I.

INTRODUCTION

Woman is first and foremost a person and, when she bears a child, a mother. Many societies
define her through her fertility and her body is adapted for this, by its shape and function.

From a biologic point of view, pregnancy and labor represent the highest function of the female
reproductive system and should be considered a normal process. Indeed, pregnancy is but a normal
physiological process. Nevertheless, medical supervision and care during pregnancy are essential to the
health and well-being of the mother and her infant throughout this period.

The wonders of motherhood start at the realization of having to give birth to a new life. In
anticipation, the mother prepares herself and does everything she can, to ensure her baby’s health. The
future health of the mother, as well as the foundation for the health, the growth and development of her
baby are dependent upon adequate maternal care especially, that of the antepartal period. The goal of
maternal care is a healthy pregnancy with a physically safe and emotionally satisfying outcome for both
the mother and infant. Thereby, the doctor, the nurse, and all the members of the medical team must
assume the responsibility for the welfare of the family throughout the maternity cycle. The nurse, by
means of her contacts with maternity patients in home, clinic and in the hospital, is able to appreciate the
social, economic and emotional factors which influence the nursing needs of each individual patient and
thus, plan for care accordingly.

Pregnancy is a time of adaptation and change, not only physically, but also psychologically, as
the woman and her partner prepare for parenthood. The body also must adapt and accommodate the
needs of the growing fetus.

While adapting to rapid changes in physiology, the pregnant woman must also come to grips with
her new role as parent. No matter how many children the woman have, each new pregnancy brings with
it a role change. Adjusting to the role of parenting is a process that occurs throughout the pregnancy and
beyond.

How a woman adjusts to her role as parent is influenced by many factors. Societal expectations
and cultural values may dictate the way a woman responds to pregnancy and the idea of parenthood.
Family influences are usually very strong. The way the woman was raised and the values of her family
affects the way a woman adapts to pregnancy. Her own personality and ability to adapt to change will
influence her response. Even her past experiences with pregnancy have an effect on the way she deals
with the current pregnancy.

Social support is critical during pregnancy. If the woman is in along-term relationship and feels
supported, she is much better prepared in handling the demands of pregnancy than the woman who feels
alone, isolated and without support. If the woman does not have a supportive partner, it is important for
her to identify someone with whom she can share the experience of pregnancy with. Often this will be a
female friend, or perhaps the woman’s own mother.

This study is conducted to Mrs. F.M.L, a resident of Lutopan Toledo City. She gave birth to a
healthy baby girl last August 25, 2009 via normal spontaneous vaginal delivery. Labor is a physiologic
process during which the products of conception (ie, the fetus, membranes, umbilical cord, and placenta)
are expelled outside of the uterus. Labor is achieved with changes in the biochemical connective tissue
and with gradual effacement and dilatation of the uterine cervix as a result of rhythmic uterine
contractions of sufficient frequency, intensity, and duration. Labor is a clinical diagnosis. The onset of
1
labor is defined as regular, painful uterine contractions resulting in progressive cervical effacement and
dilatation.
Normal Spontaneous Vaginal Delivery (NSVD) is a process which involves the different stages
and mechanisms of labor. Labor is categorized into four stages, and the first stage is divided further into
three phases:

First stage: dilation, the onset of true labor and ends with full dilation of the cervix at 10 cm.
This stage is subdivided into three phases: latent, active and transition. Latent phase begins when the
contractions of true labor start and ends when the cervix is dilated 4 cm. Active phase, begins at 4 cm
cervical dilation and ends when the cervix is dilated at 7 cm. Transition phase, is considered to be the
most difficult part of labor. This phase starts when the cervix is dilated 8 cm and ends with full cervical
dilation.

Second stage: birth, begins when the cervix is dilated fully and ends with the birth of the infant.
The woman is encouraged to use her abdominal muscles to bear down during contraction while the fetus
continues to descend and rotate to the anterior position. When the fetus is at a station of +4, she proceeds
to move through the cardinal movements of extension and external rotation, followed by delivery of the
shoulders and expulsion of the rest of the body.

Third stage: delivery of placenta, begins with the birth of the baby and ends with the delivery of
the placenta.

fourth stage: recovery, wherein the mother is under monitoring because of the tremendous
changes that the mother’s body goes through during the process of labor and delivery, this last 1 to 4
hours.

The ability of the fetus to successfully negotiate the pelvis during labor involves changes in
position of its head during its passage in labor. The mechanism of labor is also known as the cardinal
movements. Although labor and delivery occurs in a continuous fashion, the cardinal movements are
described as 7 discrete sequences such as engagement, descent, flexion, internal rotation, extension,
restitution and external rotation and expulsion.

2
 II. GENERAL DATA

Patients Name: Mrs. F.M.L

Address: Lutopan, Toledo City

Date of Birth: May 17, 1980

Place of Birth: Lutopan, Toledo City

Age: 29 years old

Sex: Female

Civil Status: Married

Citizenship: Filipino

Religion: Roman Catholic

Case no: 20562

Hospital no. : 20562

Attending Physicain: Dr. Agravante

Admission Date: August 25, 2009

Admission time: 1:25 a.m.

How admitted: Ambulatory

Final Diagnosis: Live preterm female newborn by normal spontaneous vaginal delivery
appropriate for gestational age

3
 III.HISTORY OF PRESENT ILLNESS

A case of Mrs.F.M.L, 29 years. Old, Filipino, Married, Roman Catholic, and from Lutopan
Toledo City, was admitted at Toledo City Hospital on August 25, 2009 due to labor pain.
Three hours prior to admission, Mrs. F.M.L verbalized that she felt there was a sudden gush of
water coming out from her vagina and she experienced pain starting at her lower back then radiates
around her abdomen. Thus, prompted her to go immediately to Toledo City Hospital, for She believed
that she was about to deliver the baby. They proceed directly to the labor room and (IE) Internal
Examination was performed. Upon admission through internal examination, it was noted that the patient
was 5cm dilated and cephalic fetal presentation.
Examination shows that there was a positive sign of labor and was confined due to ruptured bag
of water, with contractions occurring at 4-5 mins,30-40 sec. duration. Patient has no known medical
illness, no allergy on food and medications.

III. PAST HEALTH HISTORY

Menarche at 12 years old, regular monthly cycle, for 5 days duration using 2 pads/day (+)dysmenorrhea.
Had first sexual contact at 22 years old, with husband as a sole partner.(-) dyspareuria, (-) post coital
bleeding, (-) OCP used. Started prenatal check-up at 1 month AOG and regular visit there after to an AP.
Given multivitamins+ Fe= Calcium with good compliance. No menstrual cycle illness noted. Patient is
in good condition, having common childhood illnesses like cough, colds and fever. According to her she
was relieved by taking antipyretic drugs, cough syrups, herbal medicines and by having adequate rest.
She also claimed she experienced chicken pox during her childhood. She was able to manage
chickenpox by taking medication prescribed by the physicians. Completed the immunization; non-
hypertensive, non-diabetic, and non-smoker, non-alcoholic. No known food and drug allergies. No
history of previous hospitalization.

4
 IV. NURSING REVIEW OF SYSTEMS

A. CENTRAL NERVOUS SYSTEM

Patient experienced seldom headache. And whenever she feels it, she will take pain reliever and
take a complete bed rest to relieve such disturbance. She also claimed she had experienced dizziness
during her pregnancy but relieved by taking an adequate rest.

B. EENT (EYES, EARS, NOSE, THROAT)

Patient experienced sore throat but relieved by eating ginger or taking herbal medicine. She
claimed that it was effective on her care. She also claimed that she had seasonal rhinitis especially when
she inhales dust and string odor. She experiences runny nose when there is a change in weather
especially during cold days. No known abnormalities regarding her ears.

C. ENDOCRINE

She claimed that she had not experienced any signs of abnormalities. Neither had she experienced
goiter nor tumor nor some other alterations related to the system involved.

D. GASTROINTESTINAL SYSTEM

The patient experienced thirst and hunger like any other normal person. She had experienced
nausea and vomiting and abdominal pain sometimes, especially during her pregnancy. She also
experienced constipation and diarrhea but relieved by taking laxatives. She also experienced
hyperacidity whenever she can’t take her meals. She claimed to have no allergies in any food and drugs.

E. MUSCULOSKELETAL SYSTEM

She experienced fatigue and muscle pains. She also claimed to had experienced back pain when
she was pregnant but relieved with massage, rest and by taking pain reliever. The patient has a good
body posture when standing and sitting.

F. GENITO-URINARY SYSTEM

Mrs.F.M.L had her menarche at 12 yrs of age at 5 days duration consuming maximum of 2 pads/day at
regular monthly interval. She had experienced dysmenorrhea. She claimed to had experienced
amenorrhea when she suspected that she was pregnant. She also claimed that her micturation is normal,
as far as she can remember and she urinates frequently depending on the amount of liquid she had taken.

5
 VI. FAMILY, PERSONAL, SOCIAL AND ENVIRONMENTAL HISTORY

A. MEMBERS OF IMMEDIATE FAMILY

NAME AGE POSITION OCCUPATION GENERAL

IN THE HEALTH
FAMILY STATUS

Mr. G. L 34 Husband Livestock Buyer Healthy

Mrs.
F.M.L 29 Wife none Healthy
Ms.
G.M.M.L 8 daughter none Healthy
B. PERSONAL AND SOCIAL HISTORY
1. ROUTINES OF DAILY LIVING
Mrs.F.M.L wakes up at about 5 in the morning to prepare breakfast for her husband and to send
her daughter to school. She then cleans the house in a way that she can tolerate, not heavy works, it
serves as her exercise. She usually sleeps at 10:00 in the evening.

2. PERSONAL HABITS
After preparing her husband’s breakfast, she then do her household chores and immediately takes
a bath, eats breakfast, perform oral hygiene, and pick her daughter from school. Before going to bed at
night, she makes it sure that she is neat, clean and had performed oral hygiene.

3. HABITS AND INTERESTS

Patient loves to watch television, listen to the radio and read newspaper.

4. LANGUAGE
She speaks Visaya, Tagalog and a little English.

5. COMMUNICATION
They don’t have any telephone line as a means of communication. She and her husband have a
cellular phone as their means of communication outside their house.

6. RELIGION
She is a Roman Catholic and attends mass especially on Sundays. She’s not a member of any
catholic organization.

C. ENVIRONMENTAL HISTORY
Her family is presently residing in Lutopan Toledo City. They are living in their own house. It is
a one storey house, has adequate living space and well ventilated. They have appliances such as, radio,
electric fan, cooking stove, sala set and electric iron. They buy mineral water for drinking. Their
electricity is electrically supplied by CEBECO, their storage of water is covered pail and from the well.
their garbage are dispose properly and are collected by garbage truck.

D. HEREDO-FAMILIAL DISEASE
She said that in her mother side they have heredo-familial disease of hypertension and Asthma
on her father side.

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 VII. PHYSICAL ASSESSMENT
The patient Mrs. F.M.L, when assessed was seen lying on bed, conscious, in good condition, talking to
her husband, responsive, she was able to communicate well, coherent, very cooperative especially when
I took her vital signs, ambulatory and febrile with a temperature of 38’C without intravenous fluid.

VITAL SIGNS:
Temperature – 38C
Pulse rate – 80 beats per minute
Respiratory rate – 31 breaths per minute
Blood pressure – 120/60 mmHg

GENERAL APPEARANCE:
Normal body build, clean, neat and no body odor noted.
MENTAL STATUS:
Cooperative and responded appropriately to questions.
HEAD:
-was in normal condition (Normocephalic and symmetrical).
-Hair was evenly distributed, not extremely dry or oily.
-Scalp was smooth without lesions, lumps or masses.

FACE:
-was clean. There was an absence of pimples and other skin abnormalities.
EYES:
-was symmetrical, no lesions, and in good normal vision. Eyebrows were free of scaling; upper
eyelids partially covered the iris, lashes turned outward. Conjunctiva was pinkish in color and free of
any exudates and sclera was white. Eyes were closed symmetrically without tremors. In palpating, it
didn’t produce any exudates or tears. And it blinked normally.
NOSE:
-Symmetrical and straight at midline of the face, no discharges, without swelling and no lesions.
There were hairs and mucosa was red and moist, not tender, no lesions, air moved freely without
obstruction and was breathing normally.
MOUTH:
-Lips was light pink in color, soft moist, symmetry of contour, ability to purse lips, no swelling
noted, not tender, no lesions, tongue pink in color, in central position, smooth lateral margin, no lesions,
moved freely, no tenderness, pink gums, tonsil pink, no discharges, not inflamed and of normal size.
And can swallow painlessly.
NECK:
-Can held her neck erect and at midline. No swelling or masses noted. Can turn head to the side
without pain felt. No lymph nodes palpated. Trachea was symmetrical and in midline position. Pulsation
in the carotid artery was regular.
CARDIOVASCULAR:
Distinct heart sounds, regular rhythm without murmurs.
BREAST:
No tenderness, masses or nodules, breast was not engorged, was able to produce and secrete
breast milk, areola: no tenderness, masses or nodule and discharges, dark brown in color.

UPPER EXTREMITIES:
-Fingers, hands and wrist were straight. Elbows were at the same height and symmetrical in
appearance. Can move painlessly and no lesions or injuries. When the skin was pinch, normal color
returned quickly. Brachial pulses were equal, regular in rate and rhythm.
7
 -Can feel when being touched, can determine temperature, can identify object and numbers
correctly and coordinate movements.
LOWER EXTREMITIES:
-Thighs and legs were straight. No lesions or edema. Muscle was firm.
-Can raise legs freely at a time, can spread legs apart, can bend knees, dorsiflex foot at a time,
can sit up straight and can stand without support, and can maintain balance and execute movements
without pain felt.

VII. DEVELOPMEN
TAL DATA

AGE DEVELOPMENTAL PATIENT

TASK MANIFESTATION

Infancy Developmental task is to Patient claimed that when

Birth to 18 months form a sense of trust versus she was still an infant, she was
Trust vs. Mistrust mistrust. Child learns to be not that active. According to
loved. her mother, she normally
(Pilitteri.Vol.2:788) behaved oftentimes. She was
fond of her pacifier. She was
able to sit by herself at 8
months and learned to walk at
1 yr. Old.

During this stage, the client

Toddler Developmental task is to began bowel & bladder
18 months to3 years form a sense of autonomy training. She was shy with
Autonomy vs. Shame versus shame. Child learns to strangers but according to her
and Doubt be independent and makes mother she always asked
decisions for self. many questions.
(Pilitteri.Vol.2:807)
According to the patient,
Pre-schooler during her pre-school age, she
3 to 5 years Developmental task is to form really, really loves fairy tales.
Initiative vs. Guilt a sense of initiative vs. guilt. She also recalled that she had
It s characterized by vigorous, a bestfriend named “maica.”
intrusive behavior and strong
imagination. In school, the patient often
(Pilitteri.Vol.2:824) participatesd in mind games.
She was not that interested in
School Age physical sports. She learned to
6 to 12 years Developmental task is to swim at age of 11.
Industry vs. Inferiority form a sense of industry
versus inferiority. Child learns
how to do things well. At stage, the patient was really
(Pilitteri.Vol.2:855) socially oriented. She had
many friends and was very
Adolescence Developmental task is to active in school. Menarche
8
 13-19 years form a sense of identity versus was at 12
Identity vs. Role role confusion, adolescent y.o. After that, she had a
confusion learns he or she will be by series of physical changes.
adjusting to a new body She became mature in dealing
image, seeking emancipation with things and began to be
from parents choosing a attracted with opposite sex.
vocation, and determining a
value system.
(Pilitteri.Vol.2:879)

VII. ANATOMY AND PHYSIOLOGY OF THE FEMALE REPRODUCTIVE SYSTEM

PARTS AND FUNCTION OF FEMALE EXTERNAL STRUCTURES:

1. MONS PUBIS – is a pad of adipose tissue located over the symphysis pubis, the pubic bone
joint. It is covered by a triangle of coarse, curly hair. The purpose of the mons pubis is to protect
the junction of the pubic bone.

2. LABIA MINORA – just posterior to the mons pubis spreads 2 hairless fold of connective tissue,
the labia minora. Before menarche these folds are fairly small; by childbearing age they are firm
and full, after menopause they atrophy and again become much smaller. Normally the folds of
the labia minora are pink, the internal surface with skin. The area is abundant with sebaceous
glands so localized cysts may occur here.

3. LABIA MAJORA – are 2 folds of adipose tissue covered by loose connective tissue and
epithelium; they are positioned laterally to the protection for the external genitalia and the distal
urethra and vagina. They are fused anteriorly but separated posteriorly. Trauma to the area such
as occur form childbirth or rape, can lead to extensive edema formation in the area because of the
looseness of the connective tissue bone.

4. VESTIBULE – is the flattened, smooth surface inside the labia. The opening to the bladder
(urethra) and the uterus (vagina) both arise from the vestibule.

5. CLITORIS – is a small (approximately 1-2 cm.) rounded organ of erectile tissue at the forward
junction of the labia minora. A fold of skin, the prepuce, covers it. It is sensitive to touch and
temperature and is the center of sexual arousal and orgasm in the female. Arterial blood supply
for the clitoris is plentiful. When the ischiocavernous muscle surrounding it contracts with sexual
arousal, the venous outflow for the clitoris is blocked, leading to clitoral erection.

6. TWO SKENE’S GLANDS (PARAURETHRAL GLANDS) – are just lateral to the urinary
meatus, one on each side. The ducts open into the urethra.

9
 7. BARTHOLIN’S GALND (VULVOVAGINAL GLANDS) – are located just lateral to the
vaginal opening on both sides. Their ducts open into the distal vagina. Secretions from both these
gland help lubricate the external genitalia during coitus. The alkaline Ph of their secretions helps
to improve sperm survival in the vagina. Both Skene’s and Bartholin’s glands may become
infected and produce a discharge and local pain.

8. FOURCHETTE – the ridge of tissue formed by the posterior joining of two labia minora and
the labia majora. This is the structure that is sometimes cut (episiotomy) during childbirth to
enlarge vaginal opening.

9. PERINEUM – posterior to the fourchette. Because this is muscular area, it is easily stretched
during childbirth to allow enlargement of the vagina and passage of the fetal head. Many
exercises (such as Kegel’s, squatting and tailor sitting) are aimed at making the perineal muscle
more relaxed and more expandable.

10. HYMEN – is a tough but elastic semicircle of tissue that covers the opening to the vagina in
childhood. It is often torn during the first sexual intercourse. However due to the use of tampons
and active sports participation, many girls who have not had sexual relations do not have intact
hymen at the time of their first pelvic examination.

PARTS AND FUNCTIONS OF THE FEMALE INTERNAL STRUCTURES:

1. OVARIES – are approximately 4 cm long by 2 cm in diameter and

approximately 1.5 cm thick or the size and shape of almonds. They are grayish-white and appear
pitted or with minute indentation on the surface. The function of the two ovaries (the female gonads)
is to produce, mature and discharge ova (the egg cells). In the process, the ovaries produce estrogen
and progesterone and initiate and regulate menstrual cycles.

2. FALLOPIAN TUBE - arises from each upper corner of the uterine body
and extends outward and backward until each opens at the distal end next to an ovary. Fallopian tube
is approximately 10 cm in length in a mature woman. Their function is to convey the ovum from the
ovaries to the uterus and to provide a place for fertilization of the ovum by sperm.

3. UTERUS – is a hollow, thick-walled, muscular organ situated deeply in

the pelvic cavity between the bladder and rectum. Into its upper part the uterine tubes open, one on
either side, while below, its cavity communicates with that of the vagina. When the ova are
discharged from the ovaries they are carried to the uterine cavity through the uterine tubes. If an
ovum be fertilized it imbeds itself in the uterine wall and is normally retained in the uterus until
prenatal development is completed, the uterus undergoing changes in size and structure to
accommodate itself to the needs of the growing embryo. After parturition the uterus returns almost to
its former condition, but certain traces of its enlargement remains. It is necessary, therefore, to
describe as the type-form the adult virgin uterus, and then to consider the modifications which are
effected as a result of pregnancy.

4. CERVIX – The cervix is the lower constricted segment of the uterus. It is

somewhat conical in shape, with its truncated apex directed downward and backward, but is slightly
wider in the middle than either above or below. Owing to its relationships, it is less freely movable
than the body, so that the latter may bend on it. The long axis of the cervix is therefore seldom in the
10
 same straight line as the long axis of the body.

CONCEPTUAL FRAMEWORK OF THE PHYSIOLOGY

FERTILIZATION
↓
Fertilization takes place in the Ampulla (outer third) of the uterine tube
↓
Sperm penetrates the membrane surrounding the ovum
↓
Both sperm and the ovum are enclosed within the membrane (ZONA REACTION)
↓
Ovum nucleus becomes female pronucleus: head of the sperm enlarges to become the male pronucleus
and the tail degenerates.
↓
The nuclei fuse and the chromosomes combine restoring the DIPLOID NUMBER (46)
↓
ZYGOTE
↓
Mitotic cellular replication (CLEAVAGE) begins as zygote travels the length of the uterine tube (3-4
days) into the uterus.
↓
Blastomeres are formed with each division
↓
16-cell morula is produced within 3 days and is still surrounded by the protective ZONA PELLUCIDA
↓
Fluid passes though the zona pellucida into the intracellular spaces between the blastomeres, separating
them into 2 parts: 1. TROPHOBLAST (gives rise to the placenta) 2. EMBRYOBLAST (gives rise to the
embryo)
↓
blastocyst cavity is formed within the cell mass
↓
When cavity becomes recognizable, the whole structure of the developing embryo in known as
BLASTOCYST; outer layer of cells surrounding the cavity is the TROPHOBLAST.

IMPLANTATION
Zona Pellucida degenerates, trophoblast attaches to the uterine endometrium
↓
Trophoblast secretes enzymes (6-10 days after conception) that enable it to burrow into the endometrium
until the entire blastocyst is covered.
↓
Endometrial blood vessels erode (IMPLANTATION BLEEDING)
↓
Chorionic villi develop out of the trophoblast and extend into the blood-filled spaces of the
endometrium.
↓
After implantation, the endometrium is termed DECIDUA
1. DECIDUA BASALIS – a portion directly under the blastocyst, where chorionic villi tap maternal
blood vessels.
11
 2. DECIDUA CAPSULARIS – portion covering the blastocyst.
3. DECIDUA VERA – portion lining the rest of the uterus.
DEVELOPMENT OF THE EMBRYO
At the time of implantation, 2 fetal membranes begin to form
↓
Chorion develops from the trophoblast and contains chorionic villi on its surface
↓
Villi burrow into the deciduas basalis
↓
Chorion becomes the covering of the fetal side of the placenta (contains the mahor umbilical blood
vessels that branch out over the surface of the placenta)
↓
AMNION ( inner cell membrane) develops from the interior cells of the blastocyst.
↓
The cavity that develops between the inner cell mass and the outer layer of the cell (trophoblast) is the
AMNIOTIC CAVITY.
↓
The developing embryo drays amnion around itself to form a fluid-filled sac
↓
Amnion becomes the covering of the umbilical cord and covers the chorion on the fetal surface of the
placenta
↓
Amniotic cavity derives its fluid by diffusion from the maternal blood.
Functions of the Amniotic fluid:
1. helps maintain a constant body
temperature.
2. source of oral fluid and as a
repository for waste.
3. cushions the fetus from trauma from
the outside forces.
4. allows freedom of movement for
musculoskeletal development.
5. keeps the embryo form tangling with
the membranes facilitating symmetric
growth of the fetus.
Volume of the amniotic fluid:
1. 800-1,200 ml at term
2. less than 300 ml – oligohydramnios; associated with fetal renal abnormalities
3. more than 2 L – hydramnios; associated with G.I.T and other malformation

Contents of the amniotic fluid:

Albumin, urea, uric acid, creatinine, lecithin, sphingomyelin, bilirubin, fructose, fat, leukocytes,
proteins, enzymes, lanugo, epithelial cells.
At the same time the amniotic cavity and amnion are forming, another blastocyst cavity forms on the
other side of the developing embryonic disk, forming the YOLK SAC.
↓
BLOOD CELLS AND PLASMA is manufactured in the yolk sac (2nd to 3rd week)
↓
Primitive begins to beat and circulate the blood though the embryo, connecting stalk, chorion and yolk

12
 sac (end of 3rd week)
↓
Incorporation of part of the yolk sac into the embryo’s body (4th week) as the PRIMITIVE G.I.T
↓
The CONNECTING STALK forms the umbilical cord (5th week)
Umbilical cord contains:
1. two arteries – carry blood to chorionic villi from embryo
2. one vein – returns blood to embryo
3. diameter – 2 cm at term
4. length – 30-90 cm (average 55 cm)
5. wharton’s jelly – prevents compression of the blood vessels, ensures continued nourishment of
the embryo or fetus
↓
Placenta begins to form at implantation
↓
Chorionic villi grow into the spaces with two layers of cells
1. the outer syncytium (functional layer of the placenta)
2. the inner cytotrophoblast

3rd layer develops into anchoring septa dividing the projecting deciduas into cotyledons in each of the
15-20 cotyledons, the chorionic villi branch out and fetal blood vessels form structures of placenta is
complete by 12th week.
↓
Formation and growing of the fetus (36 weeks)
↓
Delivery

C. DISCUSSION OF THE PHYSIOLOGY

FERTILIZATION: The beginning of pregnancy
Fertilization is the union of the ovum and spermatozoon. Other terms used to describe this
phenomenon are conception, impregnation, or fecundation. Fertilization usually occurs in the outer third
of a fallopian tube, the ampullar potion. Because the functional life of a spermatozoon is about 48 hours,
possibly as long as 72 hours, the total critical time span during which fertilization may occur is about 72
hours ( 48 hours before ovulation plus 24 hours afterward). After ovulation, as the ovum is extruded
from the graafian follicle, it is surrounded by a ring of mucopolysaccharide fluid (the zona pellucida)
and a circle of cells (the corona radiate). These structures increase the bulk of the ovum, facilitating its
migration to the uterus. They probably also serve as protection from injury. The ovum and surrounding
cells are propelled into the near fallopian tube by currents initiated by the fimbriae, the fine, hair-like
structures that line the opening of the fallopian tubes. Peristaltic propel the ovum along the length of the
tube. Usually only one ovum reaches maturity each month. Once released, fertilization must occur fairly
quickly because an ovum is capable of fertilization for only 24 hours (48 hours) at the most). After that
time, it atrophies and becomes non functional. Normally, an ejaculation of semen averages 2.5 mL of
fluid containing 50-200 million spermatozoa per milliliter or an average of 400 million per ejaculation.
At the time of ovulation, there is a reduction in the viscosity (thickness) of cervical mucus, making it
easier for spermatozoa to penetrate it. Sperm transport is so efficient close to ovulation that spermatozoa
deposited in the vagina during intercourse generally reach the cervix within 80 seconds and the outer
end of a fallopian tube within 5 minutes after deposition. This is one reason why douching is not an
effective contraceptive measure.
Spermatozoa move by means of their flagella (tails) and uterine contractions through the cervix

13
and the body of the uterus and into the fallopian tubes toward the waiting ovum. The mechanism
whereby spermatozoa are drawn toward an ovum is probably a species-specific reaction, similar to an
antibody-antigen reaction. Capacitation is a final process that sperm must undergo to be ready for
fertilization. This process, which happens as the sperm move toward the ovum, consists of changes in
the plasma membrane of the sperm head, which reveals the sperm binding receptor sites. All the
spermatozoa that achieve capacitation reach the ovum and cluster around the protective layer or corona
cells. Hyaluronidase ( a proteolytic enzymes) is apparently released by the spermatozoa and acts to
dissolve the later of cell protecting the ovum. Once it penetrates the zona pellucida, the cell membrane
becomes impervious to other spermatozoa. An exception to this is the formation of hydatidiform lole, in
which multiple sperm enter; this leads to abnormal growth.
Immediately after penetration of the ovum, the chromosomal material of the ovum and spermatozoon
and ovum carried 23 chromosomes (22 autosomes and 1 sex chromosomes), a fertilized ovum has 46
chromosomes. If a X-carrying spermatozoon enter the ovum, resulting child will have two X
chromosomes and will be female (XX). If a Y-carrying spermatozoon fertilizes the ovum, the resulting
child will have an X and Y chromosomes and will be male (XY). Fertilization is never a certain
occurrence because it depends on at lest three separate factors: maturation of both sperm and ovum, the
ability of sperm to reach the ovum, and the ability of the sperm to penetrate the zona pellucida and cell
membrane and achieve fertilization. From the fertilized ovum (the zygote), the future child and also the
accessory structures needed for support during intrauterine life, such as the placenta, fetal membranes,
amniotic fluid, and umbilical fluid are formed. (Pillitterri; MCN p176)
IMPLANTATION
Once fertilization is complete, the zygote migrates toward the body of the uterus, aided by the
currents initiated by the muscular contractions of the fallopian tubes. It takes 3 to 4 days for the zygote
to reach the body of the uterus. During this time, mitotic cell division, or cleavage, begins. The first
cleavage occurs at a rate of one about every 22 hours. By this time zygote reaches the body of the uterus,
it consists of 16 to 50 cells. At this stage, because of its bumpy outward appearance, it is termed a
morula (from the latin word “morus”, meaning mulberry). The morula continues to multiply as it floats
free in the uterine cavity for 3 or 4 more days. Large cells tend to collect at the periphery of the ball,
leaving a fluid space surrounding an inner cell mass. At this stage, the structure is termed a blastocyst. It
is this structure that attaches to the uterine endometrium. The cell is in the outer ring are known as
trophoblast cells. They are the part of the structure that will later form the placenta and membranes. The
inner cell mass (embryoblast cells) is the portion of the structure that will later form the embryo.
Implantation or contact between the growing structure and the uterine endometrium, occurs approx. 8 to
10 days after fertilization. After the 3rd or 4th day of free floating (about 8 days from ovulation) the last
residues of the corona and zona pellucida are shed by the growing structure. The blastocyst brushes
against the rich uterine endometrium (in the second secretory phase of the menstrual cycle), a process
termed apposition. It attaches to the surface of the endometrium (adhesion) and settles down into its soft
folds (invasion). Stages to this point are depicted.
The blastocyst is able to invade the endometrium because as the trophoblast cells on the outside
of the structure touch the endometrium, they produce proteolytic enzymes that dissolve the tissue they
touch. This action allows the blastocyst to burrow deeply into the endometrium and receive some basic
nourishment of glycogen and mucoprotein from the endometrial glands. As invasion continues, the
structure establishes an effective communication network with the blood system of the endometrium.
The touching or implantation point is usually high in uterus, on the posterior surface. If the point of
implantation is low in the uterus, the growing placenta may occlude the cervix and make birth of the
child difficult (placenta previa). Implantation is an important step in pregnancy because as many as 50%
of zygotes never achieve it. In these instances, a pregnancy ends as early as 8 to 10 days after
conception, often before the woman is even aware it had begun. Occasionally, a small amount of vaginal
spotting appears with implantation because capillaries are ruptured by the implanting trophoblast cells.
A woman who normally has a particularly scant menstrual flow may mistake implantation bleeding for
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her menstrual period. If this happens, the predicted date of birth of her baby (based on the time of her
last menstrual period) will then be calculated 4 weeks late. Once implanted, the zygote is called embryo.
(Pillitterri; MCN p177)

EMBRYONIC FETAL AND STRUCTURE

CHORIONIC VILLI
Once implantation is achieved, the trophoblastic layer of cells of the blastocyst begins to mature
rapidly. As early as the 11th or 12th day, miniature villi or probing “fingers” termed chorionic villi reach
out from the single layer of cells into the uterine endometrium. At term, nearly 200 such villi will have
formed. Chorionic villi have a central core of loose connective tissue surrounded by a double layer of
trophoblast cells. The central core of connective tissue contains fetal capillaries. The outer of the two
covering layers is termed syncytiotrophoblast, or syncytial layer. This layer of cells is instrumental in
the production of various placental hormones, such as hCG, somatomammotropin (human placental
lactogen HPL), estrogen and progesterone. The inner layer known as the cytotrophoblast or langhans
layer is present as early as 12 days gestation. It appears to function early in pregnancy to protect the
growing embryo and fetus from certain infectious organisms such as the spirochete of syphilis.
However, this layer of cells disappears between the 20th and 24th week. This is why syphilis is considered
to have a high potential for fetal damage late in pregnancy, when cytotrophoblast cells are no longer
present. Unfortunately, the layer appears to offer little protection against viral invasion at any point.
(Pillitterri; MCN, p 178)
D.SYMPTOMATOLOGY

SIGNS & SYMPTOMS S/S MANIFESTED BY THE SCIENTIFIC BASIS

CLIENT

1. Presumptive signs “Sa wa pa ko kahibaw nga buntis Presumptive signs of

a. Amenorrhea ko, lain na jud akong pamati sa pregnancy are those that are
b. Nausea and vomiting ko lawas, kanang inig ka buntag least indicative of pregnancy;
c. Breast changes mura ko kasukaon, nagduda na taken as single entities, they
d. Weight changes jud ko ato nga buntis ko, kay wala could easily indicate other
man sad ko gidugo duha na ka conditions. These findings,
buwan. Nakamatngon sad ko nga discussed connection with the
gana kayo ko ug kaon labi na body system in which they
manggang hilaw, bananacue ug occur, are largely subjective in
linat-ang baka, Ug kun gutom na that they are experienced by
kayo, bisan unsa nalang akong the woman but cannot be
kan-on, nakabantay sad ko nga documented by the examiner.
medyo nitambok ko, nya bug-at (Pillitterri; MCN, p 203)
sad ako pamati sa akong totoy” as
verbalized by the patient”.
2. Probable signs
a. Laboratory tests “Nagpapalit jud ko sa pharmacy Probable signs of pregnancy
ug pregnancy test sa ako bana. can be documented by the
Mao to positive jud ang resulta, examiner. Although they are
pero wala pa jud ko ato more reliable than the
nakontento, niadto pa jud ko ug presumptive signs, they still
hospital para masigurado” as are not positive or true
verbalized by the patient. diagnostic findings.
b. Home pregnancy test (Pillitterri; MCN, p 204)

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 Laboratory tests are commonly
used for pregnancy based on
detecting the presence of
(hCG), in the urine or blood
serum of the pregnant woman.
These tests are accurate in
diagnosing pregnancy only
95% to 98% of the time,
positive results from these
tests are considered probable
3. Positive signs of pregnancy rather than positive signs.
a. Fetal movements felt by the (Pillitterri; MCN, p 204)]
examiner. Pagka lima na ka buwan akong
b. Visualization of fetus by tiyan nagpa kuyog ko sa center sa Several brand name kits for
ultrasound. ko bana para magpa-check up. pregnancy tests based on
Ako sad na obserbahan na immunologic reactions are
molihok na jud ang akong baby. available over the counter.
Wa pa jud ko nakontento, These tests have a high degree
nihangyo ko sa ko bana na of accuracy (about 97%) if the
magpa-ultrasound para maski sa instructions are followed
monitor lang akong makit-an exactly. They are convenient
akong baby ug lipay kayo ko because waiting for healthcare
pagkakita nako sa kong baby na appointment to have a
murag hapit na jud mahuman ug pregnancy test is anxious,
purma’ as verbalized by the stressful time for many
patient. women. (Pillitterri; MCN,
p205)
High frequency sound waves
projected toward a woman’s
abdomen are useful in
diagnosing pregnancy. If the
woman is pregnant, a
characteristic ring, indicating
the gestational sac, will be
revealed on the oscilloscope as
early as the 4th to 6th week of
pregnancy. This method also
giving information about the
site of implantation and
whether a multiple pregnancy
exists. By the 8th week, a fetal
outline can be seen so clearly
within the sac that the crown
to rump length can be
measured to establish the
gestational age of the
pregnancy. By using a real
time technique of ultrasound,
fetal heart movement may be
demonstrated as early as the 6th
16
 week with transvaginal
sonography. Seeing or hearing
a fetal heartbeat is proof of a
pregnancy for the healthcare
provider and also for the
woman.
(Pillitterri; MCN, p206)

X. MEDICAL MANAGEMENT

A. TREATMENT AND PROCEDURES

1. Vital signs taking – closely monitored because this serves as a baseline data of the patient and will
indicate whether the patient’s condition is progressing or reclining. It is a routine taking of the patient’s
temperature, pulse rate, respiration rate and blood pressure.
2. Intravenous fluid monitoring – this is important to prevent overloading and underloading on the
patients body. It is also prescribed or given to replace the patient’s loss fluid and electrolytes and also to
replace the excessive loss of blood in the woman’s body from giving birth or during delivery.
3. Perilite exposure – it is the management and care of episiotomy by means of heat lamp, it is
done after the first 24 hours for NSVD (Normal Spontaneous Vaginal Delivery). This is ordered
by the physician to the postpartum woman who had undergone perineal incision to heal the
wound.
4. Administering oral medication – oral medicines are administered or given to the patient as ordered by
their physician such as multivitamins with iron—this is to replenish the loss blood of the woman from
giving birth, antibiotics—this is to prevent infection related to the perineal incision and analgesic—to
relieve pain.
5. Perineal care – it is the cleansing of the vulva and the perineal area. It is to prevent and eliminate
infection and odor, prevent skin irritation and excortation, promote dry area of the perineal incision for
healing, provides comfort to the woman, removes secretion and excretions and irrigates perineum
following childbirth and infectious process.
6. Bedside care – this is to monitor the patient closely, to help her or assist her in ambulating or if she
needs something when her accompanying is not with her. This is also to make the patients bed clean and
free from dust.
7. Health teaching – this is to provide information to the patient about her condition and the need for her
to take her medication and so that she will also take it positively.

B. MEDICATION
1. Cefalexin ( Cefalin ) 500 mg/ cap 1 cap q8°
2. Mefenamic Acid ( Revalan ) 500 mg/ cap 1 cap PRN for pain
3. Ferrous sulfate ( Fesol )
4.Oxytocin ( Cyntocinon )
5.
C. DIAGNOSTIC PROCEDURES
LABORATORIES
Urinalysis
Macroscopic
Color: yellow
Character: slightly cloudy
PH: 7.2
Specific Gravity: 1.015
Albumin: negative
17
 Glucose: negative

CBC REPORT
WBC 12.80 X 104 /L
RBC 9/out 2
Hemoglobin 10.3g/L
Hematocrit 31g/L
Platelet adequate
Segmenters % 86
Eosinophils % .666
Lymphocyte % 12
Monocyte % 4.02

D. DIET
First when my patient was still in the delivery room she didn’t eat .After the episiotomy, when she was
delivered to her room her diet was turned to a full diet or the diet as tolerated (DAT), which means she
can eat a full meat or she can eat anything as long as she is not allergic to it.

XI. NURSING MANAGEMENT

A. ACTUAL CARE GIVEN
Since from the very beginning, I already planned and decided that Mrs. F.M.L will be the subject
of my care study. I see to it that I would establish rapport with her and her family. First and foremost, I
introduced myself and tried my very best to appear confident but not authoritative, in order for me to
gain good compliance. As soon as I’ve noticed that I’ve already built rapport with them, I did not waste
my time, and so I asked Mrs. F.M.L if she could be the subject of my care study. First, there were really
doubts and there were also a few questions about what the care study is. I then explained to her and
luckily she understood and agreed immediately. Initial care I have done was taking her vital signs. I’ve
done bed making. She responds to it positively. I also did bedside care, assisted her in ambulating,
offered myself whenever she needs anything, and assured to assist her if her husband is not around.
1. Monitored vital signs.
2. Monitored I&O.
Assess for signs of over bleeding
4. Encouraged pt. to rest & sleep.

4. Administered medication as prescribed by the physician.

5. Encouraged patient to sit in bed & walk around her room.
6. Did health teaching to the pt. regarding home care after discharge.

D. PROBLEMS ENCOUNTERED DURING IMPLEMENTATION OF NURSING CARE

It was really hard for me to implement appropriate nursing care considering that we are on a morning
shift I did my nursing care and patient teaching in a brief manner. The patient was also hesitant to
interact at first but eventually became very friendly and accommodating..she’s very cooperative,
responsive, approachable and friendly and her husband as well.
C. RESTORATIVE MEASURES USED
Since my patient was a post partal with a perineal incision, the restorative measures I used are:
Vital signs monitoring – temperature, pulse rate, respiratory rate and blood pressure until stable.
Hot Sitz Bath – as ordered by her physician to promote wound healing.
Early Ambulation – to promote good circulation.
Breastfeeding – to prevent breast engorgement.
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Perineal care – to prevent infection and odor in the area.
Perineal exercises – to relieve episiotomy discomfort and to improve circulation to the area and so help
decrease edema.
D. EVALUATION
Everyday as I took care of my patient, Ms. Balansag, I noticed the changes she undergone. I have
observed that she was able to accept and practice the things and theories I have taught her, applied the
concepts I’ve shared, and was able to accept her new role and responsibility as a mother. The bonding
between her and her child were evident as well, as manifested; mother holding her baby in a motherly
way, smoothens her baby’s hair, and singing her baby a relaxing lullaby. The patient also was able to
verbalize her concerns about about her health condition.

E. PATIENT TEACHING
Since this was the second time for Ms.Balansag to have a baby, so accepting the new role and
responsibility wasn’t quite difficult.As a student nurse, I reviewed her in the fundamentals of normal
infant development in order for her to still render effective care towards her baby. I also suggest her to
continue breastfeeding her baby until two years of age since it has a great benefits for her as well as for
her baby. I instructed her to continue taking her medication regularly as ordered by her doctor, and as
for her perineal incision, I taught her to have good and proper hygiene to promote wound healing an
minimize if not to avoid infection.

XII. A. CONCLUSION
Every family needs some individual instruction or education to prepare her to care for herself
and her newborn. However, learning does not take place if a learner is overwhelmed. Common sense is
necessary to determine when it is time to teach and when is time to observe and listen.
Postpartum period is the time of transition during which the couple gives up concept such as
‘childless’ and moves to the new beginning of parenthood. The immediate postpartum period is a neutral
time during which the couple tries out the new role and attempts to fit their expectation for that role.
We as future nurses can be instrumental in helping couples acknowledge the extent of the change
to help them gain closure on their previous lifestyle. Opening channels for communication, anticipating
new needs, and highlighting potential gains that will occur to help the patient in verbalizing their
concerns and needs.
How to handle the postpartum requirements:
Some women freeze enough meals to last a week and stock the house with non-perishables.
Nevertheless you'll still need fresh items, and someone to run for these. Often the father is willing,
although he may be loathe to leave you and the baby for very long.
Help with the laundry is a must, particularly if you are washing diapers. Regarding the housecleaning,
note the extended period recommended for assistance. Believe me, that's being conservative; ideally you
would have someone weekly for the first year or more. The last thing you'll want to do with a few
precious moments when the baby is finally asleep is to spend them mopping the floor!
Your immediate family is an ideal source of postpartum support, but it must not be your only
one. Family has by nature a somewhat limited scope, with inbred attitudes and beliefs generally made
more extreme by stress. As there is almost no time in your life more stressful than the early weeks with a
newborn, you will need the objectivity of those outside your family unit, even if you must deliberately
seek it out.
The bottom line in dealing with family members is to be honest and clear about what you do and
do not want, what you can and cannot handle. Be specific; if Mom offers to help, go ahead and ask her
to take out the trash, scrub the toilet, whatever. And d o be realistic about your emotional state at this
time; your explosive and depressive tendencies, your outright limitations. It is not the end of the world
if you have an angry outburst; your mother is old enough to understand and should be able to fend for
herself.
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 Here is a summary of the important facts and information related to pregnancy:
· Having a baby is one of the most important events in a woman's life. Most women worry about
whether the baby they are carrying is healthy.
· Early and regular prenatal care is the best insurance against problems in pregnancy.
· Prenatal tests usually assure the parents that the pregnancy is progressing normally and allow
doctors and parents to spot problems early.
· If a woman is concerned about the health of her baby, she should immediately discuss it with her
physician. Tests can often alleviate any concern.
use of the said change are extremely vital actions to implement.

E. RECOMMENDATION
I recommend this study to be focused more especially as to with health care providers, since this care
study would serve as a guideline on how to render effective nursing care particularly to postpartum
mothers. In some way or another, this study would be of great help on how to manage those postpartal
mothers who are physically and emotionally altered right after and prior to delivery.
After conducting my case study to the Ms. Balansag I recommend to her that they should start
as early as today to have a family planning since over population is one of the major problems in the
country. And to encourage the mother’s to breastfeed their babies because it can help strengthen the
immune system of the baby. Whatever the doctors has prescribed as their medication should be taken
completely even if she feels better for faster recovery. And to avoid sexual intercourse for about two to
three months to prevent laceration of the perineum and will aid in faster wound healing but instead they
can make use of other alternative aside from sexual contact.
I also recommend to other student nurses who where given the opportunity to conduct the said
case study to implement nursing care truthfully to their patient in order to restore the energy and strength
of the mother after delivery.

Preparing For Birth

No two births are alike. Labor is a series of changing conditions, and no amount of examination can
predict how a woman or her baby will respond.

What Type Of Delivery Is Best?

The mother's health and/or baby's condition will largely determine the type of delivery.
Vaginal birth is the traditional style of delivery in which the mother is an active participant. Cesarean
birth is a surgical delivery through an abdominal incision.
Often the position of your baby or the placenta affects the course of labor. Cesarean delivery
may be needed if the baby's position cannot be changed or if the placenta's position makes vaginal
delivery a risk. A Cesarean also is needed if the fetus is unable to tolerate labor and is becoming low on
oxygen, or if the labor fails to progress.

Is This Labor?
Labor is a series of uterine contractions that open the cervix for birth.
Your due date is a good guide in determining if you are indeed in labor. But it's important to
remember that babies are often born days or weeks before or after due dates.

Signs the baby will soon be born include:

Irregular tightening or contractions of the uterus
Increased and thickened vaginal secretions
20
 Pink or brown-tinged discharge indicating breakdown of the mucus plug sealing the uterus
Labor often starts slowly. Regular, uncomfortable contractions that come more often than one
every 10 minutes may mean the woman is in labor.
Many women are told to leave for the hospital when contractions are 5 to 10 minutes apart or if
there is bleeding or leaking of amniotic fluid.
If your physician believes continuing the pregnancy might harm you or your baby, he or she may
induce labor. Induction of labor often involves chemical or physical stimulation.

Techniques include:
· Physical stimulation to loosen the amniotic sac from the uterine wall
· Rupturing the membranes with a special tool
· Administering a drug to start labor, either by giving it intravenously (oxytocin) or into the vagina
(prostaglandins)
XIII. IMPLICATION OF THE STUDY TO:
A. NURSING EDUCATION
Nursing studies enables the student nurse to be well-educated and informed especially in this
particular period of postpartum. It also embarks knowledge, helpful and applicable in my chosen field of
nursing. Student nurses at all levels are legally accountable for their actions and assume new
responsibilities and accountability with every advance in education. Student nurses practicing in
maternity and pediatric settings at all levels must keep up to date with education and information on how
to help their patients and where to direct families for help when other resources are needed. When the
student nurse functions as a teacher, adviser, and resource person, it is important that the information
and advise provided should be correct, pertinent, and useful to the person in need.
B. NURSING PRACTICE
This care study enables the nursing student to acquire some sort of guidelines especially on how to
deal with postpartum cases, that when guided accordingly would lead to effective nursing practice.
The image of nursing has changed, and the horizons and responsibilities have broadened
tremendously in recent years. The primary thrust of health care is toward prevention. In addition to the
treatment of disease and physical problem, modern maternal-child care addresses prenatal care, growth
and development, and anticipatory guidance on maturational and common health problems. Teaching is
also an important aspect of caring for the childbearing and child-rearing family. Clients are educated on
a variety of topics, from follow-up of immunizations to other more traditional aspects of health.

C. NURSING RESEARCH
Because this care study is simplified and being specialized only to postpartum cases, it could be
a great help to my fellow nursing students. This study contains vital information and data needed in the
implementation of care to postpartum mother. The nurse preparing to care for today and tomorrow’s
childbearing and child-rearing families faces vastly different responsibilities and challenges than did the
maternal and pediatric nurse of even a decade ago. The reduction of incidence of communicable and
infectious diseases has made it possible to devote more attention to such critical problems as PRETERM
BIRTH, CONGENITAL ANOMALIES, CHILD ABUSE, LEARNING & BEHAVIOR DISORDERS,
DEVEOPMENTAL DISABILITIES, & CHRONIC ILLNESS. Research in these areas continues; as
these findings become available, nurses will be among the practitioners who will help translate this
research into improved health care for pregnant women, children and families. However, nurses’ ability
to translate the relevant medical research into practice is based on their understanding of the predictable
but variable phases of pregnancy and a child’s growth and development and on their understanding of
and sensitivity to the importance of family interactions.

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 APPENDICES:

Appendix A: PERMIT LETTER

Appendix B: NURSING CARE PLAN

Appendix C: DISCHARGE PLAN

Appendix D: DRUG STUDY

Appendix E: IVF STUDY

BIBLIOGRAPHY

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