West Visayas State University COLLEGE OF NURSING La Paz, Iloilo City LABOR AND DELIVERY ASSESSMENT I.

VITAL INFORMATION: Name: KJC Age: 24 Address: Brgy. Isian Victoria, Leon, Iloilo Civil Status: Single Date and Time Admitted: 8/22/12, 1:35PM Chief Complaint: Labor pain Ward: FSW Allergies: None Religious Affiliation: Roman Catholic Physicians Initial: Dr. A Impression/Diagnosis: PU due to a live FT, Bb girl via NSVD in cephalic presentation AS=8/10, BW Date and Time of Interview: 8/22/12, 5PM Relationship to Patient: Patient herself II. CLINICAL ASSESSMENT A. Obstetrical Data 1. Age of Menarche: 13 y/o 2. G2 P2 (T2 P0 A0 L2) 3. Description of Previous Pregnancies: Wala ko nabudlayan magbusong sa subang ko. As verbalized by KJC. Pregnancies: Type of Delivery: NSVD

Complications of Labor and Delivery: None 4. LMP: Nov. 27, 2011 5. EDC: Sept. 3, 2012 6. Prenatal check-up: KJC had her recent prenatal check-up on 8/8/12, Midwife on duty was Lolita Camaral. Medications prescribed were Cefalexin 500mg/capsule, TID 5 days- for cough, and Carbocistein 500mg/capsule, TID x 5 days. Urinalysis requested by midwife. 7. Description of Present Pregnancy: Naubo ko sang July, nabudlayan ko magbusong sa iya. As verbalized by KJC. 8. Medications taken during pregnancy: Carbocistein 500mg/capsule, TID x 5 days- for cough Cefalexin 500mg/capsule, TID 5 days- for cough 9. Discomfort on Present Pregnancy: Sakit tiyan, Indi kahulag maayo as verbalized by KJC.

10. Progress of Labor: (Not assessed due to situation constraints) Time Duration Frequency Interval Intensity

Time- the time when contractions starts Duration- is the time from the movement of the uterus first tenses until the time it has relaxed Frequency- timed from the beginning of one contraction to beginning of the next contraction or how often contractions occur. Interval- the period how far apart are the contractions or is to time contractions from start to start of the next contractions Intensity- is the strength of a contraction at its peak; eg, mild, moderate or strong

II . A. STAGES OF LABOR a. FIRST STAGE OF LABOR (Preparatory Stage): o First stage begins with the initiation of true labor contractions and ends when the cervix is fully dilated. Divisions: a. Latent Phase Begins with the onset of regularly perceived contractions and ends when rapid cervical dilatation begins. Contractions are mild and short, lasting 20 to 40 seconds Cervix dilates from 0-3 cm Phase lasts for 6 hours in a nullipara and 4.5 hours in a multipara Measuring the length of the latent phase is important because a reason for prolonged latent phase is a cephalopelvic disproportion that could require a cesarean birth. A woman can continue to walk about and make preparations for birth, such as doing last minute packing for her stay at the hospital or birthing center, preparing older children for her departure and the upcoming birth. Allow the woman to continue t be active Encourage her to continue or begin alternative methods of pain relief such as aromatherapy or distraction.

b. Active phase -Cervical dilatation occurs more rapidly, increasing from 4-7 cm -Contractions are stronger, lasting 40-60 seconds and occur every 3-5 minutes -Phase lasts for approximately 3 hours for a nullipara and 2 hours for a multipara -show and spontaneous rupture of membranes may occur during this time -Frightening time as a woman realizes labor is truly progressing and her life is about to change forever -Encourage woman to remain active participants in labour by assuming what position is most comfortable for them during this time PERIODS (Friedman graph): o Acceleration- 4-5 cm o Maximum Slope- 5-9 cm cervical dilatation proceeds at most rapid pace, averaging 3.5 cm pee hour in nulliparas and 5 to 9 cm per hour in multiparas

c. Transition phase Contractions reach the peak of their intensity, occurring every 2-3 minutes with a duration of 60-90 seconds Cervix dilates from 8-10 cm By the end of this phase, both full dilatation and complete cervical effacement have occurred Woman experiences intense discomfort accompanied by nausea and vomiting Woman may also experience a sense of loss of control, anxiety, panic, or irritability Focuses on the task of birthing her baby Peak of transition can be identified by a slight slowing in the rate of cervical dilatation when 9 cm is reached. as a woman reaches the end of this stage, a new sensation oc curs

b. SECOND STAGE OF LABOR (Fetal Expulsion Stage): o It is the period of cervical dilatation and cervical effacement to birth of the infant o With uncomplicated birth, it reaches up to 1 hour o Woman feels change from the characteristics crescendo-decrescendo pattern to an overwhelming, uncontrollable urge to push with each contraction as if to move her bowels. o May experience nausea and vomiting, pushes hard that she might perspire and the blood vessels in her neck might be distended o Perineum might appear bulge and tense as the fetus touches the internal side of the perineum o Anus may become everted, and stool may be expelled. o The vaginal introitus opens and the fetal scalp appears as the fetal head pushes against the perineum (opening from slit-like to oval to circular) o Change in opening is called crowning o After some time, the woman realizes that everything is all right and that it feels good to push with contractions. The need to push becomes so intense that she cannot stop herself o The woman's energy and thoughts are directed towards birth o Fetus is pushed out of the birth canals she pushes using her abdominal muscles c. THIRD STAGE OF LABOR (Placental Expulsion Stage): o Begins with the birth of the infant and ends with the delivery of the placenta. a. Placental Separation Folding and separation of the placenta occurs, due to disproportion between the placenta and the contracting wall of the uterus Active bleeding on the maternal surface of the placenta begins with separation (helps placenta to separate further by pushing it away from its attachment site Normal blood loss is 30-500 ml *SIGNS THAT INDICATE PLACENTAL HAVE LOSENED AND READY TO DELIVER: LENGTHENING OF THE PLACENTAL CORD, SUDDEN GUSH OF VAGINAL BLOOD, CHANGE IN THE SHAPE OF THE UTERUS, APPEARANCE OF THE PLACENTA AT THE VAGINAL OPENING *TYPES OF PLACENTA PRESENTATION: 1. SCHULTZE PRESENTATION-shiny and glistening from the fetal membranes 2. DUNCAN PRESENTATION-raw, red irregular with ridges of cotyledon that separate blood collection spaces showing b. Placental expulsion After separation, placenta is delivered by natural bearing down or gentle pressure on the uterine fundus by a physician, midwife or nurse. Pressure must never be applied to a uterus in a noncontracted state to prevent haemorrhage and uterus to evert Third stage is complete upon delivery of placenta Ask parents whether saving the placenta is important to them before it is destroyed Woman may be asked to donate their newborns placenta so blood can be removed and banked to be available for bone marrow or stem cell transplantation. Placenta membranes can be salvaged to be used as temporary coverings for burns.

d. FOURTH STAGE OF LABOR (Crucial Stage): o The first 1-4 hours after birth of the placenta o Close maternal observation is important at this time II. B. Schematic Diagram Normal Spontaneous Vaginal Delivery Predisposing Factor: Gestational Age (38 3/7 weeks) Precipitating Factor:

Uterine stretching Loose stools Release of Prostaglandins Increase pressure of the cervix Stimulates the release of oxytocin Pain

Oxytocin and Prostaglandins works together First Stage of Labor: Preparatory Division Initiates contractions Contractions coordinated Longitudinal traction from the contracting uterine fundus Fluid-filled membranes press against the cervix Cervical effacement Cervical dilatation Contractions change characteristics Crescendo-decrescendo pattern

-uterine smooth muscle contraction -reduced

-Bloody Show -Rupture of BOW

Backache

Overwhelming, uncontrollable urge to push with each contraction

(Ferguson Reflex) Downward movement of the biparietal diameter of the fetal head within pelvic inlet (Descent) Head bends forward unto the chest (Flexion) Pressure no longer exerted on stomach Fetal head touches internal side of perineum Vaginal introitus opens Fetal scalp appears (Crowning) Passage of fetus to birth canal Lightening

Fetal head reaches pelvic floor Suboccipitobregmatic diameter present to birth canal Occiput rotates (Internal rotation) Anteroposterior diameter in line with anteroposterior plane of the pelvis Occiput is born Head extends (Extension) Parts of the head, face, and chin are born Head rotates back to diagonal position (External rotation) Line the shoulders into anteroposterior position

Shoulder is born Downward flexion of the fetus head 2nd Stage of Labor: Fetal Expulsion Fetal Expulsion

Live, full term, appropriate for gestational age in cephalic presentation via Normal Spontaneous Vaginal Delivery

Cutting of the umbilical cord

Gush of Blood, Lengthening of the umbilical cord, change in shape of the uterus, appearance of

3rd Stage of Labor: Placental Expulsion Placental separation Placental expulsion 4th Stage of Labor: Crucial Stage 1-4 hours after Placental Expulsion

Definition of Terms 1.) Prostaglandins Are any of a group of naturally occurring, chemically related fatty acids that stimulate contractility of the uterine and other smooth muscle and have the ability to lower blood pressure, regulate acid secretion of the stomach, regulate body temperature and platelet aggregation, and control inflammation and vascular permeability; they also affect the action of certain hormones. 2.) Oxytocin Uterine contraction - Oxytocin secretion plays a major role during the second and third phases of human labor. Uterine contraction is crucial for the expansion of the cervix prior to childbirth. Many women face problems during the first couple of weeks of lactation, as breastfeeding results in painstaking uterine contractions due to Oxytocin secretion. 3.) Ferguson Reflex The Ferguson reflex is an example of positive feedback and the female body's response to pressure application in the cervix or vaginal walls. Upon application of pressure, oxytocin is released and uterine contractions are stimulated (which will in turn increase oxytocin production, and hence, increase contractions even more), until the baby is delivered. 4.) Effacement Cervical effacement refers to a thinning of the cervix.

5.) Suboccipitobregmatic diameter The diameter of the fetal head from the lowest posterior point of the occipital bone to the center of the anterior fontanelle; this is typically the smallest diameter and is the one that presents optimally in labor 6.) Kangaroo Care Kangaroo care is a technique practiced on newborn, usually preterm, infants wherein the infant is held, skin-to-skin, with an adult. Kangaroo care for pre-term infants may be restricted to a few hours per day, but if they are medically stable that time may be extended. Some parents may keep their babies in-arms for many hours per day. Kangaroo care, named for the similarity to how certain marsupials carry their young, was initially developed to care for preterm infants in areas where incubators are either unavailable or unreliable. II. C. Management a. Nursing Actual Care Given

As the student nurse to my client I was able to give proper nursing care such as getting the vital signs every 15 mins for 2 hours and every 30 mins for the following hours for both mother and baby. I assist her for ambulation and encourage her to take her medications exactly and followed the instruction given. And lastly, I was able to teach my client the proper way of breastfeeding her child so that she can perform it correctly and without any fear. Problem Encountered During The Implementation of Nursing Care

As far as my concern, my client doesnt encountered any problem as I give my nursing care for as long as she follow what is the proper care for both her and to the baby. Restorative Measure Used

Client delivered her child vaginally and doesnt have any incisions. My restorative measure that I implemented was to check her vital signs, monitor intake and output of her and to the baby, and to make sure that she take her medication accordingly. Evaluation

Client is very thankful to the staff and to the student nurses that help her in managing herself and the baby in the hospital. She also appreciates the effort of the staff in providing her anything she wanted and giving her the right medications. She learned a lot and willingly to apply it outside the premises of the hospital. Patient Teaching

Client was able to learned proper breastfeeding technique. She also taught on the pros and cons of the latter. She is also reminded on proper hygiene to her and to the child so that she can assure to be healthy for as long she implemented what we taught to her. I also include her to have a regular consultation to the nearest health center to monitor the recovery and the come back of her normal vital signs. b. Medical Treatment and Procedures

Vital signs Taking

Closely monitored to be able to have time to time basis of what our client been felt internally. Temperature Mother Baby Pulse Rate Respiratory Rate BP

Administering Oral Medication

Medication is given to the client as ordered by the physician. As to the setting, normally the nurses give medications that are independent, such as mefenamic acid, amoxicillin, ferrous sulphate, and methergine. Each drug has its own specific effects on the clients body. Perineal Care

Perineal care is done during the labor starts. It is method that cleanses the perineum after the various obstetric and gynaecologic procedures. It is practiced to remove secretion or dried blood and prevent contamination of urethral and vaginal areas. We performed this procedures before internal examination and when there is gush of blood came out or even if theres feces also. Diet

During the labor the client is instructed not to take anything by mouth (NPOnothing per orem). This is so that the patient will not defecate as the labor goes on. Right after the delivery, the client is allowed to eat so she can regain her energy. c. Surgical With delivery imminent, the mother is usually placed supine with her knees bent (ie, 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 the risk of rectal injury and are larger than the spontaneous laceration. References:

http://www.livestrong.com/article/144952-about-normal-spontaneous-vaginaldelivery/ Pilliteri, Adele, PhD, RN,PNP.Maternal and Child Health Nursing (Care of the Childbearing and Childbearing Family). (Vol.)1 and 2. 4th edition.2003 Gupta and Gupta. Nurses Pocket Dictionary (with 375 illustrations).AITBS Publishers and Distributors.2001 Forsythe, E. and Bromham, D. Faber Pocket Medical Dictionary. 4th edition. M.W. Publishing Inc. No.3 Quzon Avenue, Quezon City.1988

12. Type of Anesthetic Used: Lidocaine Hydrochloride 13. Type of Episiotomy and Description: Perineal laceration 14. Type of Delivery: NSVD 15. Type of BOW Ruptured: clear 16. Description of Placental Delivery: Schultzs presentation B. GYNECOLOGIC HISTORY KJCs menarche is when she was 13 years old and claimed that her menstrual cycle is regular. She uses 3-4 pads per day, moderately soaked. C. FAMILY PLANNING PRACTICES KJC claimed that they practice withdrawal as a form of contraceptive. D. PAST HEALTH PROBLEMS/STATUS a. Childhood Illness cough and fever during her elementary years b. Childhood Immunizations All immunizations were unrecalled but a BCG mark on the gluteus muscle is noted. c. Allergies None d. Accidents and Injuries None e. Hospitalization for serious illness None f. Medications KJC claimed to be taking vitamins but was not able to recall the name of the drug. E. FAMILY HISTORY OF ILLNESS Leukemia- maternal side F. PATIENTS EXPECTATIONS TOWARDS HOSPITALIZATION: Maayo man nga serbisyo ang mahatag sa akon. TOWARDS NURSING CARE: Maayo man tani kung atipanun niyo guid ko. III. Patterns of Functioning A. Breathing pattern Respiratory Problem: None Usual Remedy: N/A Manner of breathing: regular, deep inhalation and shallow expiration B. Circulation Usual BP: 110 / 80 mmHg History of chest pain, palpitations, coldness of extremities: None C. Sleeping Patterns

Waking time: 6:00 am -6:30 am Usual Bedtime: 9: 00pm- 9:30pm Hours of sleep: 9- 10 hours Usual Remedy: batang lang as verbalized by KJC. No. of pillows: 2 pillows, place under the head. (size: 20x 12 x4) Bedtime rituals: Spongebath Problem Regarding sleep: insomnia kon kaisa as verbalized by KJC. D. Drinking Patterns Type Drinking water Orange Juice Milk TOTAL E. Eating Patterns Breakfast Usual Food Taken medium sized fried fish (tilapia) 1 medium sized bowl of alugbate 3 cups of plain rice medium sized fried fish (tilapia) 1 medium sized bowl of alugbate 3 cups of plain rice medium sized fried fish (tilapia) 1 medium sized bowl of alugbate 3 cups of plain rice 4-5 pcs of pandesal bread, 200-300 mL of orange juice Range 7:00 -8:00 am Amount 8-9 glasses / day 1 glass / day 1 glass / day 11 glasses / day

Lunch

11:00 -12:00 pm

Dinner

7:00 - 8:00 pm

Snacks Food likes: Bicho-bicho Food dislikes: Karne F. Elimination Patterns Bowel Movement Frequency: twice a day Problem/Difficulties: None Usual Remedy: N/A Urination Frequency: 10 times a day Problems/ Difficulties: None Usual Remedy: N/A G. Exercise

3:00pm- 4:00 pm

Brisk walking Time: 8:30 9:00 am Distance: 200 300 meters Duration: 30 mins. H. Personal Hygiene 1. Bath Type: Complete Bath Frequency: once a day Time of the day: 8:00 am -8:30am 2. Oral Frequency of brushing: twice a day (morning and night) Care of dentures: N/A 3. Shaving Frequency: once a week 4. Use of cosmetics: none

I. Recreation: Ga lagaw kami sa uma sang bana ko. As verbalized by KJC. J: Health Supervision Sa barrio sang Leon. As verbalized by KJC and she was assisted by the midwife. III. A. CLINICAL INSPECTION 1. Vital Signs Date and Time Taken: August 22, 2012 5:30pm T= 37.4C by axilla PR= 76 bpm RR= 24 brpm BP= 100/80 2. Height: 173cm 3. Weight: 68kg 4. Physical Assessment: General Appearance: Clients appearance, body build, height and weight appropriate with stated age; organized grooming; no body odor noted; no signs of illness; anxious but attentive and appropriate response; organized speech. a. Integumentary System: Fair complexion and evenly distributed throughout the body ; skin temperature is within normal range; moist; good skin turgor; linia nigra present. b. Neuro-Sensory Sytem:

Cranial Nerves CN I: Olfactory

How it is elicited/examination performed Ask client to close her eyes. Test each nostril by asking client to inhale deeply and identify the object being smelled. Ask client to read a certain test at a distance of 14 inches for near vision and at a distance of 20 feet for distant vision. Examine visual acuity using a Snellen chart.

Clients response Intact CN I as evidence by client is able to identify the object (powdered coffee) being smelled. Not assessed

CN II: Optic

CN III: Oculomotor

Pupils Equally Round reacted to Light and Accommodation (PERRLA)

CN III, IV, VI: Oculomotor, Trochlear and Abducens

Ask client to follow directions of the examiners index finger as it moves into the six cardinal fields without moving the head. Stroke clients face lightly with cotton. Wisp and instruct to respond by saying yes each time she feels the stimulus. Ask patient to raise and lower eyebrows, close and open eyes, frown, smile, show teeth and puff the cheeks. Instruct patient to close her eyes and without looking at the object, identify the taste being placed on the tongue. Perform voice-whisper test. Ask patient to occlude one ear while you whisper a two-word syllable word, then ask patient to repeat the word. Test on both ears. Examine uvula movement and gag reflex by touching the uvula using a tongue depressor. Assess the patients ability to swallow by giving her a glass of water.

CN III, IV, VI intact

CN V: Trigeminal

CN V intact

CN VII: Facial

CN VII intact

CN VIII: Vestibulocochlear

Not assessed

CN: IX: Glossopharyngeal CN X: Vagus

CN IX and X intact

CN XI: Spinal Accessory

Instruct patient to turn head CN XI intact sideways against the resistance of examiners hand. Instruct patient to raise shoulders against downward resistance. Instructing the patient to put his tongue on one side of his cheek and resist the force while pressure is applied against it. CN XII intact

CN XII: Hypoglossal

c. Respiratory System Nose is at the midline, both nares are patent; absence of lesions and discharge; RR= 24brpm; regular in rate and rhythm; quick effortless breathing; deep inspiration and shallow expiration. d. Cardiovascular System Radial pulse = 76 regular beats per minute (+2); BP = 100/80; SI and S2 heart sound occur in sequence with each heart beat; absence of murmurs. e. Gastrointestinal System Lips pink; smooth and moistl; absence of lesions and swelling; umbilicus at midline; skin tones are similar to surroundings; round abdominal contour; defecates once a day. f. Genito-Urinary System Voids 2-3 times a day; pubic hair distribution inverted triangular without infestation; labia majora are equal in size; labia minora are symmetric. g. Reproductive System Duration of flow 3-4 days, 3-4 pads / day, moderately soaked; does not experience dysmenorrheal. Areola dark brown in color, nipple everted, breasts are enlarged and slightly asymmetric; no redness or swelling. h. Endocrine System Thyroid gland is palpable; non tender and ascends during swallowing; thyroid cartilage at midline. i. Musculoskeletal System Musles equal in size on both sides of the body/ symmetrical. j. Lymphatic System Neck is at the center; absence of swelling or masses on the neck; coordinated, smooth movements without discomfort; occipital, postauricular, preauricular, submanmdibular, superficial cervical, posterior cervical, and supra clavicular lymph nodes are non-palpable and non-tender upon palapation. k. Hematopoietic System: Capillary refill less than 4 seconds; no pallor or bruises noted; blood loss of approximately 300-500 mL. B. PSYCHOSOCIAL ASSESSMENT 1. Lifestyle Information KJC is 24 years old, single and a Roman Catholic. She does not drink alcohol, smoke nor take prohibited drugs. She belongs in an extended family since they live with her partners parent. Since she and her husband are unemployed, her second older sister who is working gives financial support to her family. 2. Normal Coping Patterns Whenever KJC has problems, she usually runs to her family and shares these problems to them. 3. Understanding of Current Illness 4. Personality Style KJC is active in sharing her experiences and is able to respond to questions appropriately; 5. History of Psychiatric Disorder The patient and her family have no history of mental illnesses. 6. Recent Life Changes or Stressors wala man, as verbalized by client.

7. Major Issues Raised by Current Illness

8. Mental Status 9. Appearance:

Neat Erect Posture Description:

Clean

Dishevelled Good Eye Contact

Poor Grooming Inappropriate make-up

KJC observes proper hygiene; Absence of foul body and breath odor noted; maintains good eye contact when talking. Behavior: Calm Appropriate Restless Unusual Actions Agitated Others:

Compulsions Description:

KJC is attentive. She cooperates fully during the whole duration of interview and physical assessment. Speech: Appropriate Soft Pressured Mute Loose Association Others: Loud

Description: KJC communicates effectively and expresses her thought in an organized manner. She talks softly without raising the tone of her voice. Mood or Affect: Appropriate Labile Flat Depressed

Anxious Angry Hopeless Others: Description: KJC does not show any signs of irritation and if she feels tired she would tell us that she wanted to take a rest. Thoughts: Appropriate Low self-esteem Delusions Suicidal Ideations Phobias Others:

Hallucinations Description:

KJCs thoughts are appropriate to the situation and she answers to inquiries and no suicidal ideations or delusions noted on the course of conversation issue of hospitalization.

Ability to Abstract: Impaired: YES NO Description: KJC was asked Aaanhin pa ang damo kung patay na ang kabayo? and answered ipakaon sa baka eh. while laughing. Memory: Impaired recent memory: YES NO Impaired past memory: YES NO Number of objects able to remember after 5 minutes: 4 Description: Remembered 4 out of 5 items after 5 minutes namely paper, scissor, pencil, baby Estimated Intelligence: Below Average Average Above Average Description: Patient was asked to name three former presidents of the Philippines and was able to answer with Magsaysay, Estrada and Marcos Concentration: Able to subtract by 7s from 100 correctly until number 93 Orientation: Person Time Place Situation Description: Client was able to tell her name, able to state the date and time, identify where she is, and aware of her current situation. Judgment: Realistic decision making: YES Description: When client was asked ano ubrahon mo kon may makita ka nga aso sa inyo balay? she answered, pangitaon anay kon diin halin ang kalayo eh. Insight: Good Fair Poor Description: Client has plans for her future with her family e.g. to wed by this year and work to help sustain their daily needs. III. OTHER SOURCES OF LABORATORY DATA IV. DRUG STUDY V. PROBLEM LIST 1. Pain r/t labor contraction 2. Fear r/t uncertainty of pregnancy outcome 3. Anxiety r/t medical procedures to be performed 4. Fatigue r/t loss of glucose stores through work and duration of labor 5. Risk for ineffective tissue perfusion 6. Risk.for.injury