Introduction

We the group 1b of our lady of fatima unversity with our beloved clinical instructor in ob-wards, ms. Ann margarete francisco Rn,Man, was conduted an interview in quezon city general hospital at OB-ward as part of our case study. The significance of the study is for us 2nd year student to apply the principles and concept that we have learned in the ncm (maternal and child nursing) in our rotation in NHM with the following objectives:

 To be able to review concept on the theories in maternal and child nursing

 To be able to describe the development , physiology and nusring care of a client who has undergone normal spontaneous vaginal delivery (NSVD)  To be able to design a nursing care plan for the patient who has undergone NSVD and episiotomy procedure  To be able to provide information and health teaching to the patient of the post partum peroid.  To be able tp establish a good working relationship with the patient and hospital staff.

Background study
 Gravidocadiac
 pertaining to heart disease in pregnancy.

Changes to the heart and blood vessels with pregnancy

During pregnancy, changes occur to the heart and blood vessels that add stress on a womans body and increase the workload of the heart. These changes include:

y y y y

Increase in blood volume: During the first trimester, the volume of blood increases by 40 to 50 percent and remains high throughout pregnancy. Increase in cardiac output: Cardiac output, the amount of blood pumped by the heart each minute, increases by 30 to 40 percent due to the increase in blood volume. Increase in heart rate: It is normal for the heart rate to increase by 10 to 15 beats per minute during pregnancy. Decrease in blood pressure: In some women, blood pressure may decrease by 10 mmHg during pregnancy. Blood pressure may decrease during pregnancy due to hormone changes and because more of your blood is directed toward the uterus. Most of the time, there are no symptoms of blood pressure changes and no treatment is required. Your health care provider will be monitoring your blood pressure during your prenatal appointments and can tell you if you need to be concerned about changes in your blood pressure. These changes are normal during pregnancy and help ensure that your baby will get enough oxygen and nutrients. These changes can lead to symptoms including fatigue (feeling over-tired), shortness of breath, and light-headedness during pregnancy. All of these symptoms are normal, but if you are concerned, please talk to your doctor. Women with a heart condition may need to take special precautions before and during pregnancy. Some heart conditions may increase a womans risk for complications during pregnancy. In addition, some women may have heart or blood vessel conditions that are not identified until pregnancy.

If you have a heart condition, what should you do before planning a pregnancy?
If you have a heart condition, such as those listed below, you should be evaluated by a cardiologist (a heart specialist) before you start planning a pregnancy:

y y y y y

Hypertension (high blood pressure) or high cholesterol Prior diagnosis of any type of heart or blood vessel disease, including aorta disease, arrhythmia, heart murmur, cardiomyopathy, heart failure, Marfan syndrome or rheumatic fever. Prior cardiac event (transient ischemic attack or stroke Severe narrowing of the mitral or aortic valve or aortic outflow tract, as determined by echocardiography. Ejection fraction of less than 40%. Ejection fraction is the amount of blood pumped out of the left ventricle during each heartbeat. The ejection fraction evaluates how well the heart is pumping. A normal ejection fraction ranges from 50 to 70%.(8) The cardiologist can review your health history and perform a physical exam and order diagnostic tests, as needed, to evaluate your heart function and the severity and extent of your condition. After reviewing the test results, the cardiologist can talk to you about the safety of pregnancy, based on your health condition. The cardiologist will discuss your potential risk of complications during pregnancy, including potential fetal risks and possible long-term health risks to you and your baby. The cardiologist can discuss whether medications or other treatments may be needed before pregnancy. Be sure to discuss all of your medications (including heart medications and any over-the-counter medications you take routinely) with your doctor so your medication dosages can be changed if necessary or different medications can be prescribed that may be safer to take during pregnancy.

By preparing for pregnancy and following up regularly with your cardiologist during pregnancy, most women with a heart condition can safely become pregnant and have a healthy baby.

 Uterine febroids
 Uterine fibroids (leiomyomata) are non-cancerous growths that develop in or just outside a womans uterus (womb). Uterine fibroids develop from normal uterus muscle cells that start growing abnormally. As the cells grow, they form a benign tumor.

Who Gets Uterine Fibroids? Uterine fibroids are extremely common. In fact, many women have uterine fibroids at some point in life. Uterine fibroids in most women are usually too small to cause any problems, or even be noticed. No one knows what causes uterine fibroids, but their growth seems to depend on estrogen, the female hormone. Uterine fibroids dont develop until after puberty, and usually after age 30. Uterine fibroids shrink or disappear after menopause, when estrogen levels fall. African-American women tend to get uterine fibroids two to three times as often as white women, and also tend to have more symptoms from uterine fibroids. Other factors may influence development of uterine fibroids: y y y y Pregnancy: Women who have had children are less likely to get fibroids Early menstruation: Women whose first period was before age 10 are more likely to have uterine fibroids Women taking birth control pills are less likely to develop significant uterine fibroids Family history: Women whose mothers and sisters have uterine fibroids are more likely to have them, too.

Overview of the disease

 Gravidocadiac
Preexisting cardiovascular conditions and pregnancy
Congenital heart conditions and pregnancy Atrial (ASD) and ventricular septal defects (VSD), and patent ductus arteriosus (PDA) are the most commoncongenital heart defects. With these heart defects, there is an opening in the septum (the muscular wall separating the right and left side of the heart). If the hole is large, blood from the left side of the heart flows back into the right side of the heart and gets pumped back to the lungs again. In general, most women with a congenital heart defect, especially those who have had corrective surgery, can safely become pregnant. However, the type of heart defect, severity of symptoms, presence of pulmonary hypertension or other cardiac or lung disease, and any prior heart surgeries may affect the outcome of the pregnancy. In some women who have a congenital heart defect and who also have pulmonary hypertension, pregnancy is not recommended, as theres a high risk of maternal death. Over time, symptoms of heart failure can occur or worsen in women with a congenital heart defect, increasing the mothers risk of long-term complications. There is a greater risk that the baby will develop a heart condition if either parent has a congenital heart defect. Your cardiologist may recommend a fetal echocardiogram to check the fetus heart for possible defects. This test is usually done in the 18th week of pregnancy. If you have been diagnosed with a congenital heart defect, a cardiologist should evaluate your heart condition before you plan a pregnancy. The cardiologist can provide you with guidance on the possible risks of pregnancy and can work with your health care team to monitor your health and your babys health during pregnancy. Valve disease and pregnancy Aortic valve stenosis means the aortic valve (the valve between the left ventricle and the aorta) is narrowed or stiff. If the narrowing is severe, the heart has to work harder to pump the increased blood volume out of the narrowed valve. This, in turn, can cause the left ventricle (the major pumping chamber of the heart to enlarge (hypertrophy). Over time, symptoms of heart failure can occur or worsen, increasing the mothers risk of long-term complications. One common cause of aortic valve stenosis is bicuspid aortic valve disease, a congenital heart condition in which there are only two leaflets or cusps, instead of the normal three leaflets. Without the third leaflet, the valve can become narrowed or stiff. Women with bicuspid aortic valve disease or any type of aortic valve stenosis need to be evaluated by a cardiologist before planning a pregnancy. In some cases, surgery to correct the valve may be recommended before pregnancy. Mitral valve stenosis means the mitral valve (the valve between the left atrium and left ventricle) is narrowed. This is often caused by rheumatic fever. The increased blood volume and increased heart rate that occurs with pregnancy can worsen symptoms of mitral stenosis. The right atrium can enlarge in size causing a rapid irregular heart rhythm called atrial fibrillation. In addition, heart failure symptoms can occur (shortness of breath, irregular heart beat, fatigue and swelling or edema). This can increase the risk to the mother. Medications may be used during surgery, and in some cases,percutaneous valvuloplasty may be required during pregnancy to correct the narrowed valve. Patients with mitral stenosis need to have their valve evaluated prior to becoming pregnant. In some cases, surgery to correct the valve will be recommended before pregnancy. Medications may be prescribed during pregnancy to reduce symptoms), and in some cases, percutaneous valvuloplasty may be required during pregnancy to correct the narrowed valve.

Women with mitral valve stenosis need to be evaluated by a cardiologist before planning a pregnancy. In some cases, surgery to correct the valve may be recommended before pregnancy. Mitral valve prolapse is a common condition, often not causing symptoms or requiring any treatment. Most patients with mitral valve prolapse tolerate pregnancy. If the prolapse causes a severe leak, treatment may be needed prior to pregnancy. It is always best to follow your doctors recommendations if you have mitral valve prolapse

 Uterine febroid
Types of Uterine Fibroids All uterine fibroids are similar in their makeup: all are made of abnormal uterus muscle cells growing in a tight bundle or mass. Uterine fibroids are sometimes classified by where they grow in the uterus: y y y y Myometrial (intramural) fibroids are in the muscular wall of the uterus. Submucosal fibroids grow just under the interior surface of the uterus, and may protrude into the uterus. Subserosal fibroids grow on the outside wall of the uterus. Pedunculated fibroids usually grow outside of the uterus, attached to the uterus by a base or stalk. Uterine fibroids can range in size, from microscopic to several inches across and weighing tens of pounds. Symptoms of Uterine Fibroids Most often, uterine fibroids cause no symptoms at all -- so most women dont realize they have them. When women do experience symptoms from uterine fibroids, they can include: y y y y y Prolonged menstrual periods (7 days or longer) Heavy bleeding during periods Bloating or fullness in the belly or pelvis Pain in the lower belly or pelvis Constipation Some experts believe that some uterine fibroids can occasionally interfere with fertility and pregnancy. Rarely, a uterine fibroid projecting into the uterus might either block an embryo from implanting there, or cause problems with the pregnancy later. Diagnosis of Uterine Fibroids Moderate and large-sized uterine fibroids are often felt by a doctor during a manual pelvic examination. Imaging tests are often done to confirm the presence of uterine fibroids.

Anatomy and physiology

Cardiac

1. 2. 3. 4. 5. 6. 7. 8.

Right Coronary Left Anterior Descending Left Circumflex Superior Vena Cava Inferior Vena Cava Aorta Pulmonary Artery Pulmonary Vein

9. Right Atrium 10. Right Ventricle 11. Left Atrium 12. Left Ventricle 13. Papillary Muscles 14. Chordae Tendineae 15. Tricuspid Valve 16. Mitral Valve 17. Pulmonary Valve

Coronary Arteries Because the heart is composed primarily of cardiac muscle tissue that continuously contracts and relaxes, it must have a constant supply of oxygen and nutrients. The coronary arteries are the network of blood vessels that carry oxygen- and nutrient-rich blood to the cardiac muscle tissue. The blood leaving the left ventricle exits through the aorta, the bodys main artery. Two coronary arteries, referred to as the "left" and "right" coronary arteries, emerge from the beginning of the aorta, near the top of the heart. The initial segment of the left coronary artery is called the left main coronary. This blood vessel is approximately the width of a soda straw and is less than an inch long. It branches into two slightly smaller arteries: the left anterior descending coronary artery and the left circumflex coronary artery. The left anterior descending coronary artery is embedded in the surface of the front side of the heart. The left circumflex coronary artery circles around the left side of the heart and is embedded in the surface of the back of the heart. Just like branches on a tree, the coronary arteries branch into progressively smaller vessels. The larger vessels travel along the surface of the heart; however, the smaller branches penetrate the heart muscle. The smallest branches, called capillaries, are so narrow that the red blood cells must travel in single file. In the capillaries, the red blood cells provide oxygen and nutrients to the cardiac muscle tissue and bond with carbon dioxide and other metabolic waste products, taking them away from the heart for disposal through the lungs, kidneys and liver. When cholesterol plaque accumulates to the point of blocking the flow of blood through a coronary artery, the cardiac muscle tissue fed by the coronary artery beyond the point of the blockage is deprived of oxygen and nutrients. This area of cardiac muscle tissue ceases to function properly. The condition when a coronary artery becomes blocked causing damage to the cardiac muscle tissue it serves is called a myocardial infarction or heart attack. Superior Vena Cava The superior vena cava is one of the two main veins bringing de-oxygenated blood from the body to the heart. Veins from the head and upper body feed into the superior vena cava, which empties into the right atrium of the heart. Inferior Vena Cava The inferior vena cava is one of the two main veins bringing de-oxygenated blood from the body to the heart. Veins from the legs and lower torso feed into the inferior vena cava, which empties into the right atrium of the heart. Aorta The aorta is the largest single blood vessel in the body. It is approximately the diameter of your thumb. This vessel carries oxygen-rich blood from the left ventricle to the various parts of the body. Pulmonary Artery

The pulmonary artery is the vessel transporting de-oxygenated blood from the right ventricle to the lungs. A common misconception is that all arteries carry oxygen-rich blood. It is more appropriate to classify arteries as vessels carrying blood away from the heart. Pulmonary Vein The pulmonary vein is the vessel transporting oxygen-rich blood from the lungs to the left atrium. A common misconception is that all veins carry de-oxygenated blood. It is more appropriate to classify veins as vessels carrying blood to the heart. Right Atrium The right atrium receives de-oxygenated blood from the body through the superior vena cava (head and upper body) and inferior vena cava (legs and lower torso). The sinoatrial node sends an impulse that causes the cardiac muscle tissue of the atrium to contract in a coordinated, wave-like manner. The tricuspid valve, which separates the right atrium from the right ventricle, opens to allow the de-oxygenated blood collected in the right atrium to flow into the right ventricle. Right Ventricle The right ventricle receives de-oxygenated blood as the right atrium contracts. The pulmonary valve leading into the pulmonary artery is closed, allowing the ventricle to fill with blood. Once the ventricles are full, they contract. As the right ventricle contracts, the tricuspid valve closes and the pulmonary valve opens. The closure of the tricuspid valve prevents blood from backing into the right atrium and the opening of the pulmonary valve allows the blood to flow into the pulmonary artery toward the lungs. Left Atrium The left atrium receives oxygenated blood from the lungs through the pulmonary vein. As the contraction triggered by the sinoatrial node progresses through the atria, the blood passes through the mitral valve into the left ventricle. Left Ventricle The left ventricle receives oxygenated blood as the left atrium contracts. The blood passes through the mitral valve into the left ventricle. The aortic valve leading into the aorta is closed, allowing the ventricle to fill with blood. Once the ventricles are full, they contract. As the left ventricle contracts, the mitral valve closes and the aortic valve opens. The closure of the mitral valve prevents blood from backing into the left atrium and the opening of the aortic valve allows the blood to flow into the aorta and flow throughout the body. Papillary Muscles The papillary muscles attach to the lower portion of the interior wall of the ventricles. They connect to the chordae tendineae, which attach to the tricuspid valve in the right ventricle and the mitral valve in the left ventricle. The contraction of the papillary muscles closes these valves. When the papillary muscles relax, the valves open. Chordae Tendineae The chordae tendineae are tendons linking the papillary muscles to the tricuspid valve in the right ventricle and the mitral valve in the left ventricle. As the papillary muscles contract and relax, the chordae tendineae transmit the resulting increase and decrease in tension to the respective valves, causing them

to open and close. The chordae tendineae are string-like in appearance and are sometimes referred to as "heart strings."

Tricuspid Valve The tricuspid valve separates the right atrium from the right ventricle. It opens to allow the de-oxygenated blood collected in the right atrium to flow into the right ventricle. It closes as the right ventricle contracts, preventing blood from returning to the right atrium; thereby, forcing it to exit through the pulmonary valve into the pulmonary artery. Mitral Value The mitral valve separates the left atrium from the left ventricle. It opens to allow the oxygenated blood collected in the left atrium to flow into the left ventricle. It closes as the left ventricle contracts, preventing blood from returning to the left atrium; thereby, forcing it to exit through the aortic valve into the aorta. Pulmonary Valve The pulmonary valve separates the right ventricle from the pulmonary artery. As the ventricles contract, it opens to allow the de-oxygenated blood collected in the right ventricle to flow to the lungs. It closes as the ventricles relax, preventing blood from returning to the heart. Aortic Valve The aortic valve separates the left ventricle from the aorta. As the ventricles contract, it opens to allow the oxygenated blood collected in the left ventricle to flow throughout the body. It closes as the ventricles relax, preventing blood from returning to the heart.

uterus

The female reproductive organs consist of the ovaries, uterine tubes (or fallopian tubes), uterus, vagina, external genitalia, and mammary glands.

Ovaries the two ovaries are small organs suspended in the pelvic in the pelvic cavity by ligaments. Ovaries are the female reproductive glands where the 400,000 ova or egg cells are stored. The outer part of the ovary is made up of dense connective tissue and contains ovarian follicles.

Fallopian tubes the uterine tubes extend from the area of the ovaries to the uterus. They open directly into the peritoneal cavity near each ovary and receive the oocyte. The opening of each uterine tube is surrounded by long, thin processes called fimbrae. It is a 4 inches long from each side of the uterus (fundus). It transports the mature ova form the ovaries to the uterus and provide a place for fertilization of the ova by the sperm in its outer 3rd or outer half. Parts: Isthmus portion that is cut or sealed in a tubal ligation. Ampulla widest, longest portion that spreads into fingerlike projections/fimbriae and it is where fertilization usually occurs. y Infundibulum - rim of the funnel covered by fimbriated cells (hair covered fingerlike projections) that help to guide the ova into the fallopian tube. Uterus - is as big as a medium-sized pear. The part of the uterus superior to the entrance of the uterine tubes is called fundus. The uterine wall is composed of three layers: The outer layer called the serous layer or perimetrium of the uterus The middle layer called the muscular layer or myometrium The innermost layer of the uterus is the endometrium.

y y

y y y

The uterus is supported by the broad ligament and the round ligament Vagina is a female organ of copulation and functions to receive the penis during intercourse. It also allows menstrual flow and childbirth. The superior portion of the vagina is attached to the sides of the cervix so that a part of the cervix extends into the vagina.

External Genitalia also called vulva or pudendum of the vestibule and its surrounding structures. The vestibule is the space into which the vagina and urethra open. The vestibule is bordered by a pair of thin, longitudinal skin folds called the labia minora. A small erectile structure called clitoris. The two labia minora unite over the clitoris to form a fold skin called the prepuce. Lateral to the labia minora are two prominent, rounded folds skin called labia majora. The space between the labia majora is called the pudendal.

Fertilization is the meeting of sperm cell and the fertilized ovum. It can only occur if intercourse takes place before the time of ovulation that usually occurs mid-cycle or about 14 days before the woman's next menstrual period. At the time of ovulation, the ovum is released from the ovary and transported in the fallopian tube where it remains for about 24-48 hours. Sperm cells remain viable within the female reproductive tract for about 72 hours. Only a single sperm cell is needed to fertilize the ovum, even though the average ejaculation contains approximately 300 million sperm.

Biographic Name: analyn arcega Age: 25 Sex: female Date of birth: u/r Place of birth: u/r Civil status: married Address: brgy. Kilagawa st. comm. qeuzon city Occupation: housewife Religion: inc Citizenship: Filipino Admission : January 18 2012 Hospital no.: 992431 Attending physian: dr duenas

History of present illness

A few a hours ago patient experienced labor pain associated with amber vaginal discharge, good fetal movement not avoided with vaginal bleed have the admission

Past medical history: u/r

Family history: u/r

Personal history social history : 1/1 siblings/high school graduate

Discharge summary
Arcega analyn ward ob hospital no. 992431 23 y/o female married attending physian dr dueanas Clinical abstract: this is a case ,G1 P1 who cause of labor pains, watery vaginal discharge and good fetal movement

Laboratory examinations: EGC done

B. PHYSICAL ASSESSMENT
General Appearance Head Hair with facial grimace with guarding behavior weak and pale looking with foul breath conscious and coherent with IVF hooked on right hand on NPO normocephalic symmetrical in shape no masses, no lesions evenly distributed over the scalp with black, straight and thick hair dandruff is present

Eyelids Sclera Iris

lids close symmetrically no edema, and no discharges whitish symmetrical in size round and dark brown Symmetrical in movement round and dark brown in color PERRLA (Pupils Equally Round And React To Light and Accommodation)

Pupils

Ears Nose Mouth Neck Thorax -

equal in size auricles are smooth and symmetrical pinna recoils after it is folded with dry cerumen the external nose is symmetrical and straight color is the same with the entire face lesions and tenderness were both absent nasal mucosa was pinkish both left and right nares were patent the nasal septum is intact and in midline without deviations cilia present in internal nares absence of nasal discharge appear dry and pale tongue was located at the midline, pink in color, slightly dry and furry with whitish coating tounge moves freely uvula is in midline neck movement was coordinated and difficulty in moving was not noted free from lumps and no tenderness no masses and tenderness upon palpation no adventitious breath sounds upon auscultation on both

left and right lung fields Breast Abdomen Upper extremities Lower extremities Genitalia round in shape, no lumps, no masses areola dark brown in color nipples round, equal in size same color of the body with presence of stretch marks with throbbing pain in RLQ good range of motion was noted no lesions, no presence of abnormalities, no tenderness can extend arms without difficulty skin uniform in color no varicose with limited movement With scanty vaginal bleeding

DOCTORS ORDER

01/18/12 VS. BP:110/70 RR:18 PR:68 TEMP:35.5

11:30 am

    

Please admit to OB Npo temporarily IVF D5LR 1x 30gtts/min Labs: cbc wit bt u/a Perineal preparation please  Monitor progress of labor q1  Monitored vital sign q1 , FHT q1  Refer

01/18/12 Bp: 120/80 Rr: 15 Pr:69 Temp:36.6

04:00 pm

 Ampicillin 2 grams TIV (ANST) 1 gram TIV for q6 for 24 hours  Geutany 80 mg thrue IV push for 24 hours  Refer  Please carry out IM not IV push fell D5LR 10 units oxytocin to run 30 gtts/mins  Maintain 3 liters then remove1 liter after 24 hours ,  limit intake per 1 liter  monitor input and outpot record every shift  watch out of difficulty of breathing  monitored vital sign q1  advice low salt low fat diet  refer 

08:00 pm 01/18/12 Bp: 110/70 Rr:18 Pr:78 Temp:35.4

01/19/2012 -subjective (-)cheast pain (-)abdominal (-)dob (-)caugh Decrease vaginal bleeding Objective -concious 110/80 94 21

9:30am

 Pdl , ac  Im ff up  Facilitate 20 eche with dropper ibc , pc , va  Bur, crea, CxR-PA  Watch out for congestion and dob  Well follow up patien  For referred to POND To removed epidural catheter  Refer  Epidural catheter removed  Blue TIP was shown and acknowledge by the patient  Epidural catheter site pressing was done  Advised  refer

01/19/2012 (-)pus (-)inflammation (-)dob

6:50pm

01/19/12

8pm

 low salt low fat diet  continue oral meds  continue IVF  maintain 2 liter for 24 hours then removed 1 liter after 24 hours  monitor INO every shift  monitor VS q1  watch out chest pain dob  discharge IE cervix os soft open w/ minimal bleeding uterus . invaluted to 16 weeks no adheral mass, no tenderness, no hematoma well coopetated sutures  refer

01/20/12 110/70 98 17

8:30am

     

low salt low fat diet ivf to consume limit ivf per 1 liter monitor TSO q6 monitor vs q1 maintain 2 liter and this often  watch out for chest pain dob for maxifer  for repeat cbc 6 hours for maxifer injection

addition:  still for 2d eche  refer beck to IM once with result  refer

01/20/12

8:00 pm

     

low salt low fat diet ivf to consume limit ivf per 1 liter monitor TSO q6 monitor vs q1 maintain 2 liter and this often  watch out for chest pain dob for maxifer  for repeat cbc 6 hours for maxifer injection

01/21/12

8:30 am

   

low salt low fat diet continue IVF continue oral meds for repeat cbc tomorrow morning (schedule 1/24/12)  follow up pest maxifer cbc  monitor vs q1 and record  WOF for dob  General hygein  Refer

Additional  Please repeat serum potassium outside