Delivery

Delivery Room
Room
Care
Care Study
Study
Group 31
Pregnancy is the state of carrying a developing
embryo or fetus within the female body. This
condition can be indicated by positive results on
an over-the-counter urine test, and confirmed
through a blood test, ultrasound, detection of
fetal heartbeat, or an X-ray. Pregnancy lasts for
about nine months, measured from the date of
the woman's last menstrual period (LMP). It is
conventionally divided into three trimesters, each
roughly three months long.
Delivery is the passage of the fetus and placenta
(afterbirth) from the uterus to the outside world.

For delivery in a hospital, a woman may be moved

from a labor room to a birthing or delivery room,
a room used only for deliveries. Usually, the
father, partner, or other support people are
encouraged to accompany her. If she is already in
an LDRP (for labor, delivery, recovery, and
postpartum), she remains there. The intravenous
line remains in place.
Delivery of the Baby: As delivery progresses, the doctor or
midwife examines the vagina to determine the position of
the fetus's head. When the cervix is fully open (dilated)
and thinned and pulled back (effaced), the woman is asked
to bear down and push with each contraction to help move
the fetus's head down through her pelvis and to widen the
vaginal opening so that more and more of the head appears.
When more than 1 inch (3 to 4 centimeters) of the head
appears, the doctor or midwife places a hand over the
fetus's head during a contraction to control the fetus's
progress. As the head crowns (when the widest part of the
head passes through the vaginal opening), the head and chin
are eased out of the vaginal opening to prevent the woman's
tissues from tearing.

Vacuum extraction can be used to assist in delivery of the

head when the fetus is in distress or the woman is having
difficulty pushing. Forceps are sometimes used for the
same reasons but are used less often than vacuum
extractors.
Episiotomy is an incision that widens the opening of
the vagina to make delivery of a baby easier. It is
no longer done routinely. It is used only when
necessary for immediate delivery. For this
procedure, the doctor injects a local anesthetic
to numb the area and makes an incision in the area
between the openings of the vagina and anus
(called the perineum). If the muscle around the
opening of the anus (rectal sphincter) is damaged
during an episiotomy or is torn during delivery, it
usually heals well if the doctor repairs it
immediately.
After the baby's head has emerged, the body is
rotated sideways so that the shoulders can
emerge easily, one at a time. The rest of the baby
usually slips out quickly after the first shoulder
comes out. Mucus and fluid are suctioned out of
the baby's nose, mouth, and throat. The umbilical
cord is clamped and cut. The baby is then dried,
wrapped in a lightweight blanket, and placed on
the woman's abdomen or in a warmed bassinet.
Delivery of the Placenta: After delivery of the
baby, the doctor or midwife places a hand gently on
the woman's abdomen to make sure the uterus is
contracting. After delivery, the placenta usually
detaches from the uterus within 3 to 10 minutes,
and a gush of blood soon follows. Usually, the woman
can push the placenta out on her own. If she cannot
and particularly if she is bleeding excessively, the
doctor or midwife applies firm downward pressure
on the woman's abdomen, causing the placenta to
detach from the uterus and come out. If the
placenta has not been delivered within 45 to 60
minutes of delivery, the doctor or midwife may
insert a hand into the uterus, separating the
placenta from the uterus and removing it.
PATIENT PROFILE (Mother)
Patient’s Name: FA
Citizenship: Filipino
Age: 31
Address: Serina st., Cagayan de Oro City
Birthday: October 13, 1977
Religion: Roman Catholic
Occupation: Housewife
Civil Status: Married
Height: 5 feet
Weight: 45 kg.

Vital Signs
Blood Pressure: 130/90 mm Hg
Respiratory Rate: 30
Pulse Rate: 80
Temperature: 36.5 ° C
Obstetric History

Gravida: 5
Parity: 5
Number of Full Term Infants Born: 5
Number of Preterm Infants Born: 0
Abortion: 0
Number of Living Children: 5
Date of Delivery: April 21, 2009
Time of Delivery: 1: 57 pm
Type of Delivery:(NSVD) Normal Spontaneous Vaginal Delivery
Place of Delivery: JR Borja Hospital (City Hospital)
Last Menstrual Period: July 10, 2008
Estimated date of Confinement: April 7, 2009
Age of Gestation: 40 4/7 weeks
Fetal Presentation: Cephalic
PATIENT PROFILE (Infant)

Patient’s Name: Baby Girl

Mother’s Name: FA
Citizenship: Filipino
Age: NB
Address: Serina st., Cagayan de
Oro City
Birthday: April 21, 2009
Religion: Roman Catholic
 STAGES OF
LABOR/PHYSIOLOGY
OF LABOR
First Stage
The first stage of labor is usually the longest part of labor where you
are having contractions and your cervix is dilating. This stage is
broken down into three phases. The early phase of labor is marked
by very light contractions that may be 20 minutes or more apart,
gradually becoming closer, possibly up to five minutes apart. The
key to this stage is to go about your normal schedule or if it’s the
middle of the night go back to bed! Most women will be very
comfortable during this stage and with a few exceptions those
having a hospital birth will not be in the hospital at this point.
The active phase of labor is where many women are getting serious
and withdrawing to do the hard work of labor. Contractions
generally are four or five minutes apart and may last up to 60
seconds long. Remember this still gives you a big break in between.
For women who desire medication in labor they will usually go to
the hospital in this stage of labor, while those desiring little or no
medications will go towards the end of this stage or the beginning
of transition. Mobility and relaxation are the keys to getting
through active labor.
Later, your contractions may be two or three minutes apart, lasting up
to a minute and a half. Some women will shake and may vomit
during this stage. This is normal. Remember that this stage usually
doesn’t last more than an hour or two. Partners, your support is
crucial here. Remind her how well she is doing, and help her find a
comfortable position, use cold rags for her face and give her sips
of water or ice in between contractions.
Second Stage

Pushing usually feels better for most women. They have spent
the first stage of labor relaxing and letting their body do
all the work, now they can actually do something to help.
This stage can last three or more hours, but for many
women it will not. The length of this stage is dependent
upon the positioning of the mother (upright = faster), the
positioning of the baby, whether medications have been
used, etc. The contractions will usually space out a bit, going
back to about four minutes apart. This stage ends with the
birth of your baby!
Now is the time to start your breathing exercises. Also, make
a concerted effort to relax between contractions. This will
become difficult yet important as the delivery proceeds.
The most important aspect of this stage is to forget about
the fatigue, and stay focused on the wonderful end result
of this stage.
Third Stage
After you are holding your beautiful baby, you may
be asked to push again at some point, and you
might be puzzled. This stage involves the passing
of the placenta. Delivery of the placenta may take
anywhere from five minutes to thirty, but most
deliver within a few minutes. Don’t worry about it,
this is the time you can spend bonding with your
new little one.
Fourth Stage
Postpartum is generally accepted as the fourth
stage of labor. Your body is going through many
changes now that the baby has been born. Not to
mention the large changes your family is going
through adding a new person to your family. Be
sure to ask for help. Your body will slowly change
and become more like your pre-pregnancy self,
but not exactly.
IDEAL NURSING
CARE PLAN
(Mother)

Nursing Diagnosis:
Pain related to effects of uterine contraction and pressure of
pelvic structures.

Interventions
• Assess level of clients pain from uterine contractions and
pelvic pressure
• Assess degree of discomfort through verbal and nonverbal
cues. Assess personal and cultural implications of pain.
• Encourage client to assume different positions and change
them regularly.
• Assess for verbal and non verbal indicators of pain and
evaluate response to technique use
• Respect the need for focusing during contractions- refrain
from intervening with the client during a contraction
Nursing Diagnosis:
Powerlessness related to duration and intensity of
labor

Interventions
• Assess patient with using controlled breathing
exercises and position changes.
• Slowly and clearly explain the events and changes
occurring with the active stage of labor
• Reassure, as appropriate, that labor is proceeding
without problems
• Emphasize positive aspects of situation and what
can be controlled
• Assess patient for conditioning factors related to
feelings of lost control.
Nursing Diagnosis:
Fatigue related to overwhelming
psychological emotional demands and
increased energy requirements

Interventions
-Assess degree of fatigue.
-Keep client informed of progress of labor.
-Provide comfort measures.
-Encourage client to close eyes, extend
legs, and relax between contractions.
-Monitor urine for ketones.
(Newborn)
Nursing Diagnosis:
Ineffective airway clearance related to presence of mucus or
amniotic fluid in airway

Intervention

• Suction oral prn.

• Monitor infant for feeding intolerance, abdominal distention
and emotional stressor
• Position head midline with flexion appropriate for condition
• Auscultate chest for character of breath sounds and
presence of secretions
Nursing Diagnosis:
Body temperature risk for altered

Intervention

• Maintain ambient temperature within established thermo

neutral (TNZ) considering neonates weight, gestational age
and usual clothing provides.
• Monitor neonates axillary’s skin (abdominal) or tympanic and
environmental temperature at least every 30-60 min. during
stabilization period or more frequently per protocol.
• Initiates early oral feeding.
• Collaborative:
• Make arrangement for transfer to NICU, if indicated.
Nursing Diagnosis
Risk for infection related to compromised immune system

INTERVENTIONS

-Provide isolation and monitor visitors as indicated.

-Wash hands before or after each care activity, even gloves
are used.
-Limit use of invasive devices, or procedure as possible.

COLLABORATIVE

-Administer antibiotics as prescribed.

ACTUAL NURSING
CARE PLAN
(Mother)

S:“Ma’am tabang ka anakon na kaayo ko! Sakit na kaayo akong tiyan, ka

anakon na ko!” verbalized by the patient.
O:Regular contractions
Increased bloody show
Ruptured of the membrane
Facial grimace
Bulging of the vagina
A:Acute pain related to strong uterine contraction, compression of
the nerves by presenting part of the fetus, and bladder distention.
P:At the end of 30 minutes, the patient will be able to verbalized pain
is relieved or controlled.
I: > Monitor and record uterine activity with each contraction.
> Monitor vital signs- usually altered in acute pain.
> Evaluate bladder fullness.
> Provide comfort measures like backrub, changing of position, use
of heat or cold and provide no pharmacological pain management.
> Encourage client to relax all muscles and rest between
contractions.
E:At the end of 30 minutes, the patient was able to verbalized pain
was controlled.
S:“Ma’am tabang!! nigawas na gyud ang ulo sa bata” as verbalized by
the patient.
O;Facial grimace
Sits up while lying on bed during crowning
A:Coping ineffective related to pain and stress in the labor process.
P:At the end of 30 minutes the patient will be able to demonstrate
coping ability
I: a.Call client by name
-Using client’s name enhances sense of self and promotes
individuality / self – esteem.
b. Explain process / procedures / events in simple, concise manner.
-May help client to express emotions, grasp situation, and
feel more in control
c. Allow client to express in own way without judgment.
-To encourage client to express feelings, anxiety and fears.
d. Provide for gradual implementation and continuation of
necessary behavior.
-Enhances commitment to plan.
E:After the intervention is given the patient was able to demonstrate
coping ability.
S:“Hapdos man ang akong tahi sa akong bilahan.”, as verbalized by the
patient.
O:Episiotomy repaired
A:Risk for infection related to the episiotomy repaired and tissue
trauma.
P:At the end of 30 minutes the patient may understand the cause of
pain on her vaginal opening and at the same time she will know the
proper way in taking care of her wound.
I: -Explain the causes of her pain.
Explanation can help your patient at ease. It will also increase her
knowledge about her condition so she could actively participate.
-Teach the patient the proper perineal care.
Proper cleaning can prevent infection and facilitate early wound
healing.
-Provide early ambulation.
To promote proper circulation and prevent any complications like
bedsores.
-Explain the treatment as prescribed by the physician.
To prevent any infections and complications.
E:After the intervention is given the patient was able to expressed
the feeling of understanding on what health teaching imparted to
her.
(Newborn)

S:Not applicable
O:Difficulty of breathing
Bluish color of lower extremities
A:Ineffective Breathing Pattern related to
immaturity of the respiratory center.
P:At the end of 3 minutes the neonate will be able
to establish an effective respiratory pattern.
I: > Suction airway as needed to clear secretions.
> Wipe the mucus with OS from the face, mouth
and nose
> Note emotional responses: gasping, crying,
tingling fingers.
E:After 3 minutes of rendering the nursing
interventions, the neonate was able to breathe
properly by manifesting absence of bluish
extremities and breathing thoroughly.
S:Not Applicable
O:difficulty of breathing
A:Ineffective airway clearance related to presence
of mucus or amniotic fluid in airway.
P:At the end of 3 minutes, the neonate will be able
to breathe properly.
I: > Suction oral prn.
> Position head midline with flexion appropriate
for condition
>Auscultate chest for character of breath sounds
and presence of secretions
E:At the end of 3 minutes, the neonate was able to
breathe properly.
S:Not Applicable
O:increased temperature
A:Risk for infection related to compromised immune
system
P:At the end of 3 minutes, the neonates
temperature will decreaed to normal body
temperature.
I: > Wash hands before and after each care activity
> Provide tepid sponge bath
>Monitor for signs of deterioration of condition.
E:At the end of 3 minutes, the neonates
temperature decreased to normal body
temperature
DRUG STUDY
DISCHARGE
PLANNING
END