LOURDES COLLEGE

NURSING PROGRAM

Cagayan de Oro City

In Partial Fulfillment of the

Requirements in NCM101

Related Learning Experience

A Written Report in

Submitted to:

Ms. Amihan R. Reyes, RN

Clinical Instructor

Submitted by:

Charie Mae S. Estamo

BSN 3B
 Table of Contents

I. Introduction………………………………………………………………….

II. Patient’s Profile……………………………………………………………..

III. Physiology of Labor

A. Theories of Labor……………………………………………..

B. Preliminary Signs of Labor…………………………………..

C. Signs of True Labor…………………………………………..

D. Stages of Labor……………………………………………….

E. Components of Labor………………………………………...

IV. Ideal Nursing Interventions

• Antepartum……………………………………………………………..

• Intrapartum……………………………………………………………..

• Postpartum……………………………………………………………..

V. Actual Nursing Interventions

• Antepartum………………………………………………………….....

• Intrapartum…………………………………………………………….

• Postpartum…………………………………………………………….

VI. Referral and Evaluation………………………………………………….

VII. Bibliography……………………………………………………………....

VIII. Appendix

• Assessment Tool……………………………………………………..

• Nursing Care Plans…………………………………………………..

II. Patient’s Profile

Patient’s full name is Eva Liona, 38 years old and a resident of 31-22 nd St.

Brgy. Nazareth, Cagayan de Oro City. She is originally here at Cagayan de Oro

City. She is presently not employed. She is the first daughter of four children of

Mr. Bobrino Sarans and Josephina Sarans.

This is her 3rd pregnancy. Her first child is already 15 years old and the

second is 9 years old. On her first husband, she has two children, the first and

the second child. The second husband was the father of her third child. Her first

menstruation or menarche was when she was at grade school level or

specifically when she was 12 years old.

Rena Liona is the name of second husband of Eva. 26 years old. and a

resident of 31-22nd st. Brgy. Nazareth, Cagayan de Oro City. They are living their

own house. Her husband works as a Trisikad Driver.

Based on my first visit at Brgy. Nazareth my patient vital signs were: RR-

19 beats per minute; Pulse Pressure- 69 bpm; heart Rate 76 cpm with regular

rhythm; Temperature- 36.7 degree Celsius; BP 110/80. She is cooperative during

the assessment.
A. Prenatal Assessment

Mrs. Eva Liona is a 38 years old, was born on December 6, 1970. She is

Filipino Roman Catholic. She did not expect any date on her delivery. I get the

information from the patient. Date of assessment was on January 5, 2008 in the

afternoon.

Activity/ Rest

Mrs. Eva is a plan housewife. She stays at home to work the daily house

chores and take good care of their children. Her hobbies include talking with the

neighbor, watching television and sometime if she is tried she sleep for a while.

She usually sleeps on 7-8 hours. Sometimes she experienced abdominal pain

during her pregnancy related to movement of the baby inside the mother womb.

”Usahay sakit ang tiyan katong pagburos nako”, the client verbalized. The right

and left upper extremity was normal since resistance was noted. Her muscle tone

is normal. The client both hand can flex, extend and hyperextend her elbow.

Circulation

The client has no history of hypertension and diabetes in the family, but

the side of the mother has the history of asthma. During on her pregnancy there

is no any change on her body part. She did not experience everything on her

pregnancy stage. “wala man ko kaagi og ingana sukad sa una katong pag-anak

sa akong 1st baby” the client verbalized. During her pregnancy her BP upon lying

down is 110/80 mmHg, while in sitting is 110/70mmHg, her pulse pressure was
regular with a rate of 68 bpm, no auscultatory gap was noted. Her Heart Rate -78

cpm with regular rhythm and Temperature- 36.8 degree Celsius. The color was

uniform. Her capillary refill on both fingernails of hands replenish at 1-2 seconds

with no nail abnormalities. She has no edema and varicosities in the ankle down

to the feet. Hair was thin, slightly dry and evenly distributed. Her lips are slightly

dark brown “lagom” because she uses cigarettes last year. Nail beds were

normal and pale pink in color. Conjunctiva and sclera were pinkish.

Ego Integrity

Her way on handling it is though when watching television and talking with

the neighbor. She has no financial problem so far. She is living with his husband.

Her religion was Roman Catholic. She was cooperative during assessment.

Elimination

The client moves her bowel twice a day. She doesn’t use any laxative. Her

stool is brown and well formed. She is not experienced any diarrhea and

constipation. Her urine is pale yellow. They have no history of kidney or bladder

disease.

Food/fluids

The client usual diet includes vegetable, bread and meat. She did not take

any vitamins and food supplement. She takes only 3 meals daily. She has no

food allergy and doesn’t experience any heartburn. No problem of swallowing

and no presence of dentures. Her usually weight is 55 kg. But now during her

pregnancy her weight is increased. Her weight is 60 kg. Her height is 5’2” and in

regular build. She has normal skin turgor and moist mucous membrane. Her

tongue color is pink.

Hygiene

She can perform activity of daily living independent. She has personal

bath any time in the morning. She doesn’t use any prosthesis device. She

prepared neat and clean with appropriate dress. No body odor was noted and

scalp is normal no flakes of dandruff and no lice on her head.

Neurosensory

She doesn’t experience any headache on her pregnancy. She also

doesn’t experience vision loss, hear loss. She was oriented to time, place,

person and situation as verbalizes “ako si Eva og nagpuyo sa brgy. Nazareth”.

She is alert and cooperative. She can remember recent and remote memory.

Pain and discomfort

The client doesn’t feel any pain and discomfort as she said.

Respiration

The client is not experience dypnea and cough. Their family has history of

asthma, but she has no history of that. She smoke 3 packs per day but now
when she got pregnant she stop smoking for seek of her baby. Respiratory Rate

is 19 bpm. Her nails have normal angle of 160.

Safety

The client has no allergies. She has no STD or no history of any disease.

She doesn’t experience blood transfusion. She admits because of vomiting and

diarrhea, last April 2007 when she was not pregnant. She has done on his

chickenpox when she was still young. Her temperature is normal in 36.6 degree

Celsius. She has moist and smooth skin integrity.

Sexuality

The client has no sexual concern at that moment. Her menarche started

age of 12 with 30 days of cycle. It usually lasts 4 to 5 days. The first day of her

last menstrual period was May 5, 2007. She estimated date of delivery is on

January 28, 2008, she did not use contraception like IUD. The client was use

withdrawn to discuss sexual and intimate matters.

Social Interactions

The client has engaged in an 15 years relationship with the first father of

her 1st and 2nd child and she engaged again in an 1 year relationship with the

second father of her 3rd child. On her first husband they are already separated.

She is not married to his second husband in almost 1 year. They support on their

own financial. Her 1st and 2nd child is living with her together with the second
husband. Client’s can speak clear and they are friendly with their neighbor. She

doesn’t use any speech. She is living with her husband.

Teaching/Learning

The client spoke visaya as dominant language. She still undergraduate in

grade school, she did not finish on her study because of financial problem and

she got married immediately.

B. Intrapartum Assessment

Mrs. Eva Liona is a 38 years old was born on December 6, 1970.She is a

Filipino Roman Catholic. She did not expect any date on her delivery. However

she gave birth on January 20, 2008.

Unfortunately I wasn’t able to witness the most important and memorable

moment of my OB patient Mrs. Eva Liona delivered health baby boy at their

house. She delivered the baby at 3:30 pm in the afternoon.

C. Postpartum

Mrs. Eva Liona is a 38 years old. She is a Filipino Roman Catholic. She

did not expect any date on her delivery. Source of information came form the

patient herself with the rate of 4 for reliability. Date of assessment January 27,

2008 in the morning. She did not expect any date on her delivery.
Activity/Rest

Mrs. Eva is a plan housewife. She stays at home to work the daily house

chores and take good care of their children. Her hobbies include talking with the

neighbor, watching television and sometime if she is tried she sleep for a while.

She usually sleeps on 7-8 hours and naps when the baby sleeps as well. She

does not experience excessive grogginess. She was alert and coherent. The

right and left upper extremities was normal since resistance was noted. Her

strength on both hands is good and fine.

Circulation

The client has no history of hypertension and diabetes in the family,

neither in father side nor mother side. During on her pregnancy there is no

change on her body parts and also after giving birth to the 3rd child. During her

pregnancy her BP upon lying down is 120/80 mmHg, while in sitting is

110/80mmHg, her pulse pressure was regular with a rate of 66 bpm, no

auscultatory gap was noted. Her Heart Rate -76 cpm with regular rhythm and

Temperature- 36.5 degree Celsius. The color was uniform. Her capillary refill on

both fingernails of hands replenish at 1-2 seconds with no nail abnormalities. She

has no edema and varicosities in the ankle down to the feet. Hair was thin,

slightly dry and evenly distributed. Her lips are slightly dark brown “lagom”

because she uses cigarettes last year. Nail beds were normal and pale pink in

color. Conjunctiva and sclera were pinkish.

Ego Integrity

Her way on handling it is though when watching television and talking with

the neighbor. She has no financial problem so far. She is living with his husband.

Her religion was Roman Catholic. She was cooperative during assessment.

Elimination

The client moves her bowel twice a day. She doesn’t use any laxative. Her

stool is brown and well formed. She is not experienced any diarrhea and

constipation. Her urine is pale yellow. They have no history of kidney or bladder

disease.

III. Physiology of Labor

A. Theories of Labor

The exact mechanism that initiates labor is unknown. However, a lot of

theories have been formulated to give us the idea on how it possibly happens.

The theories include:

1. Uterine Stretch Theory

The uterus becomes stretched and pressure increases, causing

physiologic changes that initiate labor. It is said that any hollow viscose tends to

contract and empty itself when distended to a certain point.

2. Oxytocin Theory
 As pregnancy progresses, there is a gradual rise in the amount of

circulating oxytocin which increases the sensitivity of the myometrium causing

contractions.

3. Progesterone Deprivation Theory

As pregnancy advances, progesterone is less effective in

controlling rhythmic uterine contractions that normally occur. In addition, there

are also decreases in the amount of circulating progesterone.

4. Fetal Adrenal Theory

In the later pregnancy, these produces increase levels of cortisols

that inhibit progesterone production from the placenta.

5. Prostaglandin Theory

As pregnancy advances, there is increased production of

prostaglandins by fetal membranes and uterine deciduas.

B. Preliminary Signs of Labor

Lightening

It is also known as descent of the fetal presenting part into the pelvis. It

gives the woman relief from diaphragmatic pressure and shortness of breath she

has been experiencing and thus lightens her load.

Increase in Level of Activity

 A woman may wake on the morning of labor full of energy in contrast to

her feelings during the previous month. This increase in activity is due to an

increase in epinephrine release that is initiated by a decrease in progesterone

produced by the placenta. Additional epinephrine prepares the woman¡¦s body

for the work of labor ahead.

Braxton Hicks Contractions

In the last week or days before labor begins, the woman usually notices

extremely strong Braxton Hicks contractions, which may interpret as true labor

contractions, slightly different from false contractions.

False Contractions True Contractions

Begin and remain irregular Begin irregularly but become regular

and predictable
Felt first abdominally and remain Felt first in lower back and sweep

confined to the abdomen and groin around to the abdomen in a wave

Often disappear with ambulation and Continue no matter what the woman¡¦s

sleep level of activity

Do not increase in duration, frequency, Increase in duration, frequency, and

or intensity intensity
Do not achieve cervical dilatation Achieve cervical dilatation

Ripening of the Cervix

It is an internal sign seen only on pelvic examination. Throughout

pregnancy, the cervix feels softer than normal like the consistency of an earlobe

(Goodell’s sign). At term, the cervix becomes still softer and can be described as
“butter soft”, and it tips forward. Ripening is an internal announcement that labor

is close at hand.

Signs of true labor involve uterine and cervical changes. The more women

know about true labor sings, the better because then they will be better able to

recognize them. This is helpful both in preventing preterm birth and being able to

feel secure during labor. The following are namely the uterine contractions, show

or bloody show, and the rupture of membrane.

C. Stage of Labor

There are three stages of labor. The first stage occurs from the time true

labor begins until the cervix is completely dilated and effaced. During the second

stage is the baby is delivered. The third stages follow the birth of the baby

through the birth of the placenta.

First stage

The first stage of the labor is the longest. There are three phases within

the first stage:

. Early or Latent Phase

. Active Phase

. Transition Phase

Latent Phase

‘It begins at the onset of regularly perceived uterine contractions and ends

when rapid cervical dilatation begins. Contractions during this phase are mild and

short, lasting to 20 to 40 seconds. Cervical effacement occurs, and the cervix

dilatves from 0 to 3 cm. The phase lasts approximately 6 hours in nullipara and

4.5 hours in multipara.

Active Phase

It characterized by cervical dilatation occurring rapidly, going from 4 cm to

7 cm. Contractions are stronger, lasting to 40 to 60 seconds and occurring

approximately every 3 to 5 minutes. This phase lasts approximately 3 hours in

nullipara and 2 hours in multipara.

Tryansition Phase

It occurs when maximum dilatation of 8 cm to 10 cm took place. Usually,

contractions reach their peak of intensity, occurring every 2 to 3 minutes with

mduration of 60 to 90 seconds. Dilatation continues at a rapid rate. If the

membranes have not previously ruptured or been ruptured by amniotomy, they

will rupture as a rule at full dilatation which is 10 cm.

Second Stage

During the second stage the baby is born. This stage of labor it contract

from 1 to up to 2 hours. The baby’s head stretch the mother’s vagina and

perineum. This may cause a burning sensation. Some women may feel as if they

have a bowel movement, and feel the urge to push or bear down. The physician

doctor or the midwife will tell you if it is the time to push. It is important during the

delivery. “Crowing” occurs as the widest part of the head appears at the vaginal
opening. The secretion must be out to the baby’s mouth and nose by using the

bulb syringe. The baby will take his/her first breath, and begin to cry. The baby I

still connecting to the placenta by the umbilical cord and Give immediately new

born care. The cord is clamped and cut.

Third Stage

Also known as placental stage refers or begins from the time the infant is

born until the delivery of the placenta. Two separate phases are involved namely

the placental separation, and placental expulsion.

Placental separation occurs automatically as the uterus resumes

contractions. Active bleeding on the maternal surface of the placenta begins with

separation. As separated is complete, the placenta sinks to lower uterine

segment or at the upper vagina. These are the following signs that the placenta

loosened and is ready to deliver namely lengthening of the umbilical cord,

sudden gush of vaginal blood, and change in the shape of the uterus.

Placental expulsion is the phase of third phase. After separation of the

placenta, it is delivered either by the natural bearing down effort of the mother or

by gentle pressure on the contracted uterine fundus by the physician or nurse

midwife (Crede’s maneuver). Pressure must never be applied to a uterus in a

noncontracted state or the uterus may invert and hemorrhage a grave

complication of birth where maternal blood sinuses are open and gross

hemorrhage occurs.
D. Mechanism of Labor

There are five classical steps in the normal mechanism of labor. They are:

. Engagement

. Descent

. Flexion

. Internal Rotation

. Extension

. External Rotation

. Expulsion

Passage of the fetus through the birth canal involves a number of different

position changes to keep the smallest diameter of the fetal head always

presenting to the smallest diameter of the birth canal. These position changes

are termed the cardinal movements of labor namely engagement, descent,

flexion, internal rotation, extension, external rotation, and expulsion.

• Engagement - is when the biparietal diameter of the pelvic inlet, the head is

said to be engaged in the pelvic inlet. In most nulliparous women this occurs

before the onset of active labor because the firmer abdominal muscles direct

the presenting part into the pelvis. In multiparous woman with more relaxed

musculature, the head often remains freely movable above the pelvic brim

(floating) until labor is established. In the majority of cases the sagittal suture

transverse to the pelvic inlet.

• Descent - is the downward movement of the biparietal diameter of the fetal

head to within the pelvic inlet. Full descent occurs when the fetal head

extrudes beyond the dilated cervix and touches the posterior vaginal floor.

The pressure of the fetus on the sacral nerves causes the mother to

experience a pushing sensation. Descent occurs because of pressure of the

fetus by the uterine fundus. Full descent may be aided by abdominal muscle

contraction.

• Flexion – while descending through the pelvis, the fetal head flexes so that

the fetal chin is touching thue fetal chest. This functionally creates a smaller

structure to pass through the maternal pelvis. When the flexion occurs, the

occipital (posterior) fontanel slides into the center of the birth canal and the

anterior fontanel becomes more remote and difficult o feel. The fetal position

remains occiput transverse.

• Internal rotation - during descent, the head enters the pelvis with the fetal

anteroposteior head diameter in a diagonal or transverse position. The head

flexes as it touches the pelvic floor, and the occiput rotates until it is superior,

or just below the symphysis pubis, bringing the head into the best diameter

for the outlet of the pelvis. This movement brings the shoulder, coming next,

into the optimal position to enter the inlet or puts the widest diameter of the

shoulders in line with the wide transverse diameter of the inlet.

• Extension - as the occiput is born, the back of the neck stops beneath the

pubic arch and acts as a pivot for the rest of the head. The head thus

extends, and the foremost parts of the head, the face and chin, are born.
• External rotation - almost immediately after the head of the infant is born; the

head rotates back to the diagonal or transverse position of the early part of

labor. The after coming shoulders arc thus brought into an anteroposterior

position which is best for entering the outlet. The anterior shoulder is born

first, assisted perhaps by downward flexion of the infant’s head.

• Expulsion - once the shoulders are born, the rest of the baby is born easily

and smoothly because of its smaller size. This is expulsion and is the end of

the pelvic division of labor.

IV. Ideal Nursing Intervention

A. Antepartum

Antepartum is the time when major changes occur in pregnant women’s

body both physically and psychologically. Most women experience ambivalence

during this stage. They became hesitant because as much as they wanted the

baby, they also want to maintain their usual state as non-pregnant women like

having their usual figure and doing the usual things those non-pregnant women

can do since they are convinced that everything will change once the fetus inside

them will start growing.

It is the time when women make certain adjustments to their lifestyle.

Pregnancy for them would mean cessation of night outs, smoking and drinking.

They couldn’t wear skimpy outfits anymore because their tummies would start
increasing in size. This is usually felt by women whose pregnancy is not

planned.

Aside from that the discomforts of pregnancy also add up to the

doubtfulness of the mother. The most common are nausea and vomiting, back

pains, leg cramps, constipation, frequent urination and fatigue.

It is very important that we asses the physical, emotional, psychological

and most importantly the spiritual status of the pregnant woman at this stage so

we can identify the problems that are most likely to occur and give appropriate

interventions to these as early as possible. Health and nutrition education is also

a must for it helps encourage women to do the best they can to protect their

health as well as of their babies.

Listed are the discomforts that the pregnant women normally experience

and their interventions.

FIRST TRIMESTER

1. Nausea, vomiting and heart burn

Encourage the women to eat low-fat protein foods and dry

carbohydrates, such as toast and crackers. Encourage the women to

eat small, frequent meals. Instruct the woman to avoid brushing her

teeth after eating. Instruct the woman to get out of bed slowly.

Encourage the woman to drink soups and liquids between meals to

avoid stomach distention. Tell the woman to limit the use of caffeine.

Inform the woman that alcohol should be limited or eliminated during

 pregnancy; no safe level of intake has been established. Inform the

woman that smoking should be eliminated or severely reduced during

pregnancy risk of spontaneous abortion, fetal death, low birth weight

and neonatal death increases with the increased levels of maternal

smoking.

2. Fatigue

Have adequate rest and sleep (8 hours average). Avoid prolonged

standing. Don’t take caffeine. Maintain proper body mechanics.

3. Varicose veins

Avoid prolonged standing. Wear supporting hose. Frequently elevate

of legs. Regular exercise

4. Urinary frequency/UTI

Instruct the woman to limit fluid intake in the evening. Instruct the

woman to void before going to bed. Encourage the woman to void

when she feels the urge.

5. Breast Tenderness

Encourage the woman to wear a bra with a wide shoulder strap for

support and to dress to avoid cold drafts. Calamine lotion may be

soothing

SECOND TRIMESTER

1. Backache
 Maintain good posture. Pelvic rocking exercise, tailor sitting and back

rub or back massage. Rest at back and wears flat shoes.

2. Pedal Edema

Assume a left lateral position frequently to promote venous return.

Avoid prolonged standing. Frequently elevate of legs and hips. Eat

high protein foods

3. Dyspnea

Sitting upright, allowing the weight of the uterus to fall away from the

diaphragm. Require two or more pillows to sleep at night

And generally, prenatal is always advised to the client, it plays very

important to check and monitor the health of the mother and to the baby

as well. And also to determine early signs and symptoms of any

abnormalities that might possibly occur during pregnancy.

THIRD TRIMESTER

1. Upon admission

Check vital signs, temperature, pulse, respirations, and blood

pressure. Check fetal heart rate. Give prep (perinea shave) and

enema. See that appropriate forms are completed. Encourage client to

void and check for sugar and acetone.

2. Dilatation
Asses contractions: mild, well-established, 5-15 minutes apart, lasting

30 to 45 seconds or intense close together. Evaluate cervix thinning.

Observe presence or increase in bloody show. Check situation:

anywhere from -2 to +1 inmultipara and toe. Check membranes: intact

of ruptured. Maintain bed rest if membranes have ruptured. Auscultate

fetal heart rate every 15 minutes and check blood pressure every 30

minutes or p.r.n. Give periodic vaginal examination to determine

progress. Observe for ruptured membranes and take fetal heart rate

immediately if membranes rupture. Encourage the presence of

husband’s presence of client’s husband significant other person.

Provide support based upon mother’s knowledge of the labor process.

Reinforced breathing techniques if client has had no classes. As the

contractions begins, have the client focused her attention on your face.

The client takes a relaxing sigh. She breathes in and out through her

nose and mouth at a rate of about 20 to 30 breathes per minute. You

might “conduct” breathing with rhythmic hand signals to help her

perceive herself. The contraction ends. The clients take another big

sigh. Don’t strain. Let go and flow with the contraction. Relax the pelvic

floor throughout second stage. Don’t tense the muscle when you feel

rectal pressure, the vaginal stretching. Relax all sphincters and the

mouth, too with your lips and jaws parted. Always take one or two deep

breaths to refuse at the start and the end of the contraction. Exhale

slowly as you bear down. Push slowly as long and hard as you feel the
 urge to do so. Avoid prolonged pushes, which affects your breathing,

circulation, and also the baby’s heart rate. Check vital signs:

temperature, pulse respirations, and blood pressure. Check fetal heart

rate. Give prep (perinea shave) and enema. Encourage client to void

and check for sugar acetone.

B. Intrapartum

Intrapartum is the time when the pregnant women area in their active

phase of labor. They usually have mixed emotion felt during this stage:

happiness, excitement, tear and most of all pain.

Pregnant women tent to be happy because finally, they will be free from

the burden of the heavy weight that they have been carrying for the past nine

months; excited to see their offspring and know if it’s a male or a female

especially for those who have not undergone ultrasound check-up; fear specially

for some pregnant women who doesn’t know yet how it is going to be during the

progress of labor and what will be done to them in case complications arise and

lastly pain. It cannot be denied that pregnancy and delivery entail pain, intense

pain to be exact.

It is necessary that proper education and thorough explanation be given to

the client for her to understand the whole process of delivery. Strategies in

lessening the problems and discomfort felt during this stage must also be

demonstrated as earlier as possible to make the woman active during labor and

delivery.
As the contraction begins; have the woman focus her attention on your face.

The woman takes a big relaxing sigh. She breathes in and out through her

nose or mouth at a rate of about 20 to 30 breaths per minute. You might

“conduct” her breathing with her rhythmic hand signals to help her perceive

herself. The contraction ends. The woman takes another big sigh. Reinforced

proper bearing-down techniques or teach bearing-down techniques if the

patient has no classes. Don’t strain. Let go and flow with the contraction.

Relax the pelvic floor throughout second stage. Don’t tense the muscle when

you feel rectal pressure, the vaginal stretching. Relax all sphincters and the

mouth, too with your lips and jaws parted. Direct to push low down and in

front-increase the pressure in your abdomen, not in your face. Don’t strain so

that you screw your eyes- you might miss the moment of birth. Always take

one or two deep breaths to refuse at the start and the end of the contraction.

Exhale slowly as you bear down. Push slowly as long and hard as you feel

the urge to do so. Avoid prolonged pushes, which affects your breathing,

circulation, and also the baby’s heart rate. Check contractions every 2 -3

minutes; contractions last 60 to 90 seconds. Transfer client carefully bed to

delivery table and place in lithotomy position. Gently raise both legs

simultaneously into stirrups and drape client. Provide client with handles to

pull on as she pushes. Cleanse vulva and perineum, using sterile technique,

commonly referred. Auscultate fetal heart tone every 5 minutes or after each

push; transient fetal bradychardia not usual due to head compression. Check

blood pressure and pulse every 15 minutes p.r.n. Encourage mother of keep
 her informed of advancement baby. Encourage mother to take a deep breath

before beginning to push with each contraction and to sustain push as long as

possible; long pushes are preferable to frequent short pushes.

C. Postpartum

Just like the previous stages, the post partum stage also entails

discomforts and problems that concern the mother. It is the most implicated

stage for women because it is when depression is most likely to develop.

Depression, if not handled properly, could result to serious psychological and

mental disorders.

As what was stated earlier, the post partum period is most likely when the

mothers become depressed. This is called post partum depression. They tend

to think negative things like their husbands will not like them anymore after

they’ve given birth and that they were just meant to bear and deliver a child

especially that at this moment, the attention of everyone is already diverted to the

neonate. This is commonly accompanied by crying for unknown reasons.

During this stage, mothers should also be taught on ways that could help

her regain her pre pregnancy figure. That is through exercise and appropriate

diet. Family members, most importantly the husband must also be taught how to

comfort the mother. They must be informed about this stage of labor and how

important it is for them to show concern to the woman who have just given birth.

With this the mother will be aware how she means a lot to them and would be

very willing to play her role once again as a wife, a mother and a woman.
 Check for gall bladder distention. Maintain intake and output first 24 hours or

until voiding is sufficient. Palpate fundus every 15 minutes and p.r.n. Massage

fundus gently if not firm, periodic relaxation is uncommon. Check

temperature, pulse, respiration and blood pressure every 15 minutes.

Encourage voiding and measure amounts. Check lochia for color consistency

and amount. Inspect perineum and for signs of bleeding, unusual redness or

swelling. Weigh perineal pads if unusual bleeding occurs. Apply icepack to

perineum if ordered. Provide warm blanket if mother is alerting (excessive

amount of fluids may cause nausea). Change mother’s gown, (gown worn

during labor is soiled and wet from perspiration). Allow mother to rest. Provide

medications for pain as ordered and needed.

V. Actual Nursing Intervention

A. Prenatal Assessment

Explain to the mother that it is normal for pregnant woman who are in the

later part of pregnancy to experience sleep disturbances because of frequent

fetal movement. It is natural that the baby will move in the mother’s womb. Tell

the mother to drink milk before going to sleep. The baby will also get more

nutrients during in the mother’s womb. Tell the mother to take a warm shower

before going to bed and to have adequate sleep.

B. Postpartum Assessment
 Encourage adequate intake of fluids (maximum intake of 2000 ml/day).

Direct to prevent the perineal discomfort to the mother. Encourage diet high in

fiber and roughage. They much eat more fiber to replace their energy after

delivery. Encourage early ambulation. Breastfeed immediately the infant after

delivery.

VI. Referral and Evaluation

 Trying to figure out if you are in the early stages of labor, or real labor can

be confusing. Some women experience something often called false labor,

meaning that it is unlikely that you will be having the baby rapidly. Labor and birth

is the culmination of pregnancy, but the beginning of parenting. Labor and birth

can be a very exciting time in your life. It is definitely one of the most memorable.

In line with this some factors are needed to be taught not only to the

woman on labor but to her partner as well. Coping with psychological and

physical factors may include on this part. It is during this time that a woman

needs support to somehow lessen the pain and the anxiety.

My patient is a mother of 3 already. When it comes to experiences on how

to care for and rear a child is not anymore a question. However, there are still

things that need to direct the mother like the proper ways of coping stress

because being pregnant is not easy. Thus, it needs a lot of perseverance and

hard work.

VII. Bibliography
 1. Pillitteri, Adele (2007). Maternal and Child Health Nursing (5th edition).

Philadelphia , J.B. Lippincott.

2. www.yahoo.com

3. www.google.com

VIII. Appendix