OB Care Study

I. INTRODUCTION

Pregnancy is one of the miracles of life. It is so amazing how a creature emerges from another creature, quite similar in genetic make-up but a totally different individual with a unique personality and a distinct characteristic. A creature undergoes pain in giving life to another creature which only shows that each of them is created with the great love felt for one another. Truly, the Creator made this life perfect, a bit of pain and suffering, but with  a basket  full of love.

Childbearing is a no shaggy dog story. It is one of the complex processes that all women who wants to have a child should undergo and it encompasses a lot of problems and complications. It has different stages, phases, and  periods, each of which has a whole new experience to offer to each conceiving mother.

The pregnancy is divided into 3 periods – Anterpartum, Intrapartum, and Postpartum period. Antepartum is the period of time from the fertilization up to the time the labor begins. Controversies over the beginning of pregnancy usually occur in the abortion debate, it is not primarily a scientific  issue since knowledge of human reproduction and development has long been refined, it is rather a linguistic and definitional question. Antepartum is also the time where  a lot of physiological changes takes place in a conceiving woman, these changes should be understood in order to have a optimum condition and the most favorable outcome (www.nursingcrib.com).

Intrapartum, the period of actual birthing process is divided into 4 stages. The 1st stage (Dilatation), 2nd  stage (Delivery), 3rd stage (Placental and 4th stage (Recovery). At this period, management and delivery of care to the women in labor is very important since it is at this stage the greatest pain of pregnancy is felt . (www.nursingcrib.com)

Postpartum period refers to the 6-week period after childbirth. This is the time of maternal changes that are both retrogressive (involution of the uterus and vagina) and progressive (production of milk for lactation, restoration of normal menstruation cycle, and beginning of the parenting role. (www.nursingcrib.com)

The students are required to provide nursing interventions to their assigned patients and compare those interventions to what they learned in school and in textbooks in order for them to understand real situations and able to compare the positive and negative corners of these type of actual situations.

II. PATIENT’S PROFILE

  • Name of Patient
  • Age
  • Address
  • Birthplace
  • Religion
  • Educational Attainment
  • Occupation
  • Name of Husband/Occupation
  • Menarche
  • Last Menstrual Period
  • GPTPAL
  • Immunization
  • Prenatal Records
  • Date of Admission
  • Time of Admission
  • Time of Delivery
  • Chief Complaints
  • Vital signs upon admission
  • Physician

III. STAGES OF LABOR

Labor is considered “normal” when the woman is at or neat term, no complications exists, a single fetus presents by vertex, and labor is completed within 24 hours. (Bobak L&M Jensen, 1993). The course of labor has 4 stages.

The first stage of labor or the stage of cervical dilatation lasts from the onset of regular contractions to effacement full dilation of cervix. This stage average about 13 hrs. for nullipara and about 7.5 hrs. for a multipara. In this stage there are 3 phases.  The first phase or the latent phase has a cervix that dilates from 0-3 cm and contractions usually every  5-20 minutes lasting 20-40 seconds and of mild intensity. These contractions will progress to about every 5 minutes and established a regular pattern.

In the active phase, the cervix dilates from 4-7 cm, the contractions are usually every 2-5 minutes lasting 30-50 sec and intensity is mild to moderate. The last phase is the transitional phase. This time the cervix dilates from 8-10 com with contractions every 2-3 minutes that lasts 50-60 seconds. Some contractions may last up to 90 seconds. The intensity is moderate to strong.

The second stage is the the Stage of Expulsion.  This stage begins with complete cervical dilation and ends with the birth of the baby. This period may last from 1-4 hours on nullipara and 20-45 minutes on the multiparas.

The third stage or the Placental Stage begins with the delivery of the baby and ends with delivery of the placenta. This may last from a few minutes – 30 minutes (include signs of placental separation).

The last stage or the Recovery Stage will lasts from the delivery of the placenta until the postpartum condition of the woman has stabilized (usually 1 hour after delivery)

PHYSIOLOGIC CHANGES DURING PREGNANCY

Anatomy of the Female Reproductive Organ

The female reproductive organ is composed of fallopian tubes, ovaries, uterus, cervix and vagina.

Uterus

Main function:

  • Accept fertilized ovum which becomes implanted into the endometrium and derives nourishment from blood vessels which develop exclusively for this purpose. The fertilized ovum becomes an embryo, develops into a fetus and gestates until childbirth.

Cervix

Main Function:

  • During pregnancy, the cervix lengthens serving as a barrier. When labor begins, the cervix begins to shorten, dilating to an opening of about 10 centimeters (about 4 inches) to allow the fetus to pass through. The cervix becomes thin and merges with the uterus (effacement) during the first stage of labor.

Vagina

Main Function

  • During childbirth, the vagina provides the channel to deliver the baby from the uterus to its independent life outside the body of the mother. The vagina  is often referred to as the birth canal. It is remarkably elastic and stretches to many times its normal diameter during vaginal birth.

Fallopian Tubes

Main Function

  • Plays an integral role in ovulation and conception. Without the fallopian tube, the egg cannot become fertilized and an embryo cannot reach the uterus for implantation.

Ovaries

Main Function

  • Each ovary takes turns releasing eggs every month; however if there was a case where one ovary was absent or dysfunctional then the other ovary would continue providing eggs to be released.

IV. IDEAL NURSING INTERVENTIONS

First Stage of Labor – Dilation of Cervix

Nursing Diagnosis:

Altered Nutrition: less than body requirements related to food restrictions during labor

Intervention:

  • Discuss eating habits, including food preferences, intolerance / aversions to appeal to client likes.
  • Emphasizes the importance of well-balanced diet, nutritious  intake

Rationale:

  • This will help patient determine the foods that she needs and the foods that are not allowed for to her to take.
  • Having a well-balanced diet will not make the patient malnourished because she has enough nutrients that her body needs.  This will also prevent her from becoming overweight.

Evaluation

  • Measure the patients I & O
  • Check the patient’s skin for good skin turgor
  • Demonstrate behaviors to monitor and correct deficit as indicated

Anxiety related to concern for self and the fetus

Intervention:

  • Promote client control where possible and help client identify and accept those things over which control is not possible
  • Provide information in verbal and written form. Speak in simple sentences and concrete terms.
  • Stay with the client or make arrangements for someone to be there for the client.

Rationale:

  • This will give the client the idea that she is still in control of the situation
  • This will help in alleviating the patient’s anxiety because she will be wondering about what will happen during the procedure.
  • Sense of abandonment can promote fear.

Evaluation:

  • Acknowledge and discuss fears, recognizing healthy and unhealthy fears.
  • Patient understands the procedure that she will be undertaking.
  • Display appropriate range of feeling and lessened fear.

Latent Phase

Nursing Interventions:

  • Maintaining Nutrition and Hydration – provide clear liquids, evaluate urine for ketones and glucose; administer intravenous fluids as indicated.
  • Relieve Anxiety – establish a relationship with woman/couple; explained the procedure to the patient, inform woman/couple of maternal status and fetal status and labor progress.
  • Controlling Pain – encourage ambulation as tolerated if membranes are not ruptures and the presenting part is engaged;  encourage diversional activities; encourage relaxation technique like warm shower; and provide  comfort measures by giving back rubs or massage.

Active/Transitional Phase

Nursing Interventions:

  • Relieving Anxiety – monitor maternal vital signs and FHR and keep woman inform of the status; provide encouragement and support; and involve support person in woman’s care.
  • Minimizing Pain – encourage position changes for comfort; assist woman with breathing and relaxation techniques; provide massage; administer prescribed analgesia as needed; observed for drug reaction; and maintain IV fluids
  • Encourage Bladder emptying – encourage woman to void every 2 hours at least 100ml
  • Strengthening Coping with Active Labor and transition – assist woman with breathing and relaxation techniques; encourage positive attitude; and provide comfort measures
  • Preventing Intrauterine Infection –  provide perineal care and change pads and linens when wet or soiled.
  • Maintaining Mobility –  encourage position change in bed as indicated; encourage ambulation and assist with back rubs, leg massage, and leg exercise while in bed
  • Encourage Effective Breathing Techniques – assist the woman in proper breathing and relaxation techniques as needed to maintain control

Evaluation:

  • Verbalized positive statements about self and fetus
  • Report pain decreased from comfort strategies and medical interventions
  • Bladder remain undistented and the woman voids
  • Absence of fever and signs of infection
  • Use breathing techniques during contractions

Second Stage of Labor – Fetal Expulsion

Nursing Diagnosis

Fear/Anxiety related to impending delivery

Interventions:

  • Give “permission” to express feelings
  • Provide opportunity for questions and answer appropriately

Rationale:

  • This will help ease the anxiety and fear of the patient
  • Enhances sense of trust and client-nurse relationship

Evaluation:

  • Display appropriate range of feelings and lessened fear
  • Verbalized accurate knowledge sense of safety related to current situation

Risk for Infection related to episiotomy and/or tissue

Interventions:

  • Cleanse incisions/inserting sites daily
  • Emphasize necessity of taking antibiotics as directed
  • Advise the patient to practice self perineal care

Rationale:

  • This will help avoid contaminating the wound.
  • The antibiotics will help the patient’s immune defense kill off the bacteria that is already affecting the wound or incision.
  • Basic perineal care will remove the dirt that are lodging in the patients perineal area that may cause infections.

Evaluation:

  • Identify interventions to prevent/reduce risk of infection
  • Demonstrate techniques, lifestyles changes to promote safe environment
  • Can follow taking the prescribed medications without the guidance of then care provider

Third Stage of Labor – Placental Expulsion

Nursing Diagnosis

Impaired Tissue Integrity related to placental separation

Interventions:

  • Check to see that the placenta and membranes are complete.
  • Evaluate the placenta for size, shape and cord site implantation
  • Evaluate vaginal bleeding

Rationale:

  • If there are parts of the placenta that will be left behind then it would cause bleeding
  • This is to assess the placenta for recording and to see if there is a full expulsion of the placenta
  • make sure that there are no fragments of the placenta that is being left behind to avoid postpartum bleeding.

Evaluation:

  • Full placenta will not cause postpartum hemorrhage
  • Patient will help in the full delivery of the placenta

NEWBORN CARE

Nursing Intervention:

  1. Weight infant and record weight.
  2. Take temperature through rectal and provide warm environment
  3. Take blood pressure

Rationale:

  1. Infant may lose 5%-10% of birth weight because of minimal intake of nutrients and fluid and loss of excess fluids.
  2. Use rectal thermometer predisposes to irritation of rectal mucosa
  3. Hypotension maybe present and require remedial action

Bathing Technique

  1. Use cotton balls or soft  disposable washcloths to wipe eyes, face and outer ears
  2. Use hypoallergenic soap
  3. Wash infant’s head gently.
  4. Tilt head back to cleanse the neck
  5. Bathe torso and extremities quickly
  6. Inspect  umbilical cord. Check for area of bleeding or foul odor. Use betadine or 70% alcohol.
  7. Cleanse genital area of infant
  8. Bathe buttocks  using gentle, patting motion

Rationale:

  1. Start from the cleanest areas.
  2. Prevents irritation of the skin.
  3. Prevents cradle crap from forming especially over the frontal head
  4. Expose the neck for more thorough cleansing
  5. Prevents unnecessary exposure and chilling
  6. Minimizes colonization by bacteria
  7. To prevent infection and edema
  8. Keep area clean and dry  to prevent rashes

Nutritional Considerations:

  1. Promote breastfeeding
  2. Provide adequate nutritional intake
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