A Case Study on

Postpartal Perineal Pain

In relation to perineal suture
 Introduction
The case study to be presented focuses mainly on
postpartal perineal pain to appropriately apply the concept
to the area of affiliation of the students who conducted the
study.
Despite the increasing availability of effective pain
management options, postpartum perineal pain from
episiorrhapy remains unnecessarily experienced. An
episiotomy is a surgical incision of the perineal body.
Traditionally, some physicians perform episiotomies to
prevent damage to the periurethra, perineum, anal sphincter
and rectum from lacerations during the birth; to prevent
damage to the posterior wall of the vagina; to prevent
jagged tears from lacerations; and to prevent future
Normally, episiorrhapy, or the repair in the perineum due to
episiotomy is done after placental delivery and blood clots
evacuation. Although the incidence of episiorrhapies in the
Philippines has declined from 57% to 35.2% in 2004, it is still
the most common surgical procedure done in the country.
The postpartal period, or puerperium, refers to the 6-week
period following childbirth. This is a time for maternal
changes that are retrogressive (the involution of the uterus
and vagina) and progressive (the production of milk for
lactation, the restoration of the normal menstrual cycle and
the beginning of a parenting role). Protecting a woman’s
health as these changes occur is important for preserving
future childbearing function and ensuring that she is
physically well enough to help incorporate her new child in to
the family. This period is popularly known termed the fourth
 Pain has been identified as an unpleasant sensory and
emotional experience associated with actual or potential
tissue damage (International Association for the Study of
Pain). It is the most common reason for seeking health
care. It occurs as the result of many disorders, diagnostic
tests and treatments. It disables and distresses more people
than any single diseases.
 BACKGROUND OF THE STUDY
Our case study was derived from our patient admitted at
Las Pinas Lying in Center,l a primary institution specializing
in the care of obstetrical cases in Las Piñas City and provides
safe and quality obstetrical care among pregnant women as
well as pediatric care to their newborn.
The institution consists of two obstetrician gynecologist,
one pediatrician, one anesthesiologist, four nurses and four
team midwives.
As one of the affiliated institutions of the Department of
Nursing of St. Dominic College of Asia, the group happened
to interact with the patient entrusted during their duties on
Jan04&05, 2010 from 10pm to 6am.
HEALTH
HISTORY
 A. Demographic data
Name: M.R.
Gender: female
Age: 25 years old
Birthday: Nov. 14, 1984
Birthplace: Paranaque
Civil Status: married
Religion: Roman Catholic
Nationality: Filipino
Address: Pulang Lupa 2, Las Pinas City
Tel No.: 0927xxxxxxx
Educational Background: 2nd year college
Occupation: Store Cashier
Usual Source of Medical Care: Clinic and Lying-in
 B. source and Reliability of Information
The group gathered pertinent data from the patient herself.
We also checked the patient’s records, chart and laboratory
studies.
 
C. Reasons for Seeking Care
CC: labor pain (uterine cramping)
January 4, 2010 at 6:45 pm
S: “humihilab po ang tiyan ko. Ang sakit na po.”
O:
 Vital signs:

BP: 110 / 80 mmHg PR: 81 bpm

Temp: 36.9 C RR: 19 cpm
vaginal discharge- bloody show
Fundic Height- 30cm
FHT- 144 bpm
3 cm dilatation
60%effaced
Station (-)3
(+) BOW
G2P2 TPAL (2001)
Labor Progress:
Onset: 4 hours prior to consultation
Interval: irregular
Frequency: 5-8 mins
Intensity: mild
Duration: 30 sec-1 min
 D. History of Present Health
Four hours prior to patient’s admission to Las Piñas
Lying-in Center, M.R. experienced progressive labor pains.
Three hours after the admission, the client delivered an alive,
baby girl on Jan. 04, 2010 at 10:38 pm via NSD. No
complications developed after birth.
 

E. Past Medical History

Interview with the mother revealed that she had no serious
illness since young up to present. She even verbalized that
she completed her childhood immunizations according to her
mother.
 
 The client’s first pregnancy was a remarkable one as she
noted that it was too painful and rated it as 9/10 in NRS. She
delivered a live baby girl via NSD and developed no
complications on postpartal period. The client stated that she
strictly complied with the medical regimen advised to her by
health care providers in a Lying in where she used to have
follow up checkups.
On her second pregnancy, she decided to seek medical
care with the same institution like the first one. She was able
to complete her scheduled visits along with the needed
laboratory studies. The client mentioned that she had taken
all the drugs prescribed to her and had received vaccines due
to her. On Jan. 04, 2010, she delivered a live, baby girl via
NSD and developed no complications after birth.
The woman said that she had no allergies to foods and
drugs.
 F. Family Tree

Legends:
Daughter
Father

Mother Client
 G. Socio-Economic Status
 
The client worked as a cashier in several stores prior to her
pregnancy. Her husband, on the other hand, works as a
contractual worker in an establishment in Las Piñas. The client
estimated their total monthly income of 16-17,000 Php.
 H. Developmental Theory(Erik Erickson’s
Psychosocial Theory)
 
The main subject of this study, M.R., is currently 25 years
of age and is now in young adulthood stage. According to
Erik Erickson, the central task of people at this stage is the
intimacy vs. isolation.
Based on the output of the interview conducted with the
client, it goes to show that she attained aspects of this central
task in positive manner. She was able to have an intimate
relationship with another person, her husband. She used to
work in a store as a cashier which means that she had a
concept of committing herself to work.
 I. 1. Review of system and physical examination

1. General / “wala akong naging Weight on first prenatal visit (May 2009)
overall state problema sa pagbubuntis ko, 58Kg
hindi ako nagkasakit kahit As of December 2009 68Kg
ubo at sipon.” Total weight gained: 10kg

2. Integument
a. Skin “may kamot ako ngayon sa Striae gravidarum over the lower
tiyan.” abdomen was visible during inspection;
  Noticeable chloasma and detectable linea
nigra
 
b. Hair No subjective data Thick hair, evenly distributed
   
c. Nails No subjective data Convex curvature; angle between nail
and nail bed of about 160 degrees;
smooth texture; pink nail bed; prompt
return of pink color in blanch test
3. Head No subjective data Normocephalic skull, no nodules
palpated, symmetric facial features,
symmetric facial movements
4. Eyes No subjective data Eyebrows symmetrically aligned with
equal movement, no discharges, shiny,
smooth and ping palpebral conjunctiva,
no edema over lacrimal gland, both eyes
coordinated, move in unison, with
parallel alignment, able to read newsprint
5. Ears No subjective data Auricles’ color same as facial skin,
symmetric position, mobile, firm and not
tender; pinna recoils after it was folded,
normal voice tone audible, able to
respond in whispered voice
6. Nose and No subjective data External nose symmetric and straight, no
sinuses discharge, uniform color, not tender, air
moved freely as the client breathed
through the nares, mucosa pink, no
lesions, nasal septum intact and in
midline
7. Mouth and No subjective data Outer lips uniform pink in color, able to
throat purse lips; buccal mucosa uniform pink
in color, moist and soft; pink gums,
smooth and intact dentures; pink tongue
centrally positioned, moved freely; light
pink, smooth soft palate; lighter pink hard
palate; uvula positioned in midline of soft
palate; pink and smooth tonsils
8. Neck No subjective data Neck muscles equal in size; head
movement coordinated, smooth and with
no discomforts; equal muscles strength;
no palpable lymph nodes; trachea was
placed centrally in midline of neck;
thyroid gland not visible on inspection
9. Breast and “Nakakapagpasuso sa anak Rounded shape, slightly unequal in size;
axilla ko.” smooth, changes of pregnancy still
apparent, appeared to have an engorged
nipple, pigmented, intact and lactating
breast
10. Respiratory No subjective data RR- 18cpm, no signs of DOB, clear
breath sounds
11. No subjective data PR- 85bpm, symmetric pulse volume;
Cardiovascular veins not visible
12. Urinary “wala naman ako problema Voiding freely 6 – 8 times within 24
sa pagihi.” hours
13. Genitalia “masakit iyong tahi ko.” With second degree laceration; intact
episiorrhapy with no redness; presence
of lochia rubra in adequate amount
Age at menarche: 11years old
LMP: March 29, 2009
14. No subjective data (-) Homans signs, no tenderness on both
muscukoskeletal calf muscles, muscles equal in size on
both sides of the body; no tremors;
muscles at rest were firm; equal strength
on each body side
15. No subjective data No bruises present, no signs of
Hematological paleness, no signs of profuse bleeding

16. Endocrine No subjective data Visible skin pigmentation (chloasma)

2. Laboratory Studies
Normal Nursing
Procedur Indicatio Actual Interpret
values / reponsibi
e / date n findings ation
findings lities
CBC (12-21-
09) To know the  
•Hemoglobin amount of 120 - 160 146
blood in Normal
•Hematocrit 0.36–0.43 0.39 Normal Explain the
preparation
•RBC Count for future
4.5 - 5.5 4.8 Normal procedure to
•WBC Count 5-10 x 10/L 8 x 10/L Normal the client
blood loss 150-350 240
•Platelet on 3rd stage Normal
Count of labor.
 Normal Interp Nursing
Procedure / Indicatio Actual
values / retatio reponsibi
date n findings
findings n lities
•Erythrocyte 0-20mm/hr 12mm/hr Normal
•Sedimentation rate 0-10mm/hr 7mm/hr Normal
•Bleeding time 1 – 3 mins 2mins Normal
•Clotting time 2 – 6 mins 3mins Normal
•Differential count 0.00 0.00 Normal
blasts    
•Stabs 0-0.02 0.01 Normal
•Neutrophils 0.40-0.60 0.50 Normal
•Eosinophils 0.01-0.03 0.01 Normal
•Basophils 0.0-0.01 0.01 Normal
•Lymphocytes 0.20-0.40 0.33 Normal
•Monocytes 0.02-0.08 0.05 Normal
•Metamyelocytes 0.00 0.00 Normal
•Mylocytes    
•Peripheral smear 0.00 0.00 Normal
•Anisocytosis
•Poikilocytosis
•Toxic granulation
 Normal
Procedur Indicatio Actual Interpr Nursing
values /
e / date n findings etation reponsibilities
findings
Rh Typing For ABO Results Type “O” Blood Explain the
compatibilit vary type O (+) procedure to the
y client.
Obtain specimen
aseptically.
Assist the medical
technician in
obtaining result.
VDRL Detects Non- Non- Negative Explain the
presence of reactive reactive for procedure to the
syphilis syphilis client.
Obtain specimen
aseptically.
Assist the medical
technician in
obtaining result.
 Normal
Procedur Indicatio Actual Interpr Nursing
values /
e / date n findings etation reponsibilities
findings
HBSAG Indicator of Negative Negative Negative Explain the
acute Hepa for Hepa procedure to the
B B client.
Obtain specimen
aseptically.
Assist the medical
technician in
obtaining result.
Urinalysis To detect Physical: Physical: No signs Explain the
substances/c Color: light Color: light of procedure to the
ellular yellow yellow infection client.
material in Appearance Appearance Obtain specimen
urine : slight : slight aseptically.
associated turbid turbid Assist the medical
with technician in
different Reaction: Reaction: obtaining result.
metabolic 7.0
and kidney
disorder
 Normal Nursing
Procedur Indicatio Actual Interpre
values / reponsibilitie
e / date n findings tation
findings s
Chemical: Specific
Protein: (-) Gravity:
Sugar: (-) 1.020
Bacteria: Chemical:
Protein: (-)
few Sugar: (-)
Epithelial Bacteria:
cells: few few
Epithelial
Cells: few
Biophysical To assess No. of Single, live Explain the
profile fetal well fetus: intrauterine procedure to the
being single pregnancy client
Presentatio of about 38
n: cephalic 2/7 wks
Cardiac AOG,
Activity: cephalic,
155 bpm anterior high
lying, Grade
III.
 Nursin
Normal
Procedur Indicatio Actual Interpretat g
values /
e / date n findings ion reponsi
findings
bilities
Fetal
breathing: Adequate
active amount of
Body amniotic fluid.
Movement: Biophysical
normal score of 8/8
Placenta: Single, live
anterior high intrauterine
lying, Grade pregnancy of
III about 38 weeks
Amniotic and 2 days
Fluid: AOG, cephalic,
adequate anterior high
index lying, Grade III.
10.1cm Adequate
Fetal amount of
breathing:2 amniotic fluid.
Fetal tone: 2 Biophysical
Fetal score of 8/8
movement: 2
 Nursin
Normal
Procedur Indicatio Actual Interpret g
values /
e / date n findings ation reponsi
findings
bilities
Amniotic
Fluid: 2
8/8 Total: 8/8
  Measurements:
  BPD: 9.5cm
 2.4-9.5cm FL: 7.4cm
1.5-7.8cm AC:33.8cm
EFBW:3,380-
4,120 grams
Average age:
38 weeks and
2 days
 J. functional assessment
Health Perception
Seven to eight months ago, the client realized that she was
pregnant and seeks medical care to an institution rendering
obstetrical care. She was able to complete her prenatal visits
along with the laboratory studies needed. For the past nine
months, the patient did not develop colds as well as other
illness.
Self Perception
M.R. believes that she’s now a mature person as she can
control her emotions over other troubling scenes. She stated
that she fulfills the tasks expected to her age and disposition
in life. The client said that she gets angry whenever
somebody else scolds her daughter and gets anxious when
her growing child gets sick.
Activity/Rest Pattern
The subject performs household chores typical for a
mother and a housewife. She cleans their house daily, cooks
for her family, washes the dishes, takes charge of the laundry
works, keeps an eye to her daughter and serves her husband
joyfully. Early in the morning, she walks around their village
with her daughter. Gradual modifications took place when
her 3rd trimester came. She was not able to do all those
activities normally. She got tired easily.
Sleep/Rest Pattern
The client sleeps at around 9-10pm and wakes up at 6am.
She naps in the afternoon together with her daughter. She
stated that there’s no need to use sleeping aids to put her to
sleep. Her daily routine (activity) is enough to make her feel
tired and go to sleep.
  Nutrition/Elimination
As recommended by health care providers, the patient eats
a well balanced diet and drinks 6-8 glasses of water a day.
She voids 5-6 times in a day and defecates twice a day. She
gained 10kg all throughout her pregnancy.
PROBLEM
LIST
 ACTUAL
Problem # Problem Date identified Remarks
1 Acute pain related to 01/04/10 Decreased pain to a
perineal suture tolerable level
0 from 8 in NRS

2 Impaired skin integrity r/t 01/04/10 No signs of wound

perineal suture complications seen

POTENTIAL
Date
Problem # Problem Remarks
identified
1 Risk for fluid volume deficit
r/t excessive blood loss during
delivery and insensible loss
2 Risk for infection r/t perineal
suture
NURSING
CARE
PLAN
Assessment Diagnosis Planning Interventions Rationale Evaluation
Subjective: Acute pain r/t After 2 hours Independent: Goals met.
perineal of rendering
“Masakit -perform pain -to rule out The patient
sutures as appropriate
iyong tahi ko”, assessment worsening of stated that the
as verbalized evidenced by nursing
underlying pain was
by the client. distraction actions, the -monitor vital conditions
reduced after
behaviors and patient will: signs
Pain scale of taking
reports of -to serve as
8/10 -report pain is -provide baseline data analgesic.
cramping
controlled to comfort She rated 0
Objective: a tolerable measures(col -to provide out of 10 in
 vital signs: level d and hot nonpharmacol pain scale (10
therapy, back ogical being the
BP management
rub) highest) at the
110/80mm
end of the 10-
Hg -intrsuct deep -to assist
6 shift.
breathing patient to
T 36.9c
exercise explore She was able
PR 81bpm methods for to enumerate
-encourage pain control ways of
RR 19cpm diversional
relief/comfort
 irritability activities
measures.
 guarded/ administer -to aid in
protectiv warm sitz wound
e bath healing
behavior
-encourage -to aid in
 restlessn high protein tissue repair
ess diet
-to prevent
 facial -encourage fatigue
grimace adequate
-to relieve
rest periods
 decrease episiotomy
mobility -advise early discomfort
ambulation
 sweating -to maintain
-promote acceptable
 expressiv
perineal level of pain
e
exercises(Ke
behavior
gel’s
exercise)
-discuss with
significant
others ways
on how they
can assist the
patient and
reduce
precipitating
factors that
may cause or
increase pain
like assisting
the patient in
activities
needing
physical
strength until
the patient’s
pain is
relieved.

Dependent:

-administer
analgesics as
prescribed
Assessment Diagnosis Planning Interventions Rationale Evaluation
Subjective: Impaired skin After 8 hours1. to assess Goals met.
integrity r/t of rendering causative /
“medyo -to determine The patient
perineal appropriate contributi
kumikirot causative displayed no
suture as nursing ng factors:
iyong tahi factors signs of
evidenced by actions, the
ko”, as a. identify wound
disruption of patient is -to identify
verbalized by underlyin infection like
skin layers expected to: exacerbation
the client g caused by purulent and
 display conditions malnutrition foul smell
Objective:
healing of / discharge, no
vital signs: wound pathology -to identify redness and
with no involved areas to be skin edges
BP addressed in
complicati were intact.
110/80mm b. determine
on teaching plan
Hg nutritional
and potential
status and
T 36.9c referral needs
potential
PR 81bpm for
delayed
RR 19cpm healing
 disruptio 1. to assess -skin is
n of skin extent of particularly
surface involvem important
(epiderm ent / avenue of
is) injury: communicat
ion for this
 8 in NRS a. note skin
population
color,
and when
texture
compromise
and
d, may
turgor
affect
b. determin responses
e
-to assist
degree /
body’s
depth of
natural
injury /
process of
damage
repair
to the
integume
ntary
system
a. note odors emitted from -to promote circulation
the skin / wound and reduce risks
associated with
1. to determine impact of
immobility
condition:
-to aid in skin / tissue
a. ascertain attitudes of
healing and to maintain
significant other /
general good health
individual about
condition. Note -enhanced commitment
misconceptions to plan, optimizing
outcomes
b. note presence of
compromised vision, -to control feelings of
hearing or speech helplessness and deal
with situation
1. to assist client with
correcting / minimizing
condition and promote
optimal healing:
keep the
area clean,
prevent
infection
encourage
early
ambulation
/
mobilizatio
n
 
 
provide
optimum
nutrition,
including
increased
protein
intake
 
to promote
wellness:
a. discuss importance of
early detection of skin
changes and or
complication
b. assist the client /
significant other in
understanding and
following medical
regimen and developing
program or preventive
care and daily
maintenance
c. assist client to learn
stress reduction and
alternate therapy
techniques
Assessment Diagnosis Planning Interventions Rationale Evaluation
Objective: Risk for After 8 hours Independent: Goals met.
deficient fluid of rendering The patient
vital signs: -assess skin -to note
volume r/t appropriate degree of did no show
turgor/oral
BP blood loss nursing hydration any signs of
mucous
110/80mm during interventions, fluid volume
membranes -to ensure
Hg delivery the patient deficit like
will -monitor I/O accurate decreased
T 36.9c picture of
demonstrate skin turgor,
-note changes fluid status
PR 81bpm behavior to altered vital
in vital signs
prevent fluid signs,
RR 19cpm -to maximize
volume -encourage decreased
intake
-slightly deficit. oral intake urine output,
moist mucous -to promote dry mucous
-encourage wellness membranes
membranes
patient to and change in
-capillary have a diary -to prevent mental status.
refill after 2 of food/fluid occurrence of
seconds intake; deficit
number and
-blood loss
amount of
during 3rd
voiding and
stage of labor
stools
Dependent:
-provide
supplementa
l fluids as
indicated
Assessment Diagnosis Planning Interventions Rationale Evaluation
Risk for After Independent: Goals met.
infection r/t performing The patient
Objective: -note skin -to assess
perineal health did not
conditions causative
- Perineal suture teaching for manifest any
factors
suture an hour and -encourage signs of
after early -to reduce risk infection such
-presence of
rendering ambulation factors as presence of
lochia rubra
nursing purulent and
-provide -to reduce risk
vital signs: actions for 8 foul smell
perineal care factors
hours, the discharge,
BP
patient is -promote -to develop redness
110/80mm
expected to: perineal self- patient’s around the
Hg
care independence perineum and
-verbalize
T 36.9c alteration in
understanding Dependent: -to correct
vital signs.
PR 81bpm of causative existing risk
factors -administer factors
RR 19cpm prophylactic
-identify antibiotics as
interventions prescribed
to
prevent/reduc
e risk of
 ANATOMY
AND
PHYSIOLOG
Y
 The vagina is the female organ of copulation and functions
to receive the penis during intercourse. It also allows the
menstrual flow and childbirth. The vagina extends from the
uterus to the outside of the body. 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.
The region between the vagina and the anus is the clinical
perineum. The skin and muscle of this region can tear during
childbirth. To prevent such tearing, an incision called
episiotomy is sometimes made in the clinical perineum.
Traditionally, this clean, straight incision is thought to result
in less injury, less trouble in healing, and less pain. However,
many studies indicate that there is less injury and pain when
no episiotomy is performed. The perineum is put under a
great deal of pressure during birth to which it responds, after
birth, with the development of edema and generalized
 Pain has been identified as an unpleasant sensory and
emotional experience associated with actual or potential
tissue damage (International Association for the Study of
Pain).
Nociceptors are receptors that are preferentially sensitive
to a noxious stimulus. These are free nerve endings in the
skin that respond only to intense, potentially damaging
[Link] may be mechanical, thermal or chemical in
nature.
Spinal Cord is the portion of the CNS enclosed in
vertebral column, consisting of nerve cells and bundles of
nerves connecting all parts of the body with the brain.
Thalamus is the relay stations for all the sensory messages
that enter the brain, before they are transmitted to the
[Link] Cortex is the one directly responsible for
consciousness, with essential roles in perception, memory,
Chemical Mediators:
Histamine causes dilation of blood vessels and
contraction of smooth muscle.
Bradykinin is a very powerful vasodilator and causes
contraction of the smooth muscle; it is formed in the
blood under certain conditions and is thought to play an
important role as a mediator of inflammation.
Acetylcholine is a neurotransmitter released at the
synapse of parasympathetic nerves and at neuromuscular
junctions.
Serotonin acts as neurotransmitter and its levels in the
brain are believed to have an important influence on
mood.
Prostaglandin is a hormone produced by the posterior
pituitary gland which mediates inflammatory responses.
THEORETICAL BASED
STIMULUS

TISSUE DAMAGE SENSORY EXPERIENCE

CHEMICAL MEDIATORS PAIN PERCEPTION

NOCICEPTOR
RESPONSE

PAIN PATHWAY TO
BRAIN
 cLIENT BASED
Normal Spontaneous
Delivery

Second degree laceration due Sensory perception

to episiotomy

Release of chemical mediators Pain perception

(bradykinin, substance p, prostaglandins)

Nociceptor response

Pain pathway to brain

 OG
OL
S I
HY
OP
T H Y
PA
NARRATIVE EXPLANATION
The source of postpartum pain related to perineal suture is the injury-
induced release of chemical mediators that occurs with the acute
inflammatory response. Bradykinin, substance p and prostaglandins
are released from the injured cells. Pain stimuli sensitize pain
receptors so that once the brief period of injury is over, long standing
changes in the neurons maintain the pain postoperatively.
 CONCEPT MAP
1. Acute pain r/t perineal sutures
S> “masakit ang tahi ko.”
O> vital signs: -performed pain assessment
BP: 110/80 mmHgTemp: 36.9 C -administer warm sitz bath
PR: 81bpm, RR: 19cpm -encouraged rest periods
-instructed perineal exercise
-administer analgesic

2. Impaired skin integrity

Vital signs:
M.R 25 years old G2P2
BP: 110/80 mmHg -determined nutritional
Normal Spontaneous Delivery
status
Acute pain r/t perineal suture
Temp: 36.9 C -assessed episiorrhapy
Impaired skin integrity
PR: 81 bpm -encouraged early ambulation
RR: 19cpm -provide perineal care
 1. PROCEDURE

PROCEDURE / DATE Indication Nursing responsibilities

Median episiotomy To prevent tearing of the •Skin preparation
(January 4, 2010, 10:30 pm) perineum with birth and to •Control bleeding
release pressure on the
fetal head with birth
Episiorrhapy (January 4, To repair episiotomy •Assist the obstetrician
2010, 10:49pm) gynecologist/midwife in
the procedure
•Control bleeding
•Assess perineum for
REEDA
•Administer warm sitz bath
•Provide perineal care
 2. PHARMACOTHERAPEUTICS
CLASSIFICATION INDICATION / DOSAGE NURSING
AND FREQUENCY RESPONSIBILITY
-advise the patient to take the
Amoxicillin Prophylaxis for bacterial drug round the clock
(antibiotic) infection -instruct patient to take entire
500 mg 1cap PO q8 x 7 days quantity of drug exactly as
prescribed
-advise patient to watch out
for signs of superinfection
like vaginal itching, loose
foul smelling stools and furry
tongue

Mefenamic Acid Relief of postpartum pain -instruct patient to take the

(analgesic) 500mg 1cap PO q6 x 7 days drug every six hours with full
and PRN stomach
-advise patient to
immediately report
persistence or failure to
relieve pain
 CLASSIFICATION INDICATION / DOSAGE NURSING
AND FREQUENCY RESPONSIBILITY

Methylergometrine Maleate Preventing postpartal -advise patient to take only

(ergot alkaloid) hemorrhage as prescribed and not to
(uterine stimulant) 1tab PO TID x 7 days exceed dose
-inform patient that
abdominal cramps may be
experienced in this
medication, however, report
severe abdominal cramps
-monitor vital signs

Ferrous Sulfate Prevention and -inform patient to take drug

(antihematenic) treatment of IDA with water or juice on an
1tab 1 tab PO TID x 7 days empty stomach; may be
PO administered with food to
OD prevent irritation
-inform patient that iron may
turn stool black; this could
mask the presence of melena
 IV Fluid

CLASSIFICATION INDICATION NURSING

RESPONSIBILITY
D5LR 1L incorporated with Initiation/improvement of - Instruct patient to report
10 units of Oxytocin uterine contractions to increased blood loss,
achieve control of post abdominal cramps,
partum bleeding or increased temperature or
hemorrhage foul smelling lochia
- Advise patient that
contractions will be
similar to menstrual
cramps
- Monitor vital signs
VII. Progress Notes
Date /Time
1/04/10 7:40 pm
Received a 25 yo, PU 38 2/7 weeks AOG CIL G2P1 (1001)
with CC of Labor Pain
Initial V/S taken and recorded
I.E. done and examined by MOD 3cm dilated, 60% effaced,
(+) BOW, station (-3)
Admission done
Consent was signed and served
Transferred to LR by wheel chair
Monitored for the progress of labor
With mild to moderate contraction
9:50 pm
I.E. 8 cm dilated, station (-2), 80% effaced , (+) BOW
Transferred to DR table
Placed in lithotomy position
Perineal prep rendered
Amniotomy done, clear liquid
10:16 pm
I.E. fully dilated, fully effaced, station (0)
10:21pm
Local anesthesia given on the lower aspect of the
fourchette
10:30pm
Median episiotomy done
10:38 pm
Delivered cephalic, through NSD, an alive baby girl
handled and delivered by MOD and was assisted by
10:49 pm
Placenta out completely (Schultze)
Blood clots were evacuated
Episiorrhapy done under local anesthesia
BP 120/80mmHg, methylergomethrine maleate 1amp given
TIM
Fixed and placed flat on a stretcher
Transferred to ward
Placed flat on bed
With contracted uterus, no sign of profuse bleeding
With pain on perineal area due to surgical incision with a scale
of 8/10
On DAT
Due meds given
Kept rested and comfortable
Instructed DBE
Back rubbing rendered
January 5, 2010
10pm – 6am
Received awake, conscious
No pain, with a pain scale of 0/10
stable v/s
On DAT
Due meds given, I&O and v/s monitored and recorded
Health teachings done
VIII. DISCHARGE PLANNING
Compliance Contents Strategy
Medications Oral Advise patient to have a list of
 Amoxicillin q8 x 1 all her medications with
week(antibiotic) dosage and time indicated for
 Mefenamic Acid q6 each medicine and have it
PRN(analgesic) posted anywhere it would be
 Ferrous Sulfate 1cap easily accessible.
OD(antihematenic)
 Methylergonovine
Maleate TID(uterine
stimulant)

Exercise  Kegel’s exercise Encourage client to have a

 Early ambulation schedule of her exercises
 Deep breathing exercises activities may be on a
calendar so she could comply
accordingly.
Encourage rest periods after
having exercise.
 Compliance Contents Strategy
Treatment  Hot sitz bath Advise client to take hot sitz
bath to promote healing of
episiorrhapy.
Health Teaching  Perineal hygiene Instruct patient to wash her
 Family Planning perineum with clean water
and feminine wash starting
from the vulva going to anus
to prevent transmission of
bacteria from anal area.
OPD Jan. 13, 2010(follow-up check Inform client to strictly abide
up) with check up as scheduled to
check the progress of
episiorrhapy and the condition
of the cervix.
List the schedule of her follow
up and check up and have it
written on their calendar so
that it would be easily
remembered.
 Compliance Contents Strategy
Diet  High fiber diet Name nutritious foods
 Increase OFI appropriate for her needs.
 Increase consumption of Emphasize the needs
foods rich in Vit. C
 IX. SUMMARY OF CLIENT’S STATUS
By the end of the interview with the patient, the group
conducted a health teaching included in discharge planning.
After the first 24 hours postpartum, the patient verbalized that
the pain felt was reduced to a tolerable level as she graded the
pain as 0 from 8 in NRS (10 being the highest). The patient
displayed no signs of wound infection like purulent and foul
smell discharge, no redness and skin edges were intact. The
patient did not show any signs of fluid volume deficit like
decreased skin turgor, altered vital signs, decreased urine
output, dry mucous membranes and change in mental status.
Positive attitudes towards others, her newborn, and self were
seen.
Thank you!!! Godspeed…