and the final trimester beginning at the start of month eight and continuing to the end of the pregnancy. For low-risk pregnancies, prenatal care may simply involve basic health checks and recommendations for healthy eating and prenatal supplements, such as increased folic acid intake. For mothers who have preexisting health conditions or are older than 35, prenatal care may involve multiple ultrasounds, blood and urine tests and fetal monitoring. Medical intervention during labor is typically up to

Labor begins with uterine contractions that gradually get closer together and more intense over time. Labor consists of three phases. During the first stage of labor, the cervix dilates and effaces, becoming thinner and opening up to a total of ten centimeters in diameter. The first stage is divided into two parts, early labor and active labor. In early labor, the dilation and effacement of the cervix occurs slowly, lasting anywhere from a few hours to multiple days. As active labor begins, the changes in the cervix speed up and contractions become more intense. The last two stages of labor are the actual delivery of the baby and the delivery of the placenta after birth.Labor can be painful and there are many options available to ease the pain. Natural methods of pain relief include breathing exercises, self-hypnosis, relaxation techniques, changing the position of the woman; and using heat and cold. Spinal blocks and epidurals, in which pain medication is directly administered to the lower spine via an injection or continuously through a tube, are common forms of pharmacological pain

FEMALE REPRODUCTIVE SYSTEM

External Genitalia 1.Mons Veneris/ mons pubis > mound of fatty tissue over symphysis pubis that cushions & protect the bone from trauma 2. Labia Majora > longitudinal folds of pigmented skin from mons pubis-perineum > served as protection of the external genitalia, urethra, distal vagina

3. Labia Minora/ Nymphae > soft, longitudinal skin folds bet. the labia majora 4. Clitoris > center of sexual arousal & orgasm, penis for male 5. Urethral Orifice > small opening of the urethra, loc. bet. the clitoris & vagina

Internal Genitalia
1.Vagina > muscular, tubular, musculomembranous organ that lies bet. the rectum > depository of semen after ejaculation, part of birth canal > conveys the sperm to the cervix so sperm can meet the ovum 2. Uterus > hollow muscular-shaped organ, located at the lower pelvis & posterior to the bladder & anterior to the rectum > site for reception, retention, implantation, nourishment to the ovum

Ovaries > 2 female sex glands located on each side of the uterus > responsible for ovulation, secretes the hormones

REPRODUCTIVE CYCLE

MESTRUATION
>complex cycle of events that occur in the hypothalamus, pituitary gland, uterine endometrium, cervix & ovaries

MENARCHE
> first menstruation

MENOPAUSE
>cessation of menstrual flow cycles, 40-55 yrs. Old

MENSTRUAL CYCLE
>reproductive cycle, periodic uterine bleeding in response to cyclic hormonal changes (estrogen, progesterone (FSH, LH)

28 DAYS
average length of menstrual cycle

2-7 DAYS/3-5
> average flow of menstrual cycle

30-80 ml. Of blood

> average amount of menstruation

11 mg.
> iron loss during menstruation

OVULATION
> maturation & release of the egg from the ovary, occurs on the day 14

LMP
> 1st day of the last normal menstrual cycle

COMPUTE FOR OVULATION DATE

> get LMP & length of cycle then less 14 days

PHASES OF MENSTRUAL CYCLE

> 1ST Phase: Proliferative CNS response: 5th-14th day > 2nd Phase: Secretory/ Ovarian response: 14th-16th day > 3rd Phase: Ischemic/ Endometrial response: > 4th Phase: Menses/ Cervix & Cervical mucous

FETAL DEVELOPMENT

One Month

Your baby is an embryo consisting of two layers of cells from which all her organs and body parts will develop.

One Month

Two Months

Your baby is now about the size of a kidney beanand is constantly moving. He has distinct, slightly webbed fingers.

Two Months

Three Months

By now your baby is about 3 inches long and weighs nearly an ounce. Her tiny, unique fingerprints are now in place.

Three Months

Four Months

Your baby is now about 5 inches long and weighs 5 ounces. His skeleton is starting to harden from rubbery cartilage to bone.

Four Months

Five Months

Eyebrows and eyelids are now in place. Your baby would now be more than 10 inches long if you stretched out her legs.

Five Months

Six Months

Your baby weighs about a pound and a half. His wrinkled skin is starting to smooth out as he puts on baby fat.

Six Months

Seven Months

By now, your baby weighs about 3 pounds and is more than 15 inches long. She can open and close her eyes and follow a light.

Seven Months

Eight Months

Your baby now weighs about 4 3/4 pounds. Hislayers of fat are filling him out, making him rounder, and his lungs are well developed.

Eight Months

Nine Months

The average baby is more than 19 inches long and weighs nearly 7 pounds now, but babies vary widely in size at this stage

Nine Months

OBSTETRIC AND GYNECOLOGIC ASSESSMENT

Name of patient: Mrs. M Age: 27 Civil Status: Married Religion: Roman Catholic Address: Purok 1, Tambacan,Iligan City Health Insurance: PhilHealth Occupation: None Income/mo: 5,000 php T: 36.80 C P: 97 bpm R:20 BP:110/70 Current weight:67 kg. Pre-pregnant weight:55kg Height:53 Age of menarche: 13 Days of menstrual cycle: 28 Days of menstruation: 5 days

Menstrual irregularities: Doesnt experienced menstrual irregularities. Blood Type: O LMP: Dec. 20, 2009 EDC: Sept. 27, 2010 AOG: 8 mos. FHB: 128 bpm Patterns of weight gain: (1st tri) 63 kg. (2nd tri) 66 kg (3rd tri) 67.5 kg Frequency of pre-natal visits: 6 Date of last prenatal visit: Aug. 3, 2010 Tetanus toxoid (number of doses completed): 4 doses Date of last dose administration: April 6,2010 G 3 P3 T3 P0 A0 L3

Type of Previous Deliveries

HEALTH ASSESSMENT DURING PREGNANCY

Assessment Parameter Observation Implication

Bathing Bathe twice a day, early in the morning and late at night. During pregnancy, sweating tends to increase because the woman excretes wastes products for herself and the fetus. Bathing should be done to refresh and remove body wastes.

Assessment Parameter

Observation

Implication

Breast care

She washed her breast using soap. Wears firm bras.

General rule is to wear a firm, supportive bra with wide straps to spread weight across the shoulder. Pregnant woman may need to buy a larger bra half way to pregnancy to accommodate increased breast size. Instruct her to wash her breast with a clear tap water ) no soap) daily to remove colostrums; she should dry nipples well by patting. If colostrums secretion is profuse, she may need to place gauze squares or breast pads inside the bra.

Assessment Parameter Dental Care

Observation Brush teeth every after meals.

Implication Good tooth brushing habits should continue throughout pregnancy. Encourage her to see her dentist regularly for routine examination in cleaning. Encourage snacking on nutritious foods such as fresh fruits and vegetables like apples and carrots to avoid sugar coming with contact with teeth.

Assessment Parameter

Observation

Implication

Perineal Hygiene

Washes her perineum after urination. Uses pH care during washing.

Woman have increased vaginal discharge during pregnancy, douching is contraindicated because the force of the irrigating fluid could cause it to enter cervix and lead to infection.

Assessment Parameter Dressing

Observation Used loose dressings and garterized pants. Wears flat shoes and slippers.

Implication Pregnant women should avoid garters, extremely firm girdles with panty legs, and knee-high stockings because these may impede lower extremity circulation. If she plans to breast feeding her new born, she might choose to buy bras suitable for breast-feeding so she can continue to lose them after the babys birth. Suggest wearing shoes with a moderate to low heel to minimize pelvic tilt an possible backache.

Assessment Parameter Sexual Activity

Observation Dont have sexual activity during pregnancy.

Implication No medical reasons exist to restrict intercourse except for a women who experienced spontaneous miscarriage during the time of pregnancy when a previous miscarriage occurred. Advise caution about male oral-female genital contact, because accidental air embolism reported from this act during pregnancy. Caution women with a no monogamous sexual partner about the partners need to use a condom.

Assessment Parameter Exercise

Observation

Implication

Do some walking everyday Exercise during pregnancy early in the morning and in during pregnancy is the late afternoon. important to prevent circulatory stasis in the lower extremities. Also offer a genital feeling of well-being. Important to strengthen the pelvic floor muscle and gain control during contraction and relaxation for easy passage of the baby at birth. Walking improves circulations and stamina.

Assessment Parameter Sleep Pattern

Observation Sleep continuously at night at a duration of 8 hours using one pillow in a lateral position.

Implication Optimal condition for body growth occur when growth hormone secretion is high during sleep. To build a new body cells. A good resting or sleeping position (sims postion) allows good circulation in the lower extremities. Pregnant woman should be certain they know not to rest with their knees sharply bent either when sitting or lying down, for there is an increased risk of venous stasis below the knee.

Assessment Parameter Employment

Observation Patient is unemployed.

Implication Women cannot continue to work throughout pregnancy because some occupation are hazardous for they bring women into contact with harmful substance. Spontaneous miscarriage may occur more frequently in women who work at strenuous jobs or those that require long period of standing. Problem may occur with employment, include interference in adequate rest and nutrition.

DISCOMFORTS DURING PREGNANCY

Assessment Parameters Breast Tenderness

Observation Experienced breast tenderness during the first trimester of pregnancy.

Implications Due to increase prolactin levels. Encourage women to wear bra with a wide shoulder strap for support in to dress warmly to avoid cold drafts if cold increases symptoms.

Assessment Parameter Constipation

Observation Doesnt experienced constipation.

Implication May occur as the weight of the growing uterus presses against the bowel and peristalsis slows. Encourage to evacuate her bowels regularly to increase the amount of roughage in her diet by eating raw fruits and vegetables, and to drink at least eight glasses of water daily.

Assessment Parameter Nausea and Vomiting

Observation Experienced nausea and vomiting during her first trimester of pregnancy.

Implication Adequate nutrition and hydration are important fetal growth and development. Client participation helps to individualize care, increase feeling of control and comfortable.

Assessment Parameter Fatigue

Observation Experienced fatigue during her second to third trimester of pregnancy.

Implication Due to increase metabolic requirements. It can be relieved by increasing the amount of rest and sleep.

Assessment Parameter Muscle Cramps

Observation Experienced muscle cramps in her both lower extremities.

Implication Caused by decrease serum calcium levels, increase serum phosphorus level, and interference with circulation. Best relieve by woman lying on her back momentarily and extending the involved leg while keeping her knee straight and dorsiflexing the foot until the pain is gone.

Assessment Parameter Hypotension

Observation Blood pressure is 110/70 mmHg. She is not hypotensive.

Implication Occurs when a woman lies on her back and uterus presses on the vena cava, impairing blood return to the heart.

Assessment Parameter Varicosities

Observation Dont have varicosities.

Implication Due to the weight of the distended uterus puts pressure on the veins returning blood from the lower extremities. This causes pooling of blood in the vessels.

Assessment Parameter Hemorrhoids

Observation Dont have hemorrhoids as the patient verbalizes.

Implication Occur commonly in pregnancy because of pressure on the veins from the bulk of the growing uterus.

Assessment Parameter Frequent Urination

Observation Experienced frequent urination during her third trimester of pregnancy. Urinate six times a day, cup every urination.

Implication Due to the pressure of the growing uterus on the anterior bladder.

Assessment Parameter Abdominal Discomforts

Observation Experienced seldom abdominal discomfort during her second trimester of pregnancy. Patient rated pain 4/10.

Implication Spinal column is suppressed due to enlarging of the uterus.

Assessment Parameter Leukorrhea

Observation Have increased vaginal discharges during her pregnancy.

Implication Occurs in response to the high estrogen levels and the increase blood supply to the vaginal epithelium and cervix in pregnancy.

Assessment Parameter Backache

Observation Seldom experienced backache during her third trimester of pregnancy. Patient rated pain 3/10.

Implication Spinal column suppress due to the enlarging fetus. As pregnancy advances lumbar lordosis occurs and postural change necessary to maintain balance causes backache. Wearing shoes with low to moderate heels reduces the amount of spinal curvature necessary to maintain an upright posture. Encourage to walk with her pelvis tilted forward.

Assessment Parameter Headache

Observation Seldom experience headache during her first trimester of pregnancy. Patient rated pain 5/10.

Implication Experience headache apparently from their expanding blood volume which puts pressure on cerebral arteries resting with cold towels on their forehead.

Assessment Parameter Dyspnea

Observation Seldomly experienced dyspnea during her third trimester of pregnancy. Patient respiratory rate is 20 breaths/min.

Implication As expanding uterus puts pressure on the diaphragm, causing some lung compression, shortness of breaths may occur. Sitting upright, allowing the weight of the uterus to fall away from the diaghragm.

Assessment Parameter Ankle Edema

Observation Dont have ankle edema.

Implication Probably cause with reduce blood circulations in the lower extremities due to uterine pressure and general fluid retention.

CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS None HEALTH HISTORY Patient dont have previous illness/ hospitalization. Patient has previous history of labor on May 4, 2004 and June 11, 2007 at Tambacan Health Center. MEDICATION HISTORY Name of Drug Dose/ Frequency Date & Time of Last Dose Reason for taking the medication. Imefer # 10 cap 1 cap a day, o.d. Aug. 8, 2010; 8 pm For iron supplement.

FAMILY HEALTH HISTORY Patient has no family health history of hypertension, diabetes mellitus, renal failure, cancer, asthma, tb, psychological problems and arthritis. Patient son and daughter has a health history of fever, cough and cold.

INTEGUMENTARY Patient has presence of striae gravidarum and linea negra. Patient skin are smooth, warm and diaphoretic. RESPIRATORY Patient dont have cough. Seldomly experienced dyspnea. CIRCULATORY Patient experienced cramps in her both lower extremities. Theres no presence of edema. DIGESTIVE Patient has dental carries. Patient dont have dentures.

NUTRITIONAL Patient has increased appetite during her second and third trimester of pregnancy. Diet are red meats, vegetables and fruits. Has an increased weight of 1.5 kg. BLADDER AND BOWEL Patient defecate three times a week early in the morning. Stool are solid and yellow. Date of last bowel movement is on August 8, 2010. HEALTH LIFESTYLE AND ILLNESS Patient experienced polyuria. Urine is amber yellow and usually urinates 150 mL every urination.

SLEEPING PATTERN Patient sleeps 8 hours a day using one pillow in a lateral position. Dont have sleeping difficulties.

FAMILY PLANNING METHOD Patient was using traditional family planning method. Patient was using pills for 3 yrs.

PHYSICAL ASSESSMENT DURING PREGNANCY

(2nd Visit)

September 4, 2010

General Survey : Patient has a BP of 110/70 mmHg; pulse rate of 92 bpm; temperature of 37.1C; respiratory rate of 24 breaths/min. The patient is restless and preparing for the babys birth. Skin, Hair and Nails : Patient has a smooth and fair complexion. There are presence of freckles in her upper extremities. Skin integrity is intact. There are presence of linea negra and striae gravidarum. Hair is black, long, thick and theres no traces of dandruff. Theres no presence of ankle edema upon inspection and palpation. Head and Neck: There is no enlargement of lymph nodes in the neck. No masses detected during palpation. Neck can move without discomfort and can do ROM.

Eyes:
Pupils are equal and round, reactive to light and accommodation. Eyebrows are evenly distributed along the margin of eyelids. Theres no lesions and secretions seen during inspection. Ears: Tympanic membranes are clear; landmarks are visible. There are no lesions and foul discharges noted in the external canal. Mouth, Throat, and Nose : Lips are pinkish without lesion. Patient does not wear dentures. Gingival tissues appear swollen and slightly reddened. Throat is pink, no redness or exudates. Nose has no foul discharges, lesions or masses. Nares are even and not inflamed. Thorax and lungs : Thorax is symmetrical with normal lung expansion. Lungs sounds are clear to auscultation bilaterally.

Breasts : The breast is smooth, warm and theres no tenderness and pain. Venous congestion is noted with prominence of veins. Montgomerys tubercles are prominent. Breast size increased and nodular and more sensitive to touch. Hyperpigmentation of nipples and areola is evident. Heart : There is normal sinus rhythm and soft systolic murmurs are audible upon auscultation at the left midclavicular line, fifth intercostal space. Peripheral Vascular: There is no presence of varicose veins in the upper and lower extremities. The upper and lower extremities can do range of motion activities. Abdomen : There is presence of striae gravidarum and linea negra in the abdomen. Abdominal contour is round. There are no lesions present.

Health Assessment During PostPartum

3rd Visit ( October 11, 2010) T: 38.1C P: 83 bpm R: 18 breaths/min BP: 110/70 mmHg Weight: 66kg Date of Delivery: September 27, 2010 Type of Delivery: Normal Spontaneous Vaginal Delivery Name of Child: Baby Boy Ricardo Genon Jr.

Health Assessment: Mrs. Maricel Genon experienced breast pain due to lactation. Linea negra and stretched marks are still present. No allergies or rashes in her upper and lower extremities. Have a slightly reddish vaginal discharges. She experienced fatigue, headache, and muscle pain. She breastfed her infant.

ASSESSMENT OF THE INFANT

Name: Ricardo Genon Jr. Head Circumference: 38cm Chest circumference: 36cm Height:54cm Weight: 5.3lbs Mid arm: 11cm Temperature: 36.9C RR:37bpm HR:125bpm

ASSESSEMENT OF NEONATE

General Survey : The neonate is clean, has no unusual body odor, and clothing is in good condition. Neonates arms and legs are in flexed position. Vital Signs : The neonate has an axillary temperature of 36.9 C; apical pulse rate of 125 bpm; respiratory rate of 37 breaths/min., breathing is unlabored, lungs sounds are clear. Measurements : The neonate weights 5.3 lbs. head circumference of 38cm. Chest circumference of 36cm. Mid-arm circumference of 11cm. Has a height of 54cm.

Skin, hair and nails : The neonate skin color is pinkish, has no strong odor and free from lesions. Skin is soft, warm slightly moist with good turgor. The neonate has a birthmark in the right lower extremity. Has milia and vernix caseosa. Hair is lustrous, silky, strong and elastic. Nails are well-formed. Head and Neck : Head is normocephalic and symmetric. Neonate dont have head control. Head is proportionate and symmetric. Neck is short with skin folds between the head and shoulder. Eyes : Sclera and conjunctiva are clear and free of discharge, lesion, redness and lacerations. Iris is brown. Pupils are equal round reactive to light and accommodation. Eyebrows are symmetric in shape and do not meet at midline. Eyelashes are evenly distributed.

Ears :

Ears has no excessive cerumen, discharge lesions and foreign body in external canal. Mouth, Throat, and Nose : Gums are pink and moist. Nose is midline in face and nares are patent. Theres no presence of discharges and tenderness.

Thorax : Neonates thorax is smooth, rounded and symmetric. Respirations are unlabored. There are no adventitious sounds heard upon auscultation.

Breast : Breast are symmetric, rounded, there is no tenderness, lesion and masses. The nipples are not retracted and it is brownish. Heart : Neonates apical pulse is 125bpm at the 4th intercostal space. Abdomen : Abdomen is protuberant. Umbilicus is pink, has no discharges, no odor and redness. Abdomen is soft to palpation and without masses or tenderness.

Male Gentalia : Urinary meatus is at the tip of glands penis and has no discharge or redness. Scrotum is free of lesions. Testes are equal in size, smooth, and free of masses. No inguinal hernias are present. Anus and Rectum : The anal opening is visible and moist. Perianal skin is smooth and free of lesions. Musculoskeletal : Feet and legs are symmetric in size, shape and movement. Extremities are warm and mobile with adequate capillary refill. The neonate spine is flexed.

Reflexes :

Rooting Reflex The neonates hand move towards the area that has been touch and opens his mouth. Sucking Reflex The neonate sucks the mother breast while placing the nipple in the neonates mouth. Palmar Grasp Reflex The neonate fingers grasp the fingers as we pressed against the palmar surface of the neonates hands from the ulnar side. Plantar Grasp Reflex The neonates toes curl downwards as weve touched his foot.

Tonic Neck Reflex The neonates head turn to ones side and the arm and leg on one side which the head is turned extend and the opposite arm and leg flex. Moro (startle) Reflex The neonate started when we rapidly lower the whole body of the neonate of a few inches. Babinski Reflex The neonate toes fanned when we hold her foot and stroked up the lateral edge and across the ball. Stepping Reflex The neonate stepped with one foot and other in a walking motion.