Lourdes College

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.

V.

Ideal Nursing Interventions •

Antepartum……………………………………………………………..

•

Intrapartum……………………………………………………………..

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Postpartum……………………………………………………………..

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: RR19 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 Begin and remain irregular Felt

first

abdominally

and

True Contractions Begin irregularly but become regular and predictable 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 Do not achieve cervical dilatation

intensity 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.

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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.

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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.

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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.

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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.

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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.

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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