INTRODUCTION

A Normal spontaneous delivery (NSD) occurs when a pregnant woman goes into labor
without use of drugs or techniques to induce labor, and delivers her baby in the normal
manner, without a cesarean section.

There are three stages of normal human birth these are First stage, second stage and third
stage. The first stage of labor starts classically when the effaced cervix is 3 cm dilated.
The second stage begins when the cervix is fully dilated, and ends when the baby is
finally delivered. In the third stage, the uterus expels the placenta (afterbirth). Maternal
blood loss is limited by the compression of the spiral arteries of the uterus as they pass
though the lattice-like uterine muscles of the upper segment. Normal blood loss is less
than 600 mL. The placenta is usually delivered within 15 minutes of the baby being born.

DEMOGRAPHIC DATA:

Name: Roselyn S. Cal

Age : 19 year old
B-date: July 24, 1988
Gender: female.
Religion: Roman Catholic
Address: San Isidro Angono, Rizal.

MEDICAL HISTORY

This was her first hospitalization.

OBSTETRICAL HISTORY

Roselyn Cal has two lived children. The first baby reach the term, the 2nd baby is
preterm. Gravida 2 Para 2 ( 1102 ).

PRESENT ILLNESS

None

PAST ILLNESS

The client encountered upper respiratory tract infection, chicken pox,

Conjunctivitis and Urinary tract infection.
ANATOMY AND PHYSIOLOGY

Uterine involution is when the uterus decrease in size at a predictable rate

during the postpartal period. After 10 days, it recedes under the pubic bone and is no
longer palpable.

Breastfeeding causes the release of prolactin and oxytocin. Oxytocin is a hormone that
causes uterine contractions. The release of oxytocin while breastfeeding speeds uterine
involution. This may also cause cramps while breastfeeding in the postpartum period.

Involution of the uterus involves two main process. First, the area where the placenta was
implanted is sealed off to prevent bleeding. Second, the organ is reduced to its
approximate pregestational size.

The uterus of breast-feeding mother may contract even more quickly, because oxytocin,
which is released with breast-feeding, stimulates uterine contractions.

DRUG STUDY

Name of Drugs Action of Contraindication Nursing

medicine consideration

Cefalexin • Inhibits • Allergy to

bacterial penicillins and • Assess
• Drozid cell wall cephalosporins patient’s
500mg synthesis previous
TID . sensitivity
7 days • Antibioti reaction to
c penicillin or
other
cephalospori
ns

• Assess
patient for
any sign of
infection

Mefenamic Acid • Aspirin- • Pregnancy and • GI

like drug lactation. discomfort,
• Dolfenal that has given after
 500mg/cap analgesic meal.
Q6 for 7 days , • diarrhea or
antipyret constipation,
ic and gas pain,
anti- nausea,
inflamm vomiting.
atory • Assess
activities patient’s
. pain before
therapy.

Methylergonometrin • Act • Pregnancy ast • Abdominal

e maleate directly and 2nd stage of pain
at the labor • Hypertentio
• Methergin uterine • Patient with n, headache
Mg smooth Preeclampsia • Assess and
TID or QID muscles and eclampsia document
1 week to fundasl tone
stimulate • Monitor
contracti vital signs
on.
• Monitor
prolactin
levels and
assess for
decrease
breast milk
production.
• For post
partum,
bleeding
report
frequency.

Ferrous Sulfate • Provides • Hypersensitivit • Nausea

elementa y to any • Vomiting
l iron. ingredient. • Diarrhea
• Essential Hemosiderosis, • Obtain
compone hemolytic baseline
nt in anemia. assessment
formatio of iron
n of deficiency
hemoglo before
bin in starting
red blood therapy
cell • Evaluate
develop hemoglobin,
ment. hematocrit
LABORATORY RESULTS
Hemoglobin 14%

Hematocrit 42%
WBC 13.05
Neutrophils 84%
Lymphocytes 16%
ABO type B
Rh blood type Positive

The Normal values of hemoglobin for female is 12 -14 g/100ml, for hematocrit it should
be at the range of 36% - 47% with the average of 40%. Neutrophils should be within the
range of 54% - 57% and for lymphocytes it should be 25% - 40%.

All pregnant women are tested for the Rh factor during the early weeks of pregnancy. A
mother and fetus may have incompatible blood types, the most common is Rh
incompatibility. Rh incompatibility occurs when the mother's blood is Rh-negative and
the father's blood is Rh-positive and the fetus' blood is Rh-positive. The mother may
produce antibodies against the Rh-positive fetus which may lead to anemia in the fetus.
Incompatibility problems are monitored and appropriate medical treatment is available to
prevent the formation of Rh antibodies during pregnancy.

DISCHARGE PLAN

M – MEDICATION

• Cefalexin

• Mefenamic Acid

• Methylergonometrine maleate

Instruct patient about the way of taking her medicines. Explain the proper
measurement and time of intake. E.g. 500 mg of Cefalexin should be taken for 1
week three times a day. 500mg/cap of mefenamic acid should be taken for one
week every six hours and methergin three times a day or four times a day for three
to 1 week.

E - EXERCISE

Encourage the patient to do some exercise every morning such as a simple

walking.

T – TREATMENT

Advice client not to engage in any house chores that might jeopardize her health.

H – HEALTH TEACHINGS
 Encourage and explain the importance of breast feeding to the client.
breastfeeding especially the first milk, colostrum, can reduce postpartum
bleeding/hemorrhage in the mother, and to pass immunities and other benefits to
the baby. Advice client to let her child expose to mild sunlight in order to balance
and avoid excess bilirubin in the blood.

O – OUT PATIENT

D – DIET

Advice client to eat proper diet. Encourage her to eat more vegetables and
frequent intake of liquids. Advise her to eat food which are rich in protein, iron
and vitamin C. Protein helps to repair body tissues, iron provides formation of
Red blood cells and ascorbic acid for helping absorption of iron.

S – SPIRITUAL

Many cultures feature initiation rites for newborns, such as naming ceremonies,
baptism, and others.

Explain to her that in Christianity, baptism is the sacramental act of cleansing in

water that admits one as a full member of the Church. Most Christians, such as
Roman Catholics, Eastern Orthodox, Lutherans, Anglicans, and Methodists are
baptized as infants. Tell them the imporatnce of this sacrament and also try to
emphasize to them the significance of accepting God to our lives. Tell them that if
they are in the midst of problem don’t hesitate to ask help to our Lord.

COARSE IN THE WARD

The doctors ordered:

• DAT when full awake

• IVF to consume
• Keep Uterus Contract
• Med 10 – 15 gtts/min

The doctor ordered DAT diet for patient because the patient is
conscious and in order for the patient to cope up at once for the speed
recovery
SIENA COLLEGE

CASE STUDY

IN

OB WARD

SUBMITTED BY:

CHARLES A. FLORENDO
BSN – 3B

SUBMITTED TO: Ms.

MILDRED GLINOGA R.N., MAN